Increasing Access to Healthy Beverages in Public Buildings and Worksites

State: NY Type: Model Practice Year: 2013

In this obesity prevention project, three local health departments (LHDs) and one four-county rural health network, serving a total of 765,323 residents, received federal stimulus funds through the New York State Association of County Health Officials (NYSACHO) and New York State Department of Health (NYSDOH) to increase access to, and encourage consumption of, healthier beverages in county buildings and at other public sites in their communities. Adapting educational materials developed by the New York City Department of Health and Mental Hygiene (NYCDOHMH), they educated county leaders and the broader public within their communities about health risks associated with sugar-sweetened beverages (SSBs) and health benefits of water and other healthy beverages. Primary goal and targets: to ensure that water, no-calorie seltzer and unsweetened iced tea are available in vending machines used by county employees and by visitors to county offices, the majority of whom are from low-income families, and that healthy beverages are served at public events. Secondary target: employees at other worksites where the employer was part of a LHD health coalition. NYSACHO developed a secure website for all its LHD members with resources such as best practices, model programs, and links to evidence-based research about the link between SSBs, obesity, and chronic diseases. After issuing an RFP, NYSACHO selected: Clinton ($35,065), Rockland ($36,000), and Orange ($36,000) County, NY Health Departments; and the S2AY Rural Health Network (Wayne, Steuben, Schuyler, and Yates County Health Departments at $52,774). Awardees implemented projects between May 1, 2011 and January 31, 2012, as outlined below*. All LHDs in NYS outside of NYC - serving an additional 10.24 million residents - received copies of adapted educational materials, a report on how to apply lessons learned; findings were presented at meetings of NYSACHO and the NYS Public Health Association. A public-facing web site at was developed and promoted to obesity prevention advocates within educational, corporate and government sectors around the nation. *ORANGE COUNTY¬-• Letter describing grant and sample policies/procedures mailed to town supervisors, mayors.• Educational materials displayed at community locations (libraries, worksites). • Provided on-going technical assistance to partners.• Policies and meeting guidelines developed and adopted by city buildings, libraries, one academic institution, county government. • Implemented countywide ‘Water Campaign’ including using table top posters at food court of local mall, Britta-filtered water stations provided to Department of Social Services, Public Library, and refillable water bottles to Little League teams promoting water as beverage of choice.• Changes made to availability and placement of healthy beverages in vending machines. • Educational materials made available at point-of-purchase. ROCKLAND COUNTY-• Educational presentations made to the county executive, purchasing department, other staff. • Collaborative efforts with worksite wellness committee (representing 45 employers). • NYC’s ‘Pouring on the Pounds’ campaign materials adapted for use. • Employee survey administered to gain insight on vending machine product mix. • County collaborated with vending company and held taste tests for employees. • Results of the employee surveys showed that people overwhelmingly wanted healthy products. Results used as evidence to request vending company to place healthy product mixes in machines. • Educational materials made available at point-of-purchase.• Seltzer (as requested by employees) sold well. • Educational campaigns were implemented in the mall and public transport (scrolling text ads/posters). Radio/ TV advertisements ran county-wide.• Over 3,000 educational materials disseminated. CLINTON COUNTY-• Educated legislature, Board of Health, County Deputy Administrator. • AmeriCorps volunteer assisted with project work. • Healthy beverage policies adopted by local TV station, city recreational department, wellness center, worksites and county government center. • Conducted successful media campaign with print and radio messages. • Promotional events at worksites successful - elements included presentations, dissemination educational materials, beverage taste tests. • Worksite wellness trainings conducted with partner organizations. S2AY RURAL HEALTH NETWORK-• Educated health human service legislative committees of all four counties. • Educational presentations made to more than 50 municipalities and 50 worksites in four county areas. • Letters introducing project mailed to city, town and village mayors and supervisors. Followed up with in-person visits. • Educational at worksite ‘Lunch and Learn’ sessions. • Policies developed and adopted by county governments and multiple worksites. • Increase of healthy beverages in vending machines. NYSACHO• Developed and maintained website.• Provided technical assistance.• Prepared and distributed to local county governments a “How To” report. • Presented findings to NYSACHO, NYSPHA • Reproduced and provided all LHDs in NYS with more than 36,000 brochures, posters, table top displays on healthy beverages.  
