Establishing Work Site Wellness Committees in Perry County, Alabama

Establishing Work Site Wellness Committees in Perry County, Alabama Perry County, Alabama ALABAMA STRATEGIC ALLIANCE FOR HEALTH IMPLEMENTATION GUIDE ...
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Establishing Work Site Wellness Committees in Perry County, Alabama Perry County, Alabama

ALABAMA STRATEGIC ALLIANCE FOR HEALTH IMPLEMENTATION GUIDE

Establishing Work Site Wellness Committees in Perry County, Alabama Section 1: Abstract Perry County, Alabama, with less than 11,000 residents in 2009, is the third least populated county in Alabama. This county has lost a significant number of people over the last few decades due to out-migration, or more people leaving the county than moving into it. From 2000 to 2009, the population declined by 1,200 residents, or nearly 11 percent of the 2000 census count.1 In 2000, Perry County was one of only 15 of the state’s 67 counties defined by the Census Bureau as 100 percent rural.2 African Americans comprise the largest racial group in the county population, at 68 percent.3 Like the other Alabama counties selected to participate in the Centers for Disease Control and Prevention Strategic Alliance for Health Program, Perry County is characterized by a high poverty rate (32 percent) and low income levels (a median household income of $26,513 in 2008 versus $42,586 for the state as a whole).4 Perry County ranked ninth highest of the state’s 67 counties in chronic disease burden, according to a report released by the Alabama Department of Public Health in 2004.5 According to the report, Perry was tied for third among all counties with the highest prevalence rates of adults with diabetes, and ranked fifth in hypertension and seventh in obesity. In addition, the rate of death from heart disease was 27 percent higher than the statewide rate in 2008.6 Strategic Alliance for Health communities seek to improve community health through sustainable, innovative, and evidence-based community health promotion and chronic disease prevention interventions that promote policy, systems, and environmental changes. To do this, Strategic Alliance for Health communities focus on building local capacity to implement policy, systems, and environmental changes related to promoting physical activity and nutrition and reducing tobacco use and exposure. Additionally, Strategic Alliance for Health seeks to improve and increase access to quality care, help eliminate racial/ethnic and health disparities, and reduce complications from and incidence of heart disease, diabetes, and obesity. Strategic Alliance for 1

Health has partnered with Sowing Seeds of Hope, a nonprofit organization in Perry County. Sowing Seeds of Hope, established in 1990, partners with community members, organizations, and churches to improve the quality of life for residents. It seeks to enhance social and physical infrastructures to meet citizen needs (e.g., improving health care, housing, transportation, and agricultural markets). In 2009, Sowing Seeds of Hope received a Strategic Alliance for Health grant from the Alabama Department of Public Health, funded by a cooperative agreement between the Alabama Department of Public Health and the U.S. Department of Health and Human Services as part of the Centers for Disease Control and Prevention Healthy Communities Program. Sowing Seeds of Hope is leading local Strategic Alliance for Health initiatives, such as advocating for a city-wide tobacco ordinance and creating new accessible places for physical activity. However, its primary focus is supporting local work sites as they establish work site wellness committees that support implementation of comprehensive work site wellness programs. The implication of this intervention is that it can improve the health of more than 3,600 employees. Sowing Seeds of Hope and Strategic Alliance for Health staff built a community consortium in Perry County in 2009. After conducting a comprehensive assessment using the Community Health Assessment aNd Group Evaluation (CHANGE) tool,7 the Perry County Strategic Alliance for Health Consortium identified work site wellness as a strategic priority. This tool assessed and documented policy, systems, and environmental supports currently in place throughout Perry County that impact chronic disease. Based on meetings with local organizations, consortium members determined that work sites recognized the importance of creating a healthy environment for their employees who spend up to eight hours a day on the job. However, work site managers felt the burden of implementing work site wellness as another item on their “to do” list. The Strategic Alliance for Health staff, consisting of the program director, two senior health educators, communities coordinator, and the Strategic Alliance for Health 2

Perry County Community Coordinator, recommended that work sites establish wellness committees. Wellness committees can lead work site wellness programming with maximum buyin from all organizational levels of the work site and share responsibility among committee members for program planning, implementation, and evaluation. A work site wellness committee identifies policy changes needed to support healthy choices within the workplace. The committee can conduct assessments of existing policy, systems, and environmental supports, develop action plans, and implement changes that will create opportunities to be physically active, make healthy eating choices, and avoid or reduce tobacco use and exposure. Four wellness committees have been established in Perry County and, through the implementation of healthy food and tobacco-free campus policies, employees are experiencing success in weight loss and decreased exposure to secondhand smoke. In addition, implementation of environmental supports, such as measured and marked walking paths and spaces dedicated to exercising, are increasing employees’ access to physical activity opportunities. Background The Strategic Alliance for Health, funded since 2008 by the Centers for Disease Control and Prevention Healthy Communities Program, creates healthier communities through the implementation of sustainable, innovative, and evidence-based community health promotion and chronic disease prevention strategies that promote policy, systems, and environmental changes across multiple sectors (community-at-large, community-based institutions, health care, schools, and work sites). Strategic Alliance for Health funds 15 communities within three categories:

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1. State-Coordinated Small Cities or Rural Areas: Dallas, Perry, and Sumter counties, supported by the Alabama Department of Public Health; and Albany, Broome, Orange, and Schenectady counties, supported by the New York State Department of Health 2. Large Cities or Urban Areas: Boston, Massachusetts; DeKalb County, Georgia; Hamilton County, Ohio; Hillsborough County, Florida; and New York City, New York 3. Tribes or Tribal Entities: Sault Ste. Marie Tribe of Chippewa Indians in Michigan, and Cherokee Nation in Oklahoma

Strategic Alliance for Health communities work collaboratively with key partners (e.g., community and state leaders, including representation from education agencies, the health care sector, business and industry, community and faith-based organizations), to build local capacity to institute policy, systems, and environmental changes. These changes are related to promoting physical activity and nutrition and reducing tobacco use and exposure; improving and increasing access to quality care; helping eliminate racial/ethnic and socioeconomic health disparities; and reducing complications from and the incidence of heart disease, diabetes, and obesity. Additional information on Strategic Alliance for Health can be found on the Centers for Disease Control and Prevention Healthy Communities Program website at: http://www.cdc.gov/healthycommunitiesprogram.

