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Healthy Children, Healthy Weights

State: OH Type: Model Practice Year: 2017

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Columbus Public Health
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Healthy Children, Healthy Weights
Columbus Public Health (CPH) is made up of a multitude of programs providing clinical, environmental, health promotion, and population-based services. The department has an annual budget of approximately $46 million and is staffed by 400 full-and part-time employees, serving more than 800,000 residents. The health status of citizens in Franklin County and the City of Columbus are troubling. According to the 2016 Franklin County HealthMap, the percentage of adults affected by obesity (30.7%) is higher than the national average (27.6%). However, this concerning trend of obesity prevalence begins in younger demographics. In 2014, the Ohio Head Start BMI Surveillance program showed more than a third (35.7%) of Head Start students as overweight or obese. Local to the City of Columbus, the prevalence of obesity is seen to increase as children develop. Columbus City Schools (CCS) is the largest school district in the city, serving approximately 53,000 students in pre-kindergarten through 12th grade. Three-fourths of CCS students receive free and reduced lunches and 61% of students are African American. According to the Columbus City School Wellness Initiative, during the 2013-14 school year, 32% of preschoolers, 28% of kindergarteners, 41% of 5th graders, and 42% of 9th graders in Columbus City Schools were overweight or obese. Since 2004, CPH's Healthy Children, Healthy Weights (HCHW) has been working with early childhood education centers (ECE) to reduce the rate of childhood obesity through a policy, system, and environmental change approach. HCHW promotes a healthy weight and growth in all children, starting with the youngest age group-birth to five years old. It is the vision of HCHW that all children in Ohio have daily opportunities for active play and access to nutritious foods that lead to children entering kindergarten ready to live, learn and play at their best. Through evidence-based technical assistance and training, HCHW encourages early ECE centers to meet five program goal areas: 1) increase physical activity, 2) reduce screen time, 3) establish healthy eating habits, 4) promote water first for thirst, and 5) welcome breastfeeding. HCHW leverages funding from a variety of public and private organizations that have their own set of annual objectives for the program. This funding supports technical assistance in ECE centers to complete this program's primary objectives: Objective 1: Engage Early Care and Education (ECE) centers in HCHW program in a policy, system, and environmental change approach through 1) 15-hour training, 2) menu improvements, 3) policy implementation, and 4) family engagement. Objective 2: Create sustainable environmental changes by implementing policies that support healthy nutrition and activity at ECE centers. Objective 3: Facilitate improvements of the nutritional quality and variety of meals and snacks provided to children. To achieve these objectives, the HCHW program model consists of at least three on-site TA visits by a Registered Dietitian or Dietetic Technician. HCHW program managers also offer the 15-hour curriculum to ECE center directors and staff, containing three different sessions aimed to address the various aspects of creating a healthy environment at the ECE center. All program objectives were met and exceeded, as evaluated through process and outcome performance measures. Between January 2016 and November 2016, 27 centers completed 15-hour training, made menu improvements, implemented at least one wellness policy, and engaged families. In working with these centers, a total of 254 policies were implemented, with each center implementing an average of 10 policies. Improvements in menu quality included the respective 3% and 99% increase in whole fruit and whole grain servings along with the 54%, 66% and 60% decrease in juice, fried and pre-fried food, and grain-based dessert servings. In addition, the HCHW program offered a total of 82.5 hours of training, reaching 117 ECE staff. Success of the program has been attributed to the key partnerships that HCHW has formed with community stakeholders and organizations, including the Ohio Department of Health (ODH), Cardinal Health Foundation, The Ohio State University, Ohio Child Care Resource and Referral Association (OCCRRA). It is through these partnerships that led to the amplification of the HCHW program statewide in the creation of the Ohio Healthy Program (OHP) designation. As of October 2016, there were a total of 1,203 Healthy Eating Active Living improvements made to ECE providers and 121 OHP-awarded providers throughout the state of Ohio. To learn more about Columbus Public Health and Healthy Children, Healthy Weights, please visit: https://www.columbus.gov/hchw/.
