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Public Health: Community Health Plan

DODGE/STEELE COMMUNITY HEALTH

ACTION PLAN 2010 -2014

Community Description:

Dodge and Steele Counties are located in the Southeast Region of Minnesota. The two counties share a border and together cover a total land area of 869 square miles. Dodge and Steele Counties are ideally located a convenient distance, 30-60 miles, from the metropolitan areas of Minneapolis/St. Paul (North), Rochester (East) and Mankato (West). The county seat of Dodge County is Mantorville and of Steele County is Owatonna. The communities within these counties are predominantly rural with Owatonna making up its limited urban area with over two-thirds of Steele County’s population.

Dodge/Steele Counties have a total population, according to the 2008 estimates from the U.S. Census Bureau, of 56,297. The ethnic breakdown for these counties is White not Hispanic 91.5%, Hispanic or Latino origin 4.8%, Black 1.9%, Asian 0.8%, American Indian/Alaskan Native 0.2% and two or more races 0.8%. According to the U.S. Census Bureau in 2000, the foreign born population in Dodge County was 2.5% and in Steele County was 3.5%.

The main employers in the counties are industry/manufacturing, schools and farming. Dodge County borders on Olmsted County and has a large commuter population. Due to the abundance of manufacturing and other industries in Steele County, the majority of the residents work within the county. According to the U.S. Census data from 2000, there are 19,266 household in Dodge and Steele Counties. The median household income in 2007 for Dodge County is $61,230 and for Steele County $53,333 with the percentage of those living in poverty in Dodge County 6.6% and in Steele County 7.1%.

There are a total of seven public school districts, six private schools and one charter school in Dodge and Steele Counties. In the 2007-08 school year, there were a total of 10,500 K-12 students in these schools. Of these students, 20.9% in Dodge County and 28.6% in Steele County were eligible to receive free or reduced meals, 4% in Dodge County and 6.5% in Steele County have limited English proficiency and 8.9% in Dodge County and 11.8% in Steele County receive special education. High school graduates, percent of persons age 25+, in 2000 for Dodge County was 86.7% and for Steele County was 86.6%. For Minnesota, in 2000, the percent of persons age 25+ that are high school graduates was 87.9%.

Dodge/Steele Counties have felt the nation’s economic crisis. Reduced hours, layoffs, staff reductions are commonplace in all areas-industry, retail, non-profits, schools and government. The unemployment rate in Dodge County in June 2009 was 8.1% up from 4.9% in June of 2008. The unemployment rate in Steele County in June 2009 was 8.8% up from 4.8% in June of 2008.

When considering the top preventable causes of death, and according to the Minnesota Behavioral Risk Factors of Adults 2007, the estimated percentage of obese individuals was 35.9 and overweight individuals was 25.8 in both Dodge and Steele County. The percent of individuals that engaged in no exercise was 16.6 in Dodge County and 16.9 in Steele County. Current smokers were 16.5% in Dodge County and 16.3% in Steele County.

Dodge/Steele Community Health has a strong history of working collaboratively with communities, healthcare professionals and other organizations to create environments that promote health and prevent disease and disability. These partnerships have created an atmosphere of support and understanding that is “priceless”.

Community Engagement: Submission to MDH required by February 2010

In 2009, a random sample opinion survey was sent to 1100 residents (age 18 or older) in Dodge and Steele Counties- 550 in each county. The purpose of this survey was to receive input from our communities regarding key public health issues and compare the finding to the survey conducted in 2003. In both 2003 and 2009, we worked closely with Dr. Ann Kinney, MDH Health Statistician. The 2009 survey questions were controlled to be able to compare to the 2003 survey findings and the responses were aligned to the Areas of Public Health Responsibility and the Essential Local Public Health Activities. Each person surveyed was asked to give his/her opinion on several issues in the following categories: 1) Chronic Health Problems and Disease; 2) Adult Disability and Aging; 3) Infectious Disease; 4) Environment; 5) Pregnancy and Birth; 6) Injury; 7) Violence; 8) Alcohol, Tobacco and Other Drug Use; 9) Child Growth and Development; 10) Health Care Delivery Systems; and 11) Mental Health. Of the 550 surveys sent to Dodge County residents, 57.6% were returned and of the 550 survey sent to Steele County residents, 45% were returned.

In addition to the community survey, we continually seek formal and informal input from the Dodge/Steele Community Health Advisory Committee, County Commissioners and other key community stakeholders, including our public health staff.

In October 2009, this Action Plan will be presented to the Dodge/Steele Community Health Services Advisory Committee, Dodge/Steele Joint Board of Health, each County’s Board of Commissioners and the Public Health staff. At that time, we will seek input regarding the timing and method of presentation of this information to our communities.

