PRIORITY:  Decrease Overweight and Obesity Among Children

 

Objective for NPM 8.1: Increase the percentage of children ages 6-11 years who are physically active at least 60 minutes per day from 31.5% in October 1, 2020 to 40.0% in September 30, 2022.

 

Objective for SPM 6: Increase the percentage of public schools with at least 50% physical education class time spent in moderate to vigorous physical activity.

 

Note: There is currently no baseline data for Objective 2.  A question is being added to the annual Department of Education Quality Physical Education Survey in the fall of 2021 that will provide those data.  Target values for subsequent years will be set at that time.

 

Objective for SPM 7: Increase the rate of Double Up Food Bucks purchases per SNAP recipient in the targeted counties.

 

Note: There is currently no baseline data for Objective 3.  Data will be available in the fall of 2021 from the Double Up Food Bucks Program as well as from the Department of Human Services regarding SNAP recipients.  Target values for subsequent years will be set at that time.

 

Description: Data sources are scarce that provide health behavior and health status information for our priority domain of children ages 0 to 11. There is no one source that captures overweight or obesity data for the entire age group, as the Youth Risk Behavior Survey does for high school students. Therefore, the MCH child obesity team relies on the National Survey of Children’s Health for children aged 6-11 on meeting daily physical activity standards (NPM 8.1) and for overall health status (NOM 19); the TN Departments of Education and Health Weight Status (BMI) Annual Report for K-12 public school students (SOM 3); and the TN WIC dataset for overweight or obesity among program participants aged 2-4 (SOM 4). Each of these datasets has its own advantages as well as limitations.

 

Available data pertaining to disparities by age, race/ethnicity, gender, and place show a significant disparity among Black non-Hispanics compared to White non-Hispanics (78.2% vs 91.7%, respectively) for the proportion reporting an overall health status of very good or excellent. Among K-12 students, males are more likely to be overweight or obese than females in 4th grade (42.7% vs. 40.5%) or 6th grade (45.7% vs. 44.2%). In addition, rural students are more likely than metro students to be overweight or obese for all grades K-12 (40.5% vs. 38.0%) and for K-6 (38.8% vs. 36.9%), grade 4 (42.8% vs.39.7%), and grade 6 (46.0% vs.42.9%), respectively. Rural male students are also more likely to be overweight or obese than rural female students for K-12 (41.0% vs. 40.1%), K-6 (39.3% vs. 38.2%), grade 4 (44.1% vs. 41.5%), and grade 6 (47.2% vs. 44.8%), respectively.

 

Among TN WIC recipients during CY 2021, 3-year-olds appear to be more overweight or obese (34.6%) than either 2-year-olds (30.5%) or 4-year-olds (30.7%). Overall, pre-school males in WIC seem to be more likely to be overweight or obese than females (32.7% vs. 31.1%). The same is true for Whites (32.6%) as compared to Blacks (30.4%) and all other racial groups (28.1%), respectively. However, Hispanics do appear to be more overweight or obese than non-Hispanics (34.6% vs. 31.5%), especially for White Hispanics (34.8%) and Other Hispanics (32.6%). Finally, WIC recipients in non-metro (rural) areas seem more likely to be overweight or obese than metro areas (32.5% vs. 31.0%).

 

Disparity Elimination Focus: Based on the available data sources and the general analysis presented above, the Child Health Obesity Team has selected geographic disparities (e.g., urban/metro vs. rural) among the early childhood population as the primary health equity focus. Data from the WIC program as well as the 2019-2020 TDH/TDE BMI Report indicate that these disparities not only exist in the priority population but persist as children enter public schools in kindergarten and beyond. In addition, unlike school-based and other programs that serve elementary, middle, and high school aged children, it is difficult to find broad, community-based health and fitness related programming for younger children besides WIC, which serves a specific and limited population.

 

The Gold Sneaker (GS) Initiative represents another reason to adopt early childhood as the priority strategy, as it is one of those few programs that engages this population directly. The TDH Family Health and Wellness Division, Chronic Disease and Health Promotion Section, developed GS over ten years ago and has worked ever since to promote and expand GS certification for childcare facilities. There were over 800 certified daycare centers statewide at the program’s height. GS endorses policies related to physical activity, nutrition, and tobacco free spaces in these facilities.

 

The GS program director recently left TDH, and COVID has certainly impacted the operation of daycares overall. However, as we emerge from COVID restrictions, now is the perfect time for TDH to reconstruct and reinvent GS while incorporating health equity through Strategy 2 below.

