The CCBH is a political subdivision providing services to over 1.2 million residents throughout Cuyahoga County. The health district served by CCBH is one of the largest in the state of Ohio. Since 1919, CCBH has successfully implemented large-scale health promotion programs for the diverse and multi-cultured northeastern Ohio population guided by a mission to work in partnership with the community to protect and improve the health and well-being of everyone in Cuyahoga County. Its work is broken down into the following service areas: Environmental Health, Prevention and Wellness, and Epidemiology Surveillance and Informatics. Cuyahoga County is a large urban county located in Northeast Ohio with a population of 1.28 million residents. Thirty-two percent of households have children under the age of six. Of Ohio's 88 counties, Cuyahoga County recently ranked 5th for clinical care but ranked 65th for health outcomes. Cuyahoga County ranks 76th in social-economic factors, 75th for overall morbidity, and 65th for overall mortality. Cleveland, the largest city within Cuyahoga County with a population of 396,815 residents, is a racially diverse community and is often referred to as a minority majority” city. Cleveland continues to be ranked by the U.S. Census Bureau as one of the poorest large cities in the nation and is tied with Detroit for having the worst child health outcomes
Early childhood obesity is one of the most important public health issues nationally. Across the country, one in four children ages 2-5 years is overweight or obese at a cost of $147 billion per year to the health care system in related illness. Almost 90,000 children under the age of 6 live in Cuyahoga County, OH. Locally, 1 in 3 children are overweight or obese and 1 in 4 children have an unhealthy blood pressure by the time they reach five years of age.
Goals: 1) support and facilitation of the EAHS coalition to make healthy environments for young children and 2) our direct service efforts through the local implementation and scale of Ohio Healthy Program.
Objectives: 1) Support a multi-stakeholder driven community coalition that works to achieve program on the strategic plan. 2) Grow the number of licensed ECE programs that achieve and maintain the OHP designation.
EAHS holds monthly coalition meetings on the 2nd Friday of every month for two hours. Meeting attendance averages between thirty and fifty members depending on the topic and location of the meeting. Of particular note, is that usually half of the attendees in the room at any one meeting are direct ECE providers themselves, which speaks to EAHS's community driven, grassroots approach to the effort. EAHS meetings are structured to ensure action is taken monthly on the EAHS strategic plan. Each meeting provides time for working groups to meet and report progress, provides space for an early childhood focused program to talk about their work, and provides an opportunity for coalition updates and networking.
Ohio Healthy Program (OHP), improves environments where children learn. OHP is a voluntary designation for ECE providers interested in addressing health above and beyond state minimum requirements. OHP is a training and technical assistance program on best practices in building healthy habits, menus, and policies for ECE programs.
EAHS Accomplishments
Connections between the Greater Cleveland Foodbank and ECE programs. The Foodbank adapted its food pantry program (currently in the school setting) for ECE. Five ECE providers that are active members of the coalition are currently implementing the program, distributed 4,000 pounds of produce and shelf stable items to young children and their families within their programs. Additionally, each site provides any remaining food to families in the surrounding community. All participating programs are located in food desert areas of Cuyahoga County.
The Cuyahoga County Public Library system has a toy lending library, making age appropriate toys available to the community through its lending system. Through involvement with EAHS, the library recognized an opportunity to incorporate age appropriate health education materials and partnered with another EAHS organization to utilize their materials. In 2017, the toy lending library reached 27,000 families with age appropriate toys and health messaging.
The Cleveland Clinic Mobile Health Unit established a partnering with one local Head Start grantee and is providing required screenings, immunizations, and lead testing on site at each of the 13 Head Start facilities.
EAHS worked with the medical residency programs at MetroHealth Medical Center and the Cleveland Clinic and has established partnerships where medical residency are doing rotations onsite at ECE programs.
Through direct technical assistance, CCBH worked with 110 ECE programs to achieve the OHP designation. This engagement impacted five thousand children (15% of children in licensed care) and reached 4,300 families through OHP. With technical assistance from CCBH, ECE participants adopted 247 nutrition and physical activity policies, increased whole fruit servings by 12%, whole grain offerings by 31%, and reduced fried foods by 67%, juice servings by 40% and sugar sweetened cereals by 100%. Not all programs engaging with OHP technical assistance required participation in the training portion of the program as they were trained in a previous calendar year.
Authentic communication, engagement, and multi-sectoral collaboartion were essential to our efforts.
www.earlyageshealthystages.org
Early childhood obesity is one of the most important public health issues nationally. Across the country, one in four children ages 2-5 years is overweight or obese at a cost of $147 billion per year to the health care system in related illness. The first 2,000 days between birth and the first day of kindergarten are critical to a child's healthy growth and development. Research strongly links physical, behavioral, and cognitive development early in life with health outcomes in adulthood. Children entering kindergarten at an unhealthy weight are four times more likely to be affected by obesity by the 8th grade. Historically, childhood obesity prevention efforts have focused on children ages 5-12 in traditional K-12 school settings. In delaying initiation of prevention and wellness programming until kindergarten, critical opportunities are missed to engage young children and their families in building healthy habits from the start.