Community Issues:

As a result of the above community engagement the community health priority issues identified for Dodge/Steele Counties are:

Obesity in adults and children with the contributing factors of unhealthy eating habits and lack of exercise.
Tobacco use by youth and adults.
Parents with inadequate/poor quality parenting skills.
Public Health Emergency Preparedness/Pan Flu/Disease Outbreak.

The 2009 Dodge/Steele Community Health survey results for priority issues greatly mirrored the priority issues identified in the 2003 survey. In the 2003 survey, obesity in adults and children was the number one issue with the contributing factors of lack of exercise and unhealthy eating habits in the top five. Tobacco use in youth and adults was also a top five issue. In the 2009 survey, the following are the issues with the highest percentage of respondents saying it is a moderate or serious problem:

Dodge County

1) Lack of Exercise 79.1%

2) Obesity Overweight Among Adults 76.0%

3) Unhealthy Eating Habits 72.0%

4) Obesity Overweight Among Children 70.5%

Steele County

1) Obesity Overweight Among Adults 84.4%

2) Lack of Exercise 80.9%

3) Unhealthy Eating Habits 80.1%

4) Obesity Overweight Among Children 74.2%

Tobacco use by adults and youth, in the 2009 survey, did not rank as high as in the 2003 survey. This change reflects the success of the work done locally and the statewide Freedom To Breathe law. But there is still much work to be done with this top preventable cause of illness and death. Even though the percentages of ranking tobacco use as a moderate or serious problem went down in our 2009 survey, the percentage still remained between 62% and 67%. Plus, according to the Community Health Status Report 2008, Dodge County continues to have 15.1% and Steele County has 17.2% of their populations who smoke.

Dodge/Steele Community Health will develop an improvement/action plan for obesity in adults and children with the contributing factors of lack of exercise and unhealthy eating habits and an improvement/action plan for tobacco use by youth and adults.

The 2003 and the 2009 Community Health Survey results reflected that more than 50% of the survey respondents felt that Alcohol Use/Abuse, Use of Illegal Drugs, Domestic Abuse, Unplanned Pregnancy, Teen Pregnancy, Adolescents Becoming Sexually Active and Parents with Inadequate/Poor Quality Parenting Skills were moderate to severe problems. These issues have a common thread and that common thread lies in the need for primary prevention and family home visiting activities. Dodge/Steele Community Health is committed to maintaining a primary prevention approach and will continue to address these issues through Maternal/Child/Family Home Visiting Programs. Support is needed for federal legislation that guarantees direct funding to local public health departments to expand or enhance a variety of evidence-based home visiting programs that include public health nurse assessments. It has been proven, that through these evidence based approaches, the issues of concern listed earlier in this paragraph are impacted positively.

Finally, the last issue is Public Health Preparedness/Pan Flu. This was not identified as a high priority issue. A question regarding Pan Influenza was the only added question to the 2009 survey so there is no comparison to with the 2003 survey. The result of the 2009 survey regarding Pandemic Influenza is alarming. This issue was recognized as a moderate/severe issue by only 10% of the survey respondents. We will and MUST continue our efforts in the area of Emergency Preparedness/Pan Flu/Disease Outbreak. We will continue to educate and prepare our communities. It must be noted that this survey was taken prior to the H1N1 Influenza of Spring 2009. We suspect that this percentage may be greater if the survey were completed today.

Dodge/Steele Community Health will not be developing an improvement/action plan in these final two areas of Maternal/Child/Family Home Visiting and Emergency Preparedness/Pan Flu. In both areas, we will continue to “do the best we can” with the limited resources and capacity that we have. It is well known that as issues, for example, H1N1 emerge or even have the potential to emerge, we act at the expense of other essential services. In agencies our size, we do not have the luxury of being specialists. We are generalists.

Please see attached Summary of Issues Worksheet for added details regarding these four issues.

ACTION PLAN

#1 Issue: OBESITY IN ADULTS AND CHILDREN

Area of Public Health Responsibility: Promote Healthy Communities and Healthy Behaviors

Goal: Increase the number of healthy weight children and adults in Dodge/Steele Counties.

Plan: Dodge and Steele County are part of a nine county SE MN collaboration that received Statewide Health Improvement Program (SHIP) funding. This collaboration applied for a Phase I Planning Grant. In each county, there is a local coalition and local staff that will manage the program for the county. The Director or designee along with an appointed member of each local coalition will be part of a regional community leadership team. The nine agency directors will also meet periodically as the governing agents.