Section 2: Planning and Development Role of the Alabama Department of Public Health The Alabama Department of Public Health was awarded funding for the Alabama Strategic Alliance for Health Program under a five-year cooperative agreement with the Centers for Disease Control and Prevention, titled Building a Healthy Nation — Strategic Alliance for Health. From 2009 to 2013, the Alabama Strategic Alliance for Health will support communities in 15 west Alabama counties as they implement policy, systems, and environmental interventions 4

targeting chronic disease. Interventions will be evidence-based and will focus on the following conditions and risk factors: Obesity, diabetes, cardiovascular disease, nutrition, physical activity, and tobacco use and exposure. Program staff at the Alabama Department of Public Health was hired at both the state and local public health area levels to provide fiscal and programmatic leadership and management for the cooperative agreement program. At the state office, a fulltime program director, and one full-time and one part-time senior health educator were hired. At the public health area level, one full-time communities coordinator and a part-time administrative assistant were initially hired; a social worker was hired later. The responsibilities of these staff are to provide training, technical assistance, and administrative support to funded communities to facilitate their successful implementation of policy, systems, and environmental interventions. To coordinate program activities in Perry County, the Alabama Department of Public Health executed a contract with Sowing Seeds of Hope. This nonprofit organization, established in Perry County in 1990, seeks to partner with community members, organizations, and churches to improve the quality of life for residents. They also seek to enhance social and physical infrastructures to meet needs, as well as improve agricultural markets, housing, health care, and transportation. This contract supported hiring of a local full-time Perry County Strategic Alliance for Health Program Coordinator to lead and guide implementation of local activities. Develop and Utilize Coalitions and Partnerships Assess Existing Coalitions or Partnerships When the Strategic Alliance for Health Program began in Perry County in 2008, the program director and communities coordinator searched for a community coalition or organization that would lead local program activities by mobilizing local partnerships and leveraging resources. Program activities would address poor nutrition, physical inactivity, tobacco use and exposure, diabetes, obesity, and cardiovascular disease through implementation 5

of policy, systems, and environmental strategies. Establishing wellness committees at local work sites to build comprehensive wellness programs would be a primary focus throughout the year.

Tip: Definitions of Policy, Systems, and Environmental Change Strategies Policy changes are changes in the laws, rules, and procedures that guide or influence behavior. An example would be a work site establishing a policy that designates it as having a tobacco-free campus. Systems changes are changes that impact the social norms of an institution, organization, or system. For example, a work site agrees to let employees take a physical activity break on work time. Finally, environmental changes can be physical (a work site creating an indoor exercise room for employees to use), social (a work site establishing a wellness committee to drive wellness programs), or economic (a work site paying part of an employee’s membership dues to a local YMCA).

With the assistance of local and regional Alabama Department of Public Health administrators familiar with Perry County resources, the program director and the communities coordinator contacted numerous organizations in the county to identify an entity experienced in coordinating policy, systems, and environmental strategies to reduce chronic disease. No such entity was found. However, a strong organization was present whose mission was reducing health disparities in Perry County — Sowing Seeds of Hope (www.sowingseedsofhope.org). Sowing Seeds of Hope is a faith-based, nonprofit organization established in Perry County in 1990, to improve the well-being of citizens. Affiliated with the Alabama Cooperative Baptist Fellowship, Sowing Seeds of Hope is committed to working collaboratively with local partners to determine the best ways to provide health care, education, job skills, economic development, and adequate housing to citizens of Perry County. When they were approached by the program director and the communities coordinator to form a partnership and coordinate local activities, the executive director was agreeable because the organization focuses on mobilizing local

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partnerships to improve community health, closely aligning with the initiatives of Strategic Alliance for Health. Build a Consortium, Involving Traditional and Non-traditional Partners The decision to create a Perry County Strategic Alliance for Health Consortium was made by the program director, the communities coordinator, the Perry County Strategic Alliance for Health Coordinator, and the local health department administrator. It was agreed that a community consortium with a singular focus on community-driven, sustainable policy, systems, and environmental interventions was necessary to achieve desired outcomes, rather than adding this focus to an existing consortium with a different mission. Numerous meetings and phone conferences were conducted by these individuals to identify possible consortium members. The Strategic Alliance for Health Program focus areas (i.e., nutrition, physical activity, obesity, cardiovascular disease, and diabetes) were used to identify potential members. The Perry County Strategic Alliance for Health Coordinator provided names of individuals in the county who might participate on behalf of an organization or agency. The coordinator also recommended individual citizens who would be affected by work site wellness initiatives, and, therefore, helpful to future planning and implementation. The local health department administrator provided suggestions based on long-standing relationships with the county and city governments, work sites, health care providers, schools, and churches. Traditional partners, those directly tied to one or more of the focus areas, were identified easily, such as a regional agent with the Alabama Cooperative Extension System and the director of the Child Nutrition Program of the Perry County School System. However, identifying nontraditional partners, those not working in these focus areas on a daily basis, was more difficult. Examples included representatives from two local colleges and from the Perry County Courthouse. Each of these representatives later proved to be integral to initiation of work site wellness initiatives. Table 1 provides information on Perry County Consortium members and their organizational role. 7

Table 1. Perry County Consortium Membership PERRY COUNTY STRATEGIC ALLIANCE FOR HEALTH CONSORTIUM MEMBERS Organization Name Organization Role Work Sites Perry County Courthouse

Clerk

TekPak, Inc.

President

Schools Perry County School System

Superintendent

Perry County School System

Child Nutrition Program Director

Albert Turner Sr. Elementary School

Teacher

Uniontown Elementary School

Teacher

Francis Marion High School

Teacher

Health Care Perry County Health Department Sowing Seeds of Hope

Alabama Department of Public Health Assistant Area Administrator Executive Director

Sowing Seeds of Hope

Program Coordinator

Marion Health Center

Physician

Perry County Rural Health Medical Program Executive Director Community-Based Institutions Uniontown Housing Authority

Director

Judson College

Outreach Coordinator

Judson College

President

Judson College

Development Director

Judson College

Nurse

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Community-Based Institutions (continued) Judson College

Vice President

Marion Military Institute

President

Marion Military Institute

Development Director

Marion Military Institute

Nurse

Samford University

School of Pharmacy Dean

Samford University

School of Pharmacy Instructor

Perry County Department of Human Resources Marion Military Institute

Director

Alabama Cooperative Extension System

Regional Agent

Perry County Head Start Program

Director

East Perry Church District

Church Member

Easy Perry Improvement Association

President

First Missionary Baptist Church of Uniontown Community-at-Large

Health Ministry Leader

Perry County Commission

Commissioner

Marion City Government

Mayor

Marion City Council

Councilman

Uniontown City Government

Mayor

Alumni Affairs Director

The Perry County Strategic Alliance for Health Coordinator and local health department administrator invited persons through face-to-face meetings and phone calls to attend the initial Consortium meeting. The location of the meeting was the community room at the Perry County Health Department because the site was familiar to invitees and convenient to most. In addition,

