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					                                                              STEPS to a Healthier Hillsborough


                                    D. (e-m) APPLICATION NARRATIVE
E.       Lead Agency

         For over half a century, the Hillsborough County Health Department (HCHD) has provided quality

public health services and disease prevention and intervention to the local community. As an agency of the

Florida Department of Health (DOH), one of the largest agencies in state government, the mission of public

health as defined by Florida Statute is: to promote, protect, maintain and improve the health of all residents

and visitors in the state. The HCHD strives to achieve this mission locally through major commitments to

maternal and child health, environmental health, communicable disease control, and health education in a

large metropolitan area with an estimated population of 1,073,407 (as of 2003), and an additional 20,000

new residents arriving each year. This public health mission is currently carried out by a staff of 500 health

care professionals and support personnel with fiscal expenditures totaling $34,668,696.00. In fiscal year

2002-2003, HCHD provided 1,603,044 services to 79,492 clients.

With ten (10) locations throughout the county and a new location opening in 2004, HCHD has

demonstrated its capability to address the needs of the target populations. In addition, HCHD provides

services in schools, homes, and neighborhoods, and has developed several initiatives and partnerships to

address target-specific health concerns. Local priorities are considered based on:

    Healthy People 2010 goals and objectives.
    Analysis of public health indicators and Florida’s Community Health Assessment Resource Tool Set
     (CHARTS) data.
    Program-specific data tracking family health services, environmental health, and disease control,
     including local epidemiological data on infectious diseases and chronic conditions.
    Information provided through participation and development of Community Coalitions and Partnerships.



Fiduciary Capabilities. The HCHD operates with an annual budget of almost $35,000,000. Accounting

and purchasing systems under the Florida Department of Financial Services are used to record all financial

transactions. These systems include Florida Accounting Information Resource (FLAIR), Financial



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Information Systems (FIS), and My Florida MarketPlace (MFMP). The Senior Management Team (SMT),

formed by the agency’s Senior Managers and the Health Department Director, reviews quarterly and

annual reports detailing expenditures to date and remaining budget balances. HCHD enters into formalized

agreements or contracts with its key partners that detail expected outcome-based deliverables and

reimbursements. Contracts require partners to provide monthly reports on their progress on the identified

deliverables. Reports are reviewed and approved by program managers and state certified Contract

Managers for meeting the required deliverables. Reports and reimbursement requests are processed by

financial staff for payment. Monthly performance reports are the basis of expenditure reimbursement thus

linking budget to performance.

Programmatic Capabilities. The HCHD is a respected community leader in promoting public health.

Several partners seek the support of the HCHD for community-based projects collaboration. HCHD also

serves as the lead agency on various collaborative ventures, including: Ryan White grant for $1.5 million to

address tuberculosis, dental, primary care, and medication for under-served AIDS patients; and a Closing

the Gap grant to reduce ethnic disparity for immunizations and infant mortality in under-served

communities. Other major collaborations, with very positive outcomes include:

   On-site case managers, Medicaid Waiver case management, access to housing, a food bank, mental
    health counseling, and support groups provided by Metropolitan Charities, Inc.

   Physicians from the University of South Florida, College of Medicine, Division of Infectious Diseases
    providing leadership and medical direction

    The HCHD is also keenly aware of new and emerging trends and technologies in public health. The

main database is the Florida Department of Health (DOH) Health Clinic Management System (HCMS).

The HCHD is often called upon to test pilot and implement these technologies prior to DOH statewide

deployment. Examples of new technologies include Geographic Information System (GIS) capability, which

allows disease tracking down to the neighborhood level and effective use of databases created by this



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department and other Federal, State and local agencies. HCHD is a pilot test site for the My Florida

MarketPlace purchasing system and was selected to implement an advanced cutting edge Teleradiology

system within the Tuberculosis (TB) program. This system provides physicians the ability to review TB

patients’ x-rays from a desktop computer and from any location within the Department of Health network.


Sustainability: To sustain this project HCHD will: 1) work with the STEPS committee to determine the

cost-savings for County government through reduction in diabetes and asthma patients seen by the

Hillsborough County Healthcare Program , and request that the County then utilize these funds to continue

STEPS prevention and intervention efforts; 2) establish on-going collaborative partnerships within the

community efforts; 3) incorporate HCHD health education efforts into successful elements of the STEPS

project; and 4) consider implementation of successful elements beyond the intervention area.

Inventory of Current Activities Related to Diabetes, Obesity, and Asthma: The HCHD works with the

state and regional offices to serve as the local home to the most successful teen tobacco prevention and

control program in the United States. Although funding has been significantly reduced, the HCHD

maintains an employee who dedicates approximately 50 % of her time to tobacco prevention and control

activities. Current anti-tobacco efforts include: maintaining a tobacco-free partnership; partnering with the

Hillsborough County School Board to empower youth aged 12-18 to become advocates of change against

the manipulation of the tobacco industry; encouraging the development of new, or implementing existing,

smoke-free policies; searching for funding sources to implement counter-advertising campaigns against

tobacco and to maintain the youth involved in anti-tobacco activities; promoting the Florida Department of

Health-sponsored quit smoking line for youth and adults; and contributing to the enforcement of the teen

tobacco possession law.




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        The HCHD also has a team of three (3) employees who dedicate approximately 50 % of their time

to activities that will increase physical activity, nutrition, and awareness of health disparities. Current

activities include: implementation of the county’s first annual Step-Up Florida walk in 2004, and the initiation

of an employee wellness program to reduce obesity, increase the level of employees’ physical activity, and

encourage positive lifestyle changes. The Florida DOH, Bureau of Chronic Disease Prevention and Health

Promotion provides support to these activities through our regional office, which serves Polk and

Hillsborough Counties. The regional Health Promotion & Education Coordinator dedicates 50% of her time

to work with HCHD’s team of local educators to promote partnerships and coalitions that address diabetes,

obesity, physical activity, nutrition, and tobacco.

        In addition, clinical services at the HCHD include a special food program for Women, Infants, and

Children (WIC), where a team of Nutritionists, Dietitians, and Pediatric health providers, work with low-

income families to ensure they have proper nutrition and make educated decisions on food consumption

and level of physical activity. The HCHD also serves as training ground for health professionals interested

in learning about chronic disease and other conditions by serving as a satellite site to transmit conferences

and training. Several recent teleconferences include childhood obesity and findings of the latest research

on chronic conditions. In addition, the HCHD is often represented in trade shows, expositions, and state

fairs, where information is provided on the leading health indicators to chronic conditions (e.g., body mass

index (BMI) goal, serving size calculation, second-hand smoke prevention strategies, and fruit & vegetable

consumption).

F.      Intervention Area

Demographics. Hillsborough County (HC) is located on the west coast of Florida near the mouth of Tampa

Bay; the county covers 1,051 square miles and is comprised of three densely populated municipalities –

Tampa, Plant City and Temple Terrace- and a large unincorporated or rural area. Hillsborough has a



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population of 1,073,407 (U. S. Census population estimates, July 1, 2003), making it the fourth largest

county in Florida. Fifteen percent (15%) of its households have an annual income below the federal poverty

level. HC is one of the most ethnically diverse counties in Florida, with Blacks and Hispanics comprising

about 15% and 18% of the population, respectively (U. S. Census 2000). The School District of

Hillsborough County (SDHC) is the 10th largest in the nation with over 160,000 students served in 175

public elementary, middle, and high schools.


Demographics of intervention area within Hillsborough County: (2000 US Census)

The intervention area is located within the city of Tampa and Temple Terrace and has a total population of

390,474 persons. The area is formed by zip codes 33602, 33603, 33604, 33605, 33606, 33607, 33609,

33610, 33611, 33612, 33613, 33616, 33617, 33619, 33629, and 33637. The political boundaries of the

area are: Bearss Avenue on the North, Madison Avenue on the South, Armenia Avenue on the West, and

Interstate-75 on the East. A map of the intervention area – marked by red line around - including various

intervention locations is enclosed in this package, after the Section “M” of Page #50. This area was

selected because it has the highest incidence of diabetes-related and chronic obstructive pulmonary

disease (COPD) (including asthma) deaths, as indicated by the Florida Community Health Assessment

Resource Tool Set (CHARTS). The area was also selected because it has higher poverty level, lower levels

of educational attainment, and higher concentration of Blacks or African Americans, and a comparable

concentration of Hispanics or Latinos. In the intervention area there are 56 Title I schools, indicative of the

high levels of poverty found in this area. Over 36,900 children attend school in the intervention area: 20.3%

are white, and 79.7% are non-white, which reflects the diverse nature of the community population.

         It is evident by the data displayed in Table 1 (disease burden) that there is great disparity in the

burden of diabetes, asthma, and obesity, and their corresponding risk factors for the population this project

will target, in comparison with other population groups. For instance while 6.3% of HC’s population have



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diabetes, the diabetes rates for Black males, low-income population, and persons with low level of

education are 12.8%, 9.3%, and 15.3% respectively.

        This health disparity also exists for asthma and obesity. The rate of asthma for Hispanics is 20.6%,

more than twice the 9.1% rate for HC. The obesity rate for HC is 21% compared to 33.8% for Blacks,

36.2% for Black Females, and more than double at 42.6% for those with 0-11 years of education. The

highest increase in obesity rates since 1990 have been among Hispanics. If not prevented, obesity rates

among this ethnic group will be at epidemic proportion.

        Prevention strategies will also need to be implemented among teenagers. As indicated in Table 1,

the percentage of students in grades 9-12 at risk for becoming overweight is higher in Hillsborough County

than elsewhere in Florida and in the United States.

