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Welcome to Module 4 of the Public Health Nurse Orientation Program. This is the Health Promotion module.

My name is Yvonne Eide. I am a Public Health Nursing Consultant for the state Division of Public Health Southern Regional Office. This module was written by Jackie Bremer, from the Northern Region and myself in consultation with the local public health nursing staff, Regional Nursing Consultants and others from the Wisconsin Division of Public Health.

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One of the five required services of a local health department is to promote health. In this module we will explore how the services are provided or assured by local public health departments. We will identify;

• statutes that relate to health promotion, • resources available, including state and regional consultants, • public health interventions that apply to health promotion, and • the public health nurse’s role in this mandated service.

The four sections that will be covered in this module include: Public health interventions that nurses can use to promote health. These are:

• social marketing, • advocacy, • policy development and • policy enforcement.

The interventions selected are based on the local Community Health Improvement Process. The second and third sections describe health promotion strategies that can be implemented by public health nurses. Those are:

• The Wisconsin Nutrition and Physical Activity State Plan and • The worksite wellness program

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• In the last section, I will describe how public health nurses promote health through activities funded by the Division of Public Health specifically the Maternal and Child Health/Children and Youth with Special Health Care Needs Block Grant, Prevention Block Grant, Reproductive Health and Family Planning Services and the Comprehensive Tobacco Prevention and Control Program.

After completing this module, participants should be able to:

• describe public health nursing services that promote health, • identify resources to develop local health promotion services, and • evaluate the outcomes of health promotion activities.

In this Section, I will focus on the four public health interventions related to health promotion:

• social marketing • advocacy • policy development and • policy enforcement

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Health promotion is defined by the World Health Organization, as the process of enabling people to increase control over, and to improve, their health.

The Bureau of Community Health Promotion in the Division of Public Health has primary responsibility to provide a statewide model of integrated public health programming across the life span. This Bureau has four sections:

• Chronic Disease and Cancer Prevention Section, • Family Health Section, • Nutrition and Physical Activity Section, and • Tobacco Prevention and Control Section.

The major functions of this Bureau include: • The development and implementation of statewide programs, practices and policies; • The development of federal grant applications; • The development and enforcement of standards and guidelines related to chronic

disease, family health, nutrition and tobacco prevention and control; and • The evaluation of existing and proposed legislation.

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In the health promotion module, we will focus on the following four yellow wedges of the public health intervention wheel: When using Advocacy, the public health nurse pleads someone’s cause or act on someone’s behalf, with a focus on developing the community, system, individual or family’s capacity to plead their own cause or act on their own behalf. Using Social marketing, the public health nurse uses commercial marketing principles and technologies for programs designed to influence the knowledge, attitudes, values, beliefs, behaviors, and practices of the population-of-interest. The Policy development intervention places health issues on decision-makers’ agendas, acquires a plan of resolution, and determines needed resources. Policy development results in laws, rules, regulations, ordinances, and policies. Through Policy enforcement others are compelled to comply with the laws, rules, regulations, ordinances and policies.

Interventions for communities, systems, individuals and families should be based on a local community health plan. This plan is developed after a Community Health Assessment is done. This process is used periodically to identify the health status changes in a community and the people that live there. Public health nurses play a key role in this.

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Components of the plan address health promotion goals, strategies and activities. A Community Health Assessment includes the collection of local data, health statistics and information. This is used to develop, implement and evaluate the community health plan. This plan addresses high priority health issues affecting the community residents. The process is known as the “Community Health Improvement Process” or CHIP. Local Health departments are required by Wisconsin Statue Chapter 251.05 to:

• Regularly and systematically collect, assemble, analyze and make available information on the health of the community.

• Develop public health policies and procedures for the community. • Involve key policymakers and the general public in determining a set of high priority

public health services and assure access to these services to every member of the community.

• And finally, Submit data, as requested, to the local public health data system established by the department.

Additional requirements in community health assessments and planning are found in the Department of Health Services Administrative Rule Chapter HFS 140.04.

The Community Health Improvement Process involves identifying and prioritizing the local health needs. Two helpful tool public health nurses can use are “Healthiest Wisconsin 2010: A Partnership Plan to Improve the Health of the Public” and the national Healthy People 2010 Plan. Each includes health priorities which can be used to guide discussion in the community. The Healthiest Wisconsin 2010 Plan identifies 11 health priorities based on local, state and national morbidity, mortality, health behavior, social and economic indicators. To assist community representatives in prioritizing local health issues, local data can be compared to data in the state and national plans.

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As part of the CHIP process, public health nurses assist community representatives to:

• First Identify health conditions and their modifiable risk factors that affect community residents.

• For example, in a rural community there may be an unusually high number of injuries related to motor vehicles.