Public Health Issue The public health issue that this program is meant to address is chronic disease, specifically overweight and obesity. The health status of citizens in Franklin County and the City of Columbus are troubling. According to the 2016 Franklin County HealthMap, the percentage of adults affected by obesity (30.7%) is higher than the national average (27.6%). People who are affected by obesity are at increased risk of many serious physical and mental diseases, including high blood pressure, Type 2 diabetes, etc. In addition, the national cost of obesity-related illness is substantial, costing over $190 billion, or almost 21% of annual medical spending in the United States.1 The Franklin County Community Health Risk Assessment done in 2013 gathered data about many health topics. One data point very relevant to this program was in regards to fruit and vegetable intake and physical activity habits. According to the 2013 Franklin County Community Health Risk Assessment, only 24% of Franklin County adults report eating 5 or more servings of fruits and vegetables daily. It is believed that this low number may be a food availability problem related to Franklin County's slightly higher percentage of low-income individuals who do not live near a grocery store, compared to the statewide and national percentages.4 Food insecurity is defined by the United States Department of Agriculture as a lack of access to enough food for an active, healthy life and a limited availability of nutritionally adequate foods.” In Franklin County, 17.7% of residents are food insecure.1 Childhood obesity alone is responsible for $14 billion in direct medical costs nationally.1 If Ohio were to achieve a reduction in obesity of only 2.5% among our youngest children, the State of Ohio could achieve a net return of $42 million in economic benefits.2 In 2014, the Ohio Head Start BMI Surveillance program showed more than a third (35.7%) of Head Start students were overweight or obese.3 Local to the City of Columbus, the prevalence of obesity is seen to increase as children develop. Columbus City Schools (CCS) is the largest school district in the city, serving approximately 53,000 students in pre-kindergarten through 12th grade. Three-fourths of CCS students receive free and reduced lunches and 61% of students are African American. According to the Columbus City School Wellness Initiative, during the 2013-14 school year, 32% of preschoolers, 28% of kindergarteners, 35% of 3rd graders, 41% of 5th graders, 44% of 7th graders, and 42% of 9th graders in CCS were overweight or obese. The prevention of obesity during early childhood (0-5 years old) is critical for several reasons. There is evidence that suggests the preferences for food and activity levels are established by the time children are 2-3 years old.5 Additionally, it is easier to impact the habits of 0-5 year olds than to change health habits in adulthood.6 Research has shown obesity prevention programs focused on 2-7 year olds to be effective and result in long-term habit change.7,8 In addition to the evidence supporting its effectiveness, it is believed that the Early Care and Education (ECE) setting is an opportune place for childhood prevention efforts. Children are increasingly seen in these early care environments, as the number of preschool-age children in child care is rising.9,10 In 2012, about 61% of children ages 3-6 were enrolled in center-based care, compared to 55% in both 1995 and 2007.10 In a national study of families with an annual income below 200% of the Federal Poverty Level, 44% of children under age 13 experienced some form of nonparental child care in addition to school.11 Additionally, more than half of the children from low-income families under five years old were in child care for more than 30 hours a week.11 Children are spending the majority of their waking hours in these settings, including most of their meals and time for physical activity. Despite the evidence supporting the great potential of addressing childhood obesity in early childhood, the inclusion of childhood obesity prevention standards in state regulations of licensed childcare facilities has been insufficient. National standards currently identify 47 standards to be included in ECE centers policies for infant feeding, nutrition, physical activity, and screen time. According to the CDC, in 2012, Ohio failed to meet these policy standards, including only 14.9% of these components.12 In lieu of the lack of mandatory preventative measures in reducing childhood obesity in Early Care and Education settings, this program is aimed to fill this need by providing technical assistance to centers who wish to go above and beyond state licensing. Columbus Public Health is located in Columbus, Ohio and serves approximately 800,000 people. Since 2004, The Healthy Children Healthy Weights (HCHW) program has impacted almost 13,000 children. Innovation The HCHW program conducted extensive literature reviews, expert interviews, and local focus groups to create a relevant and comprehensive program for ECE center staff, directors, and parents. The program is designed to improve healthy eating and activity in ECE centers using four strategies: 1) Provide training to increase ECE center staff knowledge and skill in encouraging healthy habits in young children. 2) Create sustainable environmental changes by implementing policies that support healthy nutrition and activity at ECE centers. 3) Facilitate improvements of the nutritional quality and variety of meals and snacks provided to children. 4) Encourage effective parent participation to establish healthy habits among children, families, and staff. The HCHW program had the honor of receiving status as a NACCHO Model Practice in 2005. This program was originally designed as an education program for ECE center staff, primarily using technical assistance provided by a registered dietitian to set ‘goals' around healthier menus and activities. After years of implementation, HCHW was able to show an increase in knowledge but not necessarily in healthier food consumption/offerings to children and that a healthier environment was created and sustained. In partnership with the Ohio Child Care Resource and Referral Association (OCCRRA) in 2010, HCHW created 15 hours of standardized Ohio-Approved training, formerly known as Step Up To Quality Approved, for ECE providers. In addition, the HCHW program developed numerous supporting tools to implement menu requirements that met and exceeded the Child and Adult Care Food Program guidelines. The menu requirements were as follows: 1. Offer a different non-fried vegetable and fruit every day of the week. 2. Serve at least one whole grain food each day. 3. Offer beverages with no added sugar/sweeteners. 