Table 1.        Disease Burden of HC and Florida
  DIABETES            HC        Florida                              Hillsborough
                                               BRFSS 2002 Ethnic           Diabetes is highest among:
 AADR 2002**          28.4        20.7
                                                  Disparity*               1) Black Males (12.8%),
                                                                           2) Population with income
                                             B:         H:         W:      $24,999 or less (9.3%),
 BRFSS 2002*         6.3%        8.2%
                                           12.1%       6.3%       5.3%     3) 0-11years of education
                                                                           (15.3%)
*Have Diabetes, **CHARTS data
   ASTHMA             HC        Florida                              Hillsborough
                                               BRFSS 2002 Ethnic           Asthma is highest among:
 AADR 2002**          48.0        39.1
                                                  Disparity*               1) Hispanic Female (21.8%),
                                                                           2) Population with income
                                             B:         H:         W:      $24,999 or less (15.6%)
 BRFSS 2002*         9.1%        10.7%
                                            8.6%      20.6%       6.3%     3) 0-11years of education
                                                                           (12.8%)
* Ever had asthma; ** Chronic Obstructive Pulmonary Disease (including asthma)




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Cont. Table 1
                   US          FL.        HC                            Hillsborough
   ADULT
                 BRFSS       BRFSS      BRFSS
  OBESITY
                  2000        2002       2002
                                                                             Obesity is highest among:
                                                    BRFSS 2002 Obesity
 Overweight        37.2%     35.1%       34.3%
                                                      Ethnic Disparity*
                                                                          1) Black Female (36.2%),
                                                            H:*           2) Population with income
                                                     B:
                                                            26.5     W:   $24,999 or less (25.1%),
   Obese           21.0%                 24.3%      33.8
                             22.3%                           %      21.1% 3) 0-11years of education
                                                     %
                                                                          (42.6%)
* experienced the highest increase in obesity = 73% from 1990 to 2002, according to the 2003 report of the
Florida obesity task-force
                                                                                  Hillsborough
YOUTH & CHILDREN                        YRBSS 2003*
 OVERWEIGHT &
    OBESITY                 US          FL.                HC

 At risk for becoming
                           15.4%       14.0%            16.7%          The CHD BMI calculations found
      Overweight
                                                                       Hispanic children with the highest
      Overweight           13.5%       12.4%            12.5%          obesity rate = 32.2%

*Students grades 9-12
 Adult Risk Factor         BRFSS 2002 Indicator                                    HC           Florida
 Nutrition                 Less than 5-A-Day                                            76.8%      74.3%
 Nutrition                 Advised to eat fewer high fat/cholesterol foods              23.1%      21.0%
 Nutrition                 Advised to eat more fruits and vegetables                    29.7%      27.9%
 Physical Activity         Mostly sitting/standing at job                               64.1%      62.8%
 Physical Activity         No leisure time physical activity                            27.4%      26.4%
 Physical Activity         No regular moderate physical activity                        56.7%      55.1%
 Physical Activity         No regular vigorous physical activity                        75.1%      75.6%
 Physical Activity         Advised to be more physically active                         26.4%      28.0%
 Tobacco                   Current smoker                                               22.8%      22.2%
 Tobacco                   Ever quit smoking in the past 12 months                      56.2%      55.3%




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Cont. Table 1
                           Hillsborough County: YRBSS 2003
 Youth Risk Factor        Indicator                                                US       FL       HC
 Nutrition                Ate five fruits & vegetables a day                     22%       20.7%      19.6%
                          Participated in sufficient vigorous physical
 Physical Activity        activity                                              62.6% 60.8%     58.1%
 Smoking                  Current cigarette smoking                             21.9% 18.1%     18.6%
                                                                                    HC        HC
                          Florida Youth Tobacco Survey 2002*                     Middle S   High S.
 Tobacco                  Current tobacco use (any kind)                          11.9%**   24.7%**
 * FYTS 2001/2002 was conducted among 936 middle and 1,021 high school students.


      Data for adults living in the intervention area (HCHP Networks B and D) was provided by the

County’s Department of Health and Social Services and is shown in Tables 2-6. In Fiscal Year 2003-04, the

County provided medical services for approximately 2,000 residents of the intervention area who had the

targeted conditions. Including in this figure are 1,213 adults with diabetes, 319 with asthma, and 79 with

obesity. The table below shows the numbers of diagnosed patients and prevalence rates for each clinic in

the intervention area during Fiscal Year 2002-03:

Table 2.    Patients with Targeted Conditions and Prevalence by Primary Care Clinic
Disease/Condition                          Diabetes            Asthma             Obesity
Diagnosed Patients (Pt’s) Members     Pt’s   Mbr Rate Pt’s Mbr Rate         Pt’s Mbr Rate
(Mbr) Prevalence Ratio (Rate)
B-Family Care at 30th St.              442 4090 .11       110 4090 .03      23 4090 .006
B-Family Care at Kennedy Blvd.         329 2702 .12        65 2702 .02      24 2702 .009

D-Lee Davis Health Center                   196     2674   .07       74 2674 .03         23 2674 .009
D-North Tampa Community Health              148     1379   .11       42 1379 .03          7 1379 .005
Care                                         15      219   .07        9 219 04            0 219 .000
D-Sine Domus                                 75      480   .16       16 480 .03           2 480 .004
D-Peter Davis Health Center
Total                                     1207 11753 .10            316 11753 .03        79 11753 .007


        Demographic information for patients with diabetes, asthma, and obesity are shown in the tables 3,

4, and 5 below. In comparison to the general population served, the diabetic patients are older, less likely to

be living alone, and more likely to be Black or Hispanic, and female. They are less likely to be employed


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and more likely to be disabled. Asthmatic patients are more likely to be female, unemployed, and not

disabled. Obese patients are more likely unemployed and not disabled.

Table 3.    General Demographics of patients served by HCHCP in intervention area
Gender     Female     675 (55.6)      Work       Employed              226 (18.6)
           Male       538 (44.4)      Status     Unemployed            470 (38.7)
                                                 Fixed Income          131 (10.8)
                                                 Disabled              340 (28.0)
Race       White      365 (30.2)      % of       0-100%                956 (79.2)
           Black      548 (45.3)      Federal    100-150%              198 (16.4)
           Hispanic   264 (21.8)      Poverty    over 150%              53 (4.4)
           Other       33 (2.7)       Level

Age        0-17         0 (0.0)          Family      Lone person              818   (67.4)
           18-39      177 (14.6)         Type        Family of adults         225   (18.5)
           40-64     1004 (82.8)                     Single-parent family      89    (7.3)
           65 & over   32 (2.6)                      Family with children      81    (6.7)

Table 4.    Demographics of Patients with Asthma from Intervention Area
Gender     Female    217 (68.0)       Work       Employed                60         (18.8)
           Male      102 (32.0)       Status     Unemployed             159         (49.8)
                                                 Fixed Income            22          (6.9)
                                                 Disabled                63         (19.7)
Race       White     110 (34.7)       % of       0-100%                 273         (86.1)
           Black     125 (39.4)       Federal    100-150%                35         (11.0)
           Hispanic   76 (24.0)       Poverty    over 150%                9          (2.8)
           Other       6 (1.9)        Level
Age        0-17        6 (1.9)        Family     Lone person            228         (71.5)
           18-39     115 (36.1)       Type       Family of adults        30          (9.4)
           40-64     195 (61.1)                  Single-parent family    41         (12.9)
           65 & over   3 (0.9)                   Family with children    20          (6.3)

Table 5.    Demographics of Obesity Diagnosed Patients in intervention area
Gender     Female    53 (67.1)        Work      Employed                14 (17.7)
           Male      26 (32.9)        Status    Unemployed              44 (55.7)
                                                Fixed Income              5 (6.3)
                                                Disabled                11 (13.9)
Race       White     38 (48.7)        % of      0-100%                  71 (89.9)
           Black     29 (37.2)        Federal   100-150%                  5 (6.3)
           Hispanic 11 (14.1)         Poverty   over 150%                 3 (3.8)
           Other      0 (0.0)         Level
Age        0-17       2 (2.5)         Family    Lone person             54 (68.4)
           18-39     38 (48.1)        Type      Family of adults        12 (15.2)
           40-64     39 (49.4)                  Single-parent family      8 (10.1)
           65 & over 0 (0.0)                    Family with children      5 (6.3)



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        The targeted conditions, primarily diabetes, frequently resulted in hospital visits or admissions in

the 2002-03 fiscal year. The table below shows the number of patients treated in the hospital out of all

diagnosed patients receiving care for each condition. These hospitalized patients account for 75 avoidable

hospitalizations and 177 emergency room visits due to non-control or complications arising from their

diabetes or asthma.

Table 6.    Patients Treated in the Hospital and ER for Targeted Conditions by Network
                                                           Diabetes              Asthma
                      Network B
            # (%) patients admitted                     29 (3.7)                13 (7.3)
            # (%) patients seen in ER                   36 (4.6)                44 (24.7)
            # of all diagnosed patients                  777                    178
                      Network D                                                  8 (5.7)
            # (%) patients admitted                     12 (2.8)                31 (22.0)
            # (%) patients seen in ER                   27 (6.2)                141
            # of all diagnosed patients                   436
                        Total
            # (%) patients admitted                     41 (3.4)                21 (6.6)
            # (%) patients seen in ER                   63 (5.2)                75 (23.5)
            # of all diagnosed patients                  1213                   319


Overview of Assets and Deficiencies and Resources/Partnerships Capabilities for Steps
                                 i. Assets/Resources/Capabilities

        One of the major assets is the HCHCP. This program is an effort of County government to bring

quality health care to residents who can least afford it. Since 1992, the program has received several

prestigious awards because of its innovations and successes, including the Robert Wood Johnson

Foundation National Model "Innovations in American Government," Ford Foundation's $100,000 Award for

replication activities, the U.S. Department of Health & Human Services, Bureau of Primary Care, "Models

That Work", and several other awards.

        HCHCP provides access to quality healthcare for indigent persons that have no medical insurance

and tend to use hospital emergency rooms for episodic care. In the 10-plus years that the program has

been in operation, health care costs for the county’s indigent population have been reduced from $600 to


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$280 per member per month. During the same period, lengths of inpatient hospital stay have been

decreased and inappropriate emergency room usage has been curtailed. HCHCP is financed by a 0.5%

sales tax approved by the Hillsborough County Board of County Commissioners, which serve as the

program’s governing body. The program serves approximately 28,000 unduplicated persons at an annual

cost of approximately $60 million. Individuals qualify for membership by being residents of the county and

having an income that falls within federal poverty guidelines, although some persons earning up to 150% of

poverty and having ―catastrophic‖ medical expenses and a qualifying diagnosis also may enroll in the

program. There are no premiums but those with income above poverty level do have co-pays.

