Disparities in Children’s Health: Getting to Community-based Solutions

1. Disparities in Children’s Health: Getting to Community-based Solutions Debbie I. Chang, MPH Senior Vice-President and Executive Director Nemours Health and Prevention Services AcademyHealth Health Services Research Meeting Seattle, Washington June 25, 2006

2. Overview • Nemours Health & Prevention Services • Our strategy and approach • The Potential Solution- A “Saturation Strategy” • Evolution of a Child Health Promotion Coalition • Early Success • Vision for Delaware

3. 0 Nemours • Nemours is one of the nation’s largest pediatric health care systems. Nemours provides pediatric primary and specialty health care throughout DE, northern Florida, and also parts of southeastern PA, and southern NJ. • At these various operating sites, Nemours cares for more than 225,000 children annually through 870,000 patient visits. • In DE, Nemours cares for almost 55,000 children (1/4 of the state’s population of 0-17 year olds).

4. 0 Nemours Health & Prevention Services (NHPS) • In 2003 Nemours redefined its approach: health promotion as well as health care • NHPS focuses on child health promotion & disease prevention to address root causes of health problems in the community • NHPS complements and expands the reach of clinicians by providing a broader, community-based perspective Traditional Medical Care Community-based health promotion

5. Comprehensive Health Promotion • Comprehensive health promotion • The medical model • The lifestyle or behavioral approach • The social-environmental model • Until recently, Nemours had primarily engaged in the medical model. • With NHPS, we will engage all three models and have a greater and more sustainable impact

6. NHPS VisionOptimal health and development for all children. NHPS Mission To be a leading catalyst for improving children’s health in Delaware. To engage communities and work with partners to find, develop, implement, evaluate and promote successful strategies to help children and their families live healthier lives. Summary We work with families and communities to help children grow up healthy.

7. 0 Our Approach • Focus initially on two campaigns: healthy eating and physical activity and emotional and behavioral health • Work with the community to develop, support, and be a catalyst for changes in policies, programs and practices. • Provide health promotion content expertise. • Provide tools to non-profit and community-based organizations to help them serve children and their families better. • Evaluate what works and what does not. • Share what we have learned with community leaders, stakeholders and organizations that have similar goals.

8. Obesity – A Key Issue in Delaware • High rates of children at risk • Nemours EMR data for patients age 2-19 indicates that 35.5% of all of the patients with a measured BMI were either at risk of overweight or overweight; a majority of the patients represented low-income and minority populations of Delaware • Fruits and Vegetables • 65% of parents from households with annual incomes under $30,000 say the expense of healthy food is a barrier to eating them • Too much screen time • Children in lower income households and with less educated parents watch more television than those from higher income homes and whose parents have more education. • Need for more physical activity • 40% of children from households with incomes under $30,000 live in areas where there is little or no access to safe places to play • 17% of children live in places where there is no safe place to play Source: Delaware Public Opinion Poll

9. Our Core Message: 5-2-1-Almost None • 5-2-1-Almost None healthy lifestyle mantra: • At least 5 fruits and vegetables per day • No more than 2 hours of screen time per day • At least 1 hour of physical activity per day • Almost no sugar-sweetened beverages (2 or fewer per week) • Strategically targeting groups that serve large numbers of children: • Health care providers • Child care providers • Schools • Community organizations

10. Our aspirations… • Behavior Change • Children choose fruit instead of fries • Families spend more time together playing and getting physical activity • System/Environmental Change • Child care providers offer nutritious snacks and physical activity • Insurers pay for health promotion and prevention services • School vending machines offer more nutritious options

11. 0 Obesity Prevention PilotsTargets and Outcomes • Content Areas • Healthy Eating & Physical Activity • Emotional/ Behavioral Health • Program Sectors • Childcare • Primary Care • Schools Outcomes Impact on Delaware Children and Communities (Policy, practice and program change) Community Capacity • Impacting the greatest number of children in the shortest amount of time.

