Highlights from the Presentations of Individual Speakers*
- Nemours, a pediatric health system traditionally focused on individuals and patients, has devised a cross-sector, statewide community-based approach to preventing childhood health problems, including obesity, across Delaware. (Chang)
- Nemours has served as an “integrator,” bringing together all the systems in the community involved in caring for children to work collaboratively. (Chang)
- One key lesson learned from prevention work in Delaware is to be flexible and let community partners lead the way. (Chang, Mouser)
- Early childhood programs offer an opportunity for instilling healthful eating and physical activity habits at a young age that children can take home to their families and communities. (Riley)
- Key elements of successful school programs focused on physical activity include state-initiated policy changes, leadership, and a wellness committee; sustaining the programs requires supporting individuals who are implementing them. (French)
*Highlights identified during the presentations and discussions; presenters to whom statements are attributed are indicated in parentheses.
1See Appendix C for additional information.
More than a decade ago, Delaware-based Nemours, one of the largest children’s health systems in the United States, decided to tackle the root causes of childhood illnesses through a new emphasis on prevention. The organization made a strategic move to look beyond the 50,000 children who came into its hospitals and clinics and to work on improving health outcomes for all 230,000 children served by its system across Delaware. An operating division called Nemours Health & Prevention Services (NHPS) was created to improve pediatric health over time through a cross-sector, community-based approach that includes developing, implementing, evaluating, and promoting model prevention interventions.
Four speakers presented an overview of the Nemours experience: Debbie Chang, who created NHPS and is enterprise vice president of policy and prevention at Nemours; Helen Riley, executive director of St. Michael’s School and Nursery in Wilmington, Delaware, which was a pilot site for the first early care and education NHPS project in the state; Mary Beth French, a physical educator who is content chair for physical education and health teachers in the Christina School District and chairs the Health and Physical Education Committee for the Christina School District, an NHPS partner; and Mary Kate Mouser, operational vice president of NHPS.
Chang explained that Nemours shifted its approach “from looking at biomedical [issues] to focusing on a multifaceted view of health, from focusing on acute episodes to focusing on chronic disease and prevention, from focusing on individuals and patient panels to focusing on communities and populations.” The goal was to connect clinical care and population health into an integrated community health model. “It really starts with a vision,” Chang said, “and the vision is optimal health and well-being for all children in the state of Delaware.”
Nemours initially developed the model around reducing overweight and obesity in children and has since applied it to asthma, emotional and behavioral health, and other areas. Using the best science available, Chang and her colleagues have worked on policies and practices in multiple sectors, including child care, schools, primary care, and the community. Nemours has “served as an integrator in the community,” Chang said, meaning that it has been working to bring together all the sectors that care for children to produce improved health (see Figure 7-1). One lesson learned from this experience “is to be flexible and take the lead from the community,” she noted.
One component of the Nemours initiative started with local pilot projects in early care and education focused on obesity prevention. The initiative then began working at the state policy level on collaborative projects—such
FIGURE 7-1 Nemours served as an integrator for efforts to prevent childhood obesity.
NOTE: EBH = evidence-based health care.
SOURCE: Chang, 2012. Reprinted with permission.
as with Sesame Street—aimed at promoting healthy eating and physical activity. Most recently, the initiative has gone national: Nemours is now working with the Centers for Disease Control and Prevention on diffusing its collaborative approach to nine other states across the nation. “The time is right now for spreading and scaling what works,” Chang said.
Riley presented “a case study within our state case study,” summarizing 10 years of work at St. Michael’s School in collaboration with NHPS. The school works with 160 children from 2 months to 8 years old, interacts with more than 200 families, and has 50 adult staff members.
A number of key factors influence every child’s health, Riley said: behavior accounts for 40 percent of the determinants of health, genetics
for 30 percent, social and environmental factors for 20 percent, and quality health care for 10 percent (McGinnis et al., 2002). Riley noted that many children spend most of their daily hours in early education settings and between the behavioral and social/environmental factors, “we have control over 60 percent of the determinants of children’s health.” In addition, schools help ensure that children receive immunizations and annual health care checkups and assist with early identification of and interventions for genetic issues. “We address every aspect of a child’s determinants of health,” Riley said.
Riley’s message on prevention is to begin early: “It is never too soon. If you want to work on prevention, start when a child is born.” For example, St. Michael’s carried out a healthy eating project with NHPS in which even very young children worked on planting lettuce gardens. “Early childhood programs are a good place to start,” Riley said. “Our parents come into the building twice a day to drop their children off, pick their children up. We have a high level of trust and a strong relationship that is built with them.”