 

The following strategies and activities are planned for October 1, 2022 to September 30, 2023:

 

Strategy 1: Support school-based efforts to promote physical activity and good nutrition

 

Supporting Evidence: Physical Activity: Enhanced School-Based Physical Education: Enhanced school-based physical education (PE) involves changing the curriculum and course work for K-12 students to increase the amount of time they spend engaged in moderate- or vigorous-intensity physical activity during PE classes. 

https://www.thecommunityguide.org/findings/physical-activity-enhanced-school-based-physical-education

 

Activity 1a: Collaborate with DOE to develop and implement strategies to provide professional development to physical education teachers pertaining to engaging students in moderate-to-vigorous-physical activity 50% or more of physical education class time.

 

Activity 1b: Collaborate with DOE to provide professional learning opportunities that connect mental health and physical health for PHEs and Health Councils, and youth (ie trauma-informed care, Youth Mental Health 1st Aid training, Movement as Medicine).

 

Strategy 2: Promote Gold Sneaker voluntary recognition program for licensed childcare centers

 

Supporting Evidence: Center-based early childhood education programs (ECE) aim to improve educational outcomes that are associated with long-term health as well as social- and health-related outcomes. Economic evidence indicates there is a positive return on investment in early childhood education. The benefits from students' future earnings gains alone exceed program costs. If targeted to low-income or racial and ethnic minority communities, ECE programs are likely to reduce educational achievement gaps, improve the health of these student populations, and promote health equity. https://www.thecommunityguide.org/findings/promoting-health-equity-through-education-programs-and-policies-center-based-early-childhood

 

Activity 2a: Host 1-2 technical assistance training for health promotion staff statewide in using the TrainTN system for Gold Sneaker certification training for licensed daycares.

 

Activity 2b: Provide a minimum of 1-2 trainings that address implementation practices of Gold Sneaker policies for public health educators, daycare staff, TN Department of Human Services staff, and Child Care Resource & Referral Center staff, and other partners statewide.

 

Activity 2c: Conduct needs assessment and data mapping to identify at least twenty (20) priority rural counties with high rates of childhood obesity and lower availability and/or access to childcare services overall, including licensed childcare as well as GS certified facilities.

 

Activity 2d: Reconvene the GS Task Force by engaging organizations that represent or provide services in all twenty (20) or more priority counties. These organizations should include, but not be limited to, DHS, TCCY, CHANT, TDOE, TDEC Health Parks Health Person, and Child Care Resource and Referral (CCR&R)

 

Activity 2e: Identify at least one (1) additional community-based organization or facility in each priority county, including those already GS certified, as champions to raise awareness of early childhood obesity, health disparities, and gaps in existing resources and to promote the adoption of the restructured GS Initiative and policies. Utilize the identified community-based organizations to (1) disseminate GS promotional materials through one-on-one contact or via hand off to other community-based agencies to at least thirty (30) early childcare facilities across the priority counties; and (2) enroll childcare educators and childcare professionals from at least fifteen (15) of the thirty (30) facilities into the approved GS training on the DHS TrainTN professional development clearinghouse site.

 

Strategy 3: Partner with healthcare providers to promote physical activity counseling during well-child visits

 

Supporting Evidence: Physical Activity: Family-Based Interventions. Family-based interventions combine activities to build family support with health education to increase physical activity among children. https://www.thecommunityguide.org/findings/physical-activity-family-based-interventions

 

TDH will focus on increasing provider referrals from TDH clinics in the West region, as electronic health records show referrals from the West region are low as compared to other TDH regions, and app usage in the West is less when compared to other regions of the state.  This approach will also address health equity, as the West region of the state has a higher percentage of African Americans, as compared to other regions (not including Metro Health Departments).

 

Activity 3a: Provide training for 5 health provider champions on how to incorporate the use of the Healthy Parks Healthy Person park prescription portal to increase family-based physical activity.

 

Activity 3b: Promote the use of the Healthy Parks Healthy Person park prescription program and app by PHNs, WIC staff, and other health providers in 10 additional local health departments with an emphasis in west Tennessee.

 

Strategy 4: Promote policy, systems, and environmental change (PSE) strategies to increase physical activity and promote access to healthy food and beverages

 

Supporting Evidence: Physical Activity: Creating or Improving Places for Physical Activity. In these types of interventions, worksites, coalitions, agencies, and communities work together to change local environments to create opportunities for physical activity. Changes can include creating or improving walking trails, building exercise facilities, or providing access to existing facilities. https://www.thecommunity guide.org/findings/physical-activity-creating-or-improving-places-physical-activity

 

Activity 4a: Support and provide technical assistance to at least 5 local communities who set a goal to increase physical activity through the construction of walking and nature trails.

