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2012 Model Practice Application (Public)Application Title: Healthy Choice Restaurant Program Please enter email addresses you would like your confirmation to be sent to. email1@pamela_jeralds@doh.state.fl.us; email2@cathy_montgomery@doh.state.fl.us Practice Title Healthy Choice Restaurant Program Submitting LHD/Agency/Organization Baker County Health Department Head of LHD/Agency/Organization Kerry Dunlavey/Administrator Street Address 480 W Lowder St Practice Contact Person Pam Jeralds Title Sr. Health Educator pamela_jeralds@doh.state.fl.us Submitting LHD/Agency/Organization Web Address (if applicable) http://www.doh.state.fl.us/chdbaker/ Provide a brief summary of the practice in this section. This overview will be used to introduce the model or promising practice in the Model Practices Database. Although this section is not judged, the judges use it to get an overall idea about your practice. You must include answers to the following questions in your response:
• Size of population in your health department’s jurisdiction
• Who is your target population/audience, for this practice
• Size of target population/audience, if applicable
• The number or percentage of the target population/audience reached, if applicable
• Describe the nature and gravity of the public health issue addressed
• List the goal’s and objective(s) of the practice and clearly link them to the problem or issue the practice is addressing. Briefly indicate what the practice intends to accomplish overall.
• When (month and year) the practice was implemented.
• Briefly describe how the practice was implemented, what were major activities, and any start-up and in-kind costs and funding services.
• Outcomes of practice (list process milestones and intended/actual outcomes and impacts.
• Were all of the objectives met?
• What specific factors led to the success of this practice?
• Lessons learned from the practice Baker County has a population of approximately 27,115 residents (2010 U.S. Census). According to results from a county-level Behavioral Risk Factor Surveillance Summary (BRFSS), 63.7% of adults in Baker County are overweight or obese, 18.7% of adults consume 5 or more fruits and vegetables every day; and 38.2% of adults meet moderate physical activity requirements.
According to Social Learning Theory, children tend to replicate adult behaviors through observation and modeling. To reduce the rise of overweight and obesity among children, the CHD elected to target first grade students (n = 100) at Macclenny Elementary School (MES) based on Body Mass Index (BMI) results completed annually among 1st, 3rd, 6th and 9th grade students:
Percentage of MES students at risk of being overweight:
•17% of 1st graders (2008)
•19% of 3rd graders (2008)
Percentage of MES students who are overweight:
•13% of 1st graders (2008)
•20% of 3rd graders (2008)
The CHD conducted surveys and feedback sessions among parents of first grade students to obtain information about nutrition and physical activity behaviors; why children are overweight or obese; and what activities could be implemented to address the issue. Parent results indicated:
•31% of children drink at least 2 sugar sweetened drinks every day
•42% of children spend at least 2 hours each day watching television
•23% of children eat 3-4 times per week at restaurants
•75% eat fast food < 2 times per week
The Baker CHD implemented the Healthy Choice Restaurant Program (HCRP) to provide and promote healthy food choices for Baker county residents. The project goal was intended to reduce the rise of children who are overweight and at risk of being overweight, particularly among students in a targeted elementary school who frequently ate meals at restaurants instead of home. The objective of the project was to improve healthy nutrition choices among 1st graders at Macclenny Elementary School.
Implementation of the project began in May 2009 and ended in October 2010. Fifteen locally-owned or managed restaurants, none of which were considered fast-food, participated in the Healthy Choice Restaurant Program (HCRP). Overflow: Please finish the response to the question above by using this text area. Please be mindful of the word limits. They offered menu options including smaller portion sizes (take half home); heart-healthy alternatives; substitutions for grilled versus fried; and low-fat, low-calorie substitutions. Participating restaurants received table tents, placemats, crayons, window decals and menu stickers to promote the healthy alternatives. Advertising in the local newspaper was also conducted to promote HCRP and participating restaurants. Start-up cost to print promotional items and pay for advertisements was approximately $5,000.