Riley recommends teaching healthy living in early childhood curricula and keeping important lessons clear, short, simple, and stated in positive terms. Hands-on learning activities are best. To encourage exercise, educators can try movement to music, yoga, and dance. “Activities for children need to be balanced between structured exercise, organized games, and free play,” Riley suggested. Rest and relaxation also are extremely important, she observed, since young children experience a great deal of anxiety, stress, and tiredness.
While St. Michael’s has seen success with its prevention projects, ensuring sustainability in spreading its health messages is a challenge. The hope is that the children become “the Trojan horses” who carry the healthy lessons home to their families, and that those families then spread the messages to their neighborhoods and communities. Riley also pointed out that she and other teachers and parents are not always the best models for healthful behaviors. Nevertheless, early childhood education is a fertile opportunity to address a very large population: when the school is successful, students go home and talk to their families, friends, and neighbors about what they have done and what they have learned.
French shared the Christina School District’s perspective on creating sustainable change in health prevention as a partner with NHPS. In 2006, Delaware state lawmakers concerned about childhood obesity passed legislation to pilot physical education and physical activity programs for
Those policy changes spurred the development of school pilot programs, which were subsequently scaled up for diffusion to other schools. Key factors in creating successful pilot programs included wellness committees formed within each school and technical training sessions held by NHPS with the state Department of Education. Other important factors, French noted, included acknowledging barriers and helping to find solutions.
Eight years later, these programs still continue in many Delaware schools. An example is an initiative designed to help public elementary schools incorporate 150 minutes of moderate to vigorous physical activity into the school week for every student. “Make School a Moving Experience” at Brader Elementary in the Christina School District—developed by NHPS and funded by a Carol M. White Physical Education Program grant includes a “ride and read” option whereby students can pedal stationary bikes while reading books. “These bikes are located throughout our building,” including classrooms, French said. The school district also has embedded physical activity into the busy school day with morning exercises and into subject areas with such programs as Take 10! and North Carolina Energizers.4
Some of the elementary schools in the Christina School District, such as Brader Elementary, have a review process in place that entails using data and student surveys to measure progress. Student-interest surveys are useful for determining which physical activities the children like, French said. The district also assesses fitness in students using the FITNESSGRAM®5 tool.
To sustain prevention work, noted French, it is important to provide opportunities to attend conferences where the people involved can discuss and celebrate successes and connect with current and potential future partners for cross-sector collaboration. Also important is support for writing and applying for grants to obtain financial backing. Moreover, said French, “to accelerate our movement forward, we need to take a look at continued collaboration . . . but also professional development for all parties.”
In French’s view, changing school culture to embrace physical activity in the daily routine will require making changes at the national level—such as working with textbook publishers to embed physical activity and nutrition in lessons and including physical activity in national initiatives such
241 Delaware Code, Title 14 § 4133 Physical Education/Physical Activity Pilot Program.
341 Delaware Code, Title 14 § 122(b)(23) Rules and Regulations.
4For more information, visit http://www.take10.net and http://www.eatsmartmovemorenc.com/Energizers/EnergizersForSchools.html.
as No Child Left Behind. Preservice teacher education programs also need to make physical activity breaks part of their lesson development, she said.
During the discussion period, Chang asked whether leadership from the top is one of the requisite ingredients for successfully replicating the Delaware health prevention experience. Such leadership is not necessarily required, French responded. In the Christina School District, the work started with French, as a member of its wellness committee, giving a presentation on the obesity-fighting and academic benefits of physical activity for students. Twelve schools signed onto a physical activity pilot program. Each school may have started off with one champion, but the effort took off from there. Many teachers stepped up to take on after-school programs, French said, such as the successful vegetable garden at the school where she teaches. She did not have to beg colleagues to pitch in or to bring others to help. “They just start to come,” she said.
Mouser rounded out the Nemours case study presentations by showing a slide of the NHPS conceptual model (see Figure 7-2). She summed up the NHPS philosophy: “We try to help our partners be as successful as they can. We try to remove barriers. We work with them. We take the lead from them as to what we should be doing and what we shouldn’t be doing.”
Although much work remains, Mouser and her colleagues are seeing a qualitative and quantitative impact of the NHPS efforts across the state. Evidence indicates that “in schools, we can show that a child who is more physically fit is able to have greater academic achievement.” Child care centers participating in pilot programs with Nemours all showed an increase in active living and healthy eating in their facilities. Children engaged in CATCH (Coordinated Approach To Child Health) sites with which NHPS has worked across the state increased their physical activity by 20 percent.6
Mouser pointed to other impacts, including improvements in child care regulations and a $30 million state investment in public trails and multi-use pathways.