        In an effort to respond holistically to the needs of the county’s low-income residents, responsibility

for the HCHCP is assigned to the Hillsborough County Department of Health and Social Services. HSS

social workers housed with HCHCP medical providers, screen applicants for the health care plan while

assessing the need for other services. A managed care model is utilized. Medical services are provided

through contracts with four networks of about 1,700 physicians located at 12 primary care clinics, specialist

offices, and five hospitals.

        Diabetes, asthma, and obesity have a very real financial impact on the ability of the County to

provide affordable healthcare for low-income residents. HCHCP paid almost $20 million in medical claims

for residents of the intervention area in FY 2002-03. Of this amount, more than $4 million or 20% was for

patients diagnosed with diabetes and additional $1.2 million or 6% was for patients diagnosed with asthma

or obesity.

        In addition to the tremendous resources brought by HCHCP, several HC STEPS partners are

working presently on activities that will blend with the activities presented in the Action Plan. The Tampa

YMCA has been selected as one of the 20 YMCAs in the nation to spearhead the Gulick Project aimed at

developing strategies and best practices for those individuals who have a desire to improve their own




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wellness and health. The Gulick Project involves Harvard and Stanford Universities in the design and

evaluation and has ongoing support from the Robert Wood Johnson Foundation.

        In the same YMCA spirit of bringing people together to tackle challenges facing communities,

YMCA of the USA is launching ―Activate America‖—a broad initiative with the goal of improving the health

and wellness of all Americans by equipping America’s 2540 YMCA’s to become dramatically more effective

in working in collaboration with community partners to directly help individuals and families live, and helping

lead their

        Other resources include: the USF College of Public Health has submitted an application to

investigate the role of a comprehensive, family-centered, school-based physical education program on

indicators of academic success among 3rd grade students to the CDC. Information from this will be used to

modify STEPS practices as appropriate. More Health, an educational initiative of Tampa General Hospital

is already active in key STEPS topics – obesity, physical activity, and nutrition, in most of the intervention

area Title I schools, resources will be made available to grow their service to all Title I schools and develop

a complimentary community education strategy.

        The American Heart Association (AHA) has the Search Your Heart (and De Corazón a Corazón

Spanish version) implemented in the HC area. In addition the AHA has the Jump Rope for Heart

curriculum available, Physician Education on adolescent obesity, and web-based programs on cholesterol,

women’s fitness, and diabetes that STEPS will utilize. The Community Health Advisory Partnership

(CHAP) is a local not-for-profit serving the Intervention area that provides diabetes screening and

education, health risk assessments and evaluation, and obesity prevention through retired nurses from the

Tampa Black Nurses Association. Others that have resources are detailed in Table 8 including the

American Lung Association, City and County Recreation Departments, Asthma and Allergy Foundation of

America, Partnerships in Prevention, St. Joseph’s Hospital Children’s Advocacy Center, Students Working

Against Tobacco (SWAT), SDHC, and the Healthy Start Coalition.

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                                           ii. Deficiencies

        The HCHCP lacks a mechanism to identify and/or track patients who are diagnosed with diabetes,

asthma, and obesity, as well as the capability to follow-up with patients who do not comply with treatment

recommendations. There is an overall need for education (professional and non-professional), instructional

outreach, and grass-root efforts on asthma, obesity, and diabetes education, provided by properly trained

and certified staff, and available to target area population. Several services available to the target

population either charge a fee that may not be picked-up by their insurance (many don’t have insurance) or

target specific population groups.

        Similar to national trends, there is an overall lack of engagement in physical activities; this includes

several HC schools that lack the resources to provide active physical activity programs. After school, low

or no cost, physical activity and fitness sessions are needed for youth and adults, as well as public

education on small steps that can be taken to improve physical activity and nutrition. Very few restaurants

provide menus that highlight healthy food choices # of calories contained in the food available.

        The HCHD, in partnership with the HC School District, have since 1998 contracted to implement

one of the most comprehensive and successful teen tobacco prevention and control program. Funding for

this program is no longer available. Two of the most successful program’s components were the SWAT

teams and the ―truth‖ ads. Many youth are still part of SWAT but the recruitment efforts and youth

involvement levels are down due to the lost of key staff and the lost of the momentum. Therefore, there is

a great need to bring back the momentum for these youth.



G. STEPS Project Staff (see Appendix 1 for Position Description)

        HCHD staff will include a Project Coordinator who will be supervised by the HCHD Director of

Health Promotion & Education. The Project Coordinator will be responsible for managing and coordinating

the project and, as such, will serve as the contact person with respect to the partner agencies, state

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planning, and the project officer. The Project Coordinator will chair the Leadership Team, work in

collaboration with the team to perform day-to-day management for all project activities, facilitate coalition

meetings and participation, track performance outcomes, quality improvement, evaluation activities, and

provide budget and subcontract compliance. Other project staff will include a full-time Project Assistant, part-

time Contract Manager, and a part-time nutrition Educator to provide nutritional outreach.

        HCHD will collaborate under contract and/or MOU with the School District of Hillsborough County

and the Tampa Metropolitan Area YMCA. The school district will hire a School Health Coordinator to act as

the chronic disease specialist to support students in STEPS who report diabetes, asthma, and obesity and a

Prevention Specialist to coordinate all prevention activities in schools with students, staff, and families. The

Tampa Metropolitan Area YMCA will hire a Community Resource Coordinator to act as coordinate and link

MCA services and training to other community partners, supervise Wellness Coaches (1,000 hours) to lead

community activities, deliver physical activity programs in after-school sites, daycare centers and family child

care homes, senior centers, primary health care centers, corporations and other sites in intervention area.

The coordinator will serve as a liaison to area physicians and hospitals to develop referral resources for

students requiring follow-up after screening and to transition new students or newly diagnosed students into

safe and appropriate educational environment.



H.      Community/Community Consortium

        Hillsborough County has a long and successful history of collaborative efforts centered around the

health needs of its citizens. The result of the most noteworthy collaborative effort is the development and

implementation of HCHCP, a nationally recognized health care plan for the community’s indigent population.

Rallying around the opportunities presented by the FY 2003 STEPS to a Healthier US request for proposals,

a group with broad community representation came together to prepare last year’s application. In the past

year, additional partners were identified and assistance from the University of South Florida (USF) was

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                                                               STEPS to a Healthier Hillsborough


secured to assign a graduate student to spearhead the data collection and analysis. Visits to the STEPS

project in Pinellas County were made to understand components of its successful project. In March 2004, a

community presentation was held in Tampa by Dr. William Dietz, Jr. (from CDC) and Dr. Melinda Sothern

(from Louisiana State University) to strengthen the case for collaboration among the two counties. The

presentation was attended by the Hillsborough County coalition and provided valuable insight into

successful strategies for our local initiative.

         The Hillsborough STEPS initiative will have broad community representation from the existing

coalition. This group has agree that the Leadership Team will consist of a representative from each of the

following organizations: American Heart Association, American Lung Association, Asthma and Allergy

Foundation of America, USF, School District of Hillsborough County (SDHC), DOH/HCHD, YMCA, HC

Health and Human Services Department, CHAP, faith-based representative, and a community member.

The Leadership Team will work in concert with project staff to insure timely and efficient achievement of

STEPS outcomes and objectives.

         The Leadership Team will meet at least monthly and on a quarterly basis the Pinellas STEP

initiative and the Hillsborough STEPS initiative will meet jointly. The HCHD Project Coordinator will be the

link between the team and the coalition. The team’s responsibilities are 1) to oversee the project activities;

2) to establish the governance for the coalition. 3) to determine the project budget and subcontracts; 4) to

participate in project-related meetings and national meetings; 5) to identify and address service barriers; 6)

to review and monitor project services; 7) to review system policies, procedures and protocols, and

interagency relationships; 8) to provide advise regarding critical project concerns; 9) to make

recommendations for change; and 10) to report quarterly to the coalition. The Leadership Team and key

partner organizations are described in Table 7.




                                                                                                            15
                                                                                                                  STEPS to a Healthier Hillsborough


                                                  Table 7:        Community Coalition and Resources

Partner                   Role            Expertise and Contributions to STEPS
Hillsborough County       Leadership Team Only public health agency under the Florida Department of Health with jurisdiction in Hillsborough
Health Department         member          Co. HCHD has vast experience and success track in managing large community-based projects
(HCHD)                                    through partnerships. Has been recipient of several awards for successful collaborative projects.
                                          Will provide: fiscal oversight, lead agency, office space and equipment for Project Manager,
                                          allocation of funding and subcontracts, provide reports linking budget to performance, project staff
                                          training, data gathering through Florida CHARTS and other means, community contacts, engage in
                                          efforts that will sustain successful interventions on a long-term basis.
School District of        Leadership Team 10th largest school District in the nation, has existing SHAC and on-going commitment to health
Hillsborough County,      member          services and prevention services in schools. Will provide: office space and equipment for School
Students Health Services                  Project Coordinator, trained staff, access to student body, engage in efforts that will sustain
                                          successful school interventions on a long-term basis.
Tampa Metropolitan Area Leadership Team Largest social service non-profit in the county, with 5 locations in intervention area, will provide full-
YMCA                      member          time staff dedicated to STEPS, training for peer wellness in community locations, training for various
                                          agency staff, link to YMCA of USA ―Activate America‖, corporate team challenges, general fitness
                                          education.
American Heart            Leadership Team Leader in heart disease and stroke-related conditions. In HC, AHA facilitates, teaches, coordinates,
Association (AHA)         member          advocates, collaborates, and partners to provide prevention and risk factor management programs
                                          and materials to medical professionals and the lay public. Will contribute staff and educational
                                          materials, including science-based curriculum for faith-based train-the-trainers program in English
                                          and Spanish, provide access to web-based prevention education.
American Lung             Leadership Team Provides community asthma education, smoking cessation, community education.
Association               member
H. C. Dept. of Health and Leadership Team Leaders in providing indigent health care for residents that fall within the federal poverty guidelines.
Social Services           member          County provides half-cent sales tax to fund indigent health care, has existing networks providing care
                                          in Intervention Area, may be able to provide key sustainability funds for long-term STEPS initiative.
                                          Will provide: health centers patients data, means for evaluating project success, staff support
Community Health          Leadership Team A non-profit organization dedicated to advocating, promoting, and protecting the access and
Advocacy Partnership      member          delivery of quality health care especially for the poor and under-served. Will provide: licensed
(C.H.A.P.)                                Physicians and nurses, facility space, C.H.A.P. health risk assessments health fair coordination
                                          services.