Each of the nine counties is at a different point in assigning staff and the development of their local coalitions. Dodge County is in the process of advertising to fill a SHIP position and has a coalition structure in place. Steele County has a staff person and coalition structure in place.

All the local coalitions are in the process of community assessments and selection of the provided research based interventions. See attached Intervention Selection form that is being used by each County to survey key stakeholders. A committee of directors is in the process of hiring a full-time project coordinator.

Implementation activities are scheduled to begin December 1, 2009.

SHIP funding is allowing us to address the issue of obesity in community, worksite, school and healthcare settings in a more aggressive and consistent manner across SE Minnesota. We will be able to increase capacity through increased staff time and will be able to address this issue through policy, systems and environmental changes more thoroughly.

Our vision for Dodge and Steele Counties mirrors the Minnesota Obesity 2008-2013 Plan’s that “People in Minnesota eat healthy, are physically active and maintain a healthy weight because they live in an environment designed to support healthy lifestyles across the lifespan”.

Technical assistance needs include training regarding policy, systems and environmental change work versus program development. Some of this training has already started but needs to continue in depth, for example - How to effectively and respectfully approach policymakers. Other needs include assistance in coalition building skills, developing the evaluation process or hiring the most appropriate evaluator, training in working with the media in an effective manner, media tools, and quick response from SHIP staff.

#2 Issue: TOBACCO USE BY YOUTH AND ADULTS

Area of Public Health Responsibility: Promote Healthy Communities and Healthy Behaviors

Goal: Reduce the number of youth and adults using tobacco in Dodge and Steele Counties.

Plan: SHIP funding will be used for reducing the number of youth and adults using tobacco in Dodge and Steele Counties. The structure of the process is the same as described under Issue #1.

Technical assistance needs would be the same as listed in Issue #1 with one addition. That addition is assistance with community awareness of the need to continue to address tobacco use in our communities.

Dodge and Steele Counties have additional resources and therefore capacity in this area. Partnering with two other SE Public Health Agencies (Four Corners Partnership), we applied for and received a two year Clearway grant. This project focuses on individuals 18 years and older and is committed to mobilizing local coalitions to advance policies to lower tobacco use and reduce the public’s exposure to secondhand smoke.

Four Corners Partnership, like SHIP, is in its infant stage. Like SHIP, this project began in July 2009. Each county has a staff person responsible for the work and because of the close relationship with the SHIP all activities will be closely monitored and recorded. We feel these processes will compliment each other.

Some areas that are being considered for the Clearway grant are increased promotion of the Quitplan, smoke-free post-secondary campuses, database of tobacco retailers and education of the retailers including point of purchase advertising and promotion, and continued support through media, etc. by local community members for Freedom to Breathe or other local policies, etc. Technical assistance for the Clearway grant is supported by Grassroots Solutions.

Intervention Selection Form for Community Health Boards

Tobacco Interventions

Objectives: to reduce tobacco use initiation, increase access to tobacco use cessation and decrease places where tobacco use is permitted through policy systems and environmental changes.

School Setting

	C-T-S1: Implement a post-secondary school policy of not accepting any funding, curricula, sponsorship, or other materials from any tobacco companies or their front groups for technical schools, community colleges, colleges, and universities
	C-T-S2: Implement a tobacco-free policy to apply to students, staff, and visitors on all post-secondary school grounds, in student housing, and at all school sponsored events on technical school, community college, college, and university campuses
	C-T-S3: Implement a K-12 school policy of not accepting any funding , curricula, or other materials from any tobacco companies or their front groups
	C-T-S4: Implement a tobacco-free policy to apply to students, staff, and visitors on all K-12 school grounds, in school vehicles, and at all school sponsored events
	C-T-S5: Implement mechanisms that connect students of technical schools, community colleges, colleges, and universities with existing cessation services including quitlines, quitting websites, and face-to-face counseling

Community Setting

	C-T-C1: Multi-grantee Intervention Applications only: Implement a culturally sensitive mass media counter-marketing campaign when combined with local interventions
	C-T-C2: Implement voluntary smoke-free housing policies in multi-unit housing
	C-T-C3: Implement voluntary smoke-free car policies
	C-T-C4: Implement tobacco-free policies for parks, playgrounds, beaches, zoos, fairs, and other recreational settings
	C-T-C5: low impact Implement policies that restrict youth access to tobacco such as sales laws directed at tobacco retailers to reduce illegal sales to minors

Worksite Setting

	C-T-W1: Implement worksite polices for tobacco-free grounds including parking lots
	C-T-W2: Implement mechanisms that connect people with existing effective cessation services including quitlines, quitting websites, and face-to-face counseling
	C-T-W3: Implement comprehensive cessation benefits as part of benefits package for employees

Health Care Setting

	C-T-H1: Implement tobacco free grounds policies for hospitals and other health care facilities
	C-T-H2: Implement mechanisms (such as the 5As and fax referral system) that connect people with existing cessation services

Physical Activity Interventions

Objectives: to increase opportunities for physical activity through policy, systems, and environmental changes.