ResponsivenessThe New York State Department of Health (NYSDOH) data show that adult overweight and obesity has increased in the past decade in the State from 42% to 60%. In the past three decades, overweight and obesity among children has more than tripled in the State. The health implications of obesity are diabetes, heart disease, stroke, arthritis and cancer among other chronic comorbidities. Rising obesity rates in the nation have followed the rising trend in sugar sweetened beverages (SSBs) consumption. Sugar-sweetened beverages are defined as beverages with more than 25 calories per 8-ounce serving. Research shows that caloric intake from soft drinks has increased by 228% between 1977 and 2002, and that portion sizes have increased from 6.5 fluid ounces in the 1950s to more than 20 fluid ounces today. The direct and indirect health care costs of overweight and obesity to society are immense and have a burdensome economic impact on the health care system. Direct costs include preventive, diagnostic, and treatment services rendered to illnesses stemming from overweight and obesity, and indirect costs related to morbidity (income lost from decreased productivity, restricted activity, and absenteeism) and mortality (value of future income lost by premature death) costs. , Costs related to illnesses resulting from overweight and obesity in the U.S. are an estimated $150 billion a year and approximately $9.1 billion a year in NY state. Extensive research has been conducted on the effect of SSBs on the obesity epidemic. , , SSBs include but are not limited to, soda, non-100% fruit drinks, sports drinks, flavored water, energy drinks, and pre-sweetened tea. SSBs are high in calories, have no nutritional value and are any beverage with an added sugar-based caloric sweetener, including sucrose, fructose, glucose, and other sugars, such as high fructose corn syrup. i. UCLA Center for Healthy Policy Research www.healthpolicy.ucla.eduiii. U.S. Department of Health and Human Services. The Surgeon General’s call to action to prevent and decrease overweight and obesity. (Rockville, MD): US Department of Health and Human Services, Public Health Services, Office of the Surgeon General; (2001). Available from: US GPO, Washington DC.iv. Wolf AM, Colditz, GA. Current estimates of the economic cost of obesity in the United States. Obesity Research. 1998:6(2):97-106.v. Wolf, A. What is the economic Case for treating obesity? Obesity Research. 1998:6(suppl) Vasanti S. Malik, Barry M. Popkin, George A. Bray, Jean-Pierre Despres, Walter C. Willett, and Frank B. Hu. Diabetes Care; November 2010; Sugar-Sweetened Beverages and Risk of Metabolic Syndrome and Type 2 Diabetes, A meta-analysis. Vol.33 no. 11 2477-2483.vii. California Center for Public Health Advocacy. November 2009. Sugar-Sweetened Beverages: Extra Sugar, Extra Calories, and Extra Weight. Retrieved from http://www.public . (Appendix D)viii. Susan H. Babey, Malia Jones, Hongjian Yu and Harold Goldstein. UCLA Health Policy Research Brief. Bubbling Over: Soda Consumption and Its link to Obesity in CaliforniaSeptember 2009. 16-23. Retrieved from PB FINAL 3-23-09.pdf Process used to determine the relevancy of the public health issue to the communityIn New York State, each LHD is required to prepare a Community Health Assessment every four years. This document is based on vital statistics; data from community partners, especially local hospitals; and local studies and surveys. Based on the findings and the priorities of the NY State Prevention Agenda, LHDs work with their community partners to choose two or three priority areas on which they will concentrate their work. All LHDs involved in this project had chosen the areas of chronic disease prevention and physical activity and nutrition as areas of concern in their communities. Specifically, they had prioritized ways of decreasing overweight and obesity. Strategies included implementation of policy and environmental changes, worksite interventions, community education on the problem of obesity, and increasing individual knowledge for behavior change.The practice addresses the issue of obesity prevention in several ways. A main part of the project is to make procedure /policy changes in ensuring that there are healthy beverage choices in vending machines in county buildings and other worksites in communities. Education of individual groups and the general public on the association between SSBs and obesity, and the caloric content of beverages was another approach taken. This was aimed at increasing an individual’s knowledge about beverage content to foster behavior change. Orange County’s “Water