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					                       Maximizing Resources
                           for Results!
 Extending Bright Futures through
Community-Based Nutrition Planning
The 2000 Continuing Education Program for Public Health
            Nutrition Personnel in Region IV,
     U.S. Department of Health and Human Services



                 Training Curriculum Development:
                   Susanne Phelan Gregory, MPH
                 Director, Training & Development
         Division of Chronic Disease Prevention & Nutrition
                   Virginia Department of Health

                         Coordinated by:
                   The University of Tennessee
            University of North Carolina – Chapel Hill
           Region IV Public Health Nutrition Continuing
                  Education Advisory Committee

                         Funded by:
                      DHHS, HRSA, MCHB




                                 1
                     Citation/Funding Information

Gregory SP. Maximizing Resources for Results! Extending Bright Futures
through Community-Based Nutrition Planning. DHHS Region IV Public Health
Nutrition Continuing Education Program, 2000. Knoxville, TN: Department of
Nutrition, The University of Tennessee; 2000.


This training program for public health nutrition personnel in Region IV of the
U.S. Department of Health and Human Services was made possible through a
collaborative Public Health Nutrition training grant to The University of North
Carolina-Chapel Hill and The University of Tennessee from the Health
Resources and Services Administration/Maternal and Child Health Bureau of
the U.S. Department of Health and Human Services.
(MCJ-000965-21-0).

Authorization to photocopy items for internal use by official health agencies for
staff development and training is granted.




                                        2
A word about these training materials….
These materials were designed to make it easy for you (a training participant) to
become a trainer! We have essentially created a “training-to-go” so that you
can take any or all of the materials and resources and offer this training for
various audiences. This curriculum is designed as a one-day training but by
adding state or local specific data, expanding the presentations and using more
skill-building activities, this curriculum can be adapted for a more in-depth, 2 or
2.5 day training.

The primary goal of this training is to introduce and explore Bright Futures in
Practice: Nutrition and to use the Moving to the Future: Developing
Community-Based Nutrition Services publication as a model for planning
nutrition services. The training materials, including many of the presentations
and training activities, are based on these publications.

This training package includes:

    • The training program manual:
ä   The training curriculum (on white paper).
ä   The training activities (on yellow paper).
ä   Each training section begins with a page of guidance for the trainer
    including an outline of content and materials (on pink paper).
ä   The Trainer Tips (on pink paper) can be found at the back of the training
    program. These “Tips” will help you plan and deliver a successful training
    program.

  • A floppy disk with:
ä A Microsoft Word 97 file of the training curriculum.
ä A Microsoft PowerPoint 97 file of the presentation segments.

    • A packet of master copies of the PowerPoint 97 slides which can be used
      to make overhead transparencies.

    • A videocassette with excerpts from the 1999 videoconference course
      Moving to the Future: Developing Community-Based Nutrition Services.
      The video segments provide coverage of some of the content used in this
      training. You can use the video to help you prepare to deliver some of
      the presentations.




                                        3
                          Table of Contents
                                                                 Page
Acknowledgements                                                 5-11
Training Objectives & Agenda                                     12-14
Section #1: Introductions & Climate Setting                      15
   • Your Community Resources Checklist -Pre-Training Activity
   • Trainer Introductions
   • Review Training Objectives and Agenda
   • Icebreaker – Your Group Resume – Activity
Section #2: National, State & Local Health Objectives            21
   • Healthy People 2010
   • State and National MCH Block Grant Objectives
Section #3: A Tour of Bright Futures in Practice: Nutrition      29
Section #4: Overview of the Community-Based Nutrition            35
            Planning Process
Section #5: Community Assessment – the Four Components           39
   • Define Your Community
   • Perceived Needs Data
   • Demographic, Health & Nutrition Data
   • Community Resources– Assets Data - Discussion
   • Looking at a Community’s Assessment Data - Activity
Section #6: Identifying Health Priorities and Writing Goals &    58
             Objectives –Activity
Section #7: The Nutrition Plan                                   65
Section #8: Implement the Intervention – Activity                68
Section #9: Monitoring & Evaluation                              71
Section #10: Planning in Action-A Local Success Story – Video    76
Section #11: Training Wrap-up, Trainer Tips and Evaluation       79
   • Your Next Steps – Activity
   • Trainer Tips
   • Evaluation
Resources                                                        90



                                      4
Acknowledgements


There are many public health nutritionists that participated in the development
and implementation of this continuing education program. A heartfelt thanks is
extended to each and every one of them.

The Region IV Continuing Education Advisory Committee members provided
valuable guidance and input on not only the direction for the program, but also
how it was implemented. They recommended a modified train-the-trainer
model of implementation, whereby one out-of-state trainer was paired with an
in-state trainer for each state. These pairs of teams delivered one training
session in each of the 8 southeastern states during April and May, 2000.
Participants in each of these training sessions were requested to implement the
training program in their respective local work sites, thereby extending the
continuing education regionally.

Based on the guidance and advice of the Advisory Committee, Susanne
Gregory developed this training manual. She extends a special thanks to Sandy
Benton-Davis, Kathy Davis, Betsy Haughton, Alice Lenihan, Marcie Singleton,
and Emma Walters for their thoughtful review and valuable recommendations.
The final product was certainly a refection of their collective expertise.

Once the training module was complete, the implementation strategy required
the commitment and work of the Region IV state nutrition directors. Each
director or her designee took responsibility for the logistics of implementing the
program in her respective state. This included local planning arrangements and
facilitating travel arrangements for out-of-state trainers. Their time and effort
made this part of implementation smooth and efficient.

The public health nutritionists who delivered the program in each of the states
are due special recognition. They brought the material to life and helped tailor
the materials to each state’s interests and needs. Their expertise and skill is
appreciated. Without them the module would have been an excellent resource,
but they assured that it was delivered.



                                        5
Acknowledgements, cont.

Finally, but not least, this program would not have been possible without the
financial support of the Maternal and Child Health Bureau, Health Resources
and Services Administration, US Department of Health and Human Services
through its collaborative training grant with the University of North Carolina-
Chapel Hill and the University of Tennessee.


Betsy Haughton, EdD, RD             Janice Dodds, EdD, RD         Susanne Gregory, MPH
Associate Professor                 Associate Professor           Consultant
Director, Public Health Nutrition   University of North Carolina-
The University of Tennessee         Chapel Hill




                                            6
  1999 Region IV Continuing Education Advisory Committee
Diane Anderson, PhD, RD                Betsy Haughton, EdD, RD, LDN
Medical University of South Carolina/  Associate Professor
Children’s Hospital                    Director, Public Health Nutrition
Pediatrics/Neonatology                 Department of Nutrition
165 Ashley Avenue                      College of Human Ecology
PO Box 250917                          University of Tennessee
Charleston, SC 29425                   Knoxville, TN 37996-1900
803/792-2112; 803/792-8801 (FAX)       423/974-6267; 423/974-3491 (FAX)
Anderson@musc.edu                      haughton@utk.edu

Sandy Benton-Davis, RD                     Jody Henderson, MA, RD, LD
WIC Program, 8T36                          Nutrition Services Director
61 Forsyth Street, SW                      Office of State Health Officer
Atlanta, GA 30303                          2423 North State Street
404/562-7102; 404/562-4518 (FAX)           PO Box 1700
Sandra.Benton-Davis@fns.usda.gov           Jackson, MS 39215-1700
                                           601/576-7939; 601-576-7823
Kathy Davis, RD, MPH                       jhenderson@msdh.state.ms.us
MCH Nutrition Consultant
Sam Nunn Atlanta Federal Center            Candace Jones, RD, MPH
61 Forsyth Street SW, Suite 3M 60          Policy Advisor
Atlanta, GA 30303-8909                     Division of State and National
404/562-7982; 404/730-2983 (FAX)           Initiatives
KDavis1@hrsa.dhhs.gov                      PO Box 101106
                                           Mills-Jarrett Complex
Jan Dodds, EdD, RD                         Columbia, SC 29211-0106
Associate Professor                        803/898-0661; 803/898-0380 (FAX)
Department of Nutrition                    jonesca@columb63.dhec.state.sc.us
McGavran-Greenberg Building
CB #7400                                   Alice Lenihan, MPH, RD
School of Public Health                    Chief, Nutrition Services Section
University of North Carolina               North Carolina Department of Health
Chapel Hill, NC 27599-7400                 Division of Maternal and Child Health
919/966-7229; 919/966-7216 (FAX)           Nutrition Services Section
jan_dodds@unc.edu                          PO Box 10008
                                           Raleigh, NC 27605-0008
Hans Hammer, MS, RD                        919/715-0636; 919/73301384 (FAX)
Nutrition Program Consultant (Training &   Alice_Lenihan@ncmail.net
Evaluation)
Office of Nutrition
Georgia Department of Human Resources
Two Peachtree Street, NW
Suite 8413
Atlanta, GA 30303
404/657-2884; 404/65702886 (FAX)
hmh0601@dhr.state.ga.us

                                       7
  1999 Region IV Continuing Education Advisory Committee, cont.
Connie McMichael, MS, RD                   Denise West, MPH, RD
Nutrition Services Assistant Administrator Public Health Nutrition Program
Alabama Department of Public Health        Director
RSA Tower                                  HRS Dade County Health Department
Bureau of Family Health Services, WIC      1350 NW 14th Street
Division                                   Miami, FL 33125
Suite 1374H, PO Box 303017                 305/377-5656; 305/377-5766 (FAX)
Montgomery, AL 36130-3017                  denise_west@doh.state.fl.us
334/206-5673; 334/206-2914 (FAX)
cmcmichael@adph.state.al.us

Marcie Singleton, MS, RD, LDN
Breastfeeding Coordinator
East Tennessee Regional Health Office
PO Box 59019
Knoxville, TN 37950-9019
423/549-5322; 423/549-5738 (FAX)
msingletonrd@yahoo.com
Bonnie Spear, RD, PhD
University of Alabama at Birmingham
Adolescent Medicine
1600-75h Avenue South
Birmingham, AL 35233
205/939-6299; 205/975-7307 (FAX)
BSpear@PEDS.UAB.ED

Eileen Stellefson, MPH, RD
Director, Community and Professional
Education for Medical University of South
Carolina Institute of Psychiatry
67 President Street
PO Box 250861
Charleston, SC 29425
843/792-7397; 843/792-7298 (FAX)
stellefe@musc.edu

Emma Walters, MS, RD
Chief Dietitian
Kentucky Cabinet for Human Resources
275 East Main Street
Frankfort, KY 40621
502/564-2339; 502/564-8389
Emma.Walters@mail.state.ky.us