Comment cards were collected from customers to determine (evaluate) the percentage of adults and children that selected healthier options. Comment cards collected in November 2009 (n = 111) and March 2010 (n = 108) revealed:
•68% (n = 75) of adults selected a healthy choice option
•50% of children (n = 106) selected a healthy choice option in November 2009
•70% (n = 76) of adults selected a healthy choice option
•30% of children (n = 82) selected a healthy choice option in March 2010
Educational information targeting healthy eating was sent home monthly to parents. Surveys conducted in November 2009 and March 2010 among parents of first graders at Macclenny Elementary School to 1) assess nutrition behaviors and 2) determine if parents were familiar with HCRP. For five (5) consecutive days, parents were asked to list what their child ate and drank for dinner the previous evening and if they ate at home, a restaurant or other location.
The percent of parents who were unfamiliar with HCRP decreased from 25% to 6%. Consumption rates of foods between November 2009 and March 2010 indicated:
•Fried foods – increased 15%
•Vegetables – decreased 2%
•Fruits – increased 19%
•Consumption of whole and 2% milk compared to 1% and fat-free remained the same
Lesson learned: Parents were asked to identify the name of the restaurant if their child ate out on any of the five (5) days surveys were collected. Of the 82 meals consumed at restaurants during the five day survey, only 2% of the meals were eaten at Healthy Choice Restaurants.
While the objective for this practice was not met with the targeted population, restaurant patrons did select healthy choices and customer satisfaction was achieved. As a result, the project has been sustained by several HCRP restaurant owners and managers. Describe the public health issue that this practice addresses. (350 word limit)
The intent of this project is to address healthy nutrition in an effort to reduce childhood overweight and obesity. According to the research conducted by the Centers for Disease Control (CDC), weight gain to overweight and obese levels increases conditions such as:
•coronary heart disease
•type 2 diabetes
•cancers (endometrial, breast, and colon)
•hypertension (high blood pressure)
•dyslipidemia (for example, high total cholesterol or high levels of triglycerides)
•stroke
•liver and gallbladder disease
•sleep apnea and respiratory problems
•osteoarthritis (a degeneration of cartilage and its underlying bone within a joint)
•gynecological problems (abnormal menses, infertility)
Childhood obesity is a serious medical condition that affects children and adolescents, and can lead to poor self-esteem and depression.
The causes of childhood obesity are multi-factorial. Overweight in children and adolescents is generally caused by a lack of physical activity, unhealthy eating patterns resulting in excess energy intake, or a combination of the two. Genetics and social factors – socio-economic status, race/ethnicity, media and marketing, and the physical environment – also influence energy consumption and expenditure. (U.S. Department of Health and Human Services)
Lifestyle habits such as healthy eating and regular physical activity are methods to reduce the prevalence of overweight and obesity and the incidence of other serious health problems. What process was used to determine the relevancy of the public health issue to the community? (350 word limit) A Community Needs Assessment conducted among Baker county residents in 2008 revealed that residents were concerned about the occurrence of heart disease, cancer, high blood pressure, diabetes, and obesity. Results from a county-level Behavioral Risk Factor Surveillance Survey (BRFSS) conducted in 2007 validated these concerns. The survey revealed that 63.7% of adults in Baker County are overweight or obese, and only 18.7% of adults consume 5 or more fruits and vegetables every day. Body Mass Index (BMI) data collected statewide among 1st, 3rd, 6th and 9th graders in full-service schools (schools that focus on underserved students in poor, high risk communities needing access to medical and social services) showed that 17% of Macclenny Elementary School 1st graders, and 19% of 3rd graders, are at risk for being overweight, while 13% of 1st graders and 20% of 3rd graders are overweight. How does the practice address the issue? In general, children and adolescents are eating more food away from home, drinking more sugar-sweetened drinks, and snacking more frequently. Convenience has become one of the main criteria for American’s food choices today, leading more and more people to consume ‘away-from-home’ quick service or restaurant meals or to buy ready-to-eat, low cost, quickly accessible meals to prepare at home (U.S. Health and Human Services). According to the Centers for Disease Control (CDC), access to healthy foods, including fruits and vegetables, are key strategies to help increase fruit and vegetable consumption and improve nutrition. This project increased access to better nutrition by providing healthier food options (including fruits and vegetables), offered substitutions for fried foods, and reducing portion sizes. Is the practice new to the field of public health? If so, answer the following questions. No What process was used to determine that the practice is new to the field of public health? Please provide any supporting evidence you may have, e.g. literature review. How does this practice differ from other approaches used to address the public health issue? Is the practice a creative use of an existing tool or practice? If so, answer the following questions. Yes What tool or practice (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, etc.); did you use in a creative way to create your practice? (if applicable) (300 word limit total)
a. Is it in NACCHO’s Toolbox; (if not, have you uploaded it in the Toolbox)?
b. If you used a tool or practice to implement your practice, how was your approach to implementing the tool unique and innovative for your target area/population?