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                                                                                                                     STEPS to a Healthier Hillsborough


University of South          Leadership Team The college offers Masters and Doctorate programs in a variety of areas within the field of public
Florida, College of Public   member          health. Will provide: graduate students and consultation for the process and outcome evaluation of
Health                                       the project.
Partnerships in              Leadership Team A non-profit organization dedicated to work with prevention organizations to coordinate media and
Prevention, Inc.             member          grassroots marketing efforts. Will provide: media campaign planning and design; campaign
                                             implementation and media management, campaign recap, cash contribution from corporate
                                             sponsors, media partners contribution.
Children’s Hospital of       Member          Through the Child Advocacy Center, provides leadership, experience, and expertise as a community
Tampa at St. Joseph                          and state resource to advocate for the health and well being of children and their families. It is home
                                             of the H. C. Safe Kids Coalition. Will provide: in-home asthma risk assessments and education, and
                                             an elementary school asthma health education program , dietitians, diabetes intervention.
Health 1st Consultant        Member          Managed Care Co. that works in partnership with the H. C. Pharmacy Assoc. and the Florida A& M
Services, LLC                                Univ. College of Pharmacy to provide screenings and events on diabetes, hypertension, etc. Will
                                             provide: asthma management education for parents & caregivers, partnerships with community orgs,
                                             and physicians’ offices, and pharmacies, training, certification to staffers and health outcome data
                                             collection
We Care Services, Inc.       Member          A non-profit org. that improves home environmental quality, provides elderly personal services in
                                             home, educational resources & training on clean indoor air, and assist in employment for home
                                             health care industry. Will provide: 250 copies of newsletter per quarter
City of Tampa                Member          The City Parks and City owned facilities will be available for STEPS activity sites. Staff at City sites
                                             will be trained to deliver program activities such as group exercise.
Publix                       Media Campaign Private Business. Through Partnerships in Prevention will provide sponsorships: pedometers,
                             Sponsor         prizes, etc.
More Health, Inc.            Member          Provides comprehensive health education in schools, will also develop and train community staff in
                                             Train the Trainers health modules.
HC Parks, Recreation, &      Member          County Park sites in Intervention area will be available for STEPS activities, will continue its own
Conservation Dept.                           initiation of Hearts N’ Parks (evidenced-based) program. Staff will be trained by STEPS supporters.
                                             Staff has already initiated its own internal wellness program.
Pastors on Patrol            Member          Grass-roots church coalition, African-American churches in Intervention Area will identify members
                             Leadership Team to become peer facilitators for prevention activities, home visitation for medical compliance,
                                             community support mechanism. Will have funds available for small grants to churches for STEPS
                                             activities.
American Asthma and          Leadership Team Provides education in schools and community, has validated, evidenced-based programs that


                                                                                                                                                  17
                                                                                                                STEPS to a Healthier Hillsborough


Allergy Foundation        Member          includes You Can Control Asthma, Asthma & Allergy Essentials for Child Care Providers, Wee
                                          Wheezers at Home, Asthma Management and Education for Health Professionals
Healthy Start Coalition   Member          Provides community-based services for women, children, and families. Will offer access to Family
                                          Resource and Support Centers located in the Intervention area for STEPS activities.
Hillsborough County       Leadership Team County provides half-cent sales tax to fund indigent health care, has existing networks providing care
Health and Human          Member          in Intervention Area, may be able to provide key sustainability funds for long-term STEPS initiative.
Services Department




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                                                                               STEPS to a Healthier Hillsborough


I.      Community Action Plan

        The Plan focuses on populations identified as experiencing disproportionate burden of chronic

diseases or conditions and breaks down activities into six areas: Nutrition (N), Obesity (O), Diabetes (D),

Physical Activity (P), Tobacco (T), and Asthma (A). Other abbreviations include: Long Term Outcomes

(LTO), Short Term Outcomes (STO), Evidence Based (EB), Elementary (ES), Middle (MS), and High (HS)

schools and Intervention Area (Area). Each strategy builds on the assets, attributes, and barriers of the

area (See e-Needs section). LTO have been selected from the HP 2010 Objectives for STEPS. While the

activities have been organized into areas of behaviors and conditions, the delivery of services will be

integrated at the community level to avoid duplication of services and confusion of consumers. A STEPS

brand name will be used to avoid ―turf‖ issues and competition between agencies.

Community Interventions Action Plan

        The Community Interventions Action Plan consists of strategies that target those with known

disease and those with risk factors for disease as well as prevention efforts for all in the Intervention area.

The strategies will be tailored to meet needs of the various cultural and minority groups in the Intervention

area. The Plan was developed through the existing STEPS team/consortium (STEPS team) by examining

the current services available, the needs/gaps in services, and the capacities of local organizations to fill

those needs with respect to the guidelines in the STEPS RFA. Consultation with the Pinellas County

STEPS initiative and information from other community-based prevention and intervention programs

around the nation was used in the development of the plan. The community interventions will link logically

with the school interventions by common education of instructors through More Health, ALA, AAFA, AHA,

YMCA, and others. Both components – community and school will target the same service areas within the

larger Intervention in the program’s initiation and will grow together in service to additional targets.

        Residents of the intervention area who are members of the HCHCP and have the targeted

conditions will be followed through two strategies.
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                                                                              STEPS to a Healthier Hillsborough


1. Network B will identify, track, and refer non-compliant patients with CHAP for one-on-one follow-up.
   CHAP will assist the referred patients to comply with their treatment recommendations and report back
   to their primary care clinic the results of these efforts. Network B believes 22% or 220 of its 1,000+
   patients with diagnoses are experiencing difficulty complying with treatment recommendations, and of
   the 220, 48 patients could benefit from telephone follow-up, 22 patients from face-to-face follow-up,
   and 26 patients from in-home follow-up. Network B will provide an in-kind match for these services of
   25%.
2. Network D does not have mechanisms in place to identify and track patients, or the capability to follow-
   up with non-compliant patients. Network D will purchase software to identify non-compliant patients
   with these diagnoses, contract with a medical case manager to monitor and track levels of compliance
   and reasons for non-compliance; and develop a support network of services that address patient
   issues of non-compliance and help patients gain access to these services. In addition, Network D will to
   expand its health education classes by contracting with community-based health education providers to
   offer group session on-site. Network D believes that 25% of its 609 patients diagnosed with diabetes,
   asthma, or obesity are experiencing some level of difficulty complying with treatment recommendations
   and that of this number 60 could benefit from these services. Network D will provide an in-kind match
   for these services of 25%.

        In the intervention area there are skeletal services for the prevention of diabetes, asthma, and

obesity. Most are aimed at consumers who can pay fees for the services, have transportation to access

service, and have the financial, educational, and cultural commitment to continue the services. The

community interventions below recognize that the target individuals for this project are often low-income,

less educated, non-white, and do not have reliable transportation. To overcome these barriers, HC STEPS

team is proposing to bring services to children, adults, and families in a culturally sensitive manner to their

community. Contract service providers were selected because of their expertise and fit with the

community.

Strategies to Community Intervention – HP 2010 Connection:

Area: (All = targets diabetes, asthma, obesity, nutrition, physical act., & tobacco) infrastructure:

HC Steps Team: HCHD will hire the project coordinator and an assistant by 11/03. A part time (.25FTE)

accountant/contract manager will be assigned to the project. HCHD will hire or contract staff for evaluation

services by 12/03.




                                                                                                              20
                                                                             STEPS to a Healthier Hillsborough


Area: (All) Community wide media campaign (support letters are in Appendix 2):

        LTO (HP 19-5,6; HP 22-1,2,6,7; HP 27-1a, 2b, 3, 4a, 9): To successfully prevent obesity, asthma

and diabetes and promote healthy lifestyle changes that include increased physical activity, better nutrition

and smoking prevention and cessation, a comprehensive, five year community-wide media/marketing

campaign will be launched.

All-1: HCHD will contract with Partnerships in Prevention (P in P) to coordinate a marketing/media that

includes collaboration with Pinellas County STEPS initiative by 11/04 (see P in P Director’s resume on

Appendix 1). P in P will work with the leadership team and consortium to plan and conduct the area wide

comprehensive major campaign to promote key health messages related to all STEPS behaviors and

conditions. This highly visible campaign will include marketing intense health messages via multiple media,

including television, radio, sponsorships of - and remote transmission from - large and culturally-sensitive

community events, web sites, and mailings and will sustain over the five years (support letter from P in P, in

appendix 2, includes media plan). STO: Successful 5 yr. major media campaign.

All-2: Conduct 10 focus groups in Yr.1 with children and adults inclusive of minorities and low literacy

populations to ascertain what kinds of messages/activities/ programs would appeal to them and encourage

them to adopt healthy behaviors. STO: Input given will be used to develop the campaign key messages,

incentives/disincentives and a logo.

All-3: Develop timeline for 5 Yr. Plan which types of messages and media outlets to be used.

All-4: Develop incentives/disincentives: Development and promotion a healthy kids Passport

Hillsborough to be distributed to children in schools, throughout the community events/business (see CVS

Pharmacy & Publix support letters in appendix 2). Participating restaurants and parks will be listed. When

kids go to participating restaurants or Parks and order a healthy meal, or exercise, the restaurant/Park will

stamp the passport. After a required number of stamps, the passport can be redeemed for an attractive

reward/incentive.
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                                                                              STEPS to a Healthier Hillsborough


All-5: Develop campaign theme in Yr. 1 to focus on two targeted groups: prevention and those with

existing conditions. Paid advertising promotions with rotating sub themes will address all 6-target

areas under the overall theme ―Steps to a Healthier Hillsborough.‖ For continuity, the ―Steps to a

Healthier Hillsborough‖ tag with a logo and centralized phone number will appear on every media piece.