4. Limit 100% juice no more than 4-6 fl. oz. a day, if served at all. 5. Limit fried foods to no more than twice per week, if at all. HCHW also developed evidence-based policy recommendations for implementation at ECE centers and homes. The partnership with OCCRRA allowed for statewide dissemination of these resources and creation of the Ohio Healthy Program (OHP) voluntary designation, for all ECE centers and home providers in the state of Ohio. Several improvements have since been made to the HCHW program since this statewide implementation. In 2013, HCHW implemented the Family Engagement Project to generate a Family Engagement Handbook to share with ECE providers. This handbook contains resources on communicating with families, creating healthy celebrations, and designing monthly campaigns around one of HCHW's 13 evidence-based key messages. Examples of these key messages include Water First for Thirst” and Growing Great Tasters.” The OHP designation menu requirements and 15-hour curriculum were also updated to align with 2015 Dietary Guidelines for Americans. Menu requirement updates included: 1) serve only cereals with 6 grams of sugar or less per serving, 2) reduce servings of fried foods from twice a week to once a week, and 3) do not serve the following highly processed meats: corn dogs, hot dogs, frankfurters, bologna, pepperoni, polish sausage, salami, summer sausage, and liverwurst. These updates were also incorporated into the 15-hour curriculum. In 2016, other curriculum updates included new information regarding Adverse Childhood Experiences Study (ACES) and its relationship with the development of chronic diseases, including obesity. This updated, trauma-informed curriculum now educates teachers on how to help children develop and practice self-regulation and resiliency with healthy habits. Another innovation in the HCHW program came in 2015, when the program partnered with Mid-Ohio Foodbank (MOF), the largest food bank in Ohio. The goal of this partnership was to increase access to fresh produce for families at ECE centers who have participated in the HCHW program and have been engaging families in nutrition and physical activity. HCHW recruited four ECE centers to pilot MOF's Fresh Food Partner program. The four ECE centers were selected based on their interest in and capacity to pick up produce from the local foodbank and coordinate distribution of fresh produce for families, as they picked up their children. From September 2015 to January 2016, MOF provided 11,300 pounds of food for ECE centers to distribute to their families. Through this partnership, families were able to better practice what they learn through the HCHW curriculum and provide more fresh fruits and vegetables to their children at home. HCHW was recognized in 2008 as an evidenced-based, theory sound program by Robert Wood Johnson Foundation and Centers for Disease Control and Prevention (CDC). The HCHW program and OHP designation align with the CDC Spectrum of Opportunities for Obesity Prevention in the ECE setting. The Spectrum of Opportunities is the CDC's framework for obesity prevention in the ECE setting and has identified ways for states or communities to support ECE providers in achieving recommended standards and best practices for obesity prevention. HCHW utilizes several of these suggested methods, including facility-level interventions, technical assistance, and family engagement. Other reference sources utilized in curriculum and material development include the following: American Academy of Pediatrics Academy of Nutrition and Dietetics National Academy of Medicine National Association of Sport and Physical Education Nutrition and Physical Activity Self-Assessment for Child Care Caring for our Children Child and Adult Care Food Program American Heart Association Dietary Guidelines for Americans The ChildTrauma Academy References 1. Franklin County HealthMap 2016. Central Ohio Hospital Council; 2016:82. http://www.myfcph.org/pdfs/hstat_FCHealthMap16.pdf. Accessed November 18, 2016. 2. Bending the Obesity Cost Curve in Ohio. Trust for America's Health and the Robert Wood Johnson Foundation; 2012. http://healthyamericans.org/assets/files/obesity2012/TFAHSept2012_OH_ObesityBrief02.pdf. Accessed November 18, 2016. 3. Early Childhood Overweight and Obesity, Ohio 2016. Ohio Department of Health; 2016:5. http://www.healthy.ohio.gov/-/media/HealthyOhio/ASSETS/Files/Childhood-Obesity/Ohio-Early-Childhood-BMI-Data-Brief.pdf. Accessed November 18, 2016. 4. Franklin County HealthMap 2013. Central Ohio Hospital Council; 2013. http://www.myfcph.org/pdfs/hstat_FCHealthMap13.pdf. Accessed November 18, 2016. 5. Schwartz C, Scholtens PAMJ, Lalanne A, Weenen H, Nicklaus S. Development of healthy eating habits early in life. Review of recent evidence and selected guidelines. Appetite. 2011;57(3):796-807. doi:10.1016/j.appet.2011.05.316. 6. Birch L, Savage JS, Ventura A. Influences on the Development of Children's Eating Behaviours: From Infancy to Adolescence. Can J Diet Pract Res Publ Dietit Can Rev Can Prat Rech En Diet Une Publ Diet Can. 2007;68(1):s1-s56. 7. Wen LM, Baur LA, Simpson JM, Rissel C, Wardle K, Flood VM. Effectiveness of home based early intervention on children's BMI at age 2: randomised controlled trial. BMJ. 2012;344:e3732. doi:10.1136/bmj.e3732. 8. Baidal JAW, Taveras EM. Childhood Obesity: Shifting the Focus to Early Prevention. Arch Pediatr Adolesc Med. 2012;166(12):1179-1181. doi:10.1001/2013.jamapediatrics.358. 9. Hughes SO, Patrick H, Power TG, Fisher JO, Anderson CB, Nicklas TA. The impact of child care providers' feeding on children's food consumption. J Dev Behav Pediatr JDBP. 2007;28(2):100-107. doi:10.1097/01.DBP.0000267561.34199.a9. 10. America's Children: Key National Indicators of Well-Being, 2013. Washington, DC: Federal Interagency Forum on Child and Family Statistics; 2013. http://www.childstats.gov/pdf/ac2013/ac_13.pdf. 11. Burstein N, Layzer J. National Study of Child Care for Low-Income Families: Patterns of Child Care Use Among Low-Income Families. U.S. Department of Health and Human Services; 2007. 12. Prevention Status Reports 2013-Ohio. Atlanta, GA: Centers for Disease Control and Prevention; 2014. http://www.cdc.gov/psr/2013/summaryreports/2013/combined/psrfull-oh.pdf.