 

Activity 4b: Collaborate with non-profits in east Tennessee to increase access to fresh fruit and vegetables for SNAP recipients through the Double Up Food Bucks program.

 

Planned Partnerships:  CHANT, Department of Human Services; Tennessee Council on Children and Youth, Tennessee Department of Education, Tennessee Department of Environmental Conservation, Healthy Parks Healthy Person, Child Care Resource and Referral, and Partners employing PSE strategies (funded through Project Diabetes, a state funded grant initiative)

 

Contextual Factors:  1) economic/fiscal outlook; 2) political and social influences; 3) legislation and policies (facilitators or barriers); 4) COVID variants; 5) product marketing supporting poor nutrition or sedentary lifestyles; 6) SES, racial/ethnic, geographic disparities; 7) overall trends toward sedentary behavior (e.g., screen time) and less healthy diets (e.g., fast food).

 

Assumptions:  1) Funding will be secured throughout the course of the project. Children who learn and practice good physical activity and nutrition habits will maintain these habits for life.  2) Professionals will be motivated to attend workshops (e.g., HPHP, GS, etc.) and implement lessons learned. 3) Evidenced-based program implementation as well as polices and regulations promoting nutrition/PA will lead to healthy behaviors and a reduction in obesity.

 

PRIORITY:  Increase Prevention and Mitigation of Adverse Childhood

Experiences (ACEs)

 

Objective for SPM 8:  By September 30, 2025, the percent of children with two or more ACEs will decrease from 23.0% to 21.0%.

 

Objective for SPM 9: By September 30, 2025, decrease the percent of investigated child maltreatment cases among families served by home visiting programs from 3.3% to 3.0%.

 

Objective for SPM 10: By September 30, 2025, decrease the percent of caregivers who experience intimate partner violence and do not receive professional support services among families served by home visiting programs from 8.0% to 3.0%.

 

Description: Out of 1,500 births per week in Tennessee, approximately 100 will report Spanish as their primary language spoken at home; and approximately 10 will report Arabic as their primary language spoken at home. Among our current EBHV participants, 14% (280 households) speak a language other than English as their primary language at home.

 

Under the auspices of TDH are 15 evidence-based home visiting (EBHV) local implementing agencies (LIAs). The LIAs employ 197 home visitors to provide direct EBHV services to families, 24 (14%) of which are bilingual. The languages represented among the EBHV workforce are Spanish, Arabic, Turkish and Portuguese.

 

According to a survey of EBHV LIAs in Tennessee, it is difficult to find and retain bilingual home visitors due to the high demand for bilingual persons in healthcare and other sectors. LIAs reported that the Language Line is used when there is no bilingual home visitor, but it is costly and therefore financially unsustainable. Additional limitations include various dialects not spoken by either bilingual home visitors or Language Line staff. Some LIAs reported having referred families to other programs with bilingual capabilities; and some also reported having received referrals for non-English speaking families they could not serve. One program shared, “So far this year we have received 6 referrals on Spanish-speaking only families that we were unable to serve. We used our translation services to engage them, but the relationships did not progress to enrollment”.

 

Disparity Elimination Focus: Some areas of the state have a greater need for bilingual home visitors/interpreter services than is currently available. While most bilingual home visitors speak English and Spanish, the team recognizes there are many other non-English languages spoken in the state who may be unable to access EBHV services due to an existing language barrier. The ACEs team will focus on the language disparity though Strategy 4 below.

 

The following strategies and activities are planned for October 1, 2022 to September 30, 2023:

Strategy 1: Increase knowledge and practice of ACE and Trauma Informed Care (TIC).

 

Supporting Evidence for Strategy 1:  The variety of sectors can make a difference in preventing ACEs by impacting the various contexts and underlying risks that contribute to violence and adversity and by supporting safe, stable, nurturing relationships and environments for all children while taking a trauma informed approach to prevent ACEs.

 

Centers for Disease Control and Prevention (2019). Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/pdf/preventingACES.pdf

 

Activity 1a: Develop and implement online TIC training for TDH staff, including those in the CHANT and EBHV programs. Through this training TDH staff and CHANT and EBHV programs will be able to integrate trauma informed practices into their work with families, mitigating the impact of ACEs.

 

Activity 1b: Provide ACE and TIC refresher training for child fatality teams as part of their ongoing training. This training will provide information and insight to teams on the impact of ACEs and trauma and assist in understanding the impact on social determinants of health.