Campaign” promoted water as the “best drink” and encouraged people to choose water as their beverage of choice. All of these encourage a decrease in caloric intake by choosing a healthy beverage. Does this practice address any of the CDC’s Winnable Battles? Yes, Nutrition, Physical Activity, and Obesity. Innovation Please list any evidence based strategies used in developing this practice. (Provide links or other materials for support)The goal of this project, i.e. to increase the availability of healthy beverages in county buildings and other worksites with an emphasis on vending machines, is strongly supported by evidence-based research and literature. CDC’s Healthy People 2020 Objective for Nutrition and Work Status, number 17.1, is to “Reduce the consumption of calories from added sugar”. Examples of interventions for this objective in the community setting include use of information and educational strategies to increase knowledge about a healthy diet, and improving access to healthy foods including vending machine contents. The “Guide to Community Preventive Services” states that policy and environmental approaches should make healthy choices easier and target the entire workforce by changing physical structures. This includes improving access to healthy foods by changing vending machine contents.What process was used to determine that the practice is a creative use of an existing tool or practice?  Please provide any supporting evidence you may have, for example, literature review.While a literature search indicates that reduced SSB consumption has been a focus within public school settings, and that large municipalities have engaged in public education about SSBs, the innovation of this project is focused on applying these strategies more specifically to beverage consumption by adults and children that relies on: vending machines in county and municipal buildings; county and municipality management practices regarding beverages at public meetings and events; and the use of other innovative approaches such as community education on public buses, at shopping malls, and with groups such as Little League sports teams. Including a rural health network of small LHDs was innovative and educating county and city leaders to foster obesity prevention leadership by example is a new approach.Three of the four projects utilized materials and approaches based on the New York City “Pouring on the Pounds” campaign. This campaign included the installation of water jets in 229 public schools, which provided access to free drinking water for more than 221,000 students and staff who previously may have had access to water only through vending machines. They also conducted a public education campaign that discouraged sugar-sweetened beverage consumption. An evaluation of the sugar-sweetened beverage campaign found that 75% of respondents recalled seeing one or more of the campaign ads. The approach was unique and innovated in several ways. All of the projects had a very small budget ($36,000 for a single county and $52,774 for a four county coalition). The New York City campaign was developed for a very large metropolitan area but was adapted for much smaller urban, suburban and rural areas. The primary target populations for all four projects were adults. And finally, all four projects involved their community partners to increase access to the educational aspects and to assist them with making environmental changes in their vending machines for their employees. Orange County’s “Water Campaign” and Rockland County’s project utilized local shopping malls during the December Holiday Season. Orange County also increased access to water free of charge at county sites that did not have water for drinking available, and at community sites such as Senior Centers and the library. They also worked with a local little league to change the placement of healthier beverages and offer free drinking water. (2) See 1b. The process used to determine that the practices were inventive uses of the existing New York City campaign was a comparison of the approaches used to NY City’s approach. This practice differs from other approaches used to address the public health issue of obesity and overweight. The primary target audience was the adult population. Interventions, including educational sessions took place in the workplace. In one of the campaigns, Orange County, the push was for water to be the drink of choice and only focused on increased water consumption. Local health coalitions were an important part of “spreading the word” and recruiting employer groups to implement environmental changes in their vending machines.