Nutrition, Physical Activity, and Obesity
Goals and Objectives Columbus Public Health (CPH) is made up of a multitude of programs providing clinical, environmental, health promotion, and population-based services. The mission of CPH is to protect health and improve lives in our community. Overweight and obesity reduction is one of the five strategic priorities which CPH concentrates efforts. Healthy Children, Healthy Weights (HCHW) is a childhood obesity prevention program that utilizes a policy, system, and environmental change approach to promote a healthy weight and growth in all children, starting with the youngest age group-birth to five years old. It is the vision of HCHW that all children in Ohio have daily opportunities for active play and access to nutritious foods that lead to children entering kindergarten ready to live, learn, and play at their best. Through technical assistance, HCHW encourages Early Care and Education (ECE) centers to meet five program goal areas. Increase physical activity by providing opportunities for at least 1-2 hours of play each day, including a combination of both structured and unstructured play. Physical activity is not only important for keeping children at a healthy weight; it promotes physical, cognitive and emotional development. Reduce screen time by limiting television, computers, video games and apps to no more than 30 minutes per week during ECE center operating hours for children age two and up. Children under age two are not to receive screen time while at the center. Establish healthy eating habits by serving a variety of whole fruits and vegetables. Centers are encouraged to serve more whole grains and avoid fried foods. Family style meals are promoted due to its association with better eating habits such as increased fruit and vegetable intake and decreased fried food and soda consumption. Promote water first for thirst by offering water first when a child states that they are thirsty. Sugar sweetened beverages, the primary source of excess sugar in the American diet, should be avoided at the center. Welcome breastfeeding by providing a private and sanitary place for mothers to breastfeed or express milk at the center. Breastfeeding is promoted within the centers because it has been shown to reduce the risk for several illnesses. HCHW leverages funding from a variety of public and private organizations that have their own set of annual objectives for the program. In 2016, HCHW received funding from Franklin County Family and Children First Council's Healthier Buckeyes Grant, Ohio Department of Health's (ODH) Maternal and Child Health program, and the Cardinal Health Foundation to participate in the Ohio State University's Early Head Start Collaborative. This funding supports technical assistance in ECE centers to complete this program's primary objectives: Objective 1: Engage Early Care and Education (ECE) centers in HCHW program in a policy, system, and environmental change (PSEC) approach through 1) 15-hour training, 2) menu improvements, 3) policy implementation, and 4) family engagement. Objective 2: Create sustainable environmental changes by implementing policies that support healthy nutrition and activity at ECE centers. Objective 3: Facilitate improvements of the nutritional quality and variety of meals and snacks provided to children. Implementation HCHW assists ECE centers in receiving the Ohio Healthy Program (OHP) state-wide voluntary designation. With this designation, centers are recognized as going above and beyond state and federal licensing in the five HCHW goal areas. OHP, developed from the HCHW program, is managed and awarded by the Ohio Child Care Resource and Referral Association (OCCRRA). OHP consists of four requirements to receive designation: ECE center staff and administrators attend a total of 15 hours of Ohio Approved training, created by HCHW. One lead teacher per age group at the ECE center must attend the four part training, totaling 10 hours. This teacher-focused training addresses the incorporation of physical activity, healthy eating, gardening, self-esteem, and family engagement in the classroom setting. Menu planners, cooks, and/or directors are required to attend 2 ½ hours of Ohio Approved training to discuss healthy eating behaviors, what to consider when feeding young children, and how to develop a healthy menu. The director is required to attend a 2 ½ hour Ohio Approved training focused on creating a healthier ECE environment through policy. Centers adopt, at minimum, one new wellness policy to improve the environment of the ECE center. Centers receiving the OHP designation are expected to offer an environment where children have access to healthy foods and beverages and opportunities for daily activity that ensures children are ready to live, learn and play at their best. ECE centers demonstrate an improvement in menus for the children served by going above and beyond the Child and Adult Care Food Program (CACFP) regulations. Centers offer a different non-fried vegetable and whole fruit every day of the week to increase the variety offered to children. A whole grain option must be included daily. No sugar sweetened beverages will be served and 100% juice will be limited to one serving per day. Only cereals with six grams of sugar or less will be permitted on the menu. Fried and pre-fried foods will be served no more than once per week. Highly processed meats will not be served including corn dogs, hot dogs, bologna, pepperoni, and salami. Family engagement will incorporate information from the training curriculum. ECE centers are encouraged to share the information in a variety of ways such as through newsletters, bulletin boards, or a healthy family night. HCHW provides technical assistance (TA) to ECE centers to assist them in 1) improving menus, 2) implementing policies, and 3) identifying family engagement strategies that meet the OHP requirements. HCHW begins with recruitment to identify interested ECE centers. Recruitment occurs biannually and enrollment in the HCHW program is ongoing. Participation is on a voluntary basis, therefore HCHW relies on the interest and capacity of ECE center directors who are looking to improve the environment of their centers. The HCHW program model consists of at least three on-site TA visits by a Registered Dietitian or Dietetic Technician, in addition to a TA visit to complete the OHP designation application. The first