Baker CHD used elements from a practice created in Pinellas County, Florida. The Healthy Choices Restaurant Program offered by Steps to a Healthier Florida-Pinellas County and Florida on the Move allows families to select restaurants that offer healthy meal options. Each restaurant offers items on their adult menu that are heart healthy, low calorie and low carbohydrate. In addition restaurants that also offer children menus have 25% of the menu items designated as healthy options such as choice of grilled or broiled, vegetables, fruit, or rice instead of French fries and an option for smaller portion sizes of adult menu.
Macclenny, Florida is a rural community with a median household income of $46,513 and 17% of persons living below the poverty level (2009 U.S. Census). The county maintains either fast food or locally-owned restaurants, but few “chain” restaurants that are not considered fast food. Until recently, there were no farmer’s markets or community gardens in the community.
The Healthy Choice Restaurant Program provided options for both adults and children including reducing portion sizes and offering healthy substitutions. Colorful window decals, table tents, and placemats were created for participating restaurants. Restaurant servers were provided information about the program, and encouraged to distribute comment cards to patrons. To encourage program support, advertisements were posted in local newspapers to showcase restaurants offering healthy choice options.
What process was used to determine that the practice is a creative use of an existing tool or practice? Please provide any supporting evidence you may have, for example, literature review. Healthy eating habits that include daily servings of fruits and vegetables and heart healthy food options have shown positive impacts on reducing risks of overweight and obesity which is linked to heart disease and type 2 diabetes. This project provides availability and ease for community members to eat healthier food choices daily. Based on data that supports the targeted population eating out frequently, the project aims to provide healthy food options at locations community members are already familiar.
How does this practice differ from other approaches used to address the public health issue? According to The Guide to Community Preventive Services, school-based nutrition interventions have been implemented in school settings to promote healthy nutritional attitudes, knowledge and behavior, including eating and physical activity among school-aged children and adolescents. The interventions usually target food policy, environmental factors and/or nutrition education; however, the Task Force on Community Services found insufficient evidence to determine the effectiveness of multi-component school-based nutrition interventions in increasing fruit and vegetable intake and decreasing fat and saturated fat intake among school-age children. Who were the primary stakeholders in the practice? Restaurants participating in the Healthy Choice Restaurant Program What is the LHD's role in this practice? Baker CHD was one of nine local health departments participating in a learning collaborative targeting childhood overweight and obesity. They received funding from the state health office who was a participant in the Multi-State Learning Collaborative (MLC), a project supported by the Robert Wood Johnson Foundation. The CHD administered surveys and coordinated focus groups, using the results to identify a target population and determine project activities; conducted research that supported the planning and implementation of the Healthy Choice Restaurant Program; contacted and formed agreements with local restaurants; coordinated printing and delivery of promotional materials; facilitated advertising efforts; conducted evaluation through the collection of surveys and comment cards; and reviewed trend data to determine changes in their activities.
In addition, Baker CHD worked with local school personnel at Macclenny Elementary School to distribute healthy nutrition information, and encourage parents to eat at restaurants participating in the Healthy Choice Restaurant Program.
What is the role of stakeholders/partners in the planning and implementation of the practice? A primary stakeholder in the initiative included locally-owned and managed restaurants that agreed to participate in the program. They were responsible for displaying the materials (e.g. table tents; decals) provided by the CHD, collecting comment cards, and implementing the program by offering healthy choice options.
Other stakeholders included 1st grade teachers and principal from Macclenny Elementary School who distributed and collected parent surveys and nutrition information, and parents of 1st grade students who participated in the surveys. Finally, local residents who were patrons at participating restaurants and completed comment cards which contributed to the success of the program.
