Results of a 2005 Community Health Assessment showed over three-fourths (76.4%) of Yellowstone County residents do not participate in a regular fitness program. These statistics are less favorable than state and national findings and fail to meet Healthy People 2010 standards. Only 7.4% of Yellowstone County parents report their child watches no television on a typical school day; 17.6% indicate their child watches three or more hours of television per typical school day. In the nutrition arena, 34.9% of Yellowstone County adults report eating five or more servings of fruits and/or vegetables per day (the USDA recommendation). Only one-fourth of Yellowstone County adults report eating three or more servings of dairy per day (USDA guidelines); 10% report eating zero servings of dairy per day.
Goal: Encourage and recognize events and activities in Yellowstone County that are taking progressive steps to promote healthy lifestyles.
Objective 1: By April 2009, develop criteria in the categories of physical activity, nutrition, environmental stewardship, physical activity and overall wellness for events and activities to accomplish to receive the Healthy By Design recognition.
Objective 2: By May 2009, create an application process that includes an educational component for applicants.
Objective 3: By January 2009, at least 15 community events will have been recognized as being Healthy By Design. T
he Healthy By Design (HBD) recognition was developed as a way of promoting events in Yellowstone County that are designed with health in mind. This recognition is accomplished through an application process. Each application is reviewed and evaluated by a team of experts. The five criteria addressed include safety; nutrition; physical activity; prevention and wellness; and environmental stewardship. The practice addresses the above-mentioned public health issues by deliberately infusing increased opportunities for physical activity, nutrition, and well-being into the environment of our community. Eventually this will lead to improved health status by increasing awareness and knowledge of, as well as access to, healthier lifestyles. The practice has met all of its original objectives.
By April 2009, a team of community experts developed physical activity, nutrition, environmental stewardship, and overall wellness criteria that events and activities had to meet in order to receive the HBD recognition. Following criteria development, the team developed an application process. The application process includes reference and educational materials to help the applicant complete the application to the best of his/her ability. Upon submission of the application, reviewers provide commentary on the application. The reviewers are asked to make a decision about the status of the application (approve or approve with changes). In either case, the reviewers are asked to provide feedback on the application to ensure the application process is educational. The application is not denied unless it s approved with changes and the applicant chooses not to make the changes asked for by the reviewers. As of January 2010, 19 applicants have applied for and received the HBD recognition, exceeding the goal of 15.
Obesity rates due to physical inactivity and poor nutrition are rising across the United States and Yellowstone County is no exception. Results of a 2005 Community Health Assessment showed over three-fourths (76.4%) of Yellowstone County residents do not participate in a regular fitness program. These statistics are less favorable than state and national findings, and fail to meet Healthy People 2010 standards. Only 7.4% of Yellowstone County parents report their child watches no television on a typical school day; 17.6% indicate their child watches three or more hours of television per typical school day. In the nutrition arena, 34.9% of Yellowstone County adults report eating five or more servings of fruits and/or vegetables per day (the USDA recommendation). Only one-fourth of Yellowstone County adults report eating three or more servings of dairy per day (USDA guidelines); 10% report eating zero servings of dairy per day. The CDC defines healthy places as “those designed and built to improve the quality of life for all people who live, work, worship, learn, and play within their borders – where every person is free to make choices amid a variety of healthy, available, accessible, and affordable options.” Similarly, the intent behind this practice is to deliberately influence community programs and activities to increase the accessibility of healthy lifestyle choices.
The areas of improvement are derived directly from the 2005 Community Health assessment. Childhood and adult obesity, heart disease, diabetes, nutritional intake, unintentional injury, and chronic depression were identified areas of weakness. Physical activity, nutrition, and well-being were selected as the areas of improvement because of their inter-connectedness and their collective impact on the identified community weaknesses. Physical activity is arguably the most tangible of the improvement categories. Most people are aware that exercise is good for health and reduces risk factors for chronic diseases. The challenge is creating natural opportunities for physical activity in everyday activities. Nutrition is not simply “diet,” but refers to appropriate intake of recommended vitamins and minerals. It is possible to be obese and undernourished; it is also possible to appear very “fit” and “healthy” but not have sufficient nourishment. Though more than half the population is overweight, a lower percentage of Yellowstone County residents report consuming five or more fruits and vegetables per day.