TA visit begins with the HCHW program manager providing background information on the HCHW program and OHP designation. From here, the program manager will interview the ECE center administrator to identify individual centers' needs and potential goals or areas of weakness. At this initial meeting, a copy of the centers menus and parent handbook are provided to HCHW program managers to collect for evaluation. At the second TA, program managers share their recommendations to be made to center menus and parent handbooks to comply with OHP designation requirements. These recommendations include improving the nutritional quality and variety of meals and snacks provided to children. Centers are also provided with recommended Healthy Eating Active Living (HEAL) policies to create sustainable environmental changes at the center for children, staff, and families. Once center administrators have made the recommended changes to their menus and parent handbooks, the HCHW program manager will coordinate a third TA. This TA is focused on discussing how to incorporate HCHW family engagement resources into a family engagement strategy, depending on center needs. Centers are then provided with these materials, including posters and handouts, to share with families to increase awareness of HCHW key messages. It is also at this third TA when centers are provided with the Family Engagement Kit, containing nutrition and physical activity equipment for use in the classroom or family engagement events. Examples of this equipment include but are not limited to parachutes, playground balls, healthy food models, puzzles and story books related to the 13 HCHW Key Messages, which can be seen below: [insert 13 key messages] Once centers have completed these TA's, the HCHW program manager will schedule a TA to assist the administrator in completing the online OHP application. ECE centers complete the program at their own pace, with some completing the program in as little as 3 months. However, the average amount of time to complete the HCHW program is between six months to one year. HCHW program managers offer the 15-hour curriculum quarterly to ECE center directors and staff. The curriculum contains three different sessions aimed to address the various aspects of creating a healthy environment at the ECE center. Session 1, Healthy Habits: o Healthy Activity: Participants discuss current childhood obesity rates, health risks, and learn the importance of providing physical activity opportunities in the ECE setting. Participants are provided with ideas and the opportunity to share practices on both structured and unstructured play. o Healthy Eating: Participants discuss the role of how adults support children in eating and feeding. This session provides participants with ideas on healthy snacks, positive drink choices, and how to encourage new foods in a healthy manner. o Healthy Growing: Participants will discuss how to promote a positive body image, how to encourage the creation of self-esteem, and the importance of adults as positive role models. Participants will further explore discussion of how healthy food can be grown in the ECE setting. o Healthy Families: This session focuses on strategies to encourage parent outreach. Participants will review the HCHW key messages that promote healthy habits for children. Session 2, Healthy Menus: Participants discuss healthy eating behaviors, how to plan a healthy menu, budget tips, and what to consider when feeding young children. Session 3, Healthy Policies: This session focuses on creating a healthier ECE environment through policy. Participants discuss the importance of healthy policies and how to adopt and implement a healthy policy successfully. Center Participants CPH has prioritized their efforts for the most vulnerable. HCHW began working with local Head Start programs in 2005. Head Start works with low-income families, traditionally in high need areas to provide comprehensive early care and education. In 2010, Nationwide Children's Hospital provided funding for HCHW to work with ECE centers on the south side of Columbus. Healthy Neighborhoods, Healthy Families, started by Nationwide Children's Hospital in 2008, continues to work towards revitalizing the 43205, 43206, and 43207 zip code areas to support the health and wellbeing of children. In 2013, the Cardinal Health Foundation began funding HCHW to continue working on the south side of Columbus, specifically to assist ECE centers with family engagement material. Today, HCHW receives funding from the Franklin County Family and Children First Council's Healthier Buckeyes Grant to work with ECE centers in the Franklinton area, a neighborhood going through heavy revitalization. The Cardinal Health Foundation funds HCHW to work with the Ohio State University Early Head Start centers on a continuous basis during their five year grant period. In 2016, the Mayor of Columbus asked CPH's programs to focus efforts in Hilltop and Linden, two priority neighborhoods. Participation with the HCHW program is voluntary for ECE centers. HCHW completes recruitment biannually to identify interest in the program. Timeline 2004: HCHW is started, consisting of four toolkits: ECE providers, parents, physicians, and faith-based groups. 2005: CPH engages The Strategy Team, Ltd. (TST) to conduct research and focus groups and to develop program materials. 2005: HCHW is piloted in ten head start centers. 2005: HCHW is awarded a National Association of County and City Health Officials (NACCHO) Model Practice Award. 2008: The Centers for Disease Control and Robert Wood Johnson Foundation finds that the HCHW program is an evidenced-based, theory-sound program. 2009: HCHW convenes the Growing Healthy Kids Columbus Coalition, originally known as the City of Columbus Early Childhood Obesity Prevention Coalition. 2010: HCHW is updated to use a policy system and environmental change model including technical assistance and a graduated incentive system that rewards menu and policy change in addition to education and training. 2010: With funding from ODH, OCCRRA develops the OHP criteria modeled after the HCHW program. OHP becomes available to ECE centers across the state of Ohio. 2010: HCHW is awarded the NACCHO ACHIEVE grant. 2012: HCHW creates the Family Engagement Project to engage families in HCHW key messages and activities. 2014: ODH funds OCCRRA and Creating Healthy Communities to take HCHW and OHP statewide via Creating Healthy Communities counties. 