                                        8
Maximizing Resources for Results! Region IV Training Team Members, 2000

Alabama
Connie McMichael, MS, RD                     Susanne Gregory, MPH
Nutrition Services Assistant Administrator   Consultant
Alabama Department of Public Health          Melwood Lane
RSA Tower                                    Richmond, VA 23229
Bureau of Family Health Services, WIC        804/282-1355 (Tele)
  Division                                   804/282-7801 (FAX)
Suite 1374H, PO Box 303017                   susannegregory@yahoo.com
Montgomery, AL 36130-3017
cmcmichael@adph.state.al.us


Florida
Sondra Cornett, MS, RD, LD                   Bonnie Spear, RD, PhD
Public Health Nutrition Consultant           University of Alabama at
Florida Department of Health                 Birmingham
Bureau of WIC and Nutrition Services         Adolescent Medicine
2020 Capital Circle, S.E.                    1600-75h Avenue South
Tallahassee, FL 32399-1726                   Birmingham, AL 35233
850/245-4202; 800/342-3556                   205/939-6299
Sondra_Cornett@doh.state.fl.us               BSpear@PEDS.UAB.EDU



Georgia
Hans Hammer, MS, RD                          Kathy Davis, RD, MPH
Nutrition Program Consultant (Training &     MCH Nutrition Consultant
  Evaluation)                                Health Resources and Services
Georgia Department of Human Resources         Administration
Two Peachtree Street, NW                     Office of Nutrition
Suite 11-262                                 South East Field Office
Atlanta, GA 30303-3142                       Sam Nunn Atlanta Federal Center
404/657-3814                                 61 Forsyth Street SW, Suite 3M 60
hhammer@dhr.state.ga.us                      Atlanta, 30303-8909
                                             404/562-7982
                                             KDavis1@hrsa.gov




                                       9
Region IV Training Team Members, 2000, cont.

Kentucky
Emma Trimble Walters, MS, RD          Marcie Singleton, MS, RD, LDN
Chief Dietitian                       Breastfeeding Coordinator
Cabinet for Human Resources           East Tennessee Regional Health
275 East Main St., HS 2W-C            Office
Frankfort, KY 40621                   1522 Cherokee Trail, PO Box
502/564-2339                          59019
Emma.Walters@mail.state.ky.us         Knoxville, TN 37950-9019
                                      865/549-5322
                                      msingletonrd@yahoo.com


Mississippi
Jody Henderson, MA, RD, LD            Bonnie Spear, RD, PhD
Nutrition Services Director           University of Alabama at
Office of State Health Officer        Birmingham
570 East Woodrow Wilson               Adolescent Medicine
PO Box 1700                           1600-75h Avenue South
Jackson, MS 39215-1700                Birmingham, AL 35233
601/576-7939                          205/939-6299
jhenderson@msdh.state.ms.us           BSpear@PEDS.UAB.EDU



North Carolina
Ann McLain                            Marcie Singleton, MS, RD, LDN
Regional Nutrition Consultant         Breastfeeding Coordinator
NC Division of Public Health          East Tennessee Regional Health
585 Waughtown Street                  Office
Winston-Salem, NC 27107               1522 Cherokee Trail, PO Box
336/771-4600, Ext 336                 59019
Ann.McLain@ncmail.net                 Knoxville, TN 37950-9019
                                      865/549-5322
                                      msingletonrd@yahoo.com




                                 10
Region IV Training Team Members, 2000, cont.

Connie McMichael, MS, RD
Nutrition Services Assistant Administrator
Alabama Department of Public Health
RSA Tower
Bureau of Family Health Services, WIC
  Division
Suite 1374H, PO Box 303017
Montgomery, AL 36130-3017
cmcmichael@adph.state.al.us


South Carolina
Margaret Feld, MS, RD                        Marcie Singleton, MS, RD, LDN
District Director of Nutrition               Breastfeeding Coordinator
Appalachia II Health District                East Tennessee Regional Health
PO Box 2507                                  Office
Greenville, SC 29602                         1522 Cherokee Trail, PO Box
864/282-4347                                 59019
FELDMR@grnvll61.dhec.state.sc.us             Knoxville, TN 37950-9019
                                             865/549-5322
                                             msingletonrd@yahoo.com

Sandy Spann
Office of Public Health Nutrition
SC Department of Health and Environmental Control
Robert Mills Complex
Columbia, SC 29211


Tennessee
Marcie Singleton, MS, RD, LDN                Emma Trimble Walters, MS, RD
Breastfeeding Coordinator                    Chief Dietitian
East Tennessee Regional Health Office        Cabinet for Human Resources
1522 Cherokee Trail, PO Box 59019            275 East Main St., HS 2W-C
Knoxville, TN 37950-9019                     Frankfort, KY 40621
865/549-5322                                 502/564-2339
msingletonrd@yahoo.com                       Emma.Walters@mail.state.ky.us




                                      11
                 Maximizing Resources for Results!

This one-day training program is designed to introduce important resources that
can help you plan, deliver and evaluate effective nutrition services that meet the
needs of the families and communities you serve.

These resources include:

• Bright Futures in Practice: Nutrition

• Moving to the Future: Developing Community-Based Nutrition Services

• Healthy People 2010 Nutrition Objectives

• Maternal and Child Health Block Grant Objectives

Training Objectives
Upon completion of this training, you will be able to:

1. Discuss 3 examples relating Healthy People 2010 objectives and MCH
   Block Grant Objectives to nutrition services at the local and state levels;

2. Identify at least 3 potential uses of Bright Futures in Practice: Nutrition;
   Moving to the Future: Developing Community Based Nutrition Services and
   Healthy People 2010 as resources in planning public health nutrition
   services;

3. Describe the need for partnerships in planning and funding community-
   based nutrition services;

4. Use the 5-Step Community-Based Planning Process and Bright Futures in
   Practice: Nutrition to address a nutrition issue for the MCH population;

5. Identify 3 ways you intend to share these resources and training with other
   public health personnel in your state, region or local communities.




                                        12
                Maximizing Resources for Results!
                           AGENDA
                               Morning

8:30-9:00     Registration & Pre-Training Activity
                • Your Community Resources Checklist

9:00-9:30     Section #1: Introductions & Climate Setting
                 • Trainer Introductions
                 • Review Training Objectives & Agenda
                 • Icebreaker – Your Group Resume – Activity

9:30 – 9:50   Section #2: National, State & Local Health Objectives
                 • Healthy People 2010
                 • State and National MCH Block Grant Objectives

9:50-10:15    Section #3: A Tour of Bright Futures in Practice: Nutrition

10:15-10:30 Section #4: Overview of the Community-Based Nutrition
            Planning Process

10:30-10:45 Break

10:45-12:30 Section #5: Community Assessment – the Four Components
               • Define Your Community
               • Perceived Needs Data
               • Demographic, Health and Nutrition Data
               • Community Resources – Assets Data - Discussion
               • Looking at a Community’s Assessment Data – Activity

12:30-1:30    Lunch




                                     13
              Maximizing Resources for Results!
                         AGENDA
                           Afternoon
1:30-2:15   Section #6: Identifying Health Priorities and Writing Goals &
            Objectives –Activity

2:15-2:30   Section #7: The Nutrition Plan

2:30-3:15   Section #8: Implement the Intervention – Activity

3:15-3:30   Break

3:30-3:50   Section #9: Monitoring & Evaluation

3:50-4:15   Section #10: Planning in Action-A Local Success Story – Video

4:15-4:45   Section #11: Training Wrap-up and Evaluation
                  • Your Next Steps – Activity
                  • Trainer Tips
                  • Evaluation

4:45        Adjourn




                                   14
Section #1: Introductions & Climate Setting
     • Your Community Resources Checklist – a Pre-Training Activity

        This activity can be given to trainees several days before the training
        or it can be done informally as trainees arrive for the training (*** Do
        during registration before the actual training begins.***). The results
        of this activity will be used for discussion in Section #5.

        Training Materials Needed:
           r Overhead transparencies of Instructions and Checklist (pages 9-
              12 of training curriculum)


     • Trainer Introductions (5 minutes)

           Introduce yourself and let them know that in just a moment, they
           will all have an opportunity to introduce themselves (Your Group
           Resume Activity)


     • Review Training Objectives & Agenda (5 minutes)

        Training Materials Needed:
           r Overhead transparencies of Objectives & Agenda (pages 5-7 of
              training curriculum


     • Icebreaker – Your Group Resume – Activity (20 minutes: 10
       minutes for activity & 10 minutes for reporting out/introductions)

        Training Materials Needed:
           r Overhead transparency of Activity Instructions (page 13 of
              training curriculum)
           r Each group needs flipchart paper & markers
              OR a blank transparency & pen.




                                      15
             Your Community Resources Checklist
                    Pre-Training Activity
                        Instructions
1. Use the Community Resources Checklist (pages 10-12 of training
   curriculum) to make an inventory of your community’s nutrition resources
   by noting the following for each program:

   a. If you know this service exists in your community, check “YES” under
      the “In My Community” column. If you know a contact for this program
      or service, write his/her name in the “Contact” column.

   b. If the service does not exist, check “NO” under the “In My Community”
      column.

   c. If you do not know if the service exists in your community, check “Don’t
      Know” under the “In My Community” column.

   d. If you know of other nutrition and health related programs in your
      community that are not listed on the checklist, add them as “other”
      programs.

2. Review your inventory.

   a. What kinds of services and programs are you MOST familiar with?




   b. What services and programs are you LEAST familiar with?




   c. What kind of pattern do you see?




                                      16
                                  Community Resources Checklist
Program                                          In My Community?                               Contact Name
Food & Nutrition                                 YES          NO          Don’t Know
Programs/Services
Adult Day Care
Adult Day Health Care
Child & Adult Care Food Programs
(CACFP)
Child Nutrition Programs
-----School Breakfast
-----School Lunch
-----Summer Feeding Program
-----At Risk Snack Program
Child Care Centers
Commodity Foods (TEFAP)
Congregate Meals
Convenience Stores
Farmer’s Markets
Food Banks
Food Coops
Foods Gleaning
Food Stamps
Home-Delivered Meals
Homeless Shelters
Neighborhood Food Stores
Restaurants
Soup Kitchens
Supermarkets (large or chain)
WIC
Other
Other
Health Care
Assisted Living Homes
CSHCN Clinics
Clinics Run by Religious
Organizations
Community Health Center/Rural
Health Center
Health Planning Committee
Hospices
Hospitals
Hospital Outpatient Clinics
    Adapted from Moving to the Future: Developing Community-Based Nutrition Services (Workbook & Training Manual)




                                                             17
                         Community Resources Checklist – PAGE 2
Program                                          In My Community?                              Contact Name
Health Care – cont.                              YES          NO          Don’t Know
Home Health Agencies
Intermediate Care/ Rehabilitation
Facilities
Managed Care Organization (HMO)
Medicare Program
Nursing Homes
Private Medical Clinics
Public Health Department
Specialty Clinics (homeless,
womens/mens, Hispanic, public
housing, etc)
Weight Management Programs
Other
Other
Educational
Programs or Settings
Athletic clubs: private, corporate,
YWCA, YMCA, etc.
Elementary Schools
After School Childcare Programs
(public & private)
Extension/EFNEP
Head Start
Boy Scouts/Girl Scouts
4-H
Middle and High School
EFNEP
Nutrition Education and Training
Program (NET)
Universities, community colleges
Worksites
Other
Other
Other


         Adapted from Moving to the Future: Developing Community-Based Nutrition Services (Workbook & Training Manual)




                                                             18
                          Community Resources Checklist – PAGE 3
Program                                           In My Community?                               Contact Name
Mass Media                                        YES          NO          Don’t Know
Newspaper(s)
Radio station(s)
Television station(s)
Other
Other
Professional, Volunteer, Non-
Profit Organizations
American Diabetes Assoc.
American Dietetic Assoc.
American Cancer Society
American Heart Association
American Medical Assoc.
American Nursing Assoc.
American Red Cross
Council on Aging
Healthy Mothers, Healthy Babies
March of Dimes
Local Nutrition Coalition
Parent Teacher Associations
Society for Nutrition Education
United Way
Visiting Nurses Association
Community Service Organizations
(i.e. Kiwanis)
Other
Other


     Adapted from Moving to the Future: Developing Community-Based Nutrition Services (Workbook & Training Manual)




                                                              19
                         Your Group Resume
                              Activity
                            Instructions
      You have 10 minutes to work on your resume in your small group.