Letters of support from Pinellas STEPS Director and News Channel 8 and Media General attest to

complete connection to multi-media and web-based information for the Tampa Bay area media market (see

in Appendix 2). Also provides connection to schools through News In Education that promotes use of

newspapers in education, will focus on key STEPS initiatives. All-6: Existing media outlets will be used,

including paid media (English and Spanish) and free/low cost media such as the County Government’s

Cable TV, and the city of Tampa’s cable Channel, will promote STEPS activities and consumer awareness.

Pinellas County’s main resource for information and referral ―2-1-1 Tampa Bay‖ has agreed to list the

STEPS activities, resources, sites and services on its website so that citizens can easily access them.

Newspaper columns in the minority based Florida Sentinel and La Gaceta and one in the Tampa Tribune

will regularly promote health messages regarding prevention and developing good health habits.

All-7 Design and utilization of website: The TBO.com website will be expanded to have a STEPS

Resource Center including postings of information about existing health resources, various health events,

classes and programs. This section will host an array of educational information on the six areas such as

easy to read information on the practical importance of good nutrition and how it impacts quality of life;

healthy recipes for families on the go; Five- a- Day promotions, tips for exercising; and information about

where people can connect with others who want to engage in group activities such as walking and

bicycling. Additionally general education materials will be developed and posted regarding asthma,

diabetes and obesity.

All-8: Yr. 2–5 strategies: Implement the marketing campaign; begin with continued rotational sub themes

using all media available in the area (Tampa Bay market); continue focus groups for feedback and
                                                                                                              22
                                                                              STEPS to a Healthier Hillsborough


continuous development of media strategies. Web based surveys will be developed to give continuous

feedback from those visiting the Pinellas wellness website. Feedback will be used for evaluation of

activities, media campaigns and for further development. Evidence Based: Multi-component, community-

wide media campaigns-CG, NGC, CDC.

Area: Nutrition (N) (Support letters are in Appendix 3)

LTO (HP 19-5, 19-6): Increase the % of persons aged 2 Yrs. and older who consume at least 5 fruits and

vegetables daily from 23.2% (2003) to 45% in area (2009). LTO (HP 19-5): Increase % of HS students

who ate at least 2 fruits per day for last 7 days from 19.6% (2003) to 35% in area (2009). (BRFSS,

YRBSS).

N-1: Expand HCHD nutrition services by assigning a part time nutritionist to the project and by contracting

with St. Joseph’s Hospital Children’s Advocacy Center and Tampa YMCA to provide outreach community

nutrition services by 11/04.

N-2: Conduct 1 hr class to children in after-school programs consisting of 30 minutes of 5 A Day and 30

minutes of physical activity. STO: Yr. 1: 12 sites, 600 classes, 9000 children. Yr. 2-5: 15 sites, 750 classes,

11,250 children/Yr. Evidence: 5 A Day, CDC, NCI, USDA, and AHA.

N-3: Conduct AHA Step 1 and 5 A Day, 1 hour presentations/cooking demonstrations, to youths and adults

in city, county, and neighborhood community centers, and churches. STO: Yr. 1:12 sites, 550 classes, 6000

participants, Yr. 2-5: 13 sites, 650 classes, 8000 participants.

N-4: HCHD will contract with St. Joseph’s Hospital to hire part-time dietitians by 11/04. The dietitians will

be out posted to HCHD Clinic sites to provide 5 A Day education to pediatric clients. STO: 1000 pediatric

clients/Yr. Evidence: USDA, 5A day, CDC.

N-5: Replicate Healthy Kids’ Restaurant campaign from Pinellas County to Hillsborough County to label, ―

Heart Healthy,‖ choices for adults in community and ethnic restaurant menus. Nutritionist will evaluate

menus for AHA Step I appropriateness. STO: 50 restaurants/Yr. Evidence: AHA ―Heart Healthy‖
                                                                                                                23
                                                                              STEPS to a Healthier Hillsborough


N-6: Promote and expand TBO.com wellness website section to include BMI information and links to major

health sites and nutrition and exercise classes/programs. STO: Increase monthly ―hits‖ from 300 to

500/month. Increase ―hits‖ by 125/month annually thereafter to reach 1000/month Yr. 5. Evidence:

Community Guide; multi-component media.

N-7: Develop and Promote Family Health Newsletter in English and Spanish featuring healthy eating tips

for parents. STO: Initiate distribution to 20 sites/quarter. Increase by 15sites/month/Yr. thereafter (100

sites/month Yr. 5). Evidence: See N-6.

N-8: Conduct 5 A Day and healthy choice promotion as part of major media campaigns described earlier.

Other Agencies responsible: YMCA, More Health, AHA, Faith Based Organizations, City and County

Recreation Depts.

Area: Physical Activity (P) (Support letters are in Appendix 3)

LTO (HP 22-1): Decrease the % of adults who engage in no leisure time physical activity from 27.4 %

(2002) to 20% in area (2009). LTO (HP 22-2): Increase the % of adults who engage regularly, preferably

daily, in moderate physical activity for at least 30 minutes per day from 43.4% (2002) to 55 % in area

(2009). LTO (HP 22-6): Increase the % of HS students who engage in moderate physical activity for at

least 30 minutes on 5 of 7 days from 22.7% (2003) to 30% in area (2009). LTO (HP 22-7): Increase the

% of HS students who engage in physical activity that promotes cardiovascular fitness for 20 min on 3 or

more days from 58.1% (2003) to 65% in area (2009). LTO (HP 19-2): Decrease the % of adults who are

obese from 24.3% (2002) to 22.05% in area (2009). (BRFSS, YRBSS). LTO (HP 19-3): Decrease the %

of overweight students from Yr. 1 area BMI baseline by 15%(2009).

P-1: HCHD to contract with YMCA for outreach community exercise classes by 11/04.

P-2: YMCA will provide the physical activity portion of the combined nutrition/PE education in the after-

school programs. STO: Yr. 1: 12 sites, 600 classes, 9000 children. Yr. 2-5: 15 sites, 750 classes, 11,250

children/Yr.
                                                                                                             24
                                                                            STEPS to a Healthier Hillsborough


P-3: YMCA to conduct weekly physical activity/fitness one hour sessions to youths and adults in a) 12

neighborhood community centers, city recreation centers, and churches focusing on under-served areas,

and in b) 2 HCHD clinics or other community sites. STO: Yr. 1: 14 sites, 700 classes, 8000 adults. Yr. 2-5:

18 sites, 900 classes, 10,000 adults/Yr.

P-4: Partner with YMCA to expand existing fitness activities at low or no cost to under-serviced areas in

providing scholarships for children and adults to join YMCA facilities. STO: # of scholarships provided.

P-6: a) Promote stairwell point of decision prompts in county, city, partner agencies, and community

buildings encouraging use of stairs. b) Improve stairwells environment to aesthetically pleasing. STO: 15

buildings. Add 25 buildings/Yr. Evidence: CG, RPC (AJPH 91 (12) 2001.

P-7: Develop and promote ―mall walking‖ groups (Westshore mall, University Square mall, Downtown

Temple Terrace). STO: Develop 2 walking groups. Add 2 groups/Yr. Evidence: CG, AJPM 2002 (s).

P-8: Promote and expand employee physical activity programs among partner agencies by a) YMCA

corporate challenge, b) establishing Pedometer Walking Programs in partner agencies. STO: Yearly, a)

number of agencies, b) number of employee participants, c) number of steps walked, d) increase number of

steps by 25%.

P-9: Promote and expand TBO.com to include BMI information and links to major health sites and nutrition

and exercise classes/programs. STO: Increase ―hits‖ by 15% from baseline in first year, 10% each year

thereafter.

P-10: Develop and promote ―Parent Health Bulletin‖ featuring healthy behavior tips for parents. STO:

increase distribution from 20 sites/quarter to 40 sites/month. Increase by 15 sites/month/Yr. thereafter (100

sites/month Yr. 5).

P-11: Conduct physical activity component of major media campaigns described earlier.




                                                                                                            25
                                                                          STEPS to a Healthier Hillsborough


Area: Tobacco (T): (Support letters are in appendix 3)

1. Environmental Tobacco Smoke (ETS): LTO (HP 27-9): Reduce the % of children who report being

exposed to second-hand smoke in a room or in a car on 1 or more of the past 7 days from 61.3% (2002) to

51% (2009) in MS students and 72.9% (2002) to 63.0% (2009) in HS students. (FYTS).

T-1: HCHD will contract with the School Board, Students Health Services to reassign the Students

Working Against Tobacco Coordinator to the project, who will continue to work actively with the HCHD’s

Tobacco Prevention Coordinator to implement youth-led activities that will include smoking bans policies,

as well as environmental changes and ETS-effects awareness activities. Evidence: DOH/Division of Health

Awareness & Tobacco (DHAT), Community Guide.

T-2: Tobacco-Free Partnership of Hillsborough County (led by HCHD Tobacco Prevention Coordinator) and

SWAT, partner with P in P to distribute ETS messages and smoke-free car kits through the mass media

campaign/events, diabetes and asthma community outreach, pediatric clinics, and neighborhood service

centers; and provide smoking cessation resources to parents who smoke and families living with a child

having asthma in those locations. STO: Provide ETS messages & cessation resources through 10 means

and 250 families with smoke-free car kits/year. Evidence: DHAT, Community Guide.

2. Smoking Prevention (Counter-advertising Campaigns)

LTO (HP27-3): Increase the % of committed never-smokers from 60.1% in MS to 70% and from 40.9% in

HS to 50% from 2005-2009. (2002 Florida Youth Tobacco Survey (FYTS).

T-3: Partner with SWAT to train youth as advocates of change against the manipulation of the

tobacco industry. These youth will serve as team leaders to maintain the current 16 SWAT teams active

and develop an additional 2 teams per year. STO: a) 32 advocates trained. Maintain 16 SWAT teams

active. Develop and maintain 10 new teams by 2009. Evidence: Fl DOH/DHAT

T-4: Conduct Tobacco component of major media campaigns as described earlier.