It is now widely recognized that obesity prevention efforts must begin prior to a child's first day of kindergarten. This shift acknowledges that it is easier to influence a child's health patterns while their habits are still forming to promote and maintain a healthy weight across the life course. Environments that support early childhood health are not spread equally across Cuyahoga County. Because the majority of children ages 2-5 spend time in care outside of their homes, early care and education (ECE) settings may be the only opportunity young children to access high quality, nutritious foods, be in spaces that are safe for active play, and receive needed social emotional and healthcare services. ECE programs have become a desirable setting to implement health focused policies, systems, and structures strategies that lay the foundation for healthy habits right from the start. Today, over 35,000 children spend at least 32 hours a week in a licensed ECE program in Cuyahoga County, making this setting one that could create the best opportunities for health for young children.
Early childhood health matters. In order for our children to grow and develop with opportunities to achieve their best health, we must work to make sure that they are learning and growing in healthy early learning environments with active support from healthy families and communities.
In 2014, Cuyahoga County community stakeholders mobilized to begin addressing early childhood obesity and related early childhood health issues. Our initial obesity prevention partnership laid the groundwork for the two strategies that are actively implemented today to prioritize and promote the health of young children 0-8.
EAHS was created in 2016, our first formal early childhood obesity prevention partnership. EAHS is a partnership between ECE providers, community organizations, health care, social service agencies, businesses, and families, guided by its mission to work together to create healthy environments for all young children in Cuyahoga County. The work of the coalition is directed by our vision that Cuyahoga County is a community where all young children have equal opportunities to achieve their best health. EAHS's commitment to changing environments rather than changing individual behaviors is the most impactful and sustainable approach we can use to ensure our young children are healthy throughout their early years.
EAHS values our community members as key experts in early childhood wellness and recognizes that each of the partners has something to offer to improve early childhood wellness. Achieving community consensus on our approach, EAHS works to create equitable opportunities for all young children, is a community-first approach to early childhood wellness, elevates the success of our partners, and values collaboration over replication and duplication.
In Cuyahoga County, we believe that early childhood environments are healthy if: 1) healthy foods are available; 2) there are opportunities for active play; 3) social emotional needs are met; 4) families are engaged; and 5) health care is accessible. EAHS completed a community driven strategic planning process in 2017 and is currently implementing strategies to address its five priority health issues.
The second strategy of the Cuyahoga County partnership, Ohio Healthy Program (OHP), improves environments where children learn. OHP is a voluntary designation for ECE providers interested in addressing health above and beyond state minimum requirements. OHP is a training and technical assistance program on best practices in building healthy habits, menus, and policies for ECE programs.
The four steps to become an Ohio Healthy Program include:
Attend 15 hours of state-approved professional development training. The OHP training component is achieved through attendance at 6 sessions, all geared to different roles in ECE programs, such as administrators, classroom teachers, and kitchen staff. Teachers and administrators who attend training sessions also receive educational credit through the program's partnering agency, Ohio Child Care Resource and Referral Agency
Adopt at least one health focused policy. This policy can address multiple areas pertinent to childhood health, such as breastfeed feeding practices, healthy eating, physical activity, and healthy role modeling, etc. and is selected by the ECE program director.
In addition to following the CACFP menu requirements required of all child care programs in Ohio, Ohio healthy programs must:
Serve a whole grain food everyday
Serve a different fruit and vegetable everyday
Limit juice offered to only 100% juice and served no more than once per day
Limit fried foods to once per week
Eliminate processed meats
Eliminate cereals with more than 6 grams of sugar per serving
Eliminate beverages with added sugar
Serve only unflavored milk
Hold at least one family engagement activity. Family engagement activities include, creating bulletin boards with a monthly health campaign for parents to view when dropping off or picking their children up from the program, hosting a family activity night centered around healthy habits, or working with parents to have healthy celebrations during a child's birthday and distributing stickers or pencils instead of the customary cake or cupcakes.
Programs are provided with up to three technical assistance site visits with a CCBH employee in order to implement these policy changes and menu changes, and to ensure that they are consistent with OHP requirements. CCBH also provides support with the OHP application process to become. Successfully designated programs receive classroom incentive items to support the program's efforts. The OHP designation is voluntary and must be renewed annually.
CCBH adopted OHP as an early childhood health initiative in 2014 and is currently leading the State of Ohio in the number of ECE sites engaging with the program achieving the designation. Currently, 126 ECE programs in Cuyahoga County hold the OHP designation, with several on the designee list as a multi-year renewal. In 2018, OHP efforts in Cuyahoga County impacted over 15% of young children in licensed care locally.
Target Population
Almost 90,000 children under the age of 6 live in Cuyahoga County, OH. Locally, 1 in 3 children are overweight or obese and 1 in 4 children have an unhealthy blood pressure by the time they reach five years of age. These early childhood health outcomes are not limited to one segment of our child population as they cross cut income levels, insurance status, race and ethnicity, and gender. Compounded by high concentrations of poverty, lack of access to healthy foods and safe places for physical activity, and daily stressors that contribute to poor social emotional health and underutilization of health care, young children and their families lack opportunities to achieve their best health. EAHS and OHP's target population are young children ages 0-8 in Cuyahoga County and their families.