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no fees are associated with community meetings held in county health department community rooms. A morning meeting time was set, presumably convenient to most invitees. After the meeting, noting that some invitees did not attend, the Perry County Strategic Alliance for Health Coordinator committed to follow up with individuals to assess their interest and willingness to attend future meetings. Members present also provided names of persons not previously identified who should be contacted prior to the next meeting. These were persons who could be instrumental in implementing wellness programs in local work sites. The Perry County Strategic Alliance for Health Coordinator agreed to make personal phone calls and visits to engage these persons as well. Process to Orient and Integrate Members Into the Consortium At the initial meeting, the program director, communities coordinator, and Perry County Strategic Alliance for Health Coordinator provided an overview of the Strategic Alliance for Health Program. The Perry County Strategic Alliance for Health Coordinator highlighted the important roles of the members present and their potential strengths in implementing future policy, systems, and environmental changes in Perry County, particularly ones related to work site wellness initiatives. The program director reviewed the Socio-Ecological Model, including the multiple spheres of influences on community health where change can occur and the importance of working at the outermost spheres of influence (e.g., the organizational, community, and public policy levels) in order to achieve sustainable changes and impact the greatest number of citizens (Figure 1).8 Creating wellness committees within work sites that drive comprehensive wellness programs was used as an example of change at the third sphere of influence. This approach to improving community health was new to most members present, who were more familiar with health education programming that affects individual behavior change.

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Figure 1. The Socio-Ecological Model8

Representatives present engaged in dialogue about Perry County assets and needs related to local work sites. A strength noted was that Sowing Seeds of Hope had established links to local work sites through periodic free health screenings. However, it was stated that work sites did not generally have policy, systems, or environmental change supports promoting healthy lifestyles among employees. This discussion, along with the information presented on availability of technical assistance and resources from the Strategic Alliance for Health Program, led members to verbally agree to formally establish the Perry County Strategic Alliance for Health Consortium. Consortium members consented to meet monthly in the local health department community room, complete a comprehensive community assessment, and develop a community action plan targeting policy, systems, and environmental change strategies to increase work sites with wellness committees implementing wellness programs to create healthier workforces. Existing Community Change Strategies to Build Upon Consortium members were asked to share information about ongoing community activities that might be relevant to future policy, systems, and environmental changes related to work site wellness. The purpose of eliciting this information was to identify work sites currently implementing some wellness programming and to surmise their readiness to establish formal 11

wellness committees to drive policy, systems, and environmental change interventions rather than focusing on health education programming exclusively. The following are examples of information that were offered: •

The Perry County School System Superintendent discussed recent participation in the Alliance for a Healthier Generation’s Healthy School Program. Perry County schools achieved the National Recognition Award at the bronze level in 2008. However, the Healthier Generation’s Healthy School Program did not include a work site wellness program for teachers, which was identified by the school system as a future need.



The Sowing Seeds of Hope Executive Director described the free weekly blood pressure and diabetes clinics at the local health department staffed by pharmacists from Samford University McWorter School of Pharmacy. Owners of local work sites are notified about clinics accessible to their employees. This link could facilitate initial promotion of wellness committees to upper management at these sites.



The Perry County Circuit clerk discussed past participation in the state Scale Back Program, a weight-loss program that resulted in notable weight losses among participants at the courthouse. She verbalized the need for more comprehensive work site wellness. Scale Back Alabama is an annual statewide weight-loss contest which began in January 2007. The purpose of the free 10-week contest, conducted every year from January through March, is to encourage Alabamians to lose weight, exercise, and have fun while doing it. The campaign is geared toward adults and is primarily operated with the help of local employers (companies with 10 employees or more), hospitals, and health departments. Each organization appoints one person to serve as the organization coordinator for the contest. This individual has access to a comprehensive toolkit with everything needed for hosting a contest locally and serving as a weigh-in site. Complete program information is found at www.scalebackalabama.com.

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Conduct a Needs Assessment The Perry County Strategic Alliance for Health Consortium conducted a comprehensive community assessment in the spring of 2009, to gain a better understanding of strengths and weaknesses related to chronic disease to enable future action planning for work site wellness initiatives. Consortium members viewed the assessment process as an integral step to planning and prioritizing consortium activities. Consortium members used an assessment tool created by the Centers for Disease Control and Prevention, the Community Health Assessment aNd Group Evaluation (CHANGE) tool. Assessments were completed at five sites in the following sectors, if possible: Work sites, community-based institutions, schools, and health care sites. The program director and the communities coordinator provided instruction on how to complete site assessments. Members were advised to use two or more strategies to assess each site. Two methods suggested included face-to-face interviews with multiple stakeholders and direct observation with photographic documentation. The value of photovoice, the process of documenting assessment data with photographs, was stressed. For example, a work site representative could report that a tobacco policy existed that prohibited smoking within 50 feet of the building entrance, but observation revealed cigarette butts and other tobacco litter much closer to the entrance. Photographs of the site could make the case for the critical gaps in policy enforcement.

Tip: Community Health Assessment aNd Group Evaluation (CHANGE) This tool was used to document existing policy, systems, and environmental change strategies throughout Perry County that impact chronic disease. The tool is divided into the following five sectors: Work site, school, health care, community-based institution, and the community-at-large. Within each sector, multiple sites were assessed related to the following modules: Nutrition, physical activity, tobacco, chronic disease management, and leadership. The school sector had an additional module, after-school programs. The complete Community Health Assessment aNd Group Evaluation (CHANGE) Action Guide can be downloaded at www.cdc.gov/healthycommunitiesprogram. 13