1. Each person at your table brings unique experiences and talents to this
   training.

2. Organize a “group resume” for your table by finding out and recording the
   following information:

   a. Total number of undergraduate/graduate degrees.


   b. Total number of years of professional experience.


   c. One major accomplishment of each group member over the last year.


   d. List group member involvement in local community taskforces, advisory
      committees, workgroups, and local organizations.


   e. List any special skills, such as language, computer, cultural competence
      communications, etc.


3. “Print” your resume on the flipchart and be prepared to share your
   impressive resume with the larger group. Each group will have about 3
   minutes to report out.




                                       20
Section #2: National, State & Local Health Objectives


     • Healthy People 2010 - Presentation (10 minutes)

       A brief presentation Healthy People 2010 and core services.

       Training Materials Needed:
          r Overhead transparencies or Power Point slides of presentation


     • State and National MCH Block Grant Objectives - Presentation
       (10 minutes)

       A brief presentation on the State & National MCH Block Grant
       Objectives and implications for local and state nutrition planning.

       Training Materials Needed:
          r Overhead transparencies or Power Point slides of presentation




                                     21
Healthy People 2010 National Objectives
Reference: www.health.gov/healthypeople


    • Disease prevention & health promotion agenda for the nation


    • Goals & objectives with measurable indicators

        Examples of Healthy People 2010 Objectives:

       19-11    Increase the proportion of persons aged 2 years and older who meet
                dietary recommendations for calcium. Target: 75 percent. Baseline: 46
                percent of persons aged 2 years and older were at or above approximated
                mean calcium requirements (based on consideration of calcium from foods,
                dietary supplements, and antacids) in 1988-94 (age adjusted to the year
                2000 standard population).

       22-9     Increase the proportion of adolescents who participate in daily school
                physical education. Target: 50 percent. Baseline: 27 percent of students in
                grades 9 through 12 participated in daily school physical education in 1997.

       19-4     Reduce growth retardation among low-income children under age 5
                years. Target: 5 percent. Baseline: 8 percent of low-income children under
                age 5 years were growth retarded in 1997 (defined as height-for-age below
                the fifth percentile in the age-gender appropriate population using the 1977
                NCHS/CDC growth charts; preliminary data; not age adjusted).

       19-15    (Developmental) Increase the proportion of children and adolescents
                aged 6 to 19 years whose intake of meals and snacks at schools
                contributes proportionally to good overall dietary quality.

        **Additional Example can be found in the Resources section


    • Drive public policy and funding – build justification & support for your
      local & state objectives


    • Useful for practitioners when developing health care plan goals and
      objectives at the state and local agency level




                                              22
     • All agencies can collectively make a positive impact on their populations
       and the community at large.


     • Two primary goals:
            1. Increase quality and years of healthy life.
            2. Eliminate health disparities.


• More than 500 objectives across 26 focus areas.


• Public Health encompasses three core public health functions: assessment,
  policy development, and assurance. These functions are defined further and
  expanded into 10 essential public health services.
     (from: Health People 2010 - Section 23: Public Health Infrastructure)


                                  Essential Public Health Services
1.           Monitor health status to identify community health problems
2.           Diagnose and investigate health problems and health hazards in the
             community.
3.           Inform, educate, and empower people about health issues.
4.           Mobilize community partnerships to identify and solve health problems.
5.           Develop policies and plans that support individual and community
             health efforts.
6.           Enforce laws and regulations that protect health and assure safety.
7.           Link people to needed personal health services and assure the provision
             of health care when otherwise unavailable.
8.           Assure a competent public health and personal health care workforce.
9.           Evaluate effectiveness, accessibility, and quality of personal and
             population-based health services.
10.          Research for new insights and innovative solutions to health problems.




                                                  23
Nutrition Services Example: Georgia State Office of Nutrition
Reproduced from: http:// www.ph.dhr.state.ga.us / programs / nutrition / index.shtml
Mission
The mission of the Office of Nutrition is to work in partnership with the public and
private sector to promote health and reduce the burden of disease among
Georgians. We do so by:
    • Conducting population-based services within the three core functions of
       public health Assessment, Policy Development and Assurance;
    • Increasing the demand and providing options for achieving healthy eating
       lifestyles;
    • Enabling people to make informed food choices;
    • Creating public/private partnerships to share responsibility for actions.
Assessment
   •   Assess the community to better address the nutrition problems faced by the
       individuals and families who live and work in them, using tools such as the
       Food Intake Analysis System
   •   Monitor breast-feeding rates by working with the Epidemiology & Prevention
       Branch, WIC and the DHR Office of Information Technology.
   •   In cooperation with the CDC, operate two nutrition surveillance systems for
       the pediatric and prenatal populations
   •   Conduct social marketing research (i.e., focus groups)
   •   Evaluate and monitor nutrition services in WIC and Children’s Medical
       Services
Policy Development
   •   Publish guidelines for public health professionals who provide nutrition care
       for clients
   •   Develop a plan of action that reflects the US Year 2000 Goals and Objectives
   •   Develop program policy and procedure manuals
   •   Participate in coalitions and advocacy groups that support the Office of
       Nutrition mission
   •   Form a network of partners that would enhance cooperative projects and
       resources
Assurance
   •   Develop, secure and implement grants and other resources to increase
       capacity
   •   Provide leadership and technical assistance in program development and
       client services
   •   Ensure, through the Residential Child Nutrition Program, that school-aged
       children housed in sites statewide receive balanced breakfast and lunch
       meals, and nutrition education
   •   Provide leadership for the Five-A-Day for Better Health Campaign.
   •   Sub-license coalitions and health districts to endorse and promote the
       campaign
   •   Create, evaluate, select, promote and maintain resources for use in public
       health programs



                                           24
   •   Direct a dietetic internship to increase nutrition staff competence and
       qualifications



The Relationship between Individual and Community Health

• The health of the individual is linked to the health of the community and
  environment in which individuals live, work, and play.


• Community health is profoundly affected by the collective behaviors,
  attitudes, and beliefs of everyone who lives in the community.


• Healthy People 2010 premise is that the health of the individual is almost
  inseparable from the health of the larger community and that the health of
  every community in every State and territory determines the overall health
  status of the Nation.




                                          25
Maternal and Child Health Block Grant Objectives

Primary goal: to extend and improve health and welfare services for mothers
and children.

   •   State Title V programs are required to report on progress on key maternal
       and child health indicators and other program information.

   • The Government Performance and Results Act (GPRA) of 1993 required
     the establishment of measurable goals that can be reported as part of the
     budgetary process, thus linking funding decisions with performance.


   • GPRA is intended to “...improve Federal program effectiveness and
     public accountability by promoting a new focus on results, service
     quality, and customer satisfaction.”


Comprehensive Outcomes – i.e. infant mortality reduction. Nutrition services
are a vital component.


Two types of MCH Objectives: nationally developed and state developed.


Levels of the Pyramid

   • direct health care

   • enabling

   • population-based

   • infrastructure building services




                                        26
    Maternal and Child Health (MCH) System Pyramid
Source: http:// www.ph.dhr.state.ga.us / programs / family / pyramid.shtml /




                                      27
                 Sample State MCH Block Grant Objective
Resource: http://www.mchdata.net/SEARCH/search.html, clink on state negotiated
measures, then enter in Nutrition in the Search category and a table will come up with all of
the states who have added nutrition measures.

Kentucky
Category:      Population-Based Services

Goal:          To increase the percentage of mothers who breastfeed their infants at
               discharge.

Measure:       Percent of mother in the State who breastfeed their infants at hospital
               discharge.

Definition:    Numerator: The number of mothers who exclusively breastfeed their infant at
               hospital discharge.

               Denominator: Number of occurrent births in the Sate in the calendar year.

               Units: 100     Text: Percent

Health People
2000 Objective        Objective 2.11
                      Increase to at least 75% the proportion of mothers who breastfeed their
                      babies in the early postpartum period and to at least 50% the
                      proportion who continue to breastfeed until 5-6 months old.

Data Source
And Data
Issues:     Ross Laboratories Mothers Survey; State WIC data; USDA; State Pediatric
            Nutrition Surveillance System, CDC.

Significance The advantages of breastfeeding are indisputable and include nutritional,
             immunological and pshycological benefits to both the infant and mother, as
             well as economic benefits.




                                              28
Section #3: A Tour of Bright Futures in Practice: Nutrition

      • Bright Futures Initiative and Bright Futures in Practice: Nutrition
        – Presentation (25 minutes)

         Training Materials Needed
            r Overhead transparencies or Power Point slides of presentation
            r Copy of Bright Futures in Practice: Nutrition




                                     29
The Bright Futures Initiative

• The mission of Bright Futures is to promote and improve the health,
  education, and well-being of children, adolescents, families, and
  communities.


• Bright Futures has multi-disciplinary, multifaceted approaches to care for
  children.


• Bright Futures has 3 components: medical, dental and nutrition, which have
  been integrated into a whole program.


• Bright Futures spells out specifically what needs to be done to have healthy
  kids.


• It integrates components of care into a complete package.


• It is client focused, not provider focused – what has to be done for a child,
  not what the practitioner should do.




                                       30
Bright Futures in Practice: Nutrition

   Nutrition Goals:

   Improve the partnership between health professionals, families, and
   communities to promote the nutritional health of infants, children and
   adolescents.

   Describe the roles of health professionals in delivering nutrition services
   within the community and identify opportunities for coordination and
   cooperation.