• Second Identify community strengths and resources that can be built upon to address the given health conditions.

• A community may find that they have the strength of having a good school bus system and well plowed roads.

• The Next step is to Prioritize health conditions that affect residents. • This rural community may identify the prevention of injuries related to motor

vehicles as a priority issue. • Next Develop goals, measurable objectives and implementation strategies to address

the top health priorities. • This community might establish an objective of reducing the number of injuries

due to motor vehicles by 10% over the next 5 years. • Fourth step, Incorporate health plan goals and strategies into day-to-day activities of

community partners. • This might include public health nurses doing child passenger safety seat

inspections. • Finally, the process needs to be reviewed Annually to report progress on goals,

objectives and strategies.

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The next section is on the Wisconsin Nutrition and Physical Activity State Plan and Program Guide. This plan and guide was developed using a statewide CHIP process.

This section of the Health Promotion module includes activities related to nutrition and physical fitness. Guidelines and resources for these topics are contained in the Wisconsin Nutrition and Physical Activity State Plan. The goal of this plan is to promote regular physical activity, promote healthy eating and create environments that support behaviors which are essential to reduce the epidemic of obesity.

The Wisconsin Nutrition and Physical Activity State Plan was developed using the Social Ecological Model. It is believed that the most effective strategies to improve health include all five circles of the model. Activities that focus on any one circle underestimate the effects of the others. For example, public health nurses can work toward increasing physical fitness by encouraging:

• individuals to take a walk every day,

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• families to walk together, • Employers to help workers walk during their breaks, • Communities to establish walking path and • Public Policy makers to enforce laws requiring motorists to stop when pedestrians are in

the cross walk.

The Wisconsin Nutrition and Physical Activity State Plan serves as a guiding document for the public and private organizations. By working together they can influence Public policy, Communities, Organizations, and Individual and family to improve their health. For example in one county the public health nurses worked with a service agency and a school of nursing to provide health screening and health education services to homeless families.

This Wisconsin Nutrition and Physical Activity State Plan provides a framework to help create and support environments that make it easier for all Wisconsin residents to make healthy food choices, be physically active and achieve and maintain a healthy weight. The Plan emphasizes strategies to increase physical activity, fruit and vegetable consumption and breast feeding. In addition suggestions are given on ways to decrease television viewing,

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consumption of sugar-sweetened beverages and consumption of high-energy-dense foods. Each of these topics will be explored later in this module.

It is recommended that adults engage in at least 30 minutes of moderate-intensity physical activity on most days of the week. High school students are to engage in vigorous physical activity 60 or more minutes per day. Public health nurses should incorporate these goals in their daily work. Strategies to achieve this goal might include:

• Physical activity and physical education for all children and adolescents • Access to bike trails and walking paths for all and • Putting bike racks on busses.

The Wisconsin Nutrition and Physical Activity State Plan guidelines include the following recommendations to meet the goal of increased fruit and vegetable consumption:

1) Encourage families to have fruits and vegetables available in the home for snacks and meals.

2) Educate parents about the importance of role modeling healthy eating behaviors. 3) Promote the involvement of children in meal planning and preparation. 4) Promote regular family meals to ensure optimal nutrition.

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Public health nurses can support this goal by working collaboratively with their local WIC program to encourage WIC participants to use the farmers market.

Another of the State Plan nutrition goals is to increase breast feeding. Public health nurses can move towards this goal by encouraging worksites, community programs and policies that enable women to continue to breastfeed when they return to work. The 10 Steps to Breastfeeding Friendly Health Departments is an example of a resource developed to assist local health departments, agencies and tribal clinics in their efforts to protect, promote, and support breastfeeding in Wisconsin communities and receive the “Breastfeeding Friendly” designation. http://dhfs.wisconsin.gov/health/Nutrition/Breastfeeding/index.htm

Public health nurses could support efforts to decrease consumption of sugar-sweetened beverages and high-energy dense foods by

• encouraging schools to make vending machines unavailable to students in school and • encouraging worksites to increase the number of healthy food options in vending

machines.

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One of the strategies in the Wisconsin Nutrition and Physical Activity State Plan to decrease television viewing by promoting TV Turn Off Week. Public health nurses can suggest that the families consider other activities instead of watching TV. For example: Read on your own or as a family; Take a walk; Prepare favorite meals together or experiment with foods you've never tried. Get outside and throw the ball around, pack a picnic, head to an outdoor concert or take a hike

The State Plan routinely provides progress summary reports to indicate the status of the plan objectives. As a public health nurse involved in implementing the plan locally you should review the current status and evaluate whether or not further changes need to be made to improve the outcome.

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Now let’s move on to Section III. Here we will learn strategies to promote health including the Worksite Wellness Program.