2014: The 15-hour HCHW curriculum is designated by ODH as an approved Early Childhood Nutrition Education Curriculum. 2016: Children's Hunger Alliance (CHA) adapts the HCHW curriculum for ECE home providers. The curriculum is web-based to better meet the needs of home providers. 2016: HCHW continues to be involved with state-wide decision making related to OHP material and curriculum. Stakeholders CPH manages the HCHW program but would not be successful without the support of key funders and community stakeholders. HCHW has received funds in the past from ODH, Nationwide Children's Hospital (NCH), Cardinal Health Foundation, Franklin County Family and Children First Council's Healthier Buckeyes Grant, and The Foundation for Active Living to implement the program with sustainable incentives. Early Care and Education Centers This program's accomplishments rely on the successful collaboration with local ECE centers. As a voluntary program, HCHW relies on motivated participants who have a passion for improving their centers. In 2005, HCHW began as a pilot program with Head Start programs in Columbus. Today, HCHW has had the privilege of working with over 240 ECE centers across the city of various organizational structures, including smaller independently owned centers up to entire public school district preschool classrooms. Key participants include: YMCA of Central Ohio Columbus City Schools Child Development Council of Franklin County (CDCFC) Head Start Ohio State University Early Head Start partnership Independently-owned licensed ECE centers Ohio Healthy Program ODH and the OCCRRA have worked closely with HCHW over the years. The OHP Council, consisting of ODH, OCCRRA, HCHW, and Children's Hunger Alliance (CHA), evaluate the OHP criteria annually. As licensing and regulations change, the Council strives for centers to go above and beyond. In addition, the Council aims to provide the most up to date information related to raising healthy children ages 0-5. HCHW revises the 15 hour curriculum annually for OCCRRA to share state-wide. CHA provides an adapted version of HCHW's technical assistance model to home ECE providers. To better meet the needs of and reduce burden on their clients, CHA has adapted the OHP curriculum to a web-based model. Growing Healthy Kids Columbus Coalition In 2009, HCHW developed and currently assists the Growing Healthy Kids Columbus Coalition (GHKC), formerly known as the City of Columbus Early Childhood Obesity Prevention Coalition. The GHKC is comprised of representatives from over 45 organizations/programs that serve pregnant women and young children, ages 0-5, in Columbus. These organizations include: Ohio State University Columbus City School District Ohio State University Extension Head Start programs Franklin County Public Health Columbus Public Health Nationwide Children's Hospital Children's Hunger Alliance Ohio State University Lifesports GHKC shares information, provides professional development, and coordinates implementation of policy, system, and environmental change in the community. HCHW is a steering committee member of GHKC and shares many of the materials developed by the Coalition with ECE centers and members of the community. In 2016, the Healthy Gatherings” campaign was shared with ECE centers, whose main message encourages organizations to implement healthy celebration policies. Cardinal Health Foundation Cardinal Health Foundation has provided funding for the HCHW program since 2013. Good4Growth, funded by the Foundation, is a partnership that delivers parents practical tools and tips for creating a happy, healthy environment for kids to parents, family members, and other caregivers. Good4Growth is a partnership with CPH and the Ohio Chapter of the American Academy of Pediatrics. HCHW encourages ECE centers to use the tools and resources provided by Good4Growth to reinforce the HCHW goals. Ohio State University Early Head Start Partnership In July 2015, HCHW became a service partner with the Ohio State University (OSU) Early Head Start partnership. OSU received a five year grant to provide services to 160 children in Columbus. OSU has mandated that ECE centers receiving Early Head Start (EHS) funding become an OHP designated center. HCHW has provided guidance to ensure the participating ECE centers are not only meeting the OHP requirements but are meeting the Early Head Start Performance Standards related to nutrition. Through the OSU EHS partnership, HCHW has been able to connect with: Franklin County Family and Children First Council Action for Children Community Properties of Ohio Children's Hunger Alliance Nationwide Children's Hospital Moms2B St. Vincent Family Center Franklin County Board of Developmental Disabilities Healthier Buckeyes Grant HCHW is a partner with the Franklin County Family and Children First Council's Healthier Buckeyes Council to work on the Healthier Buckeye Grant. This initiative focuses on the Franklinton neighborhood in Columbus, an area which is characterized by high rates of poverty and unemployment. The goal is to promote self-sufficiency and reduce reliance on public assistance by developing a community environment that maximizes opportunities for individuals and families to achieve optimal health. In this collaboration, HCHW has committed to providing TA with ECE centers in the Franklinton neighborhood and ensuring centers receive the OHP designation. The project has brought together key representatives of the public and private sectors including: Franklin County Family and Children First Council United Way of Central Ohio Franklin County Department of Job and Family Services Franklin County Public Health Nationwide Children's Hospital Columbus Public Health Budget HCHW has received funding from many organizations over the years to recruit and provide technical assistance, Family Engagement Kits, and other materials to ECE centers. According to past years funding, the average cost to implement this program in one center is approximately $4,300 after factoring in personnel, services, and supplies. The breakdown of center costs is shown below: Personnel costs, an estimated $3,700 per center, includes time spent completing a minimum of three on-site technical assistance visits, in addition to developing tailored recommendations to meet each centers unique needs. Rings of Fun provide lesson plan activities that cover physical