   Improve the nutritional health of infants, children, adolescents and their
   families by setting practice guidelines for prevention and care by health
   professionals.

   Identify the nutrition services essential to achieving the health outcomes as
   recommended in Bright Futures: Guidelines for Health Supervision of
   Infants, Children, and Adolescents.

   Identify desired health outcomes that promote a positive nutritional status.




                                        31
Bright Futures in Practice: Nutrition is focused on active health promotion.

      Three Critical Principles:

      • Nutrition must be integrated into children’s and families’ lives.

      • Good nutrition requires balance.

      • An element of joy enhances nutrition, health, and well-being.

Bright Futures guidelines, philosophy and goals rise from an understanding that
the health and well being of children and adolescents depends on the well-being
of their environment and the communities in which they live.

Children’s and adolescent’s eating behaviors are influenced by:
      • family,
      • friends,
      • school
      • community
      • media.

  Healthy eating practices can be promoted by consistent
           nutrition messages from all sources.




                                      32
Organization of Bright Futures in Practice: Nutrition

Section I. Introduction
Information on:
ä Health Eating and Physical Activity
ä Nutrition in the Community
ä Cultural Awareness in Nutrition Counseling

Section II. Nutrition Supervision Guidelines
Outlines critical nutrition issues for the developmental periods of:
 ä Infancy
 ä Early childhood
 ä Middle childhood
 ä Adolescence

Each chapter contains the following components:
***Turn to the Early Childhood Chapter in Bright Futures in Practice:
Nutrition – page 57***

   • Overview of age based on:
       - Growth & Physical Development
       - Social and Emotional Development
       - Healthy Lifestyles
       - Partnerships with the Community
       - Common Nutrition Concerns


   • Nutrition supervision
       - Interview Questions
       - Screening and Assessment
       - Nutrition Counseling
       - Nutrition Counseling by Visit

   • Frequently Asked Questions

   • Resources for Health Professionals and Families




                                        33
Section III. Nutrition Issues and Concerns
This section provides an overview of common pediatric nutrition issues and
concerns including:
      ä Breastfeeding
      ä Nutrition and Sports
      ä Oral Health
      ä Vegetarian Eating Practices
      ä Pediatric Undernutrition
      ä Iron Deficiency Anemia
      ä Food Allergy
      ä Diabetes Mellitus
      ä Obesity
      ä Hyperlipidemia
      ä Hypertension
      ä Children and Adolescents with Special Health Care Needs

      **Turn to the Food Allergy Chapter in Bright Futures in Practice:
      Nutrition on page 178. **

Section IV. Nutrition Tools
This section provides screening tools, strategies, and nutrition resources to help
health professionals work with infants, children, adolescents and their families.




                                        34
Section #4: Overview of the Community-Based Nutrition Planning Process


     • Overview of the Community-Based Nutrition Planning Process
       from Moving to the Future: Developing Community-Based Nutrition
       Services – Presentation (15 minutes)

        Training Materials Needed
           r Overhead transparencies or Power Point slides of presentation
           r Copy of Moving to the Future: Developing Community-Based
              Nutrition Services




                                    35
 Overview of the Community-Based Nutrition Planning Process


What is it?

   • A process that helps translate abstract ideas like core public health
     functions and essential services into concrete, on-the-ground action.

   • A process to help implement successful nutrition programs that improve
     the health of your community by meeting the needs of your community.


What are the principles it is based on?

   • The 5-Step Process
           1. Assessment
           2. Priorities, Goals & Objectives
           3. Nutrition Plan
           4. Implementation
           5. Monitoring & Evaluation

   • The process and tools can be used alone or in conjunction with other
     health planning tools.

   • The resources in the Moving to the Future publications address
     knowledge, skills and attitudes.


Why was it done?

   • To make sure nutrition was not left out of the community health planning
     process!




                                      36
Why should you use it?

  • To make sure nutrition services are available in your community

  • To improve the health of your community

  • These tools and resources make the planning process manageable


Who helped develop it?

  •   Public health professionals
  •   Private health care professionals
  •   Nutritionists
  •   Health educators
  •   Health officials
  •   Nurses


How are data important?

  • Foundation to the whole process – everything is dependent on data.

  • Success depends on meeting the needs and wants of your community and
    data is basis for determining needs and wants.

  • Subjective data and objective data are important




                                          37
The 5-Step Planning Process
Comparing an Individual-Based Encounter to Community-Based Services
      Counseling Session with a          Developing Community-Based
    Mother of a 2 year old Child               Nutrition Services
1. Assessment                         1. Assessment
   • Collect client information           • Collect community
      - weight & length                     information
      - growth trend                        - rate of overweight /
      - 24 hour recall                          underweight of 2 year old
      - eating/feeding issues &                 children
          concerns                          - % 2 year old children with
                                                appropriate weight
                                            - % of children eating
                                                enough calcium
2. Priorities, Goals & Objectives     2. Priorities, Goals & Objectives
   • Figure out what areas of diet or     • Identify nutrition and health
      eating practices to focus on          priorities of community so you
                                            know what to focus on
3. The Plan                           4. The Plan
   • Develop a diet plan to meet          • Develop a community
      child’s needs                         nutrition plan to meet
                                            community’s needs
                                            - plan your program
                                            - figure out how to evaluate
5. Implement the Intervention         4. Implement the Intervention
   • Counsel the mother and child on                   Options
      how to improve diet                 • Education programs
                                          • Medical nutrition therapy
                                          • Case management
                                          • Health policy
                                          • Social marketing
                                          • Mobilizing resources
5. Monitoring & Evaluation            6. Monitoring & Evaluation
   • In future visits check on            • Periodically check progress of
      progress                              intervention and determine
      - appropriate weight gain             effectiveness
      - diet assessment                     - % of child with appropriate
                                                weight gain
                                            - % children with nutrient
                                                dense diets


                                    38
Section #5: Community Assessment – the Four Components

     • Define Your Community – Presentation (5 minutes)
       Training materials needed:
       r Overhead transparencies or Power Point slides of presentation
       r Overhead transparency of Sample Community Definition (page 34
          of training curriculum)

     • Perceived Needs Data – Presentation (10 minutes)
       Training materials needed:
       r Overhead transparencies or Power Point slides of presentation

     • Community Demographic, Health and Nutrition Data –
       Presentation (10 minutes)
       Training materials needed:
       r Overhead transparencies or Power Point slides of presentation
       r Overhead transparencies of Friendsville Data Sheets (pages 40-50
          of training curriculum)

     • Community Resources – Assets Data – Discussion (10 minutes)
       Training materials needed:
       r Overhead transparencies or Power Point slides of presentation
       r Overhead of Community Resources Checklist (pages 9-12 of
         training curriculum)

        Discuss participant responses to questions 2a-c on the Instruction
        sheet for the Community Resources Checklist activity.


     • Looking at a Community’s Assessment Data – Activity (45
       minutes)
       Training materials needed:
       r Overhead of Instructions for Activity (page 39 of training
          curriculum)
       r Overheads of Friendsville Data Sheets (pages 40-50 of training
          curriculum)
       r Flipchart paper and markers for each small group




                                     39
Four Components of Community Assessment

    1. Define Your Community


    2. Perceived Needs Data


    3. Community Demographic, Health and Nutrition Data


    4. Community Resources – Assets Data




                               40
1. Define Your Community
ä Do this first
ä Define it broadly
     •      Geographic Area
     •      Social Institutions & Patterns of Social Interaction
     •      Opinion Leaders

       EXAMPLE                 Community Definition - Friendsville
a) Who is your target audience/population? (This may be dictated by a funding source or
organizational policy, or it may be determined after the assessment.) Example: The entire
population of Friendsville – some projects will focus on children, some on adults, and a few
on older adults.

In what geographic area is your target audience contained? (A state, county, city, or
neighborhood?) Example: Friendsville County. However, the target audience also shops in
a neighboring county, many people work in this neighboring county, and it is the closest
place for acute care services. This larger county threatens some health services offered in
Friendsville County.

What major social institutions exist in this area? (Education, health, recreation, business,
religious, media, civic organizations, government, etc.) Example: Schools in the major 4
towns; school sports are big; church is very important and nearly everyone attends; private
in-the-home card games, bible studies, etc. are popular; health care & school are largest
employers; 2 newspapers out every week; each town has a social network.

What are the patterns of social interaction in this area? (Clubs, networks, etc.) Example:
School sports, church & church-related activities, coffee & donut shops, private parties,
service clubs, senior centers.

Who are the opinion leaders in this area? (Individuals, organizations, community groups,
key decision-makers, power structures.) Example: Local physicians, county commissioners,
hospital, successful farmers.

Summarize the responses to the questions above into 1-2 sentences that define your
community. Remember, your community includes the target audience and those who
influence and interact with it. This information will be included in the “community
definition” portion of the section entitled “The Nutrition Plan.” Example: Our focus is
prevention, so target audience is kids & adults. However, older adults are key to the
community and they are increasing. Interventions must include social institutions and have
support of opinion leaders.




                                              41
2. Perceived Needs/Assets
What are the health and nutrition concerns of the people in your community?

ä Methods for collecting:
      • Study the media
      • Conduct focus groups and intercept interviews
      • Community opinion survey


ä Variety is essential

   • Use more than one method to collect perceived needs data

   • Make sure you get a representative sample – use common sense

   • Creative strategies for collecting quickly and on a shoestring –
     - web page
     - survey in shopping area
     - lobby of service organization
     - e-mail survey
     - radio talk show
     - quick phone survey to community opinion leaders




                                       42
3. Demographic, Health & Nutrition Status Assessment

ä Demographic profile
  The data you collect for demographic status of your community will likely be
  data that is generally already collected by your health agency. We strongly
  suggest that you spend most of your time looking for data that is already
  compiled and analyzed from a health perspective.

      -   Economic Status
      -   Marital Status
      -   Education
      -   Age & Gender
      -   Race/Ethnic Distribution
      -   Socioeconomic Factors


ä Health status
      -   Leading causes of mortality
      -   Years of Potential Life Lost
      -   Infant Mortality
      -   Most Prevalent Diseases
      -   Leading Causes of Hospitalization




                                      43
ä Nutrition status (examples of data colleted/reviewed)
     • Preconceptional Women and Preconceptional Adolescents
          -    Pre-pregnancy BMI
          -    Dietary Adequacy
          -    Substance Abuse

     • Pregnant Women and Pregnant Adolescents
          - Pregnancies, live births, % mothers under 19
          - Inadequate or excessive weight gain
          - Low nutrient intake
          - Substance abuse, cigarettes

     • Infants (0-1 year) and Preschool Children (1-4 years)
          - LBW & VLBW, Premature birth
          - Low or high weight/height
          - Breastfeeding
          - AIDS
          - Infant mortality rate
          - Dental caries

     • School-Age Children (5-11 years) and Adolescents (12-19 years)
          - High weight/height
          - High blood cholesterol
          - Low hemoglobin/hematocrit
          - Fruit & vegetable intake
          - High percentage of calories from fat
          - Calcium intake
          - Anorexia nervosa and/or bulimia
          - Physical activity levels
          - Dental caries

     • Adults and Older Adults
         - Obesity, Cardiovascular Disease, Hypertention, Cancer, Stroke,
             Diabetes,
         - AIDS
         - Fruit & Vegetable intake
         - High percentage of calories from fat




                                    44
            - Physical Activity

4. Community Resources

ä Collecting information on your community’s food and nutrition-related
   resources can help you:
      • assess assets and gaps
      • find new partners for planning and delivering services
      • ensure that services are not duplicated
      • ensure that consistent messages are being provided to the public


ä A community resources checklist and survey can help you collect
   information on your community resources.