By summer 2009, members had completed assessments at 11 work sites, six communitybased institutions, four schools, and seven health care sites. Eight of the 11 work sites scored very low in each module, indicating that employees are not supported or encouraged to adopt healthy lifestyles related to nutrition, physical activity, tobacco, and chronic disease management. The work sites assessed had not established a work site wellness committee to address wellness issues. The Consortium considered these results in the context of the large number of Perry County citizens working (approximately 1,700 citizens report being employed in private, non-farm settings) and concluded work site wellness initiatives would be a focus of future activities. It was decided that encouraging work sites to establish wellness committees with a designated coordinator was the first step toward implementation and adoption of comprehensive wellness programs. Identify and Engage Stakeholders Once it became clear establishing wellness committees at local work sites would be the focus of the consortium, the Perry County Strategic Alliance for Health Coordinator considered which work sites might be willing to implement wellness committees and comprehensive wellness programs. One local four-year college, one state junior college, one unit of county government, and one business were identified. Contacts were made each site to determine interest and willingness to begin work. Create an Action Plan The Perry County Strategic Alliance for Health Coordinator, the communities coordinator, and senior health educators developed an annual action plan to serve as a road map for creating wellness committees at the four work sites. The action plan included one objective and four activities. The activities listed in the action plan were helpful to ensure correct steps

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were taken in logical order, to identify persons responsible for actions, and to set target dates for completion. Table 2. Sample Annual Action Plan Sample Annual Action Plan Annual Objective: By the end of Year One, increase the number of work sites with wellness committees in Perry County from zero to three. Activities Persons Responsible Timeline 1. Establish contact with work site Strategic Alliance Perry Month 1 leadership County Coordinator 2. Secure agreement with work site Strategic Alliance Perry Month 2 leadership to establish a work site County Coordinator and wellness committee representative from work site management 3. Establish the wellness committee, Representative from work Month 3 including a coordinator and site management representation from management and employee base 4. Committee work ensues, leading to new Wellness committee and Months 4–12 policies related to improving nutrition, work site management physical activity, and tobacco use/exposure among employees

Begin Planning for Evaluation and Sustainability The communities coordinator and program director stressed the importance of gathering evaluation information throughout the process of establishing work site wellness committees for two vital reasons. First, management will want reports on committee activities, including how the committee functions and the wellness initiatives implemented. Second, the committee itself can determine how it needs to revise its activities to improve wellness initiatives outcomes. Results from evaluation data should be shared with everyone who participated in establishment of the committee and subsequent wellness initiatives — management, employees, and, if applicable, outside funders. Planning for sustainability was addressed throughout the process of establishing work site wellness committees and continued as each committee determined initiatives to implement. The 15

Strategic Alliance for Health Senior Health Educator and the Perry County Community Coordinator provided training and technical assistance to wellness committee leaders on implementing policy, systems, and environmental interventions that would last and impact the most number of employees. Examples of strategies include establishing tobacco policies, modifying lunchroom menus, modifying vending machine contents, and creating spaces where employees can walk during breaks. These interventions were contrasted with short-term, nonsustainable interventions, such as work site health fairs and health screenings.

Tip: Recommended Evaluation Questions to Address: • • • • • •

Composition of the wellness committee--Does it include representation from all areas of the work site? How could representation be improved? Has the committee completed a written action plan to drive comprehensive work site wellness? What areas of wellness are being addressed? What are some areas not being addressed? Has management been supportive? How could it be more supportive? In what ways are the wellness committee and new wellness initiatives helping employees? What could the committee do to implement more wellness initiatives?

Section 3: Action Promote Policy, Systems, and Environmental Change Strategy and Provide Outreach in the Community Based on results of the community assessment process and subsequent discussions, the consortium identified four work sites to promote formation of wellness committees and adoption of comprehensive wellness programs in Perry County. These four work sites included a catfish processing plant, the county courthouse, a four-year college, and a state junior college that is a military college. The Perry County Strategic Alliance for Health Coordinator, communities coordinator, and health educator convened meetings with representatives from these work sites to begin promoting wellness committees. Work sites sent a variety of individuals to these 16

meetings, including human resource directors, cafeteria directors, division directors, and a nurse. In these meetings, the work site representatives stated they had limited resources (e.g., money and staff) to dedicate to creating wellness programs, although they expressed concern with current costs of health care claims, increased absenteeism, and diminished productivity due to illness. The Strategic Alliance for Health Senior Health Educator, familiar with these barriers and concerns, reassured those attending that comprehensive work site wellness programs could be established with limited resources and that many wellness initiatives can be implemented that support healthy lifestyles among employees at little or no cost. The establishment of work site wellness committees was recommended as an initial strategy on which to base future wellness initiatives; a wellness committee, consisting of representatives from all areas in a work site, can maximize buy-in for initiatives. The committee can assess employee needs, develop action plans, evaluate outcome activities, and make recommendations for improving wellness programs. Representatives from the four work sites were open to forming wellness committees but were unsure of how to establish committees and how to direct subsequent wellness programming. To address this knowledge gap, the senior health educator created the Alabama Strategic Alliance for Health Work Site Wellness Toolkit. The Toolkit defines and describes work site wellness programs and committees, how to establish a wellness committee, and provides sample action plans and agendas to assist the wellness committee throughout the first year of implementation. Also included are assessment tools, model policies, suggested activities and educational opportunities, and point-of-decision prompts. Wellness committees can use these tools and resources to engage in interventions to promote healthy lifestyle choices (Appendix 1).

Tip: The Alabama Strategic Alliance for Health Work Site Wellness Toolkit will help a work site establish a wellness committee and also provides suggested agendas for meeting a calendar year. The Toolkit directs the work of the committee while allowing flexibility that is fitting for a particular work site. The Alabama Strategic Alliance for Health Work Site Wellness Toolkit can be found at www.adph.org/strategicalliance/Default.asp?id=3362. 17

It is important to note that the origin of the Alabama Strategic Alliance for Health Work Site Wellness Toolkit came from the North Carolina Division of Public Health’s Eat Smart, Move More Statewide Campaign. The Alabama Strategic Alliance for Health Senior Health Educator was granted permission to adapt this program Committee Workbook for use within the Alabama Strategic Alliance for Health Program. The Alabama Strategic Alliance for Health Work Site Wellness Toolkit is a combination of the North Carolina Committee Workbook content and resources, as well as promotional items, model policies, and evaluations created and used during the Steps to a Healthier Alabama Program. The Toolkit continues to be developed and disseminated through the Alabama Strategic Alliance for Health program. The Toolkit can be accessed three ways — hard copy, compact disc, or via the Alabama Department of Public Health Web site (http://www.adph.org/strategicalliance/Default.asp?id=3362).

TIP: Access the North Carolina’s Committee Workbook at (www. eatsmartmovemorenc.com/Work sites.html).