activity, nutrition, development, and family engagement. The Rings of Fun include the Ohio Early Learning Development Standards to assist teachers with their lesson plans. ECE centers receive four Rings, one per age group, which cost $48 per set. The Family Engagement Kit provides ECE centers resources to prompt discussion with children and families about healthy habits. The Family Engagement Kit contains an assortment of books, puzzles, healthy food models, and playground equipment. The kit, valued at $450, provides materials to address each of the HCHW key messages. The Family Engagement Kit is provided to ECE centers once they have completed all four requirements to become a designated OHP center. HCHW provides kick-stand key message signs, posters, and handouts to ECE centers upon completion of the program. These materials contain evidenced-based key messages for families. The kick-stand signs cost $23 per center and the posters and handouts cost $36 per center. Healthy Plate Placemats are provided to ECE centers to illustrate the USDA's MyPlate with pictures for the whole family. Placemats cost $44 per center. The Action Kit includes the policy handbook, sample menus, and instructions for the administrator on how to use the Family Engagement Kit. The Action Kit, which costs $30 to print, is provided to each center director at the first technical assistance visit to help guide them through the program. HCHW program managers meet ECE directors at their centers to reduce the burden of directors. Program managers are reimbursed mileage, an estimated $35 per center, to cover the cost of travel to and from centers. HCHW recruits centers biannually through mailings. The cost of this, $5 per center, includes postage stamps, envelopes, recruitment letters, brochures, and an enrollment letters.
The goal of the Healthy Children, Healthy Weights (HCHW) program is to prevent childhood overweight and obesity by promoting healthy weight and growth in all children, starting with the youngest age group - birth to five years old. Primary objectives for the practice were: Objective 1: Engage Early Care and Education (ECE) centers in HCHW program in a policy, system, and environmental change (PSEC) approach through 1) 15-hour training, 2) menu improvements, 3) policy implementation, and 4) family engagement. Process Performance Measures used: o The number of ECE staff trained in HCHW curriculum o The number of ECE centers who were engaged in the HCHW program o The number of ECE centers who completed menu improvements and policy implementation o The number of ECE centers who completed family engagement technical assistance and received the family engagement kit o The number of ECE centers who applied for the Ohio Healthy Program (OHP) designation o ECE center administrator perspective on completing HCHW program Data collection: Performance measures regarding the 15-hour training were collected by HCHW program managers through training sign-in sheets, generated by the Ohio Child Care Resource and Referral Association (OCCRRA). Continuous data regarding center enrollment and program completion were collected and tracked by HCHW program managers. Qualitative data on center administrator perspective of HCHW program was also captured through several means. Administrators of centers that had engaged with HCHW completed a program satisfaction survey. In addition, a community needs assessment survey was also conducted with center administrators across the city, including both centers that had or had not previously worked with HCHW. Evaluation results from January 2016-November 2016: o 117 ECE staff received training in HCHW curriculum. A total of 82.5 hours of training was provided by HCHW team. o ECE centers that were recruited to work with HCHW: goal was 37, actual was 51 o ECE centers with improved menus to meet OHP menu criteria: goal was 19, actual was 27 o ECE centers with newly implemented policies: goal was 19, actual was 27 o ECE centers that completed family engagement technical assistance and received family engagement kit: goal was 19, actual was 27 o ECE centers that applied for the OHP voluntary designation: goal was 19, actual was 22 o Main themes from the program satisfaction survey: majority of administrators were satisfied with the HCHW program. For centers that were unable to complete the program or apply for OHP, commonly reported barriers included attending the 15-hour training. o Main themes from needs assessment survey: general positive perception of completing the OHP designation requirements. Of the centers that had never engaged with HCHW, 87% were interested in working with the program to strengthen their center's practices by working with HCHW. Feedback: The program was successfully implemented, as the program managers met and exceeded goals in improved menus and implemented policies. According to the program satisfaction survey, participating centers were highly satisfied in the program. However, some barriers were noted in the completion of the program and application of the OHP designation. Several administrators reported that their center could not apply for the OHP designation due to logistical challenges preventing staff from being able to attend the required 15-hour trainings. In response to this finding, the program managers agreed to increase the number of trainings offered to meet these needs. In addition, technical assistance was provided to administrators to reduce burden of OHP application, as this was another commonly reported barrier. Objective 2: Create sustainable environmental changes by implementing policies that support healthy nutrition and activity at ECE centers. Outcome Performance Measures used: o The number of policies adopted by ECE centers after technical assistance o Strength and comprehensiveness of ECE center parent handbooks in nutrition, physical activity, and wellness policies. Data Collection: HCHW program managers collected and recorded center parent handbooks at initial technical assistance meeting and after center adopted health policies. Strength and comprehensiveness of parent handbooks was quantitated through use of the validated Wellness Child Care Assessment Tool (WellCCAT). Evaluation Results: o Total policies adopted in 2016 by ECE centers after technical assistance: actual was 254 o Average policies adopted by ECE center after technical assistance: goal was 5, actual was 10 o Change in average strength of ECE center