One of the key ways to maintain a healthy weight is through portion control. Research has shown that Americans often underestimate how many calories they are consuming each day by as much as 25%. Through education and encouraging appropriate portion sizing, individuals have a greater likelihood of maintaining a healthy weight. HBD criteria specifically address the nutritional balance of food served at HBD-recognized events and the serving sizes thereof. Well-being is not as easily defined, but is an important category that encompasses some of the other areas of improvement. Safety, mental health, and social capital all contribute to the well-being, or level of contentedness and welfare, of the community. The World Health Organization (WHO) defines health as “…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Well-being is included to support that concept of promoting total health, not merely the absence of obesity and undernourishment.This program clearly links to the above mentioned health problems as it is a way of deliberately infusing increased opportunities for physical activity, nutrition, and well-being into the environment of our community eventually leading to an improved health status by increasing awareness and knowledge of, as well as access to, healthier lifestyles. The practice is open to the entire community and has the ability to affect varying populations.
Agency Community RolesThe LHD facilitates the Healthy Places Initiative that originally constructed this idea. In addition, the LHD has facilitated the Healthy By Design recognition. This work includes planning the monthly meeting, taking minutes, maintaining and updating all documentation, receiving applications, dispersing applications to reviewers and summarizing reviewer comments in response to each applicant. The LHD has also provided reviewers for the applications. The Healthy Places Advisory Committee consists of community leaders from multiple sectors who have interest or expertise in areas related to community health. This committee serves as a panel of experts and community leaders who provide input in developing the Plan To Improve the Community’s Health (PITCH) and help to implement the plan. The Healthy By Design Recognition was conceived by the Advisory Committee, and they played a role in developing the Recognition Review Board. Numerous committee members serve on both the Healthy Places Advisory Committee and the Recognition Review Board.
The Recognition Review Board is made up of 15 experts in various areas and from various organizations. The reviewers are asked to provide up to four hours a month. Originally, these four hours consisted of creating the criteria and resources, designing the application for the Recognition, and developing the review process. Following the completion of this, the reviewers were asked to spend their four hours each month reviewing applications and providing feedback to the applicant. Most recently, the reviewers have also developed a plan to expand the practice by sharing it at community presentations. The Alliance is responsible for the oversight of the Healthy Places Initiative which includes the Healthy By Design application. The Alliance provides staff to attend and participate in all Healthy Place activities. In addition, they provide final approval of the PITCH and support the implementation activities of the PITCH through staffing or funding, as needed.
Costs and ExpendituresCreated in 2001, The Alliance is an affiliated partnership of the chief executive officers from the area’s two hospitals and LHD. Committed to working collaboratively on community and regional health projects, The Alliance implemented the Healthy Places Initiative. Healthy Places brings together community leaders that are working to prevent chronic disease. Healthy Places committee members include Montana State University-Billings, public transit, city-county planning, YMCA, school board, local nutritionists, and the Chamber of Commerce.
In 2006, Healthy Places committee members developed a community action plan. One goal of the plan was to hold a “Wellness Day” which would build off an existing National Day and focus on creating a community-wide effort. After reviewing existing events and activities in the community that are related to wellness, the advisory committee recognized that many such events and activities already occur. In an effort to reduce duplication, highlight the existing activities, encourage event coordinators to consider health when planning their events, and establish a standard of excellence related to designing events, the committee opted instead to create the Healthy By Design (HBD) recognition program. HBD recognizes events and activities in Yellowstone County that are taking progressive steps to promote healthy lifestyles. Recognized events and activities encourage active living and promote healthy choices. Recognition criteria are used as an educational tool to provide recommendations and guidance to event coordinators in an effort to create events/activities that enhance the health of the community.
Expenses have been minimal for the program to date, with approximately $500 used to create and print brochures and promotional materials. The health department provided a program facilitator who devotes 0.1 FTE to the program on average (more time in months with numerous applications and less in months with fewer applications). There are 15 reviewers from the two local hospitals, the health department and various organizations across the community. All reviewers volunteer time or provide in-kind time from their organization. Each reviewer was asked to devote approximately four hours per month (one hour for a face-to-face meeting and three hours for review of applications). The LHD funded the facilitator out of general public health funds supplied by the city-county government. Reviewer time was either volunteered or donated in-kind by each reviewer’s respective organization. Promotional materials were funded from a Robert Wood Johnson Foundation grant to create advocacy tools.
ImplementationTo achieve the overall goal of the practice a plan that laid out the objectives and activities to reach these objectives was created.