                                      45
            Looking at a Community’s Assessment Data
                       Small Group Activity
Instructions

               You have 40 minutes to work on this activity.

     1. Review the perceived needs summary and the data sheets for
        “Friendsville,” a suburban county in the United States.

     2. Work as a group at your tables to answer the following questions.
        Record your findings on this sheet and prepare a summary on
        newsprint to share with the large group.

  a. What is really striking about the demographic data?



  b. What are the primary nutrition and health issues for each age grouping?

     Preconceptional Women & Preconceptional Adolescents

     Pregnant Women & Pregnant Adolescents

     Infants and Preschool Children

     School-Age Children & Adolescents

     Adults & Older Adults


  c. What are some of the significant gaps in data for Friendsville?



  d. What would be your top 3 health-related priorities for Friendsville?
     Remember to consider the perceived needs data.




                                      46
                  Friendsville’s Perceived Needs Summary
Methods for collecting perceived needs data:
• A week long media survey was completed in October 99.
• 10 surveys were completed by community leaders and representatives from local
   organizations in November/December 99.
• 120 random resident intercept surveys were completed at local 3 local grocery stores (4
   question survey) in November 99.
• Focus groups are planned for March/April 2000.
Based on data collected to date, the following issues were most frequently identified as
community concerns. These are presented randomly.
ä Quality, availability and cost of daycare.
ä   Housing for the elderly versus nursing homes.

ä   Fear of groundwater contamination from a closed US Air Force Base. The extent of
    contamination is not known but the EPA, state and local officials are involved in
    assessing risk of drinking water contamination.

ä   Decreasing number of physicians in area.

ä   Increasing number of pregnant high school students.

ä   Concern that economy will turn bad and the two manufacturers in town will lay off large
    numbers of workers.

ä   Chicken processing plant on outskirts of town is health hazard for anyone living near it.

ä   Over last several years, adults seem heavier and more adults seem to have diabetes.

ä   Worried about cancer especially with risk of drinking water contamination.

ä   Interest in the low-carbohydrate/high protein diet – everyone is on it.

ä   Poor quality of food in schools. Serve pizza and soda everyday in high school.

ä   Fear of violence in middle and high schools.




                                               47
                             Friendsville, USA
                       – data for training activity ONLY

Demographic Profile
Community Description
Source and Date of Data: 1999 State & County Guide

Community Name: Friendsville County

Community Type: Suburban County

Geographic size and description: 519.1 square miles; 114 persons per square mile

Total population: 59,162 (12.9% growth since 1990)

Total Number of households: 15,136               Average household size: 2.99

Economic Status
Source and Date of Data: 1999 State & County Guide

Unemployment rate: Community 5.0          State 3.0

Per Capita Income: Community $13,491      State $23,882   U.S. $25,288

Per Capita Income as % of U.S. PCI: 53.3%

Annual household income (amount)
                                      Community                State
                                        No.           %           No.           %
<$10,000                                               14.8                      16.8
$10,000-$24,000                                        43.7                      26.3
$25,000-$49,000                                        32.5                      34.0
>$50,000                                                9.0                      22.9




                                          48
                                Friendsville, USA
                       – data for training activity ONLY

Marital Status

Source and Date of Data: 1999 State & County Guide

Marital Status    Community              State
                  No.   %          No.           %
Single
Married
Separated
Widowed
Divorced                 6.0                4.8


Education

Source and Date of Data: 1999 State & County Guide



Educational achievement                    Community                   State
% of adults who complete:
                                         No.             %       No.          %
Elementary school                                    6.2                  12.0
Plus 3 years of high school                          17.9                 29.1
High school                                          40.0                 29.6
Technical school
College – some
Bachelor’s/Associate’s Degree                        13.4                 19.3
>5 years

Total number of schools in county: 12
High school drop out rate: Community 3.9%            State 6.5
% eligible for free or reduced lunches: 49.8%




                                            49
                             Friendsville, USA
                      – data for training activity ONLY
Age and Gender

Source and Date of Data: 1999 State & County Guide

   Age Group                Community                      State
   (in years)
                       No.             %             No.                %
<5                              11.9                             7.5
5-17                            20.3                             19.1
18-24                           19.6                             9.9
25-44                           34.5                             33.3
45-64                           10.0                             20.4
64-& older                      3.7                              9.9




Race/Ethnic Distribution

Source and Date of Data: 1999 State & County Guide

 Population Distribution           Community                      State
                                 No.        %              No.                 %
Black                        25348      40.2                            28.5
White                        32285      50.8                            69.5
Hispanic                     5721       9.5                             2.8
American Indian
Asian & Pacific Islanders
Other                        2386          4.0                          2.1




                                           50
                              Friendsville, USA
                        – data for training activity ONLY
Socioeconomic Factors

Source and Date of Data: 1999 State & County Guide

    Socioeconomic Measure               Community             State
                                      No.        %      No.          %
Population below poverty level              18.5                 15.6

Female-headed households living    12,445        11.3            10.7
on incomes below the poverty
level

Food Stamp recipients                            10.0            8.5

WIC Program participants

WIC Program participants as a
percentage of all those who are
eligible

Medicaid recipients                              14.7            17.4

Homeless persons

Temporary Assistance for Needy                   2.9             2.9
Families (TANF) participants

Households on Supplemental                       1.6             2.7
Security Income (SSI) (elderly,
bind, disables)

Legal immigrants

Undocumented immigrants
(estimate)

Other: Children Living Below the                 24.7            23.5
Poverty Line

Other: Unwed births as % of all                  23.7            35.4
births




                                            51
                               Friendsville, USA
                         – data for training activity ONLY

Health Status
Source and Date of Data: 1999 State & County Guide

  Leading 5 Causes of Death          Collect/Calculate YPLL for
                                       each cause of mortality
 Community           State           Community          State
Cancer          Heart Disease

Heart Disease   Cancer

Stroke          Respiratory

Respiratory     Injury

Injury          Stroke




   5 Most Prevalent Diseases           5 Leading Causes of
                                         Hospitalization
Community            State           Community        State




                                        52
                              Friendsville, USA
                        – data for training activity ONLY

Nutrition Status
Preconceptional Women and Preconceptional
Adoloescents (ages 13-45 years)

Source and Date of Data: 1998 PPNSS data; 1998 State Health Statistics

        Nutrition-Related               Community                    State
        Health Concerns
                                      No.               %      No.           %
Pre-pregnancy BMI <19.8 (at risk                 15.9                    17.0
of inadequate weight gain)

Pre-pregnancy BMI >29 (at risk of                42%                     48%
excessive weight gain)

Dietary adequacy: Ca intake

Dietary adequacy: Fe intake

Dietary adequacy: folate intake

Substance abuse: smoking                         34%                     28%

Other: Binge Drinking                            17%                     15%

Other: Diabetes                                  6.8%                    5.1%




                                            53
                                 Friendsville, USA
                          – data for training activity ONLY

Pregnant Women and Pregnant Adolescents
Source and Date of Data: 1998 PPNSS data; 1998 State Health Statistics

         Nutrition-Related              Community                    State
         Health Concerns
                                      No.               %      No.           %
Pregnancies

Live births (rate)

Mothers under 19 years of age                    9.5                     10.0

Interconceptional period <16                     20.0                    24.0
months

Inadequate weight gain                           18.7                    29.5

Excessive weight gain                            32.7                    30.0

Low hemoglobin or hematocrit                     14.7                    12.9

Low nutrient intake                              90.7                    88.9

Births complicated by diabetes

Using cigarettes                                 36.2                    25.7

Entering prenatal care after first               25.0                    16.0
trimester or not at all

Other:

Other:




                                            54
                               Friendsville, USA
                        – data for training activity ONLY

Infants (0-1 year) and Preschool Children (1-4 years)
Source and Date of Data: Pediatric Nutrition Surveillance System; State Health Data

         Nutrition-Related              Community                    State
         Health Concerns
                                      No.            %         No.            %
Low birth weight (LBW)                           9.6                    8.8
                                                 W:6.8;
                                                 B:13.5
Very low birth weight (VLBW)                     1.7                    1.2

Premature birth                                  7.7                    9.2

Low weight-for-height                            2.5                    1.6

Low height-for-age                               6.5                    8.5

High weight-for-height (obesity)                 6.1                    7.4

Low hemoglobin or hematocrit                     23.3                   20.4

Low nutrient intake                              32.8                   30.

Breastfeeding at hospital discharge              53.0                   44.0

Breastfeeding at 6 months                        13.0                   17.0

AIDS

Infant Mortality Rate                            4.3/1000               5.4/1000

Dental caries

Other:

Other:




                                            55
                                 Friendsville, USA
                         – data for training activity ONLY

School-Age Children (5-11) and Adolescents (12-19)
Source and Date of Data: Youth Behavior Risk Factor Survey

         Nutrition-Related              Community                  State
         Health Concerns
                                      No.             %      No.            %
High weight for height/obesity                   38                   30

Low weight for height

High blood cholesterol

Low hemoglobin or hematocrit

Fruit and vegetable daily intake                                      8.0
5 servings/day
High percentage of calories from                                      40.0
fat

Dietary fiber intake

Calcium intake                                                        38.0
3-4 servings/day
Poor dieting practices

Anorexia nervosa and/or bulimia

Physical activity levels                                              42.0
20 minutes – 3 out of 7 days
Lack of nutrition education

Dental caries

Other:

Other:




                                            56
                               Friendsville, USA
                           – data for training activity ONLY

Adults and Older Adults
Source and Date of Data:

          Nutrition-Related              Community                 State
          Health Concerns
                                       No.               %   No.           %
Obesity                                           46                   54.6

Cardiovascular Disease

Hypertension                                      19.7                 21.3

Cancer                                            N/A                  63.9
Screening for Breast Cancer
Stroke

Diabetes                                                               5.9

High Blood Cholesterol                            N/A                  75.8
Screening
Iron Deficiency Anemia

AIDS                                              6.8                  14.8
Rate – per 100,000
High percentage of calories from                  N/A                  72%
fat