Nutrition, Physical Activity, and Obesity
Primary StakeholdersEach of the four projects worked closely with their community partners. These partners included: Clinton County Health Department- Clinton Community College, AmeriCorps, Action for Health which is a local health coalition, PARC Wellness Center, City of Plattsburg Recreation Department, and Clinton County Government Center. Orange County Health Department- Orange County Government, senior citizen centers, recreation and community sites, City governments, park and recreation departments, town governments, summer camps, public libraries, department of public works, emergency housing department, SUNY Orange student health services, County Departments of Social Services, Planning, Real Property, Tourism, Little leagues, and a local shopping mall. Rockland County Health Department- Steps Collaboration led by the Health Department with representatives from over 20 community organizations, Summit Park Hospital, County Purchasing Department, public transportation, and a local shopping mall. S2AY Rural Health Coalition- The local health departments of Yates, Wayne, Steuben and Schuyler Counties, Child and Family Resources Inc., a local health center, community action programs, local employers, adult homes, a skate park, local hospitals, and Catholic Charities. LHD's role The LHD’s role in the community collaboration was to act as the lead coordinator of this effort. The majority of the people with whom they worked were either part of an existing health coalition, or a community partner with whom they have worked in the past. They provided technical assistance, educational services to their employees, educational materials, and sample procedures/policies to increase the availability of healthier beverages in their worksite and at meetings.The role of the stakeholders/partners was to organize educational meetings and follow through with their boards and company leaders to make sure that the environmental changes that were needed were implemented. All four of the local health departments that participated in this project had well established community health coalitions. In 1997, the New York State Department of Health provided some grant dollars to local health departments to start up health coalitions. One reason for the success of the LHDs in this project was that they built upon well established, active, strong community health coalitions that worked with them and played an intrinsic role in the program. Implementation Strategy Specific tasks taken to achieve each goal and objective of the practiceThe first task, issuance of an RFP to all local health departments in NY State, was done in early April 2011. Applications were reviewed by the NYSACHO project leader and NYSDOH leaders, who selected four projects based on specific review criteria. Contracts were sent to the four projects at the end of April with a hope for a May 1, 2011 start date. S2AY was able to meet that deadline. The other three projects were local county health departments and their contract approval process and budget amendment is a much lengthier process. One LHD was able to process the contract by the end of May, but the other two were not able to get the contract executed until the end of August 2011. All projects used existing staff. Since most of the projects utilized already produced materials from NY City, they obtained permission from NY City Department of Health and Mental Hygiene who provided their printing company with camera ready documents for reproduction. Each project then followed their own work plan to accomplish all objectives. TimeframeAfter delays in contract execution and payment advance were ended, NYSACHO began its work on this project in March 2011 with an anticipated end date of January 31, 2012. Towards the end of the grant period, a no-cost extension was granted until August 31, 2012. NYSACHO provided technical assistance to the sub-awardees throughout the project. We worked with our web site production company and launched a secure version of our website in May 2011 to provide and update essential tools for the project as it progressed. NSYACHO monitored sub-awardee progress through monthly written reports and conference calls. In the final two months of the grant, NYSACHO identified educational materials that were reproduced and distributed to all local health departments in NY State, sent copies of its “lessons learned” report to each LHD, and developed and launched a public-facing version of its website. Lessons LearnedLessons that NYSACHO learned about the implementation include the need to allow for additional time for contracts to be approved when the process is dependent on the review of several departments and meeting specific deadlines for submission.The total budget was $314,760, including $160,000 distributed to the four sub-awardees. A large portion of the remaining money was used to reproduce and distribute materials on SSBs to the local health departments and to cover the fees of our web technology consultant.
Objective 1:Develop and establish practices that increase non-sugary beverages availability in public buildings. Each of the four projects completed a report on what they had accomplished. It included the number of policies and procedures regarding increasing the availability of healthier beverages in vending machines in workplaces were adopted and implemented. We also collected information on the number of employees and visitors who had access to these vending machines. Since the project time frame was so short (6 -7 months), we decided that even if the process of adopting a policy or fully implementing a practice was in the beginning stages, it was an accomplishment. Clinton County had 3 policies adopted including one for all county operated buildings. They also had one agency adopt a practice to increase the availability of healthy beverages. A total of 1,410 employees and 3,510 visitors to the worksites involved were affected by the efforts of the Clinton County Health Department. Orange County placed greater emphasis on increasing the availability of drinking water. They established five practices of making water more available in community partner sites and in all County operated buildings. This affected 7,345 employees and 71,937 visitors to the agencies involved. Two policies regarding the contents of vending machines were adopted by municipalities, including Orange County, which affected 9,970 employees and 6,080 visitors to the buildings involved. Rockland County adopted a practice to include more healthy beverages in the vending machine and made sure that they were placed at eye level. This had an impact on 2,500 employees and 9,000 visitors