At the population health level, a statewide children’s health survey that NHPS launched in 2006 and repeated in 2008 and 2011 has shown that rates of overweight and obesity among Delaware’s children have leveled off (NHPS, 2011). The proportion of children who get at least an hour of physical activity per day increased from 38.9 percent in 2008 to 44.8 percent in 2011 (NHPS, 2011).
One challenge has been developing a shared measurement system across
FIGURE 7-2 The NHPS conceptual model moves from broad focus areas to specific changes in behavior, practices, and policies.
SOURCE: Mouser, 2014. Reprinted with permission.
all the community partners for tracking improvement in child health outcomes so as to demonstrate the collective impact of their efforts, Mouser said. A lesson learned is the importance of mining and analyzing data to drive decision making and continuous improvement. This and other lessons learned can be harnessed to inform diffusion, scale-up, and sustainability.
In the past 2 years, NHPS has begun looking at its prevention work through the lens of health access and equity (see also Chapter 2). Mouser and her team want to apply the most appropriate evidence-based interventions to address disparities in child health while carefully considering cultural needs and environmental factors that contribute to the problem.
To ensure that the Nemours cross-sector initiative yields lasting impacts, sustainability must be at the forefront, Mouser emphasized. Three lessons learned in this regard stand out. First, Nemours and its partners must be opportunistic in determining which policy systems and environmental changes will lead to improved child health outcomes over time. Second,
they must identify and leverage grants and maximize other funding streams with partners and coalitions. Third, they must build programmatic and leadership capacity with targeted community partners and coalitions to diffuse, scale up, and sustain change.
The bottom-line requirement for establishing a sustainable statewide strategy to combat childhood obesity, Mouser emphasized, is to have effective leadership at all levels across sectors—leaders willing to make the investment to create policy systems and make environmental changes that help children grow up healthy. According to Mouser, effective leadership means coordinating programs and connecting services so that program silos are eliminated, building trusting relationships with partners to foster shared goals and leverage resources, and identifying and supporting “champion integrators.” As to the question of whether leadership must come from the top, Mouser said that leaders come in all shapes and sizes and that leadership is about “having the dream and the vision.”
Although Delaware’s statewide prevention initiative got off the ground with Nemours’ support, Mouser said, the health care system from the outset sought to work closely with community partners to determine how to make that happen. “It has really been led by partners,” Mouser emphasized. The initiative is “taking the community, the needs, and looking and seeing what those are and driving forward from there. It is a very organic approach in some ways.”
During the discussion period, Joseph Vivens, author of Chunky and Friends: Chunky and the O-Beast—a children’s book about healthy eating, active playing, and obesity—asked about strategies for engaging parents. When out selling his book, he has seen overweight children who are very receptive to messages about healthy eating, but sometimes their parents will look back at their children in an individualized blaming sort of way, Vivens said. How does one deal with that?
Riley responded that one strategy is to “start as early as possible” with talking to children about healthy habits that they then take back to their families. At St. Michael’s School, she sits in the lobby every day from 4:30 p.m. to 5:30 p.m. and engages with parents as they pick up their children. She asks students, “Can you tell your mom what vegetable you had for lunch today, or can you tell your dad what was on the menu this morning for breakfast, and did you like it and do you want it again?” The parents are standing there and hearing their children say they love beets. “Let the child make the case,” Riley said.
Another way to involve parents is by showing them what their children’s school is doing to ensure that they are healthy and then providing
opportunities to expand that approach into their homes, French said. Her school, for example, which has a successful vegetable garden, has brought parents in at night and given them vegetable seeds so they can plant their own gardens at home.
Mouser added that Nemours is starting to look at multigenerational approaches that entail involving families in its prevention work. Nemours has had a great deal of success in working with partners to get parents, grandparents, and children gardening together, she said.
During the discussion period, Chang asked the other panelists to comment on the advantages and disadvantages of taking a comprehensive, statewide approach. When Nemours decided to work with all the sectors that care for children (see Figure 7-1), “it was a lot to do at once,” she recalled. “It has paid off to approach it that way. But at the time, it was a tremendous amount of work.”
Mouser emphasized the importance in the NHPS model of bringing all the sectors together. Initiative leaders must prioritize, depending in part on the readiness of different communities, which range from inner cities to rural areas. “It is not a one size fits all,” she said of the statewide strategy. “Approaches have to be customized appropriately, taking into account the great diversity and cultures that we are working with in our state.”
A statewide approach does not mean “that everything is going to look the same in every building,” French added. Within the NHPS strategy, different partners have the flexibility to develop their own programs.
“It’s about making the case that there is common ground, and that there is value in working collectively to, again, achieve what might be different end goals for everybody, but they’re all going in the same direction.”
—Eduardo J. Sanchez of the American Heart Association
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