Fruit and vegetable daily intake                  N/A                  20.7
Eat at least 5 servings/day

No Health Insurance                                                    14.7

Physical activity levels                                               74.4
No regular exercise

Binge Drinking                                                         9.4

Cigarette Smoking                                                      26.6




                                             57
Section #6: Identify Health Priorities and Writing Goals & Objectives

     • Identifying Health Priorities – Presentation (5 minutes)

        Training materials needed:
        r Overhead transparency or Power Point slides of presentation

     • Writing Goals & Objectives – Presentation (10 minutes)

        Training materials needed:
        r Overhead transparencies or Power Point slides of presentation

     • Write a Goal and Measurable Objectives – Activity (30 minutes: 20
       for activity, 10 for reporting out)

        Training materials needed:
        r Overhead transparency of Activity Instructions (page 56 of training
           curriculum)
        r Overhead transparency of Objective Writing Cheat Sheet (page 57
           of training curriculum)
        r Flip chart paper and markers for each small group




                                    58
Prioritizing Health Problems
There are many criteria or support for selecting health problems. Why should you use
any of the following?

   a. media coverage of the problems


   b. focus group results


   c. community opinion survey results


   d. severity


   e. number of at-risk persons


   f. economic burden to the community


   g. amount of premature death


   h. preventability


   i. effectiveness of intervention




                                         59
                                              Example

Childhood Obesity
  a. media coverage
     • 10 articles in the past month; 3 day feature series

   b. focus group results
      • 4 focus groups    - parents – no problem
                          - boys 6-12 years – no problem
                          - girls 6-12 years – problem
                          - other adults - problem

   c. community opinion
      • 1 in 3 people interviewed on the street concerned

   d. severity
      • 1 in 4 children are obese

   e. number of at-risk persons
      • 10,706 children in Friendsville

   f. economic burden to the community
      • prone to develop diabetes, heart disease, and become disabled

   g. amount of premature death
      • early death from diabetes and heart disease

   h. preventability
      • difficult because of cultural patterns that reinforce eating, sitting
         and riding in vehicles

   i. effectiveness of intervention
      • difficult because of the number of triggers
      • 10-15% reduce and maintain loss.




                                    60
Writing Objectives

Objectives are central to:
  • determining program

   • writing grant proposals

   • designing evaluations

   • demonstrating worth of any effort

Make your objective RUMBA!

Relevant
  • Is your objective Relevant to your community’s needs and wants?

Understandable
  • Is your objective clear and written in a way that everyone will
     Understand (no jargon, define terms)?

Measurable
  • Do you have a baseline and target Measurement for the objective
     (number, prevalence, percentage)?

Behavioral
  • Does the objective include information on what Behaviors will change?

Achievable
     • Is it realistic for you to Achieve the objective given the time,
        resources and the proposed changes?

Good objectives also include:
(1) Timeframe
(2) The population
(3) Results to be achieved
(4) Criteria by which results are to be documented
(5) Responsibility for implementation and measuring objectives




                                       61
Examples of Goal & Objectives:
Goal: To improve and maintain the nutritional intake of the adolescents in
Orange County. [Program goals are designed to accomplish agency mission
statements. They are political statements that cannot by criticized. They are
statements of values and express the expected long-term accomplishments.
They do not need to be measurable.]

Outcome Objective: By December 2000, the prevalence of obesity (as
defined by >27 BMI) in adolescents (age 13-18) will decrease from 20% to
16%, as measured by the heights and weights survey.
[Outcome objectives intend to reflect a reduction in the prevalence of a
problem. Reduce, prevent, decrease or increase are verbs used for an outcome
objective. Outcome objectives are the “what” or “ends” to be achieved. They
focus on the population; not the services, training or activities.]

Outcome (Impact) Objective: By December 2001, increase the fruit and
vegetable intake of adolescents from 2 to 4 per day, as measured by 24
hour recalls.
[In nutrition, health status indicators are not always practical or realistic
measures of program outcomes. The measurement of dietary change can also
be an outcome objective for nutrition programs. To decrease fat intake or to
increase fiber are further examples of outcome objectives.]

Process Objective: By September 1999, design a tailored in-school
marketing program to expose all students (1,000) to a variety of fruits and
vegetables; exposure will be measured by a randomized food preference
questionnaire to be administered three times during the school year.
[Process objectives are the “how” or the “means” to achieve the outcome.
Increase, provide, serve, assess, train, make, complete, demonstrate, develop are
verbs used for the process objectives. Usually more than one process objective
is needed to complete the outcome objective.]

Structure Objective: By September 1999, purchase a refrigerated serving
cart for fresh fruits, vegetables, and salad.
[Structural objectives are materials, equipment or new hires needed to complete
the process and outcome objectives.]




                                       62
               Write a Goal and Measurable Objectives
                        Small Group Activity
                             Instructions

                    You have 20 minutes for this activity.

Based on an MCH-related health priority from the Friendsville data, write a
goal and at least one outcome, process and structure objective for the goal.

Record your final work on flipchart paper.

      Goal:



      Outcome Objective:




      Process Objective:




      Structure Objective:




      NOTE: a “Cheat Sheet” is provided for you on the following page.




                                       63
               Cheat Sheet for Objective Writing Activity

Outcome Objectives: These aim for changes in the population in:
     √attitude                     √behavior
      √knowledge                         √nutrition status
      √health status

      health outcome: improved health (reduced infant mortality)
      intermediate: improvement that will lead to desired health outcome
                    (increase breastfeeding rates)
Process Objectives: These address activities, which are carried out by health
and nutrition workers and activities related to the intervention. (increasing the
number of contacts made by a breastfeeding counselor)
Structure Objectives: These also set targets for things like:
      √budget                        √staff
      √facilities                        √equipment
      √space                             √records

These types of objectives are hierarchical in that the structural objectives make
possible the processes that lead to the successful health outcomes that address
the overall goals!

For example:

Structure    Process             Intermediate           Outcome       Goal
Given a      breastfeeding       with the expected      to help       Infants will
budget of    counselors will     result that 50 of      reduce        have a
$50,000→     counsel 500         these mothers will     infant        healthy start
             pregnant women      breastfeed their       mortality.→   in life.
             in one year,→       infants for at least
                                 6 months→




                                          64
Section #7: The Nutrition Plan

     • Purposes of a Written Nutrition Plan – Presentation (5 minutes)

        Training materials needed:
        r Overhead transparency or Power Point slides of presentation

     • Components of a Written Nutrition Plan – Presentation
       (10 minutes)

        Training materials needed:
        r Overhead transparencies or Power Point slides of presentation




                                    65
Purposes of a Written Nutrition Plan

The Plan serves as:

1. a method of systematizing the planning process;


2. a justification for the proposed program and budget;


3. a statement of health priorities and goals and objectives;


4. a description of activities to be undertaken;


5. a description of proposed methods for assessments, interventions, &
   evaluations;


6. a schedule of completion dates for activities;


7. an inventory of resources to carry out the program; and


8. a potential fundraising document.




                                        66
Seven Components of a Written Nutrition Plan: (Moving to the
Future Handbook p.26)

1. A description of the community, including its demographics and its health
   and nutrition status based on the community assessment.



2. A needs statement that describes why a nutrition intervention is necessary
   given the existing community health status.



3. A statement of goals and objectives.




4. A list of planned intervention activities and timelines explaining how and
   when objectives will be met.




5. A description of specific policies and procedures or practice guidelines that
   will guide the intervention activities and the evaluation.




6. A description of the evaluation methods to be used.




7. A list of resources required for implementation including the resources
   needed, personnel schedules, a budget and list of partners.




                                       67
Section #8: Implement the Intervention

     • Designing Successful Interventions – Presentation (10 minutes)

        Training materials needed:
        r Overhead transparency or Power Point slides of presentation


     • Brainstorming Nutrition Interventions– Activity (35 minutes: 20
       for activity, 15 for reporting out)

        Training materials needed:
        r Overhead transparency of Activity Instructions (page 64 of training
           curriculum)
        r Flipchart paper and markers or blank overhead transparencies and
           pens for small groups to record their results




                                    68
Interventions

Intervention is the process of promoting change and modifying behavior. The
most effective interventions will have strategies that address both individual
and community behavior change.

A. Environment-based - Create an environment supportive of healthy
behaviors
     • Mobilizing Community Resources for Nutrition and Food Assistance

      • Policy and Standard Practices

      • Social Marketing Campaigns

      • Altering the Food Supply

      • Intervening Where Food Decisions are Made

      • Case Management/Coordination and Referral System

    EXAMPLES of Environment-based intervention strategies:

    1. Develop Social Networks - Offer tastes of healthy foods at a grocery
    stores or encourage healthier food choices at social functions like potluck
    dinners at church

    2. Alter Physical Environments - Add 100% juices to vending machines
    or set up a breastfeeding room in the workplace.

    3. Influence policies - Require food sanitation training for day care
    providers or create policy/incentives to purchase and consume lower-fat
    milk products.

B. Individual-based - Create individual behavior change

      • Medical Nutrition Therapy & Individual Dietary Counseling

      • Nutrition Education (individual & groups)




                                       69
Brainstorming Nutrition Interventions
                             Small Group Activity
                                Instructions
              You have 20 minutes for this brainstorming activity.

For this activity you will use Bright Futures In Practice: Nutrition to help
brainstorm and identify interventions to address your MCH-related outcome
objective from Friendsville.

First Step:
As a group, brainstorm 3 non-traditional strategies for addressing your
Friendsville objective. Two of these strategies must be low- or no-cost and one
strategy can be pie-in-the-sky.

You have 15 minutes for this first step.


Second Step:
Now brainstorm 3 traditional strategies. Again, two strategies must be low- or
no-cost and one can be pie-in-the-sky.

You have 5 minutes for this second step.



Use newsprint to record your brainstorming ideas. Be prepared to share 3
of your most creative intervention strategies.




                                           70
Section #9: Monitoring & Evaluation


     • What is Successful Program Evaluation? - Presentation
       (5 minutes)

        Training materials needed:
        r Overhead transparency or Power Point slides of presentation


     • Types of Evaluation – Presentation (5 minutes)

        Training materials needed:
        r Overhead transparency or Power Point slides of presentation


     • Why Do Program Evaluation? - Presentation (5 minutes)

        Training materials needed:
        r Overhead transparency or Power Point slides of presentation


     • When to Evaluate? …before, during and after - Presentation (5
       minutes)

        Training materials needed:
        r Overhead transparency or Power Point slides of presentation




                                    71
What is Successful Program Evaluation?

      Evaluation is a systematic collection of information about program
      resources, activities and outcomes used for answering questions about
      program performance and making decisions about future program
      operations.


  ♦      A systematic process that provides the best possible information to
      answer an important question, within the given set of real-world
      constraints.




  ♦      Produces valid results and presents them in a clear, accessible
      fashion.