Once the Toolkit was complete, a hard copy of the Toolkit was provided to work site representatives. The Perry County Community Coordinator and Senior Health Educators began providing technical assistance to support establishment of wellness committees utilizing the Toolkit for guidance. Implement Policies, Systems, and Environmental Change Strategy A work site wellness committee is a group of employees who formally meet and plan activities to promote healthy choices and support healthy lifestyles for the employees of the work site. A work site wellness committee should include representatives from all organizational levels and create an open line of communication about health risks, the work of the wellness committee, and all wellness programming and activities. A wellness committee should also 18

assess work sites for opportunities to improve wellness initiatives, advocate for more opportunities to make healthy choices, and monitor and evaluate initiatives being offered. The Alabama Strategic Alliance for Health Work Site Wellness Toolkit provides a stepby-step plan for establishing and maintaining an effective work site wellness committee. This step-by-step plan, provided in the form of a suggested 12-month timeline, creates flexibility to allow work sites to adjust the steps to meet the organizational needs and circumstances of each work site. For example, a work site might work in shifts. Identifying a third shift person who can serve on the committee may be difficult. It may take altering meeting times and combining the work of several meetings into one in order to accommodate this situation. The timeline below is for one year, but it can continue to provide guidance for work in subsequent years. Table 3. Timeline Guide: This flexible timeline may be used for directing the work of the committee: Steps

Time Frame

Action

1&2

June 2010

Identifying committee members and getting started

3

July 2010

Establishing Work Site Wellness Committee

4

September 2010

Completing work site surveys

5

November 2010

Developing an action plan from results of surveys

6

January 2011

Assessing action plan progress and adjusting accordingly (continuing to collect Employee Satisfaction Surveys as activities and programs are implemented)

7

March, 2011

Assessing action plan progress and adjusting accordingly (continue to collect Employee Satisfaction Surveys as activities and programs are implemented)

8

May, 2011

Completing the 12-month evaluation, which comprises an assessment of the following surveys: Employee

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Steps

Time Frame

Action

Evaluations of a Work Site Activity, Employee Satisfaction of the Comprehensive Work Site Wellness Program, Evaluation of the Wellness Committee by Committee Members, and a repeat of the Policy and Environment Survey, as well as consideration of the survey results of the Employee Interest Survey for seamless continuation of policies, systems, and environmental initiatives 9

June 2011

Identifying new committee chairperson, new committee members, and new opportunities based on evaluation

The first step for establishing a wellness committee is to identify a committee chair and committee members. Organizational leadership will have input as to who leads the wellness committee. This person will likely be one who identifies additional committee members and navigates logistical issues related to getting the wellness committee started. Identifying committee members can be done either by a verbal invitation, letter of invitation, or by general solicitation of volunteers. Posters and announcements placed in strategic places, such as break rooms, bulletin boards, newsletters, and e-mails, can solicit volunteers to join the wellness committee. The invitation should be accompanied by an explanation of the work site’s intent to begin a comprehensive wellness program and how serving on the committee can help accomplish this goal.

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Tip: Identify “wellness champions” to join the wellness committee. They are people who are currently engaged in a healthy lifestyle, have a strong desire to engage in a healthy lifestyle, or want to be a part of a work site concerned about the health and well-being of its employees. Wellness champions help with efforts to implement policy, systems, and environmental changes, provide motivation as well as feedback on ideas and suggestions. Others who may serve on the committee include human resource department staff, nurses, all levels of management, information systems, and administrative and support staff. Please refer to the following resources in the toolkit to aid in recruiting employees to serve on the committee: Letter of Invitation: (Appendix E) Work Site Wellness Committee Member Invitation Poster: (Appendix F)

Tip: The following resources to recruit, employees to join the committee can be found in the Alabama Strategic Alliance for Health Work Site Wellness Toolkit: Letter of Invitation: (Appendix E) Work site Wellness Committee Member Invitation Poster: (Appendix F)

Following identification of wellness committee members, the first meeting should be scheduled at a date, time, and place convenient for all members. The committee chairperson should spend time prior to the meeting preparing the overview of the comprehensive wellness program, as well as having a good understanding of the Toolkit. In Perry County, the four work sites collectively have approximately 512 employees. Committees range from 4 to 12 employees. Human resource staff from each of the work sites serves on the committees, as well as an individual in management. In one case, human resources and management are represented by the same person. Management at each work site appointed one person to lead establishment of the wellness committee. Two work sites chose “wellness champions” who had participated in previous weight-loss campaigns and experienced success. One work site appointed the staff nurse, and the manager of another work site decided it would be best if she remained in a leadership role while bringing others onboard to assist her. These 21

leads, or committee chairpersons, invited other employees to join the wellness committees by verbal invitation, due to the small size of the work sites. Once the committees were in place, the work sites held their initial meetings.

Barrier: Companies may not be able to afford a designated staff person to oversee work site wellness programming. Tips for overcoming this barrier: Establishing a committee is one way to overcome this barrier. Additional options would be to utilize exercise science, health care management, or business management majors from local colleges which could serve as an internship opportunity to assist with implementation of program planning and activities.

Tip: Often, a lack of funding can be a barrier to work site wellness programs and activities. There are many creative ways to overcome this barrier when engaging a committee. One needs to answer the following questions to determine the extent of this barrier (Example: A manager says to get started — with little or no funding. He/she tells you to observe employee participation and then decisions will be made about a budget). Funding for incentives and materials: 1. Is funding available from management? 2. Is there funding available from outside sources? Work Site Policy for Wellness activities: 1. How much time is allowed for wellness activities, if any? Examples: 30 minutes per employee 3 times a week, 15 minutes per employee daily, paired with established break time, 1 hour all employees once a month for group activity. 2. Who has authority to approve time considerations for activities during regular work hours? 3. What might the restrictions be regarding wellness activities at the work site? At the initial meetings, the committee chairpersons provided an overview of the intent of their work site to have a wellness program and an overview of the Alabama Strategic Alliance for Health Work Site Wellness Toolkit. Also presented were the Action Plan Template and Sample (Appendix D in the Alabama Strategic Alliance for Health Work Site Wellness Toolkit), the Employee Interest Survey (Appendix I), and the Policy and Environmental Survey (Appendix J). Committee chairpersons directed the committee members to review the action plan and the 22