Practice Innovation
EAHS
Stakeholder groups across the country have long been focused on how to prevent childhood health issues, including obesity, seeking to implement policies, programs and practices that are effective and necessary to improve child health. Still, rates of overweight and obesity among our young children remain much too high. Gaps in both access and use of services remain while health disparities are widening. Communities remain stuck as they try to drive down rates of overweight and obesity.
EAHS recognizes authentic stakeholder engagement as critical to the success and sustainability of our early childhood health efforts. To generate collective impact, we have elevated the importance of stakeholder engagement in our work. EAHS actively works to uncover the drivers and root causes of early childhood healthy issues to inform not only what needs to be done but also how to do it effectively.
EAHS is also aligned with The Public Health 3.0 framework, as it elevates multi-sector collaboration to improve social determinants of health, and recognizes the importance of stakeholder engagement. EAHS explicitly acknowledges that addressing equity and social determinants of health through multi-sector partnerships is paramount to achieving crucial gains in population-level health outcomes.
OHP
OHP is based on several nutrition and physical activity Healthy People 2020 goals. While CCBH is implementing a statewide program with set goals and objectives, locally, we have innovated the approach and engagement strategies that serve to bring OHP to scale and make OHP the go to strategy to address nutrition, physical activity, and other health issues in the ECE setting. Our community first efforts have created a high demand for OHP in Cuyahoga County.
Evidence Base
EAHS
EAHS began a community-based, participatory approach to coalition building, allowing early childhood stakeholders throughout Cuyahoga County to determine meaningful strategies that promote early childhood wellness. Our process was modeled after the Strategic Prevention Framework (SPF), which supports a comprehensive process for addressing the substance misuse and related behavioral health problems facing their communities. EAHS adapted the SPF to close the gap in knowledge, skills, and collaborative effort around early childhood health issues. The effectiveness of the SPF begins with a clear understanding of community needs and involves community members in all stages of the planning process. To align with the best practices of the SPF, EAHS embraces a policy, systems, and environmental change approach; acknowledging that in order to reach a large population of young children and their families, coalition efforts must work beyond programmatic deliverables and begin to develop strategies that make our community more conducive to early childhood wellness. Our emphasis on community engagement through authentic relationships has been essential to EAHS success thus far. CCBH continues to utilize the SPF to guide coalition meetings, coalition structure, strategic plan implementation, and coalition evaluation.
OHP
OHP has been evaluated and deemed evidence-based by the Centers for Disease Control and Prevention. The OHP curriculum, resources, and technical assistance model are based on the recommendations from several national organizations, including but not limited to the American Academy of Pediatrics, United States Department of Agriculture, American Dietetic Association, and The Yale Rudd Center for Food Policy and Obesity.
Goal(s) and objectives of practice
Because of the strength of its relationships with community partners and the extensive trust and support from its local philanthropic community, CCBH became a local leader and innovator for early childhood obesity prevention in 2012. CCBH has invested in building agency capacity to effectively address the health of our youngest residents and promote a culture of health and wellness in ECE environments. Our comprehensive approach includes 1) the support and facilitation of the EAHS coalition to make healthy environments for young children and 2) our direct service efforts through the local implementation and scale of Ohio Healthy Program.
EAHS Implementation
EAHS Objective: Support a multi-stakeholder driven community coalition that works to achieve program on the strategic plan.
February 2014: Cuyahoga County Early Childhood Wellness Taskforce (CCECWT) formed.
The CCECWT was created in response to an identified need for formal mobilization of local stakeholders to take action on early childhood wellness outcomes, with a particular interest on preventing early childhood obesity. Members of the CCECWT were pre-determined and selected by 2 leading early education institutions in Cuyahoga County and a local philanthropic organization. Over the course of 6 months, twenty-four individuals representing sixteen organizations worked together to identify early childhood priorities, set goals, share information, and establish ways to measure successes in improving early childhood environments. The work culminated in the creation of the Cuyahoga County Early Childhood Wellness Plan (CCECWP). CCBH convened the CCECWT, facilitated the wellness plan planning sessions, and drafted the CCECWP.
July 2015: Cuyahoga County Early Childhood Wellness Plan formally presented to community.
CCBH hosted a community forum and presented the CCECWP to over 125 individuals. The forum also included a panel of early childhood experts that spoke to the connections between health and early education, and an award ceremony for the early adopters of OHP in Cuyahoga County.
The CCECWP was Cuyahoga County's first formal local commitment to addressing early childhood health and providing the foundation for making the healthy choice the easy choice for young children that live, learn, work, and play. The CCECWP was reflective of the collective interests and resources available in Cuyahoga County and strived to maximize positive health outcomes for children by helping them to reach and maintain a healthy weight. The CCECWT endorsed evidenced-based programs and best practices that supported a policy, environmental, and systems change approach to healthy eating and active living environments in early education. The CCECWP provided recommendations for adopting best practices in the areas of infant feeding, age-appropriate foods and beverages, increased physical activity, reduced screen time, and family engagement. A set of goals and objectives was generated for each area of the plan and reviewed after one year of implementation.