  ♦      Requires planning and consistent follow-through.




  ♦      Differs from research. Research looks at what CAN HAPPEN by
      studying controlled conditions. Evaluation looks at WHAT DOES
      HAPPEN in the real world.




                                      72
Types of Evaluation

Structure – measurement of environmental and personnel factors in service
delivery such as the adequacy of the facility, availability of necessary
equipment, availability and training of skilled personnel, and scheduling of
patient visits.

Process – measurement of the interaction between providers and clients, the
information collected from and about clients, diagnostic assessments made,
therapeutic and education plans, how plans are carried out, and follow-up on
problems over time.

Outcome – measurement of the success or failure of the structure and process
of care provided.

Cost Benefit or Cost Effectiveness – measurement of the costs of the program
expressed as dollars compared to the dollars saved on health care costs (cost
benefit) or compared to a measure of heath status (cost effectiveness). 1




1. Although not the focus of this training, for more information refer to:

       Ellis A, Green M, Haughton B. Cost Effectiveness Analysis for the Real World. The
       1988 Continuing Education Intervention for Public Health Nutrition Personnel in
       Region IV U.S. Department of Health and Human Services. Knoxville, TN:
       Department of Nutrition, The University of Tennessee; 1998.
       http://nutrition.he.utk.edu/cea.

       Splett P. The Practitioner’s Guide to Cost-Effectiveness Analysis of Nutrition
       Interventions. Arlington, VA: National Center for Education in Maternal and Child
       Health; 1996.




                                              73
Why Do Program Evaluation?

  The primary purposes of program evaluation are to:
    ♦ Help program mangers and staff members decide whether to change
        or continue a program or specific activities within a program.

     ♦ Help program managers assess the outcomes of the program on
       clients’ health.

     ♦ Help funding sources know that their money is being used efficiently
       and effectively.



  Do evaluation for the following reasons:

  ü performance improvement – CQI, quality assurance, build staff morale


  ü outcome assessment – determine if objectives are met, document impact
    on public health priorities.


  ü program justification – find out if program or specific activities should be
    repeated, continued, expanded


  ü accountability – verify resources are spent per plan and/or regulations


  ü program clarification -- reality check of proposed new activity


  ü cost-effectiveness -- influence funders, influence policy change




                                      74
When to Evaluate? …before, during and after


Evaluation Approaches

  BEFORE = Needs Assessment/Formative Evaluation
  ♦ program planning and development (needs assessment, formative
    evaluation, market research)

     Example: The number of children two years and older who are still using
     the bottle has increased over the past year based on WIC Program data.
     You’d like to design an intervention that would address this issue in a
     culturally-specific way.

  DURING = Process Evaluation
  ♦ during program implementation (monitoring, performance improvement,
    CQI, quality assurance, client participation and satisfaction)

     Example: Three months ago, your program made some changes in your
     hours of operation, your staffing responsibilities and your clinic flow.
     You think these changes have made a difference in clinic attendance and
     customer satisfaction but you’d like to find out for sure.

  AFTER = Outcome Evaluation
  ♦ at the end (outcomes, impact, summative)

     Example: You received a one-year grant to design and implement a
     nutrition intervention aimed at increasing the physical activity levels of
     young children and their mother. The final report is due to the funders in
     one month and you need to summarize the effect of the intervention on
     activity levels.




                                     75
Section #10: Planning in Action-A Local Success Story – Video


     • Improving the Diets of Low Income Families through the
       Organization of a Community Garden – Video Presentation (20
       minutes)

        Training materials needed:
        r TV/VCR
        r Video Clip from Moving to the Future: Developing Community-
           Based Nutrition Services videoconference (cued to Linda Lee’s
           presentation – approximately 40 minutes from the beginning of the
           videotape)


        Share the following points with the training participants:

        1. Linda Lee used the 5-step planning process to work with her
           community on this nutrition-related priority.

        2. Ask the training participants to actively seek examples of the 5-
           step planning process as they listen to Linda Lee’s presentation.

        3. At the conclusion of the video, ask participants to share some of
           their insights and examples (5 minutes for discussion).




                                      76
                  Improving the Diets of Low Income Families
               through the Organization of a Community Garden
                   Linda Lee, MPH, RD, LaCrosse, Wisconsin
Needs Assessment
§ 1995 Findings
      • 42% ran out of money to buy food
      • 55% relied on a limited number of food items
      • 34% skipped meals to make food dollars stretch

§   1996 Hunger Task Force formed
       • Goal: Eliminate hunger in the La Crosse area
       • Membership: Professionals working on hunger issues
       • 1st Task: Track Hunger Issues

§   1997 Community garden survey

Planning
§ Organized a “Garden Committee”
§ Developed garden criteria
§ February 1998 – given land by the City of LaCrosse
§ Organized garden workgroups
      • Oversight Board
      • Planting
      • Funding/Publicity
      • Distribution
      • Education
      • Volunteers
      • Building & Structures

§   3 Main concerns
       • Funding
       • Labor to dig the beds, plant them, maintain the garden & help with harvest
       • Produce distribution

§   Funding
       • Worked with media
       • Approached service clubs
       • Grants




                                            77
§   Personpower/Volunteers
       • Media
       • Community volunteer day
       • AmeriCorps
       • Master Gardeners
       • Local law enforcement system

Implementation
§ Media/press conferences kept community attention focused on project
§ Tied to existing community groups & activities
      • Very Huge Day – dug beds
      • Planting work days
      • Americorps – garden maintenance

§   Distribution schedule established
§   Education Committee taught classes and prepared handouts
§   To facilitate communication
       • Hotline
       • Minutes circulated
       • Newspaper
       • Telephone tree
       • Postings @ garden
       • E-mail
       • Bimonthly meetings kept up on task

Monitoring & Evaluation
§ Biweekly meetings – discussion/observation
§ End of season survey of recipients
§ End of season garden committee meeting – what went well, what needs improvement
Gaining Internal Support
§ Shared project development & results with supervisor & County Coordinator
§ Shared with Board of Health
§ Results: The portion of my salary paid by the County doubled (20% to 40%)
Future Plans
§ Triple size of garden
§ Increase diversity of vegetables planted
§ Hire a Garden Coordinator


                                             78
Section #11: Training Wrap-up and Evaluation

     • Your Next Steps – Activity (20 minutes: 10 for activity, 10 for
       reporting out)

        Training materials needed:
        r Overhead transparency of “Your Next Steps” activity sheet (page
           73 of training curriculum)


     • Trainer Tips – Review briefly with group – Discussion (5 minutes)
         - Planning and Logistics
         - Audio Visual/Training Equipment and Supplies
         - Training Needs Assessment
         - Training Logistics, Equipment and Supplies
         - Working with a Co-Trainers
         - Evaluating Your Training

        Training materials needed:
        r Overhead transparencies of “Trainer Tips” (pages 74-80 of training
           curriculum)


     • Evaluation – Complete training evaluations and hand in to trainer
       before leaving. (5 minutes)




                                    79
                           Your Next Steps
Now that you’ve had a chance to participate in this training, please identify
ways to share these resources and training with other public health personnel in
your state, region or local comminutes.

In your state, who would most benefit from Maximizing Resources for
Results training?




Who might be potential planning partners for the training?




What are some of the challenges or barriers you may have in designing and
delivering a Maximizing Resources for Results training?




What specific steps can you take to start planning for the training?

1.


2.


3.




                                       80
     TRAINER TIPS… TRAINER TIPS…. TRAINER TIPS…..
Planning and Logistics
Training Site
• Centrally located and as convenient as possible for all participants
• Adequate and low cost or free parking
• If some participants must travel, you may need to plan the training days
  accordingly

Number of Participants
• A good size group averages between 20-40 – especially if you want an
  interactive training with lots of discussion and activities.
• Recommend two trainers for every 25-50, more than 50 and it is nice to have
  3 trainers. See the Trainer Tips on “Working with Co-Trainers” for more
  information.

Training Room
• Light, bright, airy – especially if the training is more than one day.
• Should have room for table of 6-8 participants at each table.
• Should have extra space for ease of movement between tables.
• There should be room for a easel and flipchart at each table.
• Ask if it is OK to use masking tape to post paper on the walls.

Breaks/Lunch
• At least one morning break and one afternoon break of 15 minutes each.
• No matter what we’ve tried (and whatever size group) lunch is tough to do
  in less than 45 minutes.

Registration
• Give at least 6 weeks notice.
• You can use a training needs assessment questionnaire to market your
  training and get useful planning information. See the Trainer Tips on
  “Training Needs Assessment” for more information.




                                        81
      TRAINER TIPS… TRAINER TIPS…. TRAINER TIPS…..
Audio Visual/Training Equipment and Supplies
Audio-Visual Equipment Checklist
KEEP IT SIMPLE! We have found that you can do a lot with an overhead
projector and a few easels with flipcharts. If you have a laptop computer and an
LCD projector available (fairly expensive to rent but many agencies and
programs are now purchasing these for training and presentations) you can use
the Power Point slide show instead of producing overhead transparencies.
q Overhead projector
q Screen
q Easels & flipcharts (one per table works well)
q Wireless microphone if you have a soft voice, a larger group or if the room
   size is odd (this same wireless microphone can be used by participants at
   their tables to report out on activities, ask/respond to questions so that the
   whole group can hear.

Supplies Checklist
Here is a basic list of supplies for almost any training program.
q Flipchart markers (the thicker kind) in assorted colors (enough to give each
  table 2 colors and a few extras).
q _” masking tape for taping up sheets of flipchart paper
q 2 dozen blank overhead transparencies (“Write-on” variety)
q Overhead markers (one per table and a couple for trainers)
q 3 packets of 3”x 5” Post-It Notes in different colors
q Name tags or “Hello my name is…” labels

Training Materials
q Copy of training program and materials for each trainee and trainers
q Pocket folders or three-ring binders to hold training program and materials




                                       82
     TRAINER TIPS… TRAINER TIPS…. TRAINER TIPS…..
Training Needs Assessment

Assessing the Training Group
Gather as much information about your participants (actual or potential)
BEFORE you begin to think about what material to include.

Your opportunity to assess the training group is often limited by time
constraints and availability of data. Even in less than ideal circumstances,
however, some assessment is necessary before finalizing the design.

At the very least, you should try to answer as best you can the following
questions about your proposed training group:

1. How many participants will there be?
2. What roles and tasks do the participants perform?
3. How familiar are the participants with the subject matter of the training
    program?
4. What are the backgrounds, professional experiences and other descriptive
    factors of the participants?
5. What are their attitudes and beliefs (relevant to the training topic)?
6. What successes and problems have the participants encountered?
7. What is the skill level of the participants?
8. Is the training voluntary or mandatory?
9. How well do the participants know one another?
10. What, if any, expectations do the participants’ supervisors have with regard
    to the training program?