Employee Interest Survey in preparation for the next meeting. The action plan helps direct the short-term and long-term goals set by the committee in order to establish and sustain a comprehensive work site wellness program. The Employee Interest Survey will help determine short-term goals. The members were to complete and return the Policy and Environment Survey (see partial list of questions below) before the next meeting, so that the results could be compiled. Questions related to healthy nutrition policies, opportunities to engage in physical activity, tobacco cessation, as well as diversity, stress management, and workplace ergonomics help determine the long-term goals for the action plan. Table 4. Example of Policy and Environment Survey Questions. Committee members answer with a yes/no/not sure/not applicable: 1. Does your work site have any written policies recommending the use of healthier foods for holiday celebrations, staff meetings, or any other meetings that may be hosted within departments of your company? 2. Does your work site have a safe place for walking or other activities onsite or nearby? Name of nearby facility ________________________________________ 3. Has information on physical activity been provided to employees in the past year? How provided? __________________________________________ 4. Does your work site have any written policy or policies supporting and encouraging communication that is open, two-way, and respectful of employee diversity? 5. Have any programs or materials for managing stress been provided at your work site in the past year? This might be a class for supervisors that include information on relaxation, communication, and time management. What was provided? ______________________________________________________ 6. Does your work site have any written policy or policies that prohibit or restrict smoking at the work site? a) If YES, is smoking permitted outside on work site grounds? b) If YES, is smoking permitted anywhere in work site buildings? 7. If YES to 6 a or b, are signs posted for smoking and non-smoking areas? 8. Does your work site provide tools to organize your workspace to avoid injuries?

Additional items that may be completed at the initial meeting include naming the Work Site Wellness Committee/Wellness Program and formulation of a mission statement. The name 23

selected for the Work Site Wellness Committee and Wellness Program should suggest a longterm commitment to creating a healthier work site for employees. A mission statement is an overall expression of what the Work Site Wellness Committee wants to accomplish and may include a description of the value of the program to both the employer and the employee.

Tip: Tools for the initial meeting found in the Alabama Strategic Alliance for Health Work Site Wellness Toolkit: Employee Interest Survey: This is a 30-question survey allowing employees to gauge their interest on a scale of one to three in relation to physical activity, nutrition, and tobacco cessation (Appendix D). Employee Interest Score Sheet: After the Employee Interest Survey is completed, wellness committee members compile the data through this score sheet to determine employees’ interest in specific areas related to physical activity, nutrition, and tobacco cessation. This tool allows the committee to plan the work to address high priorities of interest for employees (Appendix S). Policy and Environment Survey: This is a survey completed by the Work Site Wellness Committee members which asks questions related to the availability of opportunities to make healthy choices at work (Appendix J). Policy and Environment Survey Score Sheet: After the Policy and Environment Survey is complete, data are compiled with this score sheet to determine the strengths, weaknesses, opportunities, and barriers to creating a healthier work site (Appendix T). Work Site Tobacco Policy Evaluation Tool: This is a one-page tool that allows work sites to assess tobacco usage and tobacco cessation opportunities for employees (pages 117-118). Additional tools that may be used during the first meeting: Agenda with Talking Points (page 19). Sample Agenda (Appendix H). Naming Your Work Site Wellness Program and Sample Mission Statements (Appendix M).

With a small work site, the Policy and Environmental Survey can be done verbally. A meeting can include an informal assessment of current policies and environmental components of the work site related to health and wellness. The information gleaned helps define starting places for the wellness committees to begin work. This type situation illustrates the opportunity to be flexible while utilizing the Toolkit.

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Tools for the second meeting found in the Alabama Strategic Alliance for Health Work Site Wellness Toolkit: Agenda with Talking Points (page 23). Sample Agenda (Appendix R). Cover Letter for Employee Interest Survey (Appendix Q). After employees complete the Employee Interest Survey and the Policy and Environment Survey and committee members tabulate the results, a third meeting can be scheduled to begin developing the action plan, which will have short-term and long-term goals. The Action Plan Template (Appendix C) found in the Toolkit allows those committee to determine details, such as the timeline and the committee members responsible for implementing policy, systems, and environmental changes. In Perry County work sites, the third meeting was a significant turning point. The action plan provided a way to document and clarify which policy and environmental changes needed to take place. Committee members were able to determine that employees were interested in opportunities for physical activity during the day based on survey results. Employees also ascertained unhealthy vending machine choices and unhealthy food served in meetings were hindering efforts to address healthy eating habits. Two work sites had a documented policy stating they were tobacco-free facilities and/or campuses, but both needed assistance in promoting the policy through signage. In this meeting, committees were able to create an action plan for the following: •

Short-term goals: o Tobacco-free signage: The courthouse wanted tobacco-free signs that were consistent with the historic nature of the facility. The junior college wanted clingon type signs to post on doors. o Baseline screenings: The courthouse wanted to partner with a local health care provider to conduct health screens and weigh-ins for employees on a recurring 25

basis to allow employees to track important personal health information and weight loss. •

Long-term goals: o Increase opportunities for physical activity: All work sites planned to create identifiable and measured walking paths surrounding buildings, parking lots, or local neighborhoods. One work site planned to establish an onsite fitness facility. Two work sites planned to erect point-of-decision prompts, when strategically placed for visualization, encouraging the use of stairs instead of elevators. Pointof-decision prompts encourage employees to make healthy choices, such as at elevators, on walking paths, and in napkin holders in a cafeteria. o Healthy food options: All work sites planned to modify vending machines to provide better selections of healthier options. Two work sites planned to provide health education and promotion tip sheets in cafeterias. The wellness committees in Perry County addressed these goals by establishing policies

or implementing environmental changes. For example, one work site implemented a policy for the following environmental changes: (1) dedicated space for indoor exercising; (2) flex-time for employees to engage in physical activity by utilizing the walking path or exercise room; and (3) documentation of a policy statement endorsing work site commitment to continued efforts toward creating a healthy workplace. Other work sites implemented environmental supports by utilizing point-of-decision prompts for stair well use and healthy lifestyle choices in the cafeterias. Signage for walking paths and tobacco-free buildings has also been effective in promoting the tobacco-related policies implemented by work site wellness committees in Perry County.

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Tip: Point-of-decision prompts encourage employees to make the healthier choice when strategically placed for visualization, such as at elevators, on walking paths, and in napkin holders in a cafeteria. Examples of point-of-decision prompts used in Perry County can be found in the Alabama Strategic Alliance for Health Work Site Wellness Toolkit.