                                                                                                         26
                                                                             STEPS to a Healthier Hillsborough


Tobacco-Smoking Cessation:

LTO (HP27-1a): Decrease the % of adult current adult smokers from 22.8% (2002) to 20% in area (2009)

(BRFSS). LTO (HP27-2b): Decrease the % of HS students who smoked cigarettes on one or more of the

past 30 days from 16.7% (2002) to 15% (2009) (FYTS).

T-5: Partner with ALA to implement youth tobacco cessation using the Not-On-Tobacco curriculum among

teens. STO: teen cessation program at 6 locations /Yr.

T-6: Promote use of Florida Quit-For-Life smoking cessation hot-line among youth and adults. STO:

refer 150 smokers/Yr.

T-7: SWAT Coordinator and Tobacco-Free Partnership will work with the Court House, Dept. of Law

Enforcement, and School Board to implement a class for youth tobacco offenders (recommended by law

and currently not available). Evidence: DHAT and Fl. Dept. of Law Enforcement. (use effective

curriculum used in other counties: Teg & Tap, Students Teach Students, N-O-T, or Life Skill Training)

T-8: The SWAT and Tobacco Prevention Coordinators will promote existing local tobacco cessation sites

for adults that are evidence-based. Reduce out-of pocket costs by providing coupons and incentives to

quit (currently, there are 5 cessation programs in the intervention area, not all are science-based).

Determine what programs are evidence-based and use approaches recommended by the Community

Guide prior to promoting the services. STO: successful identification of effective local programs, and

increase in number of smokers attending those programs/Yr. (need to establish baseline). Evidence:

Guide to Community Services.

Area: Diabetes (D): (Support letters are in Appendix 3)

LTO (HP 5-2, 5-3): Reduce the number of persons who are told they have diabetes by a doctor from 6.3%

(2002) to 5% in area (2009)(BRFSS); specific attention to reduce from current 12.8% of black males with

diabetes to 10.5% by 2009. LTO (HP 5-12, 13, 14, and 15): increase by 16% from baselines established in

Yr. 1. (BRFFS diabetes module)
                                                                                                           27
                                                                            STEPS to a Healthier Hillsborough


D-1: HCHD to contract with community providers for a diabetes coordinator, diabetes educators and

part-time health promoters by 11/04.

D-2: The diabetes coordinator to organize a diabetes program to serve as Diabetes Intervention

Prevention Program (DIPP) for the STEPS initiative.

D-3: Conduct ADA Diabetes Self-Management Education (DSME) in community neighborhood centers.

STO: a) 5 sites b) 48 four-week sessions (one two-hour class per week) c) 500 diabetics and 300 family

members. Evidence: ADA, CDC, FMQAI, FDCP, and CG

D-4: Provide weekly diabetes awareness seminars in Intervention area targeting minority population and

refer participants identified as diabetic to DSME programs. STO: a) 50 seminars b) 1500 participants

D-5: Conduct youth diabetes prevention class integrating exercise and healthy eating using the

Community Health Assessment and Promotion Project (CHAPP CDC model). STO: a) 4 sites b) four ten-

week sessions (one two-hour class per week) c) 1000 youth.

D-6: Administer the Diabetes Assessment Questionnaire, ―Are you at Risk?‖ to residents in the IA using

health promoters, volunteers, faith-based groups and community partners. STO: Complete 1000 ADA

―Risk Assessments.‖ Evidence: CDC, ―Small Steps, Big Rewards.‖

D-7: HCHD, hospitals, and Medical Societies to provide educational opportunities through grand rounds,

resident lectures, and seminars for health care providers on a) practical use of FMQAI/FDCP standards

and guidelines and b) availability of DSME resources. STO: a) 4 events/Yr. b) 300 health care

providers/Yr. Evidence: CME Management Guidelines

D-8: HCHD to contract with St. Joseph’s Hospital to conduct monthly group nutrition education for diabetics

in HCHD clinics and other sites in the intervention area, including label reading, cooking classes and menu

planning. STO: a) 12 groups per Yr. b) 120 diabetics and family members. Evidence: ADA.

D-9: Offer one-on-one dietary intervention (open to the public) for diabetics in community and clinic sites.

STO: 120 diabetic/Yr. Evidence: ADA, USPSTF.
                                                                                                          28
                                                                            STEPS to a Healthier Hillsborough


D-10: Provide mini grants to 10 faith-based groups to start health ministry to provide exercise, healthy

eating, and diabetes awareness education. STO: 10 faith-based groups, number of participants

(baseline). Yr. 2-5: increase by 5 churches/Yr.

D-11: Conduct diabetes awareness promoting ADA ―Are you at Risk?‖ as part of major media campaigns

described earlier. All activities for Diabetes target minority and under-served diabetics. Organizations

Responsible: HCHD, Faith Based Organizations, CHAP, HCHCP, YMCA.

Area: Obesity (O) (Support letters are in Appendix 3)

LTO (HP19-2): Decrease the % of adults who are obese from 24.3% (2002) to 22% in area (2009)

(BRFFS); specific attention to reduce the current 36.2% of black females diagnosed as obese to 33% by

2009; specific attention to Hispanic population to reduce trend toward obesity and reduce % of obese

adults from current 26.5% to 24.5% by 2009 . LTO (HP19-3): Decrease the % of overweight children by

15% in area (2008) from Baseline BMI established in Yr. 1.

O-1: HCHD, Medical Societies, and hospitals to present obesity prevention and reduction presentations to

health care providers at local hospital grand rounds and other educational forums encouraging use of

NHLBI Obesity Guidelines and of NDEP ―Small Steps Big Rewards‖ health care providers tool-kit.

STO:100 area physicians and health providers annually.

O-2: Distribute BMI charts, posters and wheels to physician practices to encourage them to consider BMI

as a ―vital sign.‖ STO: 100 practices/Yr. Evidence: USPSTF Clinical Guide.

O-3: St. Joseph’s Hospital dietitian to offer Choose To Lose, a six weeks session (2 classes per week)

weight management program, at 2 community sites (open to public) STO: yearly, a) 8 sessions, b) 120

participants. Evidence: USPSTF Clinical Guidelines.

O-4: St. Joseph’s dietitian to offer children's weight management program at 2 community sites (open to

public). The program is a 6-week session (1 class/week) for children 9-12 Yr. old using a non-diet, family



                                                                                                           29
                                                                            STEPS to a Healthier Hillsborough


oriented approach based on the social cognitive theory to learning. Topics are presented weekly,

separately to children and to parents and incorporate nutrition and physical activity. STO: Yearly, a) 6

sessions, b) 60 children and their families.

O-5: Expand TBO.com Wellness website to include BMI information.

O-6: Encourage HCHD, SDHC, and HCHCP to create a local policy to perform BMI on clients as part of

―vital signs.‖ Model after Pinellas STEPS. STO: Yr. 1, Policy established. Yr. 2, Establish BMI baseline for

all clients.

O-7: Conduct obesity awareness component of major media campaigns described earlier.

Area: Asthma (A) (Support letters are in Appendix 3)

1. Children’s Outreach/Case Management and Environmental Interventions: LTO (HP24-2a, b):

Reduce the number of hospitalizations for asthma-children less than 18 Yrs. of age from 625 (2001 County

AHCA Data) to 500 by 2008. LTO (HP24-3): Reduce by 25% the number of emergency department visits

for case managed asthma-children by 2008.

LTO (HP24-5): Reduce by 25% number of school days missed by case managed children with asthma

due to asthma by 2008. Establish baseline data Yr. 1.

A-1: HCHD will contract with St. Joseph’s Hospital (SJH) Child Advocacy Center to hire an outreach case

manager by 11/04.

A-2: St. Joseph’s to provide outreach and case management (CM) services for children with asthma.

Services includes monthly face to face or telephone contact, monitoring medication compliance, patient and

family counseling, education, appointment reminder system, referral and follow-up for community, family, or

mental health services, and documentation of self-report of number of days missed for school/work. STO:

a) 400 children case managed annually. b) 90% of CM children have a primary care provider. c) 80% of

CM children will comply with their medication regimen. d) 70% referral completion rate. e) Reduce the

number of hospitalizations at ACH for asthma-children less than 18 Yrs. of age by 5%/Yr. (ACH asthma
                                                                                                           30
                                                                             STEPS to a Healthier Hillsborough


hospitalizations: 333 in Yr. 02-03). Evidence: National Asthma Education & Prevention Program disease

management.

A-3: Asthma and Allergy Foundation of America (AAFA) to provide indoor air quality assessments

consisting of standard tests and observation to identify environmental asthma triggers for children referred

by SJH, ALA, and the SDHC. Reports with recommendations for improving the indoor air quality,

informational materials, and referral to other agencies will be given to the family and to the outreach case

manager. STO: Conduct 120 home and 25 commercial indoor air quality assessments. Yr. 2-5: 180

home and 50 commercial inspections/Yr.

A-4: Provide phone consultations as needed and serve as an information center for CM children. STO: a)

Number of phone consultations. b) Information packages distributed. Evidence: EPS, Committee on the

Assessment of Asthma and Indoor Air. Existing Programs: Currently a fee for service inspection program

exists. No free program is available.

2. Asthma Education for health care providers

A-5: AAFA to identify asthma champions in private physician offices, health care facilities, and FQHC clinic

sites. STO: 5 asthma champions annually. Evidence: AJRCCM 6/13/04 online

A-6: AAFA to conduct assessment to establish number of Certified Asthma Educators in the community.

STO: Baseline: Number of Certified Asthma Educators.

A-7: Develop simplified tools to assist consumers and health care providers to comply with standard of

care. STO: a). Develop tools in Yr. 1. b) Number of tools distributed.

A-8: HCHD, SJH, and Medical Societies will provide educational opportunities through grand rounds,

resident lectures, and seminars for health care providers on practical use of NAEPP guidelines in the

clinical setting. STO: a) 4 events b) 300 health care providers/Yr. Evidence: NAEPP Asthma Guidelines




                                                                                                           31
                                                                             STEPS to a Healthier Hillsborough


3. Asthma Community Education

LTO (-HP24-6): Provide asthma education to at least 4000 persons by 2009 to increase the proportion of

persons with asthma that receive formal patient education including information about community and self-

help resources. (No local baseline available).