The CCECWT also recognized that true improvements in early childhood health status can and will only occur through effective community partnerships. The CCECWT approved the creation of a community-led, community-first early childhood health coalition, charged with advancing the goals and objectives of the 2015 CCECWP and identifying additional opportunities for change.
March 2016 – September 2017: Launch of EAHS coalition and community driven strategic planning process.
EAHS began a community-based, participatory approach to coalition building, in March 2016, which allowed early childhood stakeholders throughout Cuyahoga County to determine meaningful strategies that promote early childhood wellness. The process was modeled after the Strategic Prevention Framework (SPF) which supports a comprehensive process for addressing the substance misuse and related behavioral health problems facing their communities. EAHS adapted the SPF to close the gap in knowledge, skills, and collaborative effort around early childhood health issues. The effectiveness of the SPF begins with a clear understanding of community needs and involves community members in all stages of the planning process. To align with the best practices of the SPF, EAHS embraces a policy, systems, and environmental change approach; acknowledging that in order to reach a large population of young children and their families, coalition efforts must work beyond programmatic deliverables and begin to develop strategies that make our community more conducive to early childhood wellness. Our emphasis on community engagement through authentic relationships has been essential to EAHS success thus far.
The use of evidence-based methodology for substance use prevention within the realm of early childhood has brought state and local attention to EAHS as an innovator in the field of early childhood wellness promotion. Utilizing previous professional training, EAHS staff members led early childhood stakeholders in Cuyahoga County through the collaborative process, allowing the coalition to build capacity, identify priorities, understand root causes and location conditions, and develop evidence-informed change strategies. Access to healthy foods, safe spaces for active play, health care access, positive social emotional development and family engagement were identified as essential to improve early childhood wellness locally through a combination of observation and available local data.
The results is three-year, early childhood strategic plan, one that was built on authentic relationships and recognizes the significant contributions that ECE providers play in the health and development of young children. The strategic planning process created five health priority areas for EAHS, each supported by an active working group charged with bringing the plan to life. Today, our community first approach to early childhood health and wellness has generated a membership of approximately 300 individuals and over 100 organizations that are involved with and/or support the work of the coalition.
January 2018 – Present:
EAHS holds monthly coalition meetings on the 2nd Friday of every month for two hours. Meeting attendance averages between thirty and fifty members depending on the topic and location of the meeting. Of particular note, is that usually half of the attendees in the room at any one meeting are direct ECE providers themselves, which speaks to EAHS's community driven, grassroots approach to the effort. EAHS meetings are structured to ensure action is taken monthly on the EAHS strategic plan. Each meeting provides time for working groups to meet and report progress, provides space for an early childhood focused program to talk about their work, and provides an opportunity for coalition updates and networking.
OHP Implementation
OHP Objective: Grow the number of licensed ECE programs that achieve and maintain the OHP designation.
2014
CCBH attends OHP train-the-trainer and begins marketing OHP opportunity to licensed ECE programs in Cuyahoga County.
2015- 2016
CCBH sends additional staff member to OHP train-the-trainer and implements OHP in Cuyahoga County. CCBH provides 15 hours of approved professional development training and up to three technical assistance visits to ECE providers to assist in the achievement of the OHP designation.
CCBH structured its training schedule to best meet the needs of ECE staff. CCBH provides OHP training from September thru May each calendar year on a rolling basis. Trainings are scheduled during business hours, in the evenings, and on weekends to maximize opportunities for staff to participate.
Following training, technical assistance visits are scheduled based on the availability of the ECE program.
In 2015, 7 licensed ECE programs were designated as OHP; in 2016, 22 programs achieved designation.
2016-Present
CCBH has 1.5 FTEs providing training and technical assistance to interested ECE programs. Because of its successful outcomes, CCBH maintains training and technical assistance approach. CCBH maintains CCBH currently has a waitlist of providers interested in working with CCBH to achieve and/or maintain the OHP designation. CCBH also implement OHP customer survey to understand customer experience with CCBH and impact of program. CCBH will use this information to support continuous quality improvement efforts.
In 2017, 57 programs achieved OHP designation; to date in 2018, 104 programs have become an OHP. OHP designation and renewal applications occur on a rolling basis.
Criteria
EAHS
EAHS does not have any criteria for membership and welcomes any passionate individual or organization that is aligned with our mission and driven to improve health outcomes for young children and their families.
OHP
Training and technical assistance through OHP is available to any licensed ECE program in Cuyahoga County interested in addressing health above and beyond minimum licensing standards.
Timeframe
EAHS
EAHS's commitment to changing environments rather than changing individual behaviors is the most impactful and sustainable approach we can use to ensure our young children are healthy throughout their early years. EAHS values our community members as key experts in early childhood wellness and recognizes that each of the partners has something to offer to improve early childhood wellness. Stakeholders have been involved since the inception of the work in 2014.
OHP
OHP has directly involved ECE providers since the program began in 2015.
Partner Role in Implementation
EAHS
CCBH has served in a backbone and facilitation role for EAHS. Community partners were responsible for generating the content of both the CCECWP and, most recently, the EAHS 2017-2020 strategic plan. CCBH facilitates monthly EAHS meetings but relies on and supports community partners who are involved directly in the activities of the working groups.