to County operated buildings.S2AY Rural Health Network had five practices implemented by their community partners which involved 300 employees and 700 visitors to the buildings involved. They also had one of the involved counties approve a policy to change the contents of their vending machines in all of the County buildings. Three other policies in the other counties were pending. Rockland County did an employee survey and used this to convince the vending company to add healthier beverages such as seltzer and unsweetened iced tea. A key finding was that seltzer became one of the fastest selling beverages in their machines. Taste tests also helped to convince employees to change their choice of beverage. Each of the four projects had very similar lessons learned. Vending machines are placed in buildings through a contract with the vending company. These contracts are complex and difficult to change, and vending machines vary in size and type of beverage containers that they can hold. In County operated buildings, it was very important to have the purchasing department involved from the beginning since they issue the bid specifications for the type and contents of vending machine, and these can be so specific that they may include the type and placement of beverages in the machine. Several county employee groups that the projects approached were reluctant to change anything for fear of the loss of revenue, but the Rockland County experience with seltzer contradicts that assumption. The projects also learned that it was easier to sell their ideas using evidence based information. Many of the employer groups preferred making small changes first before making a policy change. Several also preferred making changes through practices, i.e. beverages served at meetings, rather than a policy being issued. Objective 2:Educate and engage community based organizations in activities about the link between sugar-sweetened beverages and obesity. All four projects provided education to their own employees along with their community partners. In the evaluation report that each project completed for us, we captured the number of sites where educational materials were posted or distributed, and the approximate reach of the media distribution. Clinton County distributed materials to seven community employer groups and the County Government Center with an approximate reach of 4,000 employees. They also had two articles in local newspapers and a jingle on SSBs on a local radio station. Orange County put their emphasis on increasing water consumption with the use of posters, fact sheets, water pitchers and cups. These materials were distributed to 10 employer and community sites with an approximate reach of 811,643. In addition, a major outreach campaign was held at a large local shopping mall during the holiday season with table top posters adhered to the tables in the food court on why water is the best drink. Rockland County Department of Health conducted a major media campaign on SSBs. They utilized leaflets, brochures, decals for vending machines, door clings and posters. They adapted the educational materials of the NY City “Pouring on the Pounds” campaign. They also utilized their shopping mall to educate people by having door clings on the entrance doors and mall directories about SSBs. They worked with the transportation system in Rockland County and had electronic scrolling messages about SSBs in both Spanish and English. They utilized local television and ran commercials about SSBs for a 2 month period with the commercials running 5 to 7 times a week on the Food Network, ABD Family, E Entertainment, Spike and TBS. It was difficult to determine the approximate number of individuals touched by these efforts. Their education campaign for Rockland County employees reached approximately 2,500 employees.S2AY Rural Health Network worked in four counties. They provided 17 employer groups with approximately 1,515 employees with a power point presentation and educational materials. In working with one of their Parks and Recreation Department, the department decided that it would totally stop selling SSB’s from their concession. Lessons learned by the four projects include adapting existing materials and models to educate both employees and the public. You also need to have in-person meetings to educate key stakeholders. Your major stakeholders have to be supportive in order to effectively make changes. All of the projects found that using evidence based information was key for recruitment and increasing awareness. All four projects also used their existing partner network to get the word out and assist with the distribution and posting of educational materials. NYSACHO also reviewed a sample of all of the educational materials used by the four projects and reproduced over 36,000 brochures, posters and table top displays and distributed them to 57 local health departments in NY State. We also produced a report on “Increasing Access to Healthy Beverages in Public Buildings and Worksites” and distributed five copies of the report to each local health department in NY State to share with their county executive/supervisor, purchasing department and their own health education staff.
All four projects will continue to monitor the contents of the vending machines in their respective county operated buildings. One county has worked with their purchasing department to re-do the RFP that will be distributed in the future to vending companies for the beverage vending machines in county buildings. It contains specifications to ensure that healthy beverages are available and that they are placed at eye level in all machines. Orange County has a “Healthy Orange Coalition” and the work of this project will become part of that coalition. Clinton County will continue to educate local businesses with materials that they have developed. They will also continue to use the AmeriCorps volunteer to conduct educational session in the community. Rockland County is going to continue to make presentations on SSBs as part of their “Lunch and Learn” programs in community worksites. They are also planning to work with a local hospital on incorporating educational materials as part of the hospital’s “Lose and Win” program and their Diabetes Education programs. S2AY is planning on sharing their experiences and educational presentations with the other counties in their network. NYSACHO will be conducting a follow-up survey of how all of the local health departments utilized the educational materials and ‘Lessons Learned” report distributed to them. The public-facing web site will be maintained and updated with new materials as they are identified, and promoted periodically.