                                        83
       TRAINER TIPS… TRAINER TIPS…. TRAINER TIPS…..
Training Needs Assessment
Assessing the Training Group - continued

Techniques for Collecting Needs Assessment Information
1.   Observation
2.   Questionnaires (hard-copy, email, fax)
3.   Key Consultants
4.   Print Media (professional journals, legislative news, list serves, in-house
     publications
5.   Interviews (phone or in person)
6.   Group Discussion
7.   Records, Reports
8.   Work Samples
9.   Mangers/Supervisors

What if there is no time to do a proper assessment?
1. Phone contact with person who may have some familiarity with the
   participants and ask the basic questions listed above.
2. Phone a few participants, introduce yourself, and ask them some key
   questions. Hope that their responses are representative and treat them as a
   sample of the larger group. Or ask a contact person to set up a phone
   interview schedule for you.
3. Have any relevant materials (e.g. surveys, meeting notes, records) faxed,
   emailed or express mailed to you.
4. Contact other trainers who have worked with your training group to get their
   impressions.
5. Talk to participants who arrive early and obtain whatever information you
   can.
6. Design some activities to enable you to make some assessments of the group
   at the beginning of the program.




                                           84
      TRAINER TIPS… TRAINER TIPS…. TRAINER TIPS…..
Getting the Training Group “Warmed Up”
Climate Setting/Icebreakers

Icebreakers:
ä Allow all participants to get involved right away.

ä Include activities that allow everyone to feel like they have something to
   contribute (no knowledge questions, quizzes involved). The focus is on
   sharing information about yourself with others in the group.

ä Help group members feel more comfortable with one another.

ä Can help set a friendly, fun, sharing tone for the training.

ä Use a variety of icebreakers depending on the audience and the focus of the
   training. Sometimes an icebreaker that is totally unrelated to content can
   work well.

Setting Group Norms:
1. Encourage participants to express themselves honestly.

2. Ask that confidentiality be respected.

3. Urge risk taking.

4. Expect participation from everyone.

5. Promote the value of performance feedback.

6. Require participants to sit in different spots.

7. Reassure participants that their questions are welcomed.

8. Insist on punctuality.




                                         85
       TRAINER TIPS… TRAINER TIPS…. TRAINER TIPS…..
Working with Co-Trainers
Working as a team of 2-3 trainers is an excellent way to design and deliver and training
program. The most effective approach to co-training is when the trainers work together to
design, plan and share the training responsibilities. Effective co-trainers need a great deal of
openness and honesty.
Keep these things in mind:

ä   Co-training works best when both trainers are in the room providing input to trainees.

ä   While one trainer delivers the content, the other trainer focuses on the process
    (watching the trainees for reactions and undercurrents).

ä   If the process trainer notices some body language indicating that something is wrong, he
    or she should speak up – “Excuse me, I think we’ve got a question here.”

ä   The process trainer should also pay attention to the content through the eyes and ears of
    the trainees and address this with the content trainer. This gives the trainees the
    assurance that you are listening and you are with them.

ä   Who’s In Charge?
      Someone has to make decisions like when to move on to the next topic or dropping a
      segment of the training when time is tight. Whoever is delivering the content is “in
      charge” for that segment. The role of content trainer and process trainer should shift
      between trainers throughout a training program. Plan this out ahead of time as part of
      your training design. This way each trainer knows their responsibilities and there are
      not gaps or power struggles. The result is a smoother, well-organized training that
      provides variety for the trainees and the trainers.

ä   What should the process person do if the content person leaves something out?
      The most effective trainers will pause for a minute in case the content trainer is
      approaching the item from a different direction. If it is apparent that something was
      skipped, you can raise a question; for example, “Helen, are you going to cover item
      number 7 now or in the next segment?” This provides a cue without being a putdown.

       It is also useful for the content trainer to occasionally ask the other trainers if they
       have additional comments or thoughts to add to the content or any examples to share.




                                              86
      TRAINER TIPS… TRAINER TIPS…. TRAINER TIPS…..
Evaluating Your Training
Before –
ä   Use your needs assessment and draft review process to make sure you are on track.
ä   This formative evaluation is important as you work through the task of designing and
    delivering a training.

During -
ä   Regularly ask participants if you are on track
ä   Keep an eye on your timing and the material covered. It it looks likes you are in a time
    crunch or you have extra time in your agenda, ask the participants what is most important
    for them and adjust the schedule accordingly.
ä   Mini-evaluations after a morning session or at the end of the day can be fun, risk-free
    activities. Provide brightly colored post-it notes and have the participants answer a
    couple of quick questions like:
        • How will you use what you have learned this morning?
        • What is one thing you learned that you will be able to use immediately?
        • What else would you like to focus on in the training?
        • “During the rest of the training I hope we……”
Have participants “post” their notes up on a blank piece of flipchart paper as they leave the
room for lunch or a break. You can read over the comments and suggestions and when the
participants come back for the next session, you can discuss any issues and come to
agreement on any changes for the afternoon.

After-
In addition to an evaluation form at the end of the session, you may want to consider other
options to find out the training has had an impact on participants’ work, decision-making and
behaviors.
ä Send 4-5 short evaluation questions by email, summarize the responses and share back
    with the group. These questions should focus on application of the training materials
    rather than knowledge-based questions.
ä Set-up a web-based “resource chart room” for training participants to share their
    successes and challenges with implementing change.
ä A short follow-up survey can be administered by mail or by phone. One advantage of a
    phone call would be an opportunity to provide technical assistance and support to the
    training participant.

A follow-up survey (no matter how it is administered) can get at the application of the
information and skills gained through training. A follow-up can also help identify barriers,
like lack of agency or supervisory support or lack of an important resource that is making it
difficult to follow-through on intended plans.




                                              87
                              Evaluation
                Maximizing Resources for Results!
1. What 3 specific steps will you take to start sharing these resources and
   training in your area?

v

v

v


2. What are 3 potential uses of Bright Futures in Practice: Nutrition in your
   work?

v

v

v


3. What are 3 ways to use the community-based planning process in your
   work?

v

v

v


4. What MCH-related nutrition issue in your community would you like to
   see addressed using Bright Futures in Practice: Nutrition and the 5-step
   planning process?




                                        88
   4a. How likely are you to take steps to address this issue?
      (not at all) 1     2      3      4     5 (very)


5. Circle the number that best represents your reaction to this training program.

   a. I feel that I will be able to use what I have learned.
      (not at all) 1        2      3     4      5 (a lot)

   b. The program was presented in an interesting manner.
      (never)    1     2     3      4      5 (often)

   c. The training facilities met my needs.
      (not at all) 1       2     3    4     5 (very well)

   d. The program covered the promised objectives.
      (not at all) 1   2      3    4     5 (very well)

   e. The trainers encouraged participation and questions.
      (never) 1    2     3     4      5 (often)


6. What did you find most useful in the program?



7. What did you find least useful in the program?



8. What could be improved?



9. What would you like for follow-up or technical assistance as you plan your
   training?




                                        89
                         Resources

Appendix A:   A Sample of Healthy People 2010 Nutrition Related
              Objectives




                               90
Appendix A:
A Sample of Healthy People 2010 Nutrition Related Objectives

22-6   Increase the proportion of adolescents who engage in moderate physical
       activity for at least 30 minutes on 5 or more of the previous 7 days.
       Target: 30 percent. Baseline: 20 percent of students in grades 9 through 12 engaged
       in moderate physical activity for at least 30 minutes on 5 or more of the previous 7
       days in 1997.

22-9   Increase the proportion of adolescents who participate in daily school physical
       education. Target: 50 percent. Baseline: 27 percent of students in grades 9 through
       12 participated in daily school physical education in 1997.

22-11 Increase the proportion of children and adolescents who view television 2 or
      fewer hours per day. Target: 75 percent. Baseline: 60 percent of persons aged 8 to
      16 years viewed television 2 or fewer hours per day in 1988-94.

19-3   Reduce the proportion of children and adolescents who are overweight or
       obese. Target and baseline:
                                         1988–94       20210
                                         Baseline†     Target
       19.3a Aged 6-11 years             10%           5%
       19.3b Aged 12-19 years            10%           5%
       19.3c Aged 6-19 years             11%           5%

19-4   Reduce growth retardation among low-income children under age 5 years.
       Target: 5 percent. Baseline: 8 percent of low-income children under age 5 years were
       growth retarded in 1997 (defined as height-for-age below the fifth percentile in the
       age-gender appropriate population using the 1977 NCHS/CDC growth charts;31
       preliminary data; not age adjusted).

19-5   Increase the proportion of persons aged 2 years and older who consume at least
       two daily servings of fruit. Target: 75 percent. Baseline: 28 percent of persons aged
       2 years and older consumed at least two daily servings of fruit in 1994-96 (age
       adjusted to the year 2000 standard population).

19-7   Increase the proportion of persons aged 2 years and older who consume at least
       six daily servings of grain products, with at least three being whole grains.
       Target: 50 percent. Baseline: 7 percent of persons aged 2 years and older consumed
       at least six daily servings of grain products, with at least three being whole grains in
       1994-96 (age adjusted to the year 2000 standard population).




                                              91
19-9  Increase the proportion of persons aged 2 years and older who consume no more than
      30 percent of calories from fat. Target: 75 percent. Baseline: 33
      percent of persons aged 2 years and older consumed no more than 30 percent of daily
      calories from fat in 1994-96 (age adjusted to the year 2000 standard population).
19-11 Increase the proportion of persons aged 2 years and older who meet dietary
      recommendations for calcium. Target: 75 percent. Baseline: 46 percent of persons
      aged 2 years and older were at or above approximated mean calcium requirements
      (based on consideration of calcium from foods, dietary supplements, and antacids) in
      1988-94 (age adjusted to the year 2000 standard population).

19-13 Reduce anemia among low-income pregnant females in their third trimester.
      Target: 20 percent. Baseline: 29 percent of low-income pregnant females in their
      third trimester were anemic (defined as hemoglobin < 11.0 g/dL) in 1996.

19-15 (Developmental) Increase the proportion of children and adolescents aged 6 to
      19 years whose intake of meals and snacks at schools contributes proportionally
      to good overall dietary quality.

19-18 Increase food security among U.S. households and in so doing reduce hunger.
      Target: 94 percent. Baseline: 88 percent of all U.S. households were food secure in
      1995.

16-16 Increase the proportion of pregnancies begun with an optimum folic acid level.
      Target and baseline:
                                           1991–94       2010
                                           Baseline*     Target

       Consumption of at least 400           21%          80%
       Micrograms of folic acid each
       day from fortified foods or dietary
       supplements by nonpregnant
       women aged 15 to 44 years

16-19 Increase the proportion of mothers who breastfeed their babies. Target and
      Baseline
                                        1998          2010
                                        Baseline      Target

       In early postpartum period            64%          75%
       At 6 months                           29%          50%
       At 1 year                             16%          25%




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