OHP
CCBH promotes the OHP opportunity via EAHS newsletter, EAHS website, and EAHS social media channels. Because OHP is a state program, CCBH must follow the OHP training modules as they are provided to us. CCBH has customized the technical assistance process to our community, resulting in high collaboration and engagement with ECE programs. CCBH staff are responsive to each individual ECE program's needs and allows the ECE program director to set meaningful goals and objectives for OHP that meet the program where they are at and help to ensure the ECE program has a successful OHP experience. Our approach has generated high demand for OHP in Cuyahoga County, with there often being a waitlist for programs interested in working with CCBH to achieve designation.
Funding
Fiscally, CCBH manages EAHS and OHP as a combined budget under the umbrella of early childhood obesity prevention. Costs provided below are actual budget numbers from individual funding streams. In total, CCBH has leveraged over $725,500.00 since 2014 to support our efforts.
2014-2017 costs: $190,000.00
Local Philanthropy: $150,000.00
Salary and Fringe: $123,200.00
Supplies: $ 26,790.00
State Health Department: $40,000.00
Salary and Fringe: $30,680.00
Supplies: $ 9,311.00
2017-Present: $535,565.00
Local Philanthropy: $300,000.00
Salary and Fringe: $206,949.00
Supplies: $ 93,051.00
State Health Department: $81,565.00
Salary and Fringe: $70,938.00
Supplies: $10,626.00
Nemours Foundation: $119,000.00
Salary and Fringe: $41,585.00
Contracts: $31,000.00
Supplies: $46,415.00
Tufts University: $10,000.00
Salary and Fringe: $9,260.00
Supplies: $ 740.00
Nestle Foundation: $25,000.00
Supplies: $25,000.00
What did you find out?
EAHS Objective: Support a multi-stakeholder driven community coalition that works to achieve program on the strategic plan.
OHP Objective: Grow the number of licensed ECE programs that achieve and maintain the OHP designation.
CCBH utilizes a mixed-method approach to evaluating the work of its early childhood health efforts. CCBH maintains databases and project management systems to capture progress on efforts. To supplement programmatic data, CCBH also conducts annual surveys of stakeholders in both programs to inform changes and improvements to programmatic efforts.
EAHS
CCBH staff track process outcomes for the work of EAHS. Since 2016, CCBH has convened 27 coalition meeting, actively engaging approximately one thousand individuals over the course of the monthly coalition meetings.
Accomplishments in the health priority areas included:
Connections between the Greater Cleveland Foodbank and ECE programs. The Foodbank adapted its food pantry program (currently in the school setting) for ECE. Five ECE providers that are active members of the coalition are currently implementing the program, distributed 4,000 pounds of produce and shelf stable items to young children and their families within their programs. Additionally, each site provides any remaining food to families in the surrounding community. All participating programs are located in food desert areas of Cuyahoga County.
The Cuyahoga County Public Library system has a toy lending library, making age appropriate toys available to the community through its lending system. Through involvement with EAHS, the library recognized an opportunity to incorporate age appropriate health education materials and partnered with another EAHS organization to utilize their materials. In 2017, the toy lending library reached 27,000 families with age appropriate toys and health messaging.
The Cleveland Clinic Mobile Health Unit established a partnering with one local Head Start grantee and is providing required screenings, immunizations, and lead testing on site at each of the 13 Head Start facilities.
EAHS worked with the medical residency programs at MetroHealth Medical Center and the Cleveland Clinic and has established partnerships where medical residency are doing rotations onsite at ECE programs.
EAHS created locally relevant social media toolkits in an effort to create consistent messaging and expand communication on early childhood health issues and efforts. Toolkits were made available to all EAHS partner organizations and also utilized on all EAHS social media channels. EAHS reached approximately 2000 individuals via social media and have over 500 engagements throughout the campaigns.
CCBH conducts an annual survey of the EAHS membership. The goals are to understand if EAHS has effectively engaged our community, experience at monthly coalition meetings, and to understand areas for opportunity moving forward. Highlights from the 2018 annual survey results include: 69% of members are satisfied or highly satisfied with coalition meetings; 61% find the opportunity to network and gaining an awareness of new resources as the most valuable tool they gained by participating; and 89% believe that EAHS has contributed to improving early childhood health in Cuyahoga County.
CCBH will be establishing a project management system for EAHS in 2019. It is CCBH's hope to streamlined and make more efficient the progress the coalition is making on the strategic plan efforts in real time. CCBH will also be working to enhance the coalition's infrastructure to include a more formalized working group structure.
OHP
To date, in 2018, there are 329 ECE programs that are designated OHP across the State of Ohio. One hundred and twenty five of those designated programs are in Cuyahoga County. CCBH has experienced exponential growth in the program reach and outcomes since 2014. All outcomes presented below reflect 2018 engagement to date with OHP.
CCBH engaged with 88 licensed ECE programs through the OHP training sessions. Reaching 247 individuals in total, CCBH supported 121 classroom teachers, 75 menu planners, and 51 program directors to increase knowledge and skills in healthy habits, menus, and policies.