 

Strategy 2: Ensure a strong start for children by promoting a healthy parent-child attachment through implementation of home visiting programs throughout the 95 counties of Tennessee.

 

Supporting Evidence for Strategy 2: Effective home visiting models have demonstrated many benefits for children and parents. Early childhood home visitation can prevent ACEs by providing information, caregiver support, and training about child health, development, and care to families in their homes to build a safe, stable, nurturing and supportive home environment. Children participating in a home visiting program have better cognitive and language development, better academic achievement, fewer behavioral problems, lower rates of substance use, and fewer arrests, convictions, and parole violations by age 19. Home visiting is associated with better pregnancy outcomes, improved parenting practices, reductions in the use of welfare and other government assistance, greater employment, lower rates of substance use, and reduced exposure to intimate partner violence.

 

Centers for Disease Control and Prevention (2019). Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/pdf/preventingACES.pdf

 

Activity 2a: Teach positive parenting skills through home visitation in partnership with local EBHV implementing agencies. This will include encouraging social-emotional learning and parent-child relationship whose instability has been exacerbated by the COVID-19 global pandemic.

 

Activity 2b: Provide health education through EBHV home visiting programs in counties throughout Tennessee. Communicating the importance of children having a medical home to parents promotes high quality and culturally effective integrated care.

 

Activity 2c: Provide supportive care and additional services to families and children through EBHV home visitation. By connecting families with concrete services and knowledge of parenting and child development improve protective factors which mitigate or prevent ACEs.

 

Strategy 3: Intervene to lessen immediate and long-term harms by linking families to health and social services.

 

Supporting Evidence for Strategy 3:  Traumatic events in childhood can be emotionally painful or distressing and can have effects that persist for years. Factors such as the nature, frequency and seriousness of the traumatic event, prior history of trauma, and available family and community supports can shape a child’s response to trauma. Creating and sustaining safe, stable, nurturing relationships and environments for all children and families can prevent ACEs and help all children reach their full health and life potential.

Centers for Disease Control and Prevention (2019). Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/pdf/preventingACES.pdf

 

Activity 3a: Screen and assess families for enrollment in CHANT to identify health and social needs that have long term impact on families and children. By identifying the needs of families’ immediate needs, priority services can be provided to families.

 

Activity 3b: Provide referrals to families for identified health care and social service needs. Identifying which of the sixteen pathways of care families have identified as needs increase the protective factors within a family by providing concrete services at the time identified.

 

Activity 3c: Assist families in navigating the healthcare and social services system through the CHANT care-coordination model. Aiding in navigating any of the sixteen pathways, including obtaining a medical home or an EPSDT, is solution focused as barriers and other obstacles are addressed. Through this, family resiliency is increased as a strategy to eliminate and mitigate ACEs the family might have experienced.

 

Strategy 4: Increase access of non-English speaking families to infant and early                                           child health and development education and services.

 

Supporting Evidence for Strategy 4:  While many non-English languages are spoken in the state, most bilingual home visitors speak English and Spanish. Home visitors who are not bilingual currently use the Language Line for interpreter services. EBHV LIAs report this is costly and not sustainable due to the costs. Also, curricula used is not available in the languages needed and the cost to translate is cost prohibitive. Additional limitations include various dialects not spoken by either bilingual home visitors or Language Line staff.  According to a survey of EBHV LIAs in Tennessee, it is difficult to find and retain bilingual home visitors as these positions are competitive and more expensive. Some programs reported having referred families to other programs with bilingual capabilities. Further, some reported having received referrals for non-English speaking families that they could not serve.

 

Activity 4a: Analyze birth file data to determine the language needs across the state. Utilize existing EBHV service data from LIAs and meetings with community partners to determine where language disparities exist based on region.

 

Activity 4b: Utilize language disparity data to inform funding amounts for interpreter/language services for EBHV LIAs, and work towards establishing a contract with the TDH interpreter/language services vendor to increase availability of interpreter services in order to expand accessibility of EBHV services to more non-English speaking families.

 

Activity 4c: Obtain current estimates on the cost to have the Welcome Baby universal outreach booklet translated to Spanish and Arabic.

 

Planned Partnerships:  TDH maintains and continues formal partnerships with the Tennessee Council on Children and Youth (TCCY)/Building Strong Brains (BSB) Committee; Home Visiting Leadership Alliance (HVLA); Young Child Wellness Council (YCWC); and Regional and Metro Health Departments.

 

Contextual Factors:

TDH will demonstrate leadership in promoting ACE mitigation factors.

 

Assumptions:

Partners will be informed about ACES and implement trauma informed care practices in their work. Families will demonstrate positive interactions with their children.