The epidemic of overweight and obesity in our Nation and in Wisconsin is well known. It was estimated that more than 62 percent of Wisconsin adults were overweight or obese in 2007. The annual obesity-related medical cost was also estimated to be $1.5 billion dollars. This epidemic is placing a huge burden on our healthcare system and economy. What can be done? Communities, schools and worksites are taking action.

• Community Wellness Coalitions have been developed in many areas of Wisconsin. Local coalitions may have a very specific focus or more general physical activity or nutrition goals. The public health nurse can be involved in establishing or being a member of these coalitions working to implement local wellness interventions.

• Strategies used in School Wellness Programs include: • nutrition education • physical activity & • guidelines for all foods available on the school campus.

An example of a Worksite Wellness Program will be described in detail in the next segment.

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As an example, I will describe how worksites can improve the nutrition and physical activity of employees. The focus of the Worksite Wellness Resource Kit is to reduce risk factors associated with obesity and chronic diseases. The Wisconsin Worksite Wellness Resource Kit was developed to assist businesses in starting, adding to or maintaining a wellness program.

Employees often experience improved overall physical fitness and mental alertness in worksites with wellness programs. Such programs also have been shown to improve morale, reduce absenteeism and presenteeism because of sudden illness or chronic health issues and may help employees live healthier, longer lives. Presenteeism, is the situation in which employees are physically present on the job but are not at their most productive or effective best.

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Worksite wellness programs benefit businesses in many ways. The key factors are decreased health care costs, increased productivity, improved staff retention and better morale. Rising healthcare benefit costs are a significant concern and poor health habits and unnecessary medical care costs consume a large portions of our corporate resources as well as the employee paycheck. The worksite is an ideal setting for health promotion programs. Employees spend many of their waking hours at work, nearing 50 hours per week. That’s why the workplace is an ideal setting for public health nurses to address health and wellness issues.

Here is an overview of the steps to take for a successful program that matches available resources.

• Some strategies cost little or nothing while others require a large financial investment. • Some strategies require change by individuals, others changes to the environment and

others require policy changes. • Businesses can choose the strategies to best meet their needs and resources.

For examples of Wellness Strategies to promote individual action might be to map out on-site trails or nearby walking routes. An environmental change or cue to encourage healthy food choices may be to highlight these healthy food choices. A no smoking policy can create a smoke free environment. Choosing the right strategy for a business is key. Public health nurses can play a key role in this process.

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There are six basic steps to setting up a Wellness Program. Step One: Identify the benefits of the program as well as the expected return on the investment. The extent of the program will depend on resources. Step Two: Secure buy-in by management and develop a company wellness committee. Step Three: Do an assessment to help decide what program to offer.

1. Assess the current worksite environment including the health of the employees. 2. Learn what employees would like to happen. 3. Collect or use other existing data that may be helpful in decision making.

Step Four: Identify activities. Some programs require few resources others require many resources. Step Five: Pick areas where there are sufficient resources to be successful. Determine priorities and set up a plan to make them happen. Policy changes and even small environmental changes can have great impact at little or no cost. Step Six: Plan for evaluating the program before it is implemented. Evaluation of the program can be very simple to very complex. Keep in mind that this method can be used in many different settings.

In Section IV, the state funding sources for local health promotion activities will be identified.

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Most funding for local health department health promotion activities in Wisconsin are supported by local tax allocations. Additional funds come from the Division of Public Health programs including the Maternal and Child Health (MCH) Program, Children and Youth and Children with Special Health Care Needs (CYSHCN) Program Block Grant, the Preventive Health and Health Services Block Grant, the Reproductive Health and Family Planning Services, and the Comprehensive Tobacco Prevention and Control Program. This section will briefly review each of the Division of Public Health programs as they relate to health promotion.

The purpose of the MCH Services Block grant is to assure the health all mothers and children in Wisconsin but with a special focus on unmet needs. It is the Federal government’s pledge to support states in their efforts to extend health and welfare services for mothers and children. Although amended several times, the underlying goal has remained constant.

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The Maternal and Child Health/Children and Youth with Special Health Care Needs Program is intended to be used to increase healthy birth outcomes and promote optimal growth and development for children and their families. Public health nurses take steps to reduce racial and ethnic disparities and healthy birth outcomes in their communities.

One local health department used their MCH funds to create an environment to promote healthy eating in a local school. Public health nurses worked with the school staff and students in this program. As a result, the school has more healthy food choices in the vending machines and they are discussing how they can make more healthy food choices available for sale at concession stands.

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In another local health department program, Latino children learned about serving sizes and how to make healthy food choices by interpreting information on food labels. The local health department worked with the hospital and other community partners in this project.