12. The Potential Solution: A “Community Saturation Strategy” • Working to change policies, programs and practices, wherever children live, learn, and play: • Child care • Schools • Primary care • Community organizations • 198,000 children in Delaware—our goal is to eventually reach them all Goal: To improve the quality of care, systems and environments for children through the above sectors.

13. Why Start in Sussex County? • The fastest growing county population of people in Delaware • High rates of poor health and socio-economic indicators • Large Hispanic and African-American populations • Large population of immigrant farm workers • Rural community with few resources and services • Low unemployment rate • Public transportation and affordable housing are challenges • Residents have a lower rate of post-secondary educational activity • History of working together as a community

15. Sussex County Coalition: Our Strategy • Working with large, carefully chosen organizations (building strategic partnerships), we plan to catalyze policy, practice, and program changes on a large scale that reaches more children by: • Sharing learning and technical assistance to engage them in health promotion • Showing them how to apply promising practices • Helping them to sustain change

16. Who Are We Working with in Sussex? • Formed relationships with key leaders • Business (e.g., trucking, poultry industries—large employers) • Government officials (state legislators, Sussex county officials, mayors, town managers) • Libraries • Nonprofit leaders (Sussex Boys & Girls Clubs, 4H) • School districts (officials, leading teachers) • Large child care centers and family day care providers (Del Tech, Telamon) • Leaders of local health care systems (Nanticoke Health Systems) • Primary care physicians (Nemours and others) • Local media (newspapers, TV, radio) • Grew our relationship network • Hundreds of face-to-face meetings • Presentations to groups

17. Sussex County Collaborative • Launched Sussex County Child Health Learning Collaborative in August 2005 • 35 participants from 14 community organizations • Provided interactive training in collaboration, program planning & evaluation, leadership, program content • Met for 5 monthly sessions • Customer satisfaction: >93% “I really enjoyed the sessions that I attended – thank you Nemours…” –Collaborative Participant

18. What have we accomplished? • Early successes in… • Child care • Schools • Primary care • Community organizations

19. Child Care Sector • Child care provider workshops: “Helping Kids Grow Up Healthy--Moving More, Eating Well” reaching 6 providers/centers in Sussex County serving 680 children • Two child care pilot programs in Healthy Eating/Physical Activity reaching 400 children • Telamon Head Start (Serves primarily Hispanic families) • Delaware Technical Community College’s Child Development Center

20. Telamon Head Start • We are partnering to develop model approaches in the center’s policies, programs and practices: • Daily physical activity using structured programs led by teachers • More fruits and vegetables for lunch and snack menus • Teachers acting as role models • Engagement of families and children in center change • Integration of learning about health with reading and math skill building through a children’s fruit and vegetable market Results: One parent reported that while shopping her child asked for cucumbers because that was what she “bought” at her child care center.

21. School Sector • School Action Teams in 2 elementary schools • 2 School Wellness Centers promoting 5-2-1-Almost None • Delaware Department of Education a partner • Issues include • Vending options • Cafeteria menu • Physical education • Health curriculum • Access to playgrounds and indoor play space “Wow! I am simply blown away by the level of commitment that Nemours has shown for improving the health and well-being of children. We are so fortunate to have your powerful voice in Delaware speaking out for our children. I look forward to walking along side you as we make our vision a reality!” --Garrett W. Lydic, 2006 Delaware State Teacher of the Year

22. Primary Care Sector • Providing support for clinical practices serving nearly 10,000 children: • Education and tools to help practices better prevent, identify, and manage childhood overweight • EMR Enhancements, e.g., prompt indicating patient has a BMI >/=85th percentile • Providing resources connecting primary care practices to the community: • “Healthy Quest” online mapping tool links families to resources • “Health Navigator” helps families make behavior changes and connects them to community services • “Growing Healthy Kids” 10-week pilot program for families