A-9: AAFA to develop a local Asthma Resource Directory and update yearly. STOs: Number of resource

directories distributed. Evidence: Cochrane Review

A-10: AAFA to and promote their Asthma website to include resource directory, speakers bureau, local

asthma education classes, and links to other major asthma websites. STO: Number of website hits

(baseline) and increase by 25% /Yr.

A-11: Conduct an annual Asthma Family Day, an education program for children with asthma and their

families. STO: 140 participants/Yr.

A-12: Contract with ALA to provide the Asthma U half-day education seminar for adults with asthma or

care for someone with asthma. Topics include how to develop a personal asthma action plan, recognize

and avoid triggers, proper use of controller and quick relief medications, how to react during an asthma

flare-up, and asking the right questions of physicians. STO: 200 participants per Yr. Pre/post test for all

participants. Evidence: Modeled after the Healthy Jacksonville 2010 program and Pinellas STEPS.

A-13: Contract with AAFA to provide the ―Asthma & Allergy Essentials for Child Care Providers”

Awareness in-service for pre-school and childcare providers (Both center-based and in-home licensed

provided. Topics include symptoms, environmental factors, self-management behaviors, and information

for adult caregivers about simple steps to help preschool children with asthma. STO: a) 2 training/Yr. b)

At least 50 participants/Yr. c) Pre/post test for all participants. Evidence: Pre/Post test and evaluations.

A-14: Establish asthma support groups for SJH CM children and HCHCP patients (open to others). STO:

Monthly group meetings at 2 sites. Add one community site/Yr.

A-15: Conduct asthma awareness component of major media campaigns described earlier.
                                                                                                               32
                                                                            STEPS to a Healthier Hillsborough


Section 2: School Action Plan

ii. School Interventions

        The School District of Hillsborough County (SDHC) Division of Student Services and Federal

Programs has a strong, established foundation on which to build a focused health initiative. Currently, the

School District of Hillsborough County supports a broad- based Coordinated School Health Program

(CSHP) program model and has substantial, active community partnerships. A School Health Advisory

Committee (SHAC) also supports family and community involvement. It is 60 members strong and includes

parents, community agencies, University pediatric and child development specialists, local corporations, a

US Congressman and three State Representatives. The Health Services branch of SDHC has provided

health screenings for students in the school setting and health promotion for staff with cancer screening via

a mobile unit, blood pressure screening, and counseling. Hillsborough County is also a pilot county for the

Volunteer School Nurse Project to supplement school nurse services in return for licensing credits and fee

waivers. Every school in the District has qualified guidance counselors with access to psychological and

social services. The Programs for Limited English Proficient Students Department provides translation for

all parents that need support with any of the available student services

        The curriculum and instructional division also works to support wellness. There is a sequential

physical education and health education curriculum for all students. High school physical education is

moving from a competitive sport base to a wellness curriculum through a Carol White Physical Education

for Progress Grant. Some elementary schools have incorporated a Wlk4Life component in their physical

education curriculum. An intervention team provides HIV education for all 12th grade students with

curriculum being developed for 11th grade and middle school. Tobacco Use Prevention Education has

begun in the high schools and middle schools along with Youth Empowerment Anti-Tobacco Programs.

Tobacco and clean air policies and facilities maintenance also provide a healthy school environment.



                                                                                                           33
                                                                              STEPS to a Healthier Hillsborough


         Student Nutrition Services, feeding 180,000 students daily, also is responsive to the need for a

coordinated wellness effort through changes in food choice and food presentation. Healthy Express meals

of salads, sandwiches, and yogurt are available in a special ―fast lane‖ for students. French fries have

been eliminated from combo meals substituting a fresh salad or fresh fruit. Nutrition services are working

on a computer program to enable parents to see their children’s weekly meal choices. Healthy Breakfast

for All is provided free for all students.

         The diagram depicts the CSHP District model components.

                                                          The student need for the services provided by the

                                                  District and their partners continue to grow. There were

                                                  937,874 total clinic visits in the schools this year. In 2003-

                                                  2004, 12,917 students reported asthma, and 341 reported

                                                  diabetes. The population of students who had BMI

                                                  screening was small but demonstrated a trend toward

increased percentages of overweight children as the students became older. Kindergarten screening

(N=696) reflected 7% overweight, third grade (N=278) indicated 15.1% overweight, and sixth grade

(N=145) 23.4% overweight. The 2003 Youth Risk Behavior Survey responses for Hillsborough County

indicate that 80.4% of the students did not eat five or more fruits and vegetables per day. There is a strong

need for professional development in the areas of asthma, diabetes, obesity, nutrition, physical activity and

tobacco prevention; it is not part of professional development offerings in the school system. School based

interventions for Hillsborough STEPS build on the current foundation to address both control of diabetes,

asthma, obesity and prevention of their associated risk factors of physical inactivity, poor nutrition, and

tobacco use.

Control. Part of the responsibilities of The School Health Program Coordinator (SHC) will be to act as a

chronic disease specialist to support students in STEP schools who report diabetes, asthma, and obesity
                                                                                                              34
                                                                              STEPS to a Healthier Hillsborough


(currently 3425 students). As these students enter the school, the on site school nurse will be notified. The

coordinator will work directly with the school nurse in providing training to the student, the parents, and the

child’s teachers to enable the child to succeed in a normal educational environment. Home visits will occur

when need is indicated for further support with self management and health care referrals will be

coordinated by the SHC. The Coordinator will serve as a mentor and coach to the nurse, the guidance

counselor, and the social worker as they gradually fill the role of advocate for the students experiencing

chronic disease. This will create a sustainable model. The Asthma and Allergy Foundation of America will

support this effort through the School Asthma and Allergy Management Plan (SAAMP). This training

educates all staff including clerical, transportation, maintenance, faculty, and health services, with

information needed to keep children safe and free from crisis emergency care. Additionally, SAAMP will

provide ―Teens Talk About Asthma‖ on Saturdays and weekends. These are interactive, creative sessions

that allow teens to learn self -management and introduce peak flow meters and monitoring into their

management plan. Diabetic students will also receive support and self -management instruction.

        School attendance of identified students will be tracked to determine if the project is supporting

continuity in the educational process for chronic disease students.

Prevention. A Prevention Specialist, a nurse experienced in the implementation of CSHP, will coordinate

the prevention strand of the school interventions. These interventions will encompass the three at risk areas

of poor nutrition, physical inactivity, and tobacco use. CSHP teams will be phased into the schools; 10

schools the first, second and third year, and 26 the fourth year. A stipend will be offered to the team

members. The Prevention Specialist will work to develop adult programs for the staff and to help the school

implement evening activities for families in coordination with the community. All elementary schools will

receive pedometers. The CSHP teams will coordinate competitions between grade levels and other schools

to award increased activity logged with the pedometers. Middle and High school students will design their

own competitions. Contest incentives will be sought throughout the community to keep students motivated.
                                                                                                             35
                                                                                 STEPS to a Healthier Hillsborough


Poor nutrition: Empowerment and education for all stakeholders is the key to positive change in this area.

Through Hillsborough STEPS students will receive classroom education with the Nutrition Diner, an

interactive CD in Spanish and English provided by the State of Florida. More Health, sponsored by Tampa

General Hospital, will additionally provide nutrition education to elementary, middle and high school

students. The third grade students will receive ―Pyramid Power‖ with real sized food models helps students

learn to make healthy choices. Middle school students experience ―Fit for Life‖ which includes exercise,

nutrition and strong bones. Students set personal goals and track their own progress toward them. High

school students learn about eating disorders and body image, self -esteem and societal pressure to help

them make good lifestyle choices. The students receiving the 3rd grade lesson in year 1 and year 2 will also

receive the 7th grade lesson in year 4 and 5. Students receiving the 7 th grade lesson in year 1, year 2, and

year 3 will receive the high school lesson in year 3, 4 and 5. Repeating the nutrition and fitness messages

to the students builds upon the initial concepts taught and its effectiveness will be measured and followed.

Students are taught in individual classrooms, not assemblies. In addition, the MORE HEALTH message of

nutrition and fitness will be implemented at the Fitness Fiesta, nutrition and fitness fairs for parents and

children.

            Faculty and food service personnel will receive training, provided by a qualified nutrition

educator, to help students learn to make healthy eating choices. Parents will receive training both through

the interactive Nutrition Diner disk and nutrition classes. Progress in healthy nutritional choices will be

tracked through the line item sales list for the school cafeteria, which provides month-to-month data

concerning children’s food selections. This data can be compared to non-participating schools to see if

there is a program impact.

        Physical inactivity: Education again plays a strong role in this initiative and is accompanied by

activities designed to encourage physical activity. The Florida Administrative Code changed to mandate

growth and development screening at 1st, 3rd and 6th grade. Parents will be notified of BMI for all students.
                                                                                                               36
                                                                                STEPS to a Healthier Hillsborough


Through Hillsborough STEPS, 3rd grade students who demonstrate BMI above or below the norm will be

tracked for progress through 8th grade. Nurses will be trained to use PDA’s (i.e. Palm Pilots) to log data and

transmit it to the health department, SDHC mainframe, and track individual BMI at site. The at- risk

students will be screened again in 4th grade; parents will receive a follow up letter with a referral to their

health professional. Staff development will help elementary teachers incorporate movement into the daily

routine of their students. School staff and parents will be provided with physical activity opportunities

designed by the prevention specialist, supported through the YMCA through community programs and staff

wellness programs. SDHC is especially looking forward to ―Walk the Talk‖ challenge that pits the School

District of Hillsborough County staff against the staff of Pinellas County Schools to determine who best

steps up to the healthy challenge.

        Tobacco use: SDHC will work with the community SWAT initiative to incorporate Tobacco Use

Prevention Education in its professional study day and to enable the youth empowerment component to

take place on the school’s campus.