Tip: Additional information regarding these types of environmental changes: • Take the Stairs (pages 110–112) can also be accessed at http://www.adph.org/healthycommunities/index.asp?id=4017. • Map of work site walking path on campus (this is an example of signage for a walking path as well): (page 116). o Be creative in recognizing opportunities for physical activity. Parking lots, work site indoor routes, a neighborhood with sidewalks surrounding the campus, and the courthouse square make excellent choices for areas to engage in physical activity. o Be mindful of liability issues related to creating areas for physical activity. Be on the lookout for potholes in parking lots, broken sidewalks, and broken tile or unraveling carpet in a facility. Make necessary repairs. If this is not possible at the time, consider tagging or marking the area, if the area can be safely navigated. o Ask the local parks and recreation department or the athletic department of a local college/university to either loan their measuring wheel or have them help with the measurement of the walking path. Measuring wheels can be purchased. • Education information for napkin holders in college cafeterias: (pages 88–93). • Be creative in recognizing opportunities for promoting healthy food choices: o Identify healthy snacks in vending machines by placing stickers by the item number. Check out this resource for a vending machine campaign: http://adph.org/NUTRITION/index.asp?id=4929. o Feature a healthy food choice in your work site cafeteria at the entrance. Post information regarding food labels in break rooms. o Use consistent messaging and symbols. • Tobacco-Free cling-on: o Promote the tobacco-free policy with consistent signage. o If a work site cannot go completely tobacco-free, designate acceptable smoking areas. Try keeping the areas away from entrances, and provide outdoor ashtrays or receptacles to hold cigarette butts.

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Historical Cling On/Traditional Cling-on

Partnering with the Perry County Strategic Alliance for Health Consortium and additional community stakeholders had many advantages to furthering the work of the wellness committee. For example, a work site in Perry County is partnering with a local health care provider to conduct health screenings and weigh-ins for employees on a recurring basis. This activity allows employees to track important personal health information. Additional examples of policy changes that may result from effective partnering that other communities, both urban and rural, could engage in include negotiating reduced rates for utilization of an off-site exercise facility or indoor pool at a local college, and partnering with the city to ensure the gates of a park are open and lights are on at least one hour after the close of business each afternoon to allow employees to walk. Frequently, city or rural parks close when business slows down at the end of the day, as a result, citizens are provided with few safe places to walk. In addition, local businesses may be able to sponsor events for work sites. A restaurant may feature a healthy dish and offer it at a discount to employees. These are just a few examples of partnering within the community to further the work of wellness committees. 28

Table 5. Addressing Barriers through Partnerships Barrier

Tip

Toolkit Resource

Access to Physical Activity: Incentive-based programs may be costly to implement; however, they can be successful in getting people up and moving.

Consider partnering with local businesses to offer incentives or investing in several big prizes. Employees who meet their goal(s) can be placed in a drawing for these prizes.

Model policy for incorporating physical activity into the work day can be found on page 109.

Healthy Food Options: Companies who cater cafeterias or meetings, as well as vending companies, are sometimes reluctant to add healthier food items because they often don’t sell as well due to the higher cost.

Try to work with vendors to strategically keep costs reasonable for healthy foods, drinks, and snacks. This can be a challenge, but insist on dialogue that clearly indicates your company is committed to offering healthier selections.

A list of recommended healthy foods for cafeterias and healthy snacks for vending machines is on pages 102– 103. Model policies for healthy foods being served at a work site and healthy vending machines in a work site are on pages 104–105.

Access to Smoking Cessation Programs: Companies may feel they lack resources to offer this type of service to employees, and, therefore , do not take action to make this a possibility for employees.

Use monthly or seasonal events, such as the Great American Smoke Out, to provide health information regarding tobacco use. Check with your local or state health department for information regarding cessation resources, or partner with your insurance agency to facilitate smoking cessation programs.

Model policy for a Smoke-Free Workplace can be found on pages 118–119. Some companies have opted to provide smoking cessation opportunities to employees during a period between the announcement of the new policy and the implementation of the new policy of a tobacco- free work site.

Review Evaluation and Sustainability Activities and Strategies It is important for the wellness committee to review its work by utilizing the action plan and assessing the implementation of any strategies or steps started or completed from the last meeting. It is also important to discuss any obstacles or barriers encountered during implementation. Adjustments should be made accordingly. This process can continue at the fourth, fifth, and year-end meetings. A discussion of work site wellness evaluation is highly recommended. The committee has several opportunities to evaluate the comprehensive work site wellness program. One is to complete the Policy and Environment Survey again (Appendix J in

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the Toolkit), as well as to complete an Evaluation of Wellness Committee questionnaire (Appendix X). Two evaluation tools that need to be assessed are the employee’s Evaluation of the Work Site Activity (Appendix U), which should be completed either ongoing or at the conclusion of the activity provided, as well as the Employee Satisfaction Survey (Appendix V) of the comprehensive work site wellness program (Appendix I in the Toolkit) before the yearend meeting. At the last meeting, plan to discuss the outcomes of these surveys. This process will help identify areas where the design and delivery of activities may need improvement or change, as well as provide data on the major accomplishments of the comprehensive wellness program. Additionally, these evaluations will help determine the progress being made and provide important data, to include the number of people being impacted, whether attitude toward health choices are changing, and the effectiveness of implemented initiatives. This review provides a continuation of the work of the wellness committee for subsequent years and should be particularly useful in a seamless continuation if a new committee chairperson is assigned and/or new committee members join. The Alabama Strategic Alliance for Health Work Site Wellness Toolkit provides evaluations to assess the work of the wellness committee and the effectiveness of the Toolkit itself. The following assessments are in the Toolkit: •

Evaluation of Wellness Committee by Committee Members: This is a questionnaire designed to help the wellness committee assess the work site wellness program in terms of strengths and weaknesses. It is intended to guide the work and discussion of a wellness committee to help determine how well the committee functions and how the wellness program can improve (Appendix X of the Toolkit).