During pregnancy, public health nurses help women and men develop the skills needed to become parents. At least 40 years ago, Reva Rubin, a nurse specializing in maternity care doing doctoral work at the University of Chicago, carefully observed women during their pregnancy, labor and delivery and during the early postpartum period. She integrated those observations into a theory about the development of maternal identity. There are four maternal tasks the mother deals with during pregnancy. These are: (1) seeking safe passage; (2) ensuring the acceptance of the child by others; (3) binding in or bonding with the fetus; and (4) learning to give of oneself. http://steppingup.washington.edu/whatsnew_10-03.asp Adapted from Reva Rubin Public health nurses help women

• find Prenatal care • adjust food intake to meet the needs of the pregnancy, refer them to WIC • adjust activities to stay safe during pregnancy especially in their work environment

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Public health nurses do ensure acceptance of the baby by helping the parents

• Identify people they can count on to help them take on the new role as parents and • Encourage the support people to participate in the public health nursing visits, other

health services visits and community services

Many public health nurses help parents attach to the fetus during pregnancy by:

• Showing pictures of the development at each visit to make the baby more real • Identifying unique characteristics of their baby, i.e. the baby moves to the mother’s

voice • Listening to baby’s heartbeat which shows how healthy the baby is • Celebrating parents’ successes in adapting to the pregnancy

• Adjusting diet to meet the needs of the pregnancy • Attending birthing classes

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Public health nurses can help parents take on their new role and put their baby’s needs first by:

• Discussing the expectations they have of being a parent. • Identifying lifestyle adjustments that may be necessary to accommodate the needs of

the baby such as, change in usual sleeping and change eating schedule, being willing to give up personal comfort to meet the urgent needs of their baby.

• Being with a parents during pregnancy is a unique experience for public health nurses and it is one way to make sure the mother and baby are healthy and the family is ready to care for their new baby.

Now I want to say a little bit about how public health nurses collect MCH data to show the outcome of services. The SPHERE system is the data system that the state supports for this purpose. SPHERE is the acronym for the Secure Public Health Electronic Record Environment. It is the required data system that health departments and Tribal clinics use to measure the outcome of contract objectives that are funded by the MCH Services Block Grant. The data is used by the MCH Program to meet federal and state demographic and health reporting requirements. SPHERE data is used by local health departments and private providers for tracking comprehensive and coordinated services, best practices, and health outcomes related to national and state performance measures.

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Through the Reproductive Health/Family Planning Program public health nurses take steps to reduce the number of unintended pregnancies, and provide access to quality and affordable contraceptive and related reproductive health services.

Health departments that receive funds from the Early Intervention and Detection of Pregnancy Services Program, also known as EIDP, provide services in the following four areas:

1. Information about family planning and reproductive health and pregnancy related health and services.

2. Information and enrollment into Badger Care Plus benefits. 3. Pregnancy tests, and 4. Contraceptive services including emergency contraception. These services may be

provided directly or through referral.

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The Comprehensive Tobacco Prevention and Control Program also provides funding to support health promotion objectives and activities. The purpose of this Program is to address aggressively the burden of tobacco use and exposure in Wisconsin. Through these grant funds local communities take steps to prevent initiation of tobacco use among youth and adults, protect youth and adults from secondhand smoke, promote tobacco dependence treatment for adults and youth, and identify and eliminate tobacco related disparities.

Increasing the number of municipalities in a county to newly adopt smoke free policies is an example of an objective of the tobacco prevention and control program.

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To find out more about health promotion, I encourage you to go to the Department of Family Services web site or talk to your public health nurses in your department. As a public health nurse, you promote the health of all the communities, families and individual that you serve every day. This work is critical to making Wisconsin the Healthiest state in the nation.

This program was developed through a partnership between the Wisconsin Department of Health Services and the University of Wisconsin-Madison School of Nursing through the “Linking Education and Practice for Excellence in Public Health Nursing Project” funded by DHHS/HRSA/#D11HP07731. This module would not have been possible without the input of the many public health nurses in academia and practice across the State of Wisconsin who contributed to this program. We would like to give special thanks to those who provided content review of this module.

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Expert Consultation was provided by the following staff from the Bureau of Community Health Promotion, Wisconsin Division of Public Health:

• Ann Altman Stueck, MSN, RN, Infant and Child Health Nurse Consultant • Linda Hale, RN, BSN, Chief Family Health Section • Mary Pesik, RD, CLE, CD, Nutrition and Physical Activity Program Coordinator • Katie H. Gillespie, RN, BSN, Maternal/Perinatal Nurse Consultant • Expert technical assistance was provided by Rodney W. D. Ploessl, M.Sc, C.N.A, Office

Manager, DPH, Southern Regional Office