Through direct technical assistance, CCBH worked with 110 ECE programs to achieve the OHP designation. This engagement impacted five thousand children (15% of children in licensed care) and reached 4,300 families through OHP. With technical assistance from CCBH, ECE participants adopted 247 nutrition and physical activity policies, increased whole fruit servings by 12%, whole grain offerings by 31%, and reduced fried foods by 67%, juice servings by 40% and sugar sweetened cereals by 100%. Not all programs engaging with OHP technical assistance required participation in the training portion of the program as they were trained in a previous calendar year.
OHP data is gathered via primary data collection by CCBH staff and inputted into an OHP database that the agency has created and maintained since the program's inception. Tools used during the technical assistance process for program outcomes include the Let's Move Childcare Checklist and the Wellness Child Care Assessment Tool (WellCCAT) from the UConn Rudd Center for Food Policy and Obesity.
To further understand the true impact of OHP, CCBH partnered with the Case Western University's Master in Public Health program to conduct a study to evaluate the impact of OHP training and technical assistance on menu changes and number of healthy policies, as well as determine what characteristics are predictive of poor initial policies scores, and what characteristics are predictive of the most improvement in their policy scores. A pre and post assessment of these criteria were conducted by a CCBH employee by analyzing centers' policy handbooks utilizing a WellCCAT assessment. The WellCCAT is an evidence based tool, used to evaluate the comprehensiveness and strength of program policies. Scores can range from 0 to 100 for both comprehensive and strength scores. Center menus were also analyzed in order to quantify the number of fruits, vegetables, whole grains, servings of juice, fried foods, and processed meats that were served in centers every two weeks. Pre assessments were conducted after centers had received training, but before they received their first technical site visit. Post assessments were conducted using the same assessment tools, after centers completed all technical assistance visits.
Centers receive two scores, a comprehensive score between 0 and 100, and a strength score between 0 and 100. ECE programs' policy handbooks are evaluated based on the degree to which they address 5 main policy domains with 65 policy topics in total. The five policy domains they are evaluated on are Communication and Evaluation, Physical Activity, Nutrition Education, Promoting Healthy Eating in the Child Care Setting, and Nutrition Standards for Foods and Beverages. Programs' policy handbooks are then analyzed to determine to what degree the program policies match or address the 65 policy topics or items. If a policy topic is mention or addressed in policy handbooks it can receive a score of either 1 or 2 based on the strength of the policy. If a policy topic is not addressed, then a score of 0 is assigned for that policy topic. If a policy topic is addressed, then based on how strong, clear, enforceable, and detailed the policy is, a score of 1 or 2 will be assigned to the policy. The total number of policy topics that are addressed are used to calculate the comprehensive score, and the number of policy topics that are addressed and given a score of 2 (indicating a strong policy) are used to calculate the strength score.
There were statistically significant changes in mean pre and post values for all of the dependent variables regarding number of policies. Comprehensive WellCCAT scores increased significantly (pre: 47.81, post: 56.47 p <.0001), WellCCAT strength scores also increased from (pre: 24.23, post: 30.68 p<.0001). Total number of policies increased (pre: 22.73, post: 27.30 p <.001), as well as number of nutritional policies (pre: 9.30, post: 12.60 p <.0001), and number of physical activity policies increased as well (pre: 7.52, post: 8.26 p <.0001). Refer to table 2.
All paired t-test comparing the menu changes from the pre and post assessment were statistically significant. Servings of fruit (pre:19.06, post: 20.65 p <.0001), servings of non-fried vegetables (pre: 11.52, post: 12.98 p <.0001), servings of whole grain foods (pre: 10.83, post: 17.10 p <.0001) all increased significantly. Servings of juice (pre: 3.63, post: 2.38 p <.0001) and number of fried foods (pre: 2.16, post: 0.49 p <.0001) decreased significantly. Refer to table 2.
Home based programs were 2 times more likely to be in the upper 25% of WellCCAT score change (RR: 1.968, 95 CI: 0.991-3.906, p =.053). Centers located in the city of Cleveland were 47% less likely to be in the upper quartile of change, although this finding was marginally significant with a p-value of .059 (RR: 1.968, 95 CI: 0.269-1.026, p =.059). Refer to table 5.
1 star facilities, on average, increased their WellCCAT strength scores by 3 points (B: 2.815, 95 CI: (-0.163) (5.794), p = .064) compared to the reference group. This finding, with a p-value of .064 was marginally significant. 3 star facilities, on average, increased their WellCCAT strength scores by 6 points (B: 5.86, 95 CI: (2.298) (9.421), p = .001) compared to the reference group. Refer to table 6.
2 star facilities added 3 new policies regarding nutrition after the intervention (B: 3.162, 95 CI: (0.912) (5.412), p = .006) when compared to the reference group, and 3 star facilities added, on average, 2 new policies regarding nutrition after the intervention (B: 2.436, 95 CI: (-0.003) (4.875), p = .05). Refer to table 7.
The analysis conducted in this project has provided evidence for the effectiveness of OHP as an intervention to increase the number and strength of written healthy policies. Comprehensive WellCCAT scores in particular, increased almost 10 points on average after the OHP intervention. The number of policies regarding nutrition increased by an average of three, and centers added around 5 new policies on average after the intervention.
