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
1
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
2
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).
3
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
Communitybased health
promotion
4
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
5
NHPS Vision
Optimal 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.
6
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.
7
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
8
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
9
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
10
Obesity Prevention Pilots
Targets and Outcomes
Content Areas
1) Healthy Eating &
Physical Activity
2) Emotional/
Behavioral Health
Program Sectors
1) Childcare
2) Primary Care
3) Schools
Community Capacity
Outcomes
Impact on
Delaware
Children and
Communities
(Policy, practice
and program
change)
Impacting the greatest number of children in the shortest amount of tim
11
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.
12
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
13
14
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
15
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
16
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
17
What have we accomplished?
 Early successes in…
–
–
–
–
Child care
Schools
Primary care
Community organizations
18
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
19
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.
20
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
21
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
22
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
23
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
24
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
25
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 5-2-1Almost 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
26
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
27
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.
28
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:
1. People that care for children practice health promotion in
places where children live, learn, and play
2. Delaware citizens understand that children’s health and
wellness matters to everyone – they are our future
3. Statewide messages about child
health promotion are adopted and
broadly disseminated
29
System Vision 2015 (continued)
4. Child-serving organizations have improved capacity to:
•
Influence policy
•
Deliver services effectively and efficiently
•
Use data to drive decision-making
5. Increased total resources for child health promotion and
increased ability to serve more children
6. Statewide system in place for tracking, monitoring, and
reporting on child health
30
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
31
“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
32
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
33