Work Site Wellness Toolkit Evaluation Form: This survey allows for a work site wellness committee to provide feedback on the Toolkit in order to make improvements (Appendix Y of the Toolkit). 30

Work site wellness committees can utilize these assessment tools to continue to direct work and determine progress. The assessments serve as tools to provide information for decision making on all aspects of the comprehensive wellness program, allows for program accountability, and identifies ways to improve and sustain future activities and programs. In addition to these assessments, the action plan summarizes the findings of the committee as it relates to the successes, lessons learned, and recommendations for ongoing strategies and steps. This information should be shared with organization leadership to ensure ongoing support. Studies continue to indicate that a comprehensive work site health program that focuses on lifestyle and behavior change can lead to improvements in health behaviors among employees, and a return benefit for the employers. For example, in the article “Financial Impact of Health Promotion Programs: A Comprehensive Review of the Literature,” the authors demonstrated that work sites with health promotion programs saved an average of $3.72 on health care costs and an average of $5.06 on absenteeism for every $1 invested in work site wellness (American Journal of Health Promotion; 2001: 15: 296-30). Section 4: Evaluating and Sharing The setting for this policy, systems, and environmental change strategy is work sites in Perry County. The goal, as noted above, is to establish work site wellness committees. The establishment of work site wellness committees is a new and fresh approach in Perry County to sustainable work site wellness initiatives. Wellness committees can help overcome the barriers typically encountered in work site wellness programming. Two obstacles typically reported include lack of money to support activities and lack of dedicated personnel to ensure implementation of activities. Thus, the establishment of wellness committees to help identify ways to overcome funding barriers and to provide necessary leadership is an ideal way to address these obstacles.

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Evaluation Plan / Data Collection / Preliminary Findings The evaluation focuses on the implementation of work site wellness committees and their work. Indicators of increased interest and participation by employees in the wellness committee include the following: • Changes in attitudes of the work site culture to increase opportunities to make healthy choices • Passing policies as identified through the Policy and Environmental Survey • Providing time during the day to work on initiatives • Developing a wellness budget • Other outcome measures include an increase in employees actually choosing the healthier options provided, and changes in health based on indicators monitored. Results of completed surveys have been collected and reviewed. The county courthouse surveyed its employees and determined employees were interested in continuing efforts to increase physical activity and healthy food choices. The wellness committee decided to measure and mark the sidewalk square surrounding the courthouse. In order to encourage employees to utilize this walking path, the human resource director created a policy stating that, at 10:00 a.m., workload permitting, employees would be allowed to use their 15-minute break for a walk around the square. Employees are encouraged to walk at other times if they are unable to walk at 10:00 a.m. Additionally, space was created and dedicated to an indoor exercise room. Employees can access a treadmill, mats, resistance and weighted balls, and exercise videos. The courthouse also decided to remove the vending machine snacks to support employees’ efforts to maintain weight loss achieved in a previous weight-loss campaign. Point-of-decision prompts were posted to encourage employees to take the stairs. The tobacco-free campus policy was reinforced through signs designed to reflect the historical heritage of the courthouse.

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Another work site wellness committee assessed its campus and found a tobacco-free campus policy was already in place. The committee decided to encourage staff and faculty to engage in physical activity and healthy eating choices. Point-of-decision prompts were strategically placed in the cafeteria. Educational posters were placed on the walls, messages promoting healthy choices were placed in napkin holders, and plate planners were placed on food trays. The sidewalks surrounding the campus were measured and marked with signage to denote walking routes and distances. Maps of these walking paths were also created and distributed to staff and faculty. Preliminary data indicated that employees and organization leadership were interested in a work culture that encourages healthy choices; they want to participate in creating this culture. Leadership is committed to combat rising health care costs and diminished productivity from absenteeism due to chronic disease. Creating budgets for work site wellness in this small county with few employment opportunities will continue to be a challenge, but work sites, through the work of wellness committees, are working strategically to make healthy choices a priority. As the human resource director commented in a written statement, “The county courthouse wellness program is designed to encourage individuals to take measures to prevent the onset or worsening of a disease or illness and to lead lifestyles that are healthier. The wellness program will increase productivity, reduce absences, and improve employee morale. The wellness committee will develop a health plan responsive to participants’ needs and will be responsible for managing all health promotion efforts.” The following data grid shows progress made through the work of wellness committees in the four work sites in Perry County. This information was shared with the Perry County Consortium and all major stakeholders who participated in related activities. Results were also shared with new communities throughout Alabama that sought to promote healthy workplaces for employees. 33

Table 6. Policy, Systems, and Environmental Change Tracking Database for Wellness Committees in Perry County Wellness Committees Policy, Systems, and Environmental Change Tracking Database

Courthouse

Junior College/ Military Institute

4-year college

Dedicated exercise space

X

X

X

Healthy vending machines

X

Dedicated exercise time

X

Catfish Plant Policy Adopted

Environmental Changes/Supports Measured and marked walking paths

X

Monthly health screenings for employees

X

Signs supporting tobacco-free work site campuses Use of point-of-decision prompts (traditional and non-traditional): stairwell usage, napkin dispenser posters, full-size posters promoting healthy choices, plate planners on cafeteria trays, and healthy choice prompts on vending machines

X

X

X

X

X

X

X

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References

1

U. S. Census Bureau, Annual Estimates of the Resident Population for Counties: April 1, 2000 to July 1, 2009, Census Bureau Website, http://www.census.gov/popest/counties/CO-EST2009-01.html and Cumulative Estimates of the Components of Resident Population Change for Counties: April 1, 2000 to July 31, 2009, Census Bureau Website, http://www.census.gov/popest/counties/CO-EST2009-04.html 2 Basically, the Census Bureau defines “rural” as the population living in places (cities, towns, and open territory) of less than 2,500 in population, although there are a number of other technical qualifications associated with the definition as well. For more information see: U.S. Census Bureau, Urban and Rural Classification, Census Bureau Website, http://www.census.gov/geo; www/ua/urbanruralclass.html. For the data cited above see: U. S. Census Bureau, 2000 Census of Population, Summary File 1, Table P2, Census Bureau Website, http://www.census.gov 3 U. S. Census Bureau, 2000 Census of Population, Summary File 1, Table P3, Census Bureau Website, http://www,census.gov 4 U. S. Census Bureau, Model-based Small Area Income and Poverty Estimates (SAIPE) for School Districts, Counties, and States, Census Bureau Website, http://www.census.gov/did/www/saipe/ 5 Phillips, Martha M. Chronic Disease in Alabama, pages 16-17, Montgomery, Alabama: Alabama Department of Public Health, Bureau of Health Promotion and Chronic Disease, 2004 6 County Health Profiles, Alabama, 2008, pages 3 and 109, Montgomery, Alabama: Alabama Department of Public Health, Center for Health Statistics, December, 2009 7 Centers for Disease Control and Prevention. Community Health Assessment aNd Group Evaluation (CHANGE) Action Guide: Building a Foundation of Knowledge to Prioritize Community Needs. Atlanta: U.S. Department of Health and Human Services, 2010 8 County Health Profiles, Alabama, 2008, pages 3 and 109, Montgomery, Alabama: Alabama Department of Public Health, Center for Health Statistics, December, 2009

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