The paired t-tests also provided support for the evidence that OHP is an effective intervention for making significant changes to program menus, to adopt practices that go beyond the CACFP requirements. Although all measurements of menu requirements were statistically significant, servings of whole grain foods and fried foods differed significantly, post intervention. Servings of whole grain foods per every two weeks increased from 10 servings, on average per center, to 17 servings. The average servings of fried foods per two weeks decreased from 2 servings to a half serving after the intervention.
Based on these findings, CCBH recognizes that there is a greater need amongst non-rated and lower rated ECE programs as they most likely to lack comprehensive and strong policies regarding health and healthy practices, and they tend to show less improvement after completing the intervention compared to other programs. CCBH will be adjusting its recruiting efforts in 2019 to address this need. Future efforts by CCBH should be also focused on targeting and recruiting home based programs, since these programs improved the most after receiving the intervention, making them an important an important demographic to retain for future OHP efforts as well.
What did you find out?
EAHS Objective: Support a multi-stakeholder driven community coalition that works to achieve program on the strategic plan.
OHP Objective: Grow the number of licensed ECE programs that achieve and maintain the OHP designation.
CCBH utilizes a mixed-method approach to evaluating the work of its early childhood health efforts. CCBH maintains databases and project management systems to capture progress on efforts. To supplement programmatic data, CCBH also conducts annual surveys of stakeholders in both programs to inform changes and improvements to programmatic efforts.
EAHS
CCBH staff track process outcomes for the work of EAHS. Since 2016, CCBH has convened 27 coalition meeting, actively engaging approximately one thousand individuals over the course of the monthly coalition meetings.
Accomplishments in the health priority areas included:
Connections between the Greater Cleveland Foodbank and ECE programs. The Foodbank adapted its food pantry program (currently in the school setting) for ECE. Five ECE providers that are active members of the coalition are currently implementing the program, distributed 4,000 pounds of produce and shelf stable items to young children and their families within their programs. Additionally, each site provides any remaining food to families in the surrounding community. All participating programs are located in food desert areas of Cuyahoga County.
The Cuyahoga County Public Library system has a toy lending library, making age appropriate toys available to the community through its lending system. Through involvement with EAHS, the library recognized an opportunity to incorporate age appropriate health education materials and partnered with another EAHS organization to utilize their materials. In 2017, the toy lending library reached 27,000 families with age appropriate toys and health messaging.
The Cleveland Clinic Mobile Health Unit established a partnering with one local Head Start grantee and is providing required screenings, immunizations, and lead testing on site at each of the 13 Head Start facilities.
EAHS worked with the medical residency programs at MetroHealth Medical Center and the Cleveland Clinic and has established partnerships where medical residency are doing rotations onsite at ECE programs.
EAHS created locally relevant social media toolkits in an effort to create consistent messaging and expand communication on early childhood health issues and efforts. Toolkits were made available to all EAHS partner organizations and also utilized on all EAHS social media channels. EAHS reached approximately 2000 individuals via social media and have over 500 engagements throughout the campaigns.
CCBH conducts an annual survey of the EAHS membership. The goals are to understand if EAHS has effectively engaged our community, experience at monthly coalition meetings, and to understand areas for opportunity moving forward. Highlights from the 2018 annual survey results include: 69% of members are satisfied or highly satisfied with coalition meetings; 61% find the opportunity to network and gaining an awareness of new resources as the most valuable tool they gained by participating; and 89% believe that EAHS has contributed to improving early childhood health in Cuyahoga County.
CCBH will be establishing a project management system for EAHS in 2019. It is CCBH's hope to streamlined and make more efficient the progress the coalition is making on the strategic plan efforts in real time. CCBH will also be working to enhance the coalition's infrastructure to include a more formalized working group structure.
OHP
To date, in 2018, there are 329 ECE programs that are designated OHP across the State of Ohio. One hundred and twenty five of those designated programs are in Cuyahoga County. CCBH has experienced exponential growth in the program reach and outcomes since 2014. All outcomes presented below reflect 2018 engagement to date with OHP.
CCBH engaged with 88 licensed ECE programs through the OHP training sessions. Reaching 247 individuals in total, CCBH supported 121 classroom teachers, 75 menu planners, and 51 program directors to increase knowledge and skills in healthy habits, menus, and policies.
Through direct technical assistance, CCBH worked with 110 ECE programs to achieve the OHP designation. This engagement impacted five thousand children (15% of children in licensed care) and reached 4,300 families through OHP. With technical assistance from CCBH, ECE participants adopted 247 nutrition and physical activity policies, increased whole fruit servings by 12%, whole grain offerings by 31%, and reduced fried foods by 67%, juice servings by 40% and sugar sweetened cereals by 100%. Not all programs engaging with OHP technical assistance required participation in the training portion of the program as they were trained in a previous calendar year.
OHP data is gathered via primary data collection by CCBH staff and inputted into an OHP database that the agency has created and maintained since the program's inception. Tools used during the technical assistance process for program outcomes include the Let's Move Childcare Checklist and the Wellness Child Care Assessment Tool (WellCCAT) from the UConn Rudd Center for Food Policy and Obesity.