Objective 1 tasks included: development of a review team; research into existing programs or practices (although this did not yield the results intended); development of review team expectations, collection of criteria resources (e.g. USDA guidelines); facilitated meetings with reviewers; and developing a system for feedback and response
Objective 2 tasks included: summarizing criteria into application questions; testing of the application; pulling together resources and educational materials; facilitated meetings with reviewers; and creating a process for feedback from reviewers to be passed on to applicants
Objective 3 tasks included: development of a brochure to promote HBD recognition; seeking potential applicants via phone, email and through connections with Healthy Places members; providing technical assistance to applicants; creation of an evaluation; and facilitated meetings with reviewers
Each objective came with a set timeframe starting with four months to develop the criteria, one month to turn the criteria into an application and six months to assess the start-up of the practice. The timelines for the first two objectives were set in stone, as the goal was to have the criteria and application completed so that the practice could be introduced at a community-wide health summit planned for May 2009. The timeframe for assessing the start-up of the practice was based around inclusion into the updated Plan To Improve the Community’s Health (PITCH). The PITCH was to be updated in January 2010 with approval from The Alliance by the end of January. The goal was to be able to evaluate the status of the project and create new objectives for the practice for inclusion in the newly updated PITCH. This timeline was accomplished and new objectives have been set which include increasing the exposure of the practice and getting venues/caterers to offer Healthy By Design options.
Encourage and recognize events and activities in Yellowstone County that are taking progressive steps to promote healthy lifestyles. By April 2009, develop criteria in the categories of physical activity, nutrition, environmental stewardship, physical activity and overall wellness for events and activities to accomplish to receive the Healthy By Design recognition. The expectation was that in order to meet Objective 1 review team members would need to contribute at least four hours a month from January–April 2009 to develop criteria in the five chosen categories. One of these hours would be devoted to a face-to-face meeting and the remaining work could be done online. It was expected one facilitator from the LHD could lead the creation of the criteria at approximately 0.1 FTE.
By April 2009, the end deliverable was to be a completed set of criteria.Minutes from each face-to-face meeting were recorded and emails saved. Reviewers were not asked to record the time they spent away from the meeting working on the project nor was the LHD facilitator asked to delineate project time. All applicants were sent an evaluation following their event or activity that included evaluation questions about the criteria. The LHD facilitator was asked to create minutes from every meeting, save emails from the reviewers and turn them into a document summarizing the criteria. The feedback from the reviewers was that the time expectation was appropriate. The facilitator did require help from other staff to help review and finalize criteria.
To date, 16 evaluations of the HBD recognition initiative have been received. 100% of the respondents indicated that the criteria were achievable. Six applicants who completed an evaluation noted they met barriers to implementing all aspects of the HBD application. These barriers included problems getting contractors (e.g. caterers or venues) to implement the criteria; lack of adequate funds or time to implement the criteria; and difficulty understanding the expectations of the reviewers.The criteria were completed by April 2009 in all five chosen categories as intended. Currently the reviewers are working on creating an educational program for contractors to explain to them their role in the implementation of the criteria. One unintended consequence of this session was the bonding of the review team members. Since the development of the criteria required a lot of discussion, feedback and some compromising, the reviewers developed a rapport that has since served them well in the application review process. Another unintended consequence was that the HBD recognition grabbed the attention of the local National Weather Service. They asked to join the group and update the safety criteria to include weather safety, particularly for outdoor events. By May 2009, create an application process that includes an educational component for applicants.The expectation was that in order to meet Objective 2 review team members would need to contribute at least four hours during the month of April 2009 to create an application process. One of these hours would be spent in a face-to-face meeting, and the remaining work could be done online. It was expected one facilitator from the LHD could lead the creation of the criteria at approximately 0.1 FTE.
By May 2009, the end deliverable was to be a completed application process that included educational components.Minutes from the face-to-face meeting were recorded. All applicants were sent an evaluation following their event or activity. The LHD facilitator was asked to create minutes from every meeting, save emails from the reviewers and turn them into a document spelling out the criteria. The feedback from the reviewers was that the time expectation was appropriate. To date, 16 evaluations have been received. 100% of the respondents indicated that the application criteria were easy to find, access and the instructions were clearly written. Fifteen (93.8%) said that the necessary res
HBD recognition is part of the overall Plan To Improve The Community’s Health (PITCH). The PITCH was originally developed in 2006 and formally approved by The Alliance in 2007. The PITCH is updated every two years. By inclusion in the PITCH document and subsequent approval by The Alliance, the practice gains long-term commitment from The Alliance member organizations including adoption into their individual strategic plans. This commitment also includes staffing and funding to be provided as deemed necessary for the success of the projects described in the PITCH.
In addition, grant funding continues to be sought for the entire Healthy Places Initiative to continue to expand. The Alliance commitment to this project – as evidenced by the adoption of the updated PITCH at the end of January 2010 -- ensures staff time from each respective organization will be provided for at least the next two years (evaluation of the practice will be done again in 2012). New objectives for the next two years have been written for the practice. These include expanding exposure and participation in the practice. All Alliance organizations have media/communication staff that work to put together a communication plan to achieve this objective.