What does the LHD do to foster collaboration with community shareholders? Describe the relationship(s) and how it furthers the practice's goals. In an effort to promote healthy nutrition within the community, the CHD continues to maintain relationships with partners who assisted in the healthy restaurant initiative, and develop new collaborations with community stakeholders. As a result of their initial collaboration with Macclenny Elementary School, the CHD has continued to work with the school to promote healthy nutrition. The CHD and school have collaborated to provide raised bed gardens in two 2nd and one 3rd grade classrooms. Students have planted fourteen (14) different vegetables in the school garden, and are receiving weekly lessons on healthy nutrition.
For those restaurants continuing to sustain the program, the CHD recognizes and promotes their efforts.
In addition, the CHD has worked with local stakeholders and partners, including a lifelong gardener, to cultivate a community garden. Through relationships created with the local Department of Corrections, the garden is maintained by prisoners released for work camp. Vegetables and herbs from the garden are provided to the local food bank which provides assistance to low-income residents.
The CHD participated in a steering committee to coordinate a Farmer’s Market. It maintains two board members who help govern the market. Farmers from Baker and surrounding counties provide opportunities to purchase fresh produce every Saturday at a convenient location in the community. In an effort to reach low-income residents, the CHD is currently exploring information and vendor criteria for accepting WIC vouchers and SNAP cards.
Describe lessons learned and barriers to developing collaborations Keeping restaurants engaged in the project was time-consuming. The CHD would visit participating restaurants at least once monthly to collect comment cards and distribute additional materials. Some restaurants did not distribute or collect comment cards, and two restaurants did not post decals or materials identifying them as a Healthy Choice Restaurant. Begin by identifying from the targeted population where families most frequently dine out, then invite the top five (5) restaurants to participate in the initiative – especially when piloting the program.
In an effort to collect parent surveys, the CHD offered a $1.00 value for every survey collected. Approximately 450 out of 500 possible surveys were collected from parents in November 2009, and 410 out of 500 were received in March 2010. Funds were used to purchase basketball hoops and nets, soccer goals and balls, and other physical education equipment for the school. This created a positive collaboration between the CHD and school personnel. After collecting surveys in November 2009, the CHD posted a thank you letter in the local newspaper to Macclenny Elementary School and parents participating in the survey. This may be linked to the high response rate in March 2010.
When conducting focus groups and surveys to identify nutrition behavior, it is imperative to determine where adults and children are dining out. After implementation of the project and through data collection, the CHD noted that parents were eating more frequently at fast food restaurants rather than locally-owned and managed dine-in restaurants.
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.
Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
List up to three primary objectives for the practice. For each objective, provide the following information: (750 word limit per objective)
The project goal was intended to reduce the rise of children who are overweight and at risk of being overweight. The objective of the project was to improve healthy nutrition choices among 1st graders at Macclenny Elementary School. • Performance measures used to evaluate the practice: List the performance measures used in your evaluation. Depending on the type of evaluation conducted, these might be measures of processes (e.g., number of meetings held, number of partners contacted), program outputs (e.g., number of clients served, number of informational flyers distributed), or program outcomes (e.g., policy change, change in knowledge or attitude, change in a health indicator)
• Data: List secondary and primary data sources used for the evaluation. Describe what primary data, if any were collected for each performance measure, who collected them, and how.
• Evaluation results: Summarize what the LHD learned from the process and/or outcome evaluation. To what extent did the LHD successfully implement the activities that supported that objective? To what extent was the objective achieved?
• Feedback: List who received the evaluation results, what lessons were learned, and what modifications, if any, were made to the practice as a result of the data findings.