To further understand the true impact of OHP, CCBH partnered with the Case Western University's Master in Public Health program to conduct a study to evaluate the impact of OHP training and technical assistance on menu changes and number of healthy policies, as well as determine what characteristics are predictive of poor initial policies scores, and what characteristics are predictive of the most improvement in their policy scores. A pre and post assessment of these criteria were conducted by a CCBH employee by analyzing centers' policy handbooks utilizing a WellCCAT assessment. The WellCCAT is an evidence based tool, used to evaluate the comprehensiveness and strength of program policies. Scores can range from 0 to 100 for both comprehensive and strength scores. Center menus were also analyzed in order to quantify the number of fruits, vegetables, whole grains, servings of juice, fried foods, and processed meats that were served in centers every two weeks. Pre assessments were conducted after centers had received training, but before they received their first technical site visit. Post assessments were conducted using the same assessment tools, after centers completed all technical assistance visits.
Centers receive two scores, a comprehensive score between 0 and 100, and a strength score between 0 and 100. ECE programs' policy handbooks are evaluated based on the degree to which they address 5 main policy domains with 65 policy topics in total. The five policy domains they are evaluated on are Communication and Evaluation, Physical Activity, Nutrition Education, Promoting Healthy Eating in the Child Care Setting, and Nutrition Standards for Foods and Beverages. Programs' policy handbooks are then analyzed to determine to what degree the program policies match or address the 65 policy topics or items. If a policy topic is mention or addressed in policy handbooks it can receive a score of either 1 or 2 based on the strength of the policy. If a policy topic is not addressed, then a score of 0 is assigned for that policy topic. If a policy topic is addressed, then based on how strong, clear, enforceable, and detailed the policy is, a score of 1 or 2 will be assigned to the policy. The total number of policy topics that are addressed are used to calculate the comprehensive score, and the number of policy topics that are addressed and given a score of 2 (indicating a strong policy) are used to calculate the strength score.
There were statistically significant changes in mean pre and post values for all of the dependent variables regarding number of policies. Comprehensive WellCCAT scores increased significantly (pre: 47.81, post: 56.47 p <.0001), WellCCAT strength scores also increased from (pre: 24.23, post: 30.68 p<.0001). Total number of policies increased (pre: 22.73, post: 27.30 p <.001), as well as number of nutritional policies (pre: 9.30, post: 12.60 p <.0001), and number of physical activity policies increased as well (pre: 7.52, post: 8.26 p <.0001). Refer to table 2.
All paired t-test comparing the menu changes from the pre and post assessment were statistically significant. Servings of fruit (pre:19.06, post: 20.65 p <.0001), servings of non-fried vegetables (pre: 11.52, post: 12.98 p <.0001), servings of whole grain foods (pre: 10.83, post: 17.10 p <.0001) all increased significantly. Servings of juice (pre: 3.63, post: 2.38 p <.0001) and number of fried foods (pre: 2.16, post: 0.49 p <.0001) decreased significantly. Refer to table 2.
Home based programs were 2 times more likely to be in the upper 25% of WellCCAT score change (RR: 1.968, 95 CI: 0.991-3.906, p =.053). Centers located in the city of Cleveland were 47% less likely to be in the upper quartile of change, although this finding was marginally significant with a p-value of .059 (RR: 1.968, 95 CI: 0.269-1.026, p =.059). Refer to table 5.
1 star facilities, on average, increased their WellCCAT strength scores by 3 points (B: 2.815, 95 CI: (-0.163) – (5.794), p = .064) compared to the reference group. This finding, with a p-value of .064 was marginally significant. 3 star facilities, on average, increased their WellCCAT strength scores by 6 points (B: 5.86, 95 CI: (2.298) – (9.421), p = .001) compared to the reference group. Refer to table 6.
2 star facilities added 3 new policies regarding nutrition after the intervention (B: 3.162, 95 CI: (0.912) – (5.412), p = .006) when compared to the reference group, and 3 star facilities added, on average, 2 new policies regarding nutrition after the intervention (B: 2.436, 95 CI: (-0.003) – (4.875), p = .05). Refer to table 7.
The analysis conducted in this project has provided evidence for the effectiveness of OHP as an intervention to increase the number and strength of written healthy policies. Comprehensive WellCCAT scores in particular, increased almost 10 points on average after the OHP intervention. The number of policies regarding nutrition increased by an average of three, and centers added around 5 new policies on average after the intervention.
The paired t-tests also provided support for the evidence that OHP is an effective intervention for making significant changes to program menus, to adopt practices that go beyond the CACFP requirements. Although all measurements of menu requirements were statistically significant, servings of whole grain foods and fried foods differed significantly, post intervention. Servings of whole grain foods per every two weeks increased from 10 servings, on average per center, to 17 servings. The average servings of fried foods per two weeks decreased from 2 servings to a half serving after the intervention.
Based on these findings, CCBH recognizes that there is a greater need amongst non-rated and lower rated ECE programs as they most likely to lack comprehensive and strong policies regarding health and healthy practices, and they tend to show less improvement after completing the intervention compared to other programs. CCBH will be adjusting its recruiting efforts in 2019 to address this need. Future efforts by CCBH should be also focused on targeting and recruiting home based programs, since these programs improved the most after receiving the intervention, making them an important an important demographic to retain for future OHP efforts as well.
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