School Setting

	C-PA-S1: Implement policies and practices that create active schools by increasing opportunities for non-motorized transportation (walking and biking to-and-from school) and access to school recreation facilities
	C-PA-S2: Implement policies and practices that support quality school-based physical education

Community Setting

	C-PA-C1: Implement policies and practices that create active schools y increasing opportunities for non-motorized transportation (walking and biking) and access to community recreation facilities
	C-PA-C2: Implement policies and practices that support physical activity in licensed childcare and pre-school settings
	C-PA-C3:low impact Implement signage prompting use of stairs5

Worksite Setting

	C-PA-W1: Implement policies and practices that create active worksites by increasing opportunities for non-motorized transportation (walking and biking) and access to worksite recreation facilities
	C-PA-W2:low impact: Implement signage prompting use of stairs5

Nutrition Interventions

Objectives: to increase access to high quality nutritious foods and increase initiation, exclusivity, and duration of breastfeeding through policy, systems and environmental changes.

School Setting

	C-N-S1: Implement comprehensive nutrition policies including: breakfast promotion; healthy lunch and snacks, including classroom celebrations and incentives, fundraising, concessions, and vending; school gardens; and Farm to-School initiatives
	C-N-S2: Implement school policies that encourage and enable staff and older students to breastfeed their children, such as: educate and train about breastfeeding; provided designated private space for breastfeeding or expressing milk; allow flexible scheduling to support milk expression during work; and provide information on resources for obtaining high-quality breast pumps

Community Setting

C-N-C1: Implement policies, practices, and environmental changes that improve access to nutritious foods such as fruits and vegetables (limited to):

Increase availability and affordability of nutritious foods in grocery stores, corner stores, concession facilities, faith institutions, long-term care facilities, social service agencies, and other food vendors (e.g. staple food ordinances, health y corner store initiatives, and affordable transportation options to grocery stores selling nutritious foods);
Require calorie or nutrition labeling on menus;
License and facilitate the development of new farmer’s markets and promote their use; and

Create zoning ordinances that facilitate the development of new community gardens and other small scale food productions strategies (e.g. backyard gardening, youth gardening unrelated to schools, etc.) and promote their use

C-N-C2: Implement policies and practices that support healthy eating in licensed child care and pre-school settings

Worksite Setting

	C-N-W1: Implement policies and practices that support increased consumption of fruits and vegetables and other nutritious foods such as: healthy food service and catering options , healthy vending, and access to community supported agriculture
	C-N-W2: Implement worksite policies that support breastfeeding such as: educate and train about breastfeeding; provide designated private space for breastfeeding or expressing milk; allow flexible scheduling to support milk expression during work; and provide information on resources for obtaining high-quality breast pumps

Health Care Setting

C-N-H1: Implement breastfeeding practices in maternity care that provides prenatal, birth, and postpartum services, for example: develop a written policy on breastfeeding, provide education and training, encourage early breastfeeding initiation, support cue-based feeding, restrict supplements and pacifiers for breastfed infants, and provide for post-discharge follow-up

Healthy Weight and Healthy Behaviors Interventions

Objective: to increase opportunities to maintain healthy weight and healthy behaviors through policy, systems, and environmental changes

Worksite Setting

C-HWHB-W1: Implement a comprehensive employee wellness initiative that provides health assessment with follow-up coaching; ongoing health education, and has policies and environment supports that promote healthy weight and healthy behaviors

Health Care Setting

	C-HWHB-H1: Support implementations of Institute for Clinical Systems Improvement (ICSI) Guidelines for “Prevention and Management of Obesity’ and “Primary Prevention of Chronic Disease Risk Factors” by health care providers for adults and children where applicable.
	C-HWHB-H2: Develop relationships among health care providers and community leaders and build partnerships to facilitate active referral of patients to local resources that increase access to high quality nutritious foods, opportunities for physical activity, and tobacco use cessation
	C-HWHB-H3: Implement client or patient self-management support strategies of information exchange and collaborative decision making in order to motivate and aid clients and patients in making daily decisions to improve their behaviors relating to eating, physical activity, and abstinence from tobacco use