(see response below) The objective of the project was to improve healthy nutrition choices among 1st graders at Macclenny Elementary School. Overflow (Objective 1): Please finish the response to the question above by using this text area. Please be mindful of the word limits. Number of MES students parents who participated in surveys regarding weekly food consumption conducted in 2009 and 2010 were 450 (target = 500) and 410 (target = 500) Number of comment cards collected from children who selected healthy food options •November 2009 – 53 out of 106 (50%) •March 2010 – 30 out of 82 (37%) Number of children from MES dining at participating Healthy Choice Restaurants •November 2009 – 19% •March 2010 – 17% Rates of food consumed by 1st graders from November 2009 to March 2010 •Fried foods- increase 15 % •Vegetables- decreased 2% •Fruits- increased 19% The CHD provided surveys to 1st grade teachers for distribution to parents. Surveys were conducted over 5 days to assess childrens' food choices. Surveys were collected each day by teachers, and results entered in a database by CHD staff. Data: Comment cards were provided to restaurants participating in the Healthy Choice Restaurant Program. Servers distributed comment cards with the patron’s check, asked customers to complete the card, and provide to cashier. CHD staff collected comment cards once monthly and entered results in a database. Evaluation Results: Based on survey results, the CHD learned that parents and children were dining at fast food restaurants more frequently than locally-owned dine-in restaurants, and nutrition behaviors at home were not being impacted by nutrition information provided to parents. However, while the CHD had little impact on the targeted population, restaurant patrons appeared satisfied with the healthy alternatives provided. Some restaurants sustained the program based on customer feedback. Feedback: Baker CHD shared results with 1st grade parents, teachers and principal at Macclenny Elementary School, Baker CHD staff, and CHDs participating in the collaborative. Based on this information and consumption rates of unhealthy foods (e.g. fried) versus fruits and vegetables at home, the CHD capitalized on nutrition education being provided to students. The CHD partnered with a local gardener and worked with the school to implement raised bed school gardens. Results from comment cards were shared with participating restaurants. Overflow (Objective 2): Please finish the response to the question above by using this text area. Please be mindful of the word limits. N/A Overflow (Objective 3): Please finish the response to the question above by using this text area. Please be mindful of the word limits. N/A What are the specific tasks taken that achieve each goal and objective of the practice? 1. Conduct focus groups and survey parents about eating habits and physical activity of family outside of school.
2.Collect and track BMI of 1st graders at Macclenny Elementary School from 2008-2011.
3.Conduct research on evidenced-based and model programs related to healthy nutrition.
4.Implement Healthy Choice Restaurant Initiative
a.Identify restaurants willing to participate
b.Contact Pinellas County for artwork
c.Coordinate printing of resources (e.g. table tents; placemats; decals)
d.Distribute resources to restaurants
e.Coordinate advertisements in local newspapers
5.Develop questions for comment card surveys.
a.Print comment cards
b.Distribute to restaurants
6.Collect comment cards from participating restaurants.
a.Enter information in database.
b.Track trends
c.Identify opportunities for improvement, and make changes to activities
7.Conduct surveys among parents of 1st graders to determine healthy nutrition choices at home or dining out.
a.Enter information in database.
b.Track trends
c.Identify opportunities for improvement, and make changes to activities
What was the timeframe for carrying out these tasks? Baker CHD began this project by first reviewing data for adults and children in Baker county. Focus groups and surveys were completed in November 2008 and BMI data was collected in April 2009. Implementation of the Healthy Choice Restaurant Program began in September 2009, and comment cards from participating restaurants were collected in November 2009 and March 2010. Surveys to determine the eating habits of the target population and parental awareness of the HCRP were collected in November 2009, and again in March 2010. Six (6) weeks of advertising in local newspapers was completed between November 2009 and March 2010. Is there sufficient stakeholder commitment to sustain the practice? Describe how this commitment is ensured. Based on customer feedback and support provided by the Baker CHD, some restaurants are continuing to engage in the Healthy Choice Restaurant Program. Other partners are committed to continuing the Farmer’s Market and school and community gardens that target more community-wide populations. Describe plans to sustain the practice over time and leverage resources. Until resources become unavailable, Baker CHD plans to support restaurants (e.g. printed materials) continuing to participate in the Healthy Choice Restaurant Program as an additional program option to increase the consumption of healthier foods among community members. Additional school gardens (a total of 7 garden beds) are now planted at Macclenny Elementary School. Based on outcomes and funding, the CHD may expand school gardens to other school sites.
Baker CHD hopes to gain greater compliance by researching activities that most resonate with parents and their families, and use the activities as a vessel to educate about healthy foods options. Additionally, the CHD is conducting research, and identifying evaluation methods, to better determine the impact of community and school gardens on healthy food choices.
Practice Category Choice 1: Chronic Disease (Obesity) Practice Category Choice 1, Part 2: Practice Category Choice 2: Practice Category Choice 2, Part 2: Practice Category Choice 3: Practice Category Choice 3, Part 2 Check all that apply. NACCHO Web Site |
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