parent handbooks after HCHW technical assistance: actual was 66% o Change in average comprehensiveness of ECE center parent handbooks after HCHW technical assistance: actual was 30% Feedback: Based on policy implementation evaluation, HCHW technical assistance was successful in ECE center policy implementation and improving average strength and comprehensiveness of center parent handbooks. Future evaluation will be intended to focus on translation of implemented policy to daily practice in the classroom setting, using observational data collection. Upon further analysis of policies adopted, interesting trends were seen. The most commonly adopted policies included the following: o Center staff will not use physical activity or withhold opportunities for physical activity as punishment.” o Television or videos are never shown in the facility.” o OHP Menu Requirements o We make drinking water freely available so children can serve themselves at meals and throughout the day, both inside and outdoors.” o All child care center staff will be trained in the proper storage and handling of human milk, as well as ways to support breastfeeding mothers.” Objective 3: Facilitate improvements of the nutritional quality and variety of meals and snacks provided to children. Outcome Performance Measures used: o Comparing the number and variation of whole fruits, non-fried vegetables, whole grains, juice, fried foods, and grain-based desserts served in centers before and after HCHW technical assistance. Data Collections: HCHW program managers collected and recorded the number of various foods served by each center at meals and snacks in a two week period of time, as reported in center menus. A follow up collection of menus was completed in 2012 to assess the maintenance of OHP menu requirement compliance, 3-7 months after last HCHW technical assistance. Evaluation Results: o Average change in servings of whole fruits, non-fried vegetables, and whole grains: Actual was a 3%, 0%, and 99% increase in number of servings, respectively. o Change in servings of juice, fried and pre-fried foods, and grain-based desserts: actual was a 54%, 66% and 60% decrease in number of servings, respectively. o Change in variability of whole fruits and non-fried vegetables served: actual was 1% increase and 1% decrease, respectively. o Centers that maintained OHP menu requirements regarding servings of whole fruits, non-fried vegetables, and whole grains daily: 72.7%, 54.5%, and 27.3% of centers at 3-7 month follow up, respectively. o Centers that maintained OHP menu requirements regarding the restriction of fried foods, flavored milks, and juice: 90.9%, 81.8%, and 100% of centers at 3-7 month follow up, respectively. Feedback: Based on these menu evaluations, this program was seen as effective in increasing the servings of whole fruits and whole grains and decreasing the servings of juice, fried foods, and grain-based desserts at ECE centers. However, the negligible change in vegetable servings indicates the need for strengthening OHP menu requirements regarding non-fried vegetable servings. Long term follow up data also supported more frequent re-engagement of ECE centers, as maintenance of OHP menu requirements were seen to decrease 3-7 months after technical assistance. In response to this, quarterly menu checks will be piloted for centers that have completed TA.
The importance of continued engagement with centers has been seen in the practice and evaluation of long-term menu maintenance. This has been accounted for in the Ohio Healthy Program (OHP) designation, as centers are required to reapply for the designation every year. To assist centers in reapplying for the designation, the Healthy Children, Healthy Weights (HCHW) program follows up 6-9 months after the center was awarded their OHP designation to re-engage and provide additional technical assistance towards renewal. In order for Early Care and Education (ECE) providers to renew their designation, appropriate staff must have completed the 15-hour curriculum, adopt at least one new wellness policy, ensure menus meet current OHP requirements, and describe their method of family engagement. Thus, ECE providers will continually be engaged in the future years. Sustainability of the HCHW program has been ensured through the partnership with Ohio Department of Health (ODH) and Ohio Child Care Resource and Referral Association (OCCRRA) in creating the OHP designation. This designation has enabled ECE providers of all types across the state to continue the program for many years to come. OHP for family ECE providers is led by Children's Hunger Alliance, which has adapted the curriculum and technical assistance model to a webinar-based training and technical assistance program to meet family providers' needs. In addition, ODH has written OHP as a strategy for its Creating Healthy Communities and Maternal and Child Health Program grants to expand implementation to other local health departments across the state. It is currently the only strategy listed in the Maternal and Child Health Program for local health departments to reduce obesity in early childhood. It is through this expansion that, as of October 2016, there were 121 OHP-awarded providers throughout the state of Ohio. In 2015, ODH collected data in partnership with Children's Hunger Alliance and PDA, Inc. to quantify the impact of the OHP designation on ECE provider policies and practices, statewide. This research found that providers who had received OHP designation were meeting more Let's Move Childcare Checklist Quiz Best Practices after receiving technical assistance and attending training. In addition, the 15-hour curriculum was delivered to 73 out of 88 counties statewide from 2014-2015. A total of 1,203 Healthy Eating Active Living (HEAL) improvements were made as a result of the OHP designation, 451 of which were menu improvements made by ECE providers, and 752 were total policy changes. The HCHW team continues to receive funding from several public and private sources: OCCRRA, Maternal and Child Health block grant, ODH, Columbus City Council, and Cardinal Health Foundation. These funds are committed to funding the program into 2017, while the program seeks additional funding. HCHW also leverages community partnerships and will continue to help facilitate the prevention of childhood obesity in areas of need in the city.
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