23. Community Sector • Sussex County 4-H • Boys & Girls Clubs • First State Community Action • Nanticoke Health Systems • Delmarva Rural Ministries “One year ago, I had never heard of this organization. Now you’re everywhere--congratulations!” --A key leader in Sussex County

24. Building the Sussex County Coalition • Conducted Partner Workshops from Jan-May 2006 • Customer satisfaction: >90% • 100% of organizations participating in the Collaborative have become active participants in Partner Workshops • Sussex County Child Health Coalition will officially be launched with 31 member organizations in May 2006 • Mission: We exist to engage the entire community in collaborative efforts to improve the health of our children and youth. • Vision: We envision a community in which our citizens and institutions are actively engaged in child health promotion as a shared community good, and working together to create a cultural and physical environment which supports healthy lifestyles for our children and youth and their families. “I feel inspired to not only promote the vision, but live it!” –Coalition Member

25. Child Health Outcomes: Obesity Prevention • Measure the impact on children as a result of all activities: • Improved child health behaviors • Policy changes and additional environmental/system supports in place to promote healthy eating and physical activity • Reduction in overall trajectory of overweight for children These measures will be tracked over time in each area

26. Measures (examples) • Child care providers: % (and #) of providers that have knowledge that their child care is implementing the 5-2-1-Almost None campaign and its recommendations • Schools: % (and #) of schools that formally adopt and implement the 5-2-1- Almost None approach to healthy eating and physical activity • Communities: % (and #) of community organizations that engage in promotion of healthy eating and physical activity • Parents: % (and #) of parents who have knowledge of the 5-2-1- Almost None campaign and its recommendations • Children and youth: % (and #) of children who have knowledge of the 5-2-1- Almost None campaign and its recommendations

27. Statewide Surveillance • To measure the cumulative effect of NHPS’ work over time on the health of Delaware’s children we will conduct primary statewide surveillance • The statewide sample will be designed to allow comparisons • Among locations—New Castle, Kent, and Sussex Counties and City of Wilmington • Race/ethnicity (African-American/Other) by area location • Age group (0-5, 6-12, and 13-18) by area • Age group by race/ethnicity (African-American/Other) • One child under age 18 sampled per household • 770 interviews per area (3,080 total) • ~270 African-American children and ~500 Other children

28. Our Strategy Is Working • In Sussex County we are… • Building partnerships and disseminating knowledge and know-how in all 4 sectors in which children live, learn, and play • Saturating the geographical area with our 5-2-1-Almost None healthy lifestyles mantra to inspire grassroots behavior change • We will learn from our evaluations and use similar strategies in New Castle & Kent Counties, as well as the City of Wilmington • 2007: City of Wilmington and New Castle County • 2008: Kent County • We know it takes knowledge, information and resources to sustain the effort; We seek to bring together these components.

29. Vision for Overall System in Delaware—2015 Overall system that cares for, educates, socializes, and supports all children must change to accomplish this vision. The ideal system includes: • People that care for children practice health promotion in places where children live, learn, and play • Delaware citizens understand that children’s health and wellness matters to everyone – they are our future • Statewide messages about child health promotion are adopted and broadly disseminated

30. System Vision 2015 (continued) • Child-serving organizations have improved capacity to: • Influence policy • Deliver services effectively and efficiently • Use data to drive decision-making • Increased total resources for child health promotion and increased ability to serve more children • Statewide system in place for tracking, monitoring, and reporting on child health

31. Summary • NHPS is only part of the puzzle; we are a catalyst • We seek to understand and meet the needs of the community • We provide technical assistance and support services to assist organizations build their capacity • We focus on our vision: Optimal health for all children We believe it is a collaborative and collective effort

32. “Although the determinants of health disparities are complex and varied, we do not need to unravel every last piece of this puzzle to begin to take action.” Neil Calman, Institute for Urban Health

33. Nemours Health and Prevention Services Planting the seeds for better health Debbie I. Chang, MPH Senior Vice President and Executive Director DChang@nemours.org www.Nemours.org/GrowUpHealthy 302.444.9127