        The School Health Program Coordinator is a full time position (Appendix 1) located in the

School Health Services Department. The qualifications would include a Bachelor of Science Degree in

Nursing (preferred) and a minimum of 5 years supervisory experience in the school health/public health

field. The Coordinator will be responsible to assume leadership role in planning, development,

implementation, and evaluation phases of this project. Included in these responsibilities would be ongoing

training and monitoring of project staff; bridging the community consortium in project’s activities and

decision making through regular meetings, chairing the School Health Council meetings and seeking

additional resources for the project activities, and budget management. The School Health Coordinator

(SHC) will interface with Department of Health and Department of Education at State level to stay current

on new and pending legislation. The Coordinator will also work directly with the implementation in the

Control activity strand to provide the chronic disease support stated in section ―a‖.
                                                                                                                 37
                                                                               STEPS to a Healthier Hillsborough


        A school health council will be formed from volunteer members of the already existing School

Health Advisory Board. Three additional members will be recruited; a middle school student, a high school

student, and a current member of the PTA Board. In addition to calendar meetings, Members of the Council

will be kept current through Steps Web site and Steps newsletters from participating schools.

        Research supports the focus of the school proposal. The publication of the first Surgeon’s

General’s report on physical activity and health was a catalyst for change much in the way that the first

Surgeon General’s report on smoking triggered change. The report concluded that nearly half of American

youths aged 12-21 are not vigorously active on a regular basis and that physical activity declines

dramatically during adolescence. The school proposal tracks and supports at risk third grade students to

avoid this decline. The Healthy People 2010 prevention agenda lists physical activity and overweight

/obesity as the first two Leading Health Indicators that reflect major national health concerns. The focus of

the school project aligns with these concerns.

        Varied fields of research support the proposal design. The CDC Guidelines for School Health

Programs published in 1996 espoused the school environment as an optimal place for health promotion.

The guidelines state, ― It is recommended that strategies to influence dietary changes and multiple

opportunities to practice these changes complement cognitive focused curricula because knowledge alone

does not necessarily promote behavioral change‖. The SDHC component of Hillsborough STEPS is a part

of the larger collaborative community effort and it provides activities to follow up the education for all

stakeholders- students, parents, and staff. The Every Day, Lots of Ways (EDLW) knowledge based

nutrition curriculum studied by the CDC showed a significant improvement in nutrition knowledge scores

among students. However, changes in the students’ lunch-time eating behaviors were not significant. In

this proposal, inclusion and training of food service personnel as well as the monitoring of lunch room

choices to enable formative adjustment promises different results.



                                                                                                             38
                                                                             STEPS to a Healthier Hillsborough


        The design of the chronic disease control strand of the proposal is also research supported. In the

article, ―Collaborative Approach to Nutrition Education in Schools and Communities: Exploring the lessons‖

(William Potapchuk, Journal of Nutrition Education, Sept/Oct, 1998), stated that collaboration builds

comprehensiveness, reduces fragmentation and brings together separate streams of reform to reshape the

way services are delivered. Additionally the Rand Panel ―Improving Childhood Asthma in the U.S., A

Blueprint for Policy Action‖ emphasizes that school health and social agencies need to work together to

create an asthma friendly environment. Both the asthma and diabetes control options in this proposal

include self-management lessons, home visits, referrals, and the involvement of social services.

Planning and research of bet practices have formulated the SDHC component of the STEPS design.

Strategies to School Intervention – HP 2010 Connection:

The School Action Plan breaks down activities in 5 areas: All (ALL); Nutrition & Obesity (N); Physical

Activity (P); Tobacco (T); and Asthma (A). School Health (SH). Intervention strategies previously

described in the Community Plan are not repeated in this section.

Area: All (All components) (Support letters are in Appendix 4)

LTO (HP7-2e, h, i): All of the Title I schools in the Intervention area will offer enhanced SH Education

ALL-1: HCHD contracts with SDHC to hire the STEPS Coordinator and Prevention Coordinator by 11/04 to

facilitate integration of health education, physical education, student health services, Safe and Drug Free

Schools, food service & nutrition and related STEPS activities.

ALL-2: Existing School Health Advisory Committee members will be identified to serve as the School

Health Council (SHC) The coordinator will expand council membership and lead each monthly meeting.

STO: The SHC will oversee implementation of STEPS activities for approximately 36,900 students in 56

Title I schools (34ES, 11 MS, and 2 HS). Evidence: American Cancer Society's Guide on the Role of the

S H Coordinator and Guide to SHC. Existing Programs: Comprehensive Sequential Health Education

Curriculum (grades K-6, 8,10). High school moving to a wellness curriculum through Carol White PE Grant.
                                                                                                              39
                                                                            STEPS to a Healthier Hillsborough


Training for teachers providing professional development related to healthy eating habits, tobacco use

prevention & student fitness. More Health education offered .

Area: Nutrition & Obesity (N, 0)

LTO (HP7-2h): 100 % of schools will offer enhanced SH Education on healthy dietary patterns. LTO

(HP19-5): Increase % HS students who ate at least 5 fruits /day for last 7 days from 19.6% (2003) to 35%

in area (2009) (YRBSS). LTO (HP19-3): Decrease the % of overweight students from Yr. 1 area BMI

baseline by 15%(2009). BMI collection will be completed in Year 1.

N-1: Expand "Five a Day‖ to schools in Intervention Area, 10-20 schools/Yr. STO: Annual 50% of students

per school selecting healthy choices..

N-2: Provide faculty and food service personnel training in healthy food choices. STO: Train staff from 10

schools annually.

N-3: Introduce "MORE Health curriculum in all 3rd, 7th, and 10th grade classes in intervention areas. (2-

50minutes presentations) STO: 100% of students receiving More Health education/Yr.

N-4: Produce and disseminate Healthy Eating and physical activity materials (district TV channel,

Newspapers in Education, posters in school cafeterias, video materials, etc.) and expand in Yr. 2-5. STO:

Monthly school media productions/Yr.

N-6: Pilot a new customized YRBSS in 3rd grader of Yr. 1 intervention schools and expands to the 20 ES,

4-6/Yr. STO: Yearly results of customized YRBSS. Evidence for Nutrition Activities: a) National

Association of State Boards of Education's report: Fit, Healthy and Ready to Learn: A SH Policy Guide Part

1. (Bogden, J. 2000) b) CDC, Guidelines for SH to Promote Lifelong Healthy Eating, MMWR.



Area: Physical Activity (P)

LTO (HP7-2I): 100% of the Title I of schools will offer enhanced SH Education on physical activity through

classroom fitness curriculum. LTO (HP22-6): Increase the % of HS students who engage in moderate
                                                                                                             40
                                                                               STEPS to a Healthier Hillsborough


physical activity for at least 30 minutes on 5 of 7 days from 22.7% (2003) to 30% in area (2009). LTO

(HP22-7): Increase the % of MS students who engage in physical activity that promotes cardiovascular

fitness for 20 min on 3 or more days from 54.3% (2001) to 65% in area (2008) (YRBSS). LTO (HP19-3):

Decrease the % of overweight students from Yr. 1 area BMI baseline by 15% in 2009.

P-1: Annually, administer FitnessGram (H.S9) physical fitness assessment, including BMI, to ES, MS, and

HS students in PE. STO: a) Establish baseline of students meeting minimum fitness levels in 3 or more

physical fitness areas; b) Establish BMI baseline for ES (20,000), MS (10,000) & HS (5000). Evidence:

Fitnessgram Cooper Institute for Aerobics

P-2: Expand federal Carol M. White Physical Education Grant activities to all target schools, 3/Yr. This ―fit

and healthy for life‖ program focuses on individual fitness gains and well being over athleticism to optimize

fitness activities with technology (Polar Heart Rate monitors). STO: # students participating in the Carol

White PE program/Yr.

Evidence: Prevention Research Center (PedExSci15: 156-2003)

P-3: Establish a Staff Walking Program with pedometers to model & promote fitness activities. STO: a) #

of staff participating in walking program/Yr. b) Establish in Yr. 1, baseline # of steps walked by staff

(Increase by 25%/Yr.).

P-4: Establish after school Family Obesity Education Services to increase physical activity for obese

students and their families (2 sites annually). Modeled after the Activity Calendar Program (Yackel, E.,

2003). STO: a) # of obese students (by BMI) referred/Yr. b) # of students participating in Family Obesity

Education Services/Yr. Other Evidence: a) 2002 California DOE. b) CDC report, Guidelines for School

and Community Programs to Promote Lifelong Physical Activity Among Youth. Existing PE requirements:

ES daily, MS daily for 2 semesters/Yr., HS for 2 semesters over a 4-Yr. period.

Area: Tobacco Use (T)



                                                                                                             41
                                                                           STEPS to a Healthier Hillsborough


LTO (HP7-2e): 95% of ES students (24,225 annually) will receive enhanced SH education on tobacco use

and addiction (School reports). LTO (HP27-4): Decrease % of MS students who smoke a whole cigarette

before age 13 from 23.2% (2001) to 18% in area (2008) (YRBSS).

T-1: Train all ES teachers yearly to implement grade level instructional material on tobacco use and

addiction (H.S4) into daily lesson plans. STO: # of ES Teachers trained/Yr. Grade 5 will maintain less

than 2% tobacco use (local survey). Evidence: Florida Tobacco Control. Existing Programs: HS ―N-O-T‖

Smoking Cessation & Education Program (H.S5). Grades 1-5 Health Education Tobacco Curriculum.

Area: Asthma (A)

LTO (HP-24-6): Provide asthma specific health education to 1000 children - asthma by 2008.

A-1: HCHD contracts with ALA to provide the Open Airways Program (H.S14) to 4th and 5th graders with

asthma. The intervention consists of 6 sixty minutes sessions with groups of 8-12 children. STO: a) 30

programs, b) 250 children/Yr. and c) pre/post test questionnaire (H-S15). Evidence: CDC website lists

ALA program as successful intervention. Existing Program: Intermittently offered based on funding.

        The chart below aligns the needs, objectives, activities and timeline for the schools.

                                         School Based Activities
     Need               Objective              Activities                          Timeline
                                                                     Yr1       Yr2    Yr3   Yr4        Yr5
Number of          Increase              1.Gather baseline           
children           attendance for        attendance data
reporting asthma   children identified   2.SHC (*) trains &                                        
and diabetes       with chronic          coaches school nurses
                   disease in            3 SHC & Nurse work                                        
                   targeted schools      with families and child
                                         4. SHC trains &coaches                                     
                                         school social worker
                                         and counselor
                                         5. SHC &Nurse work                                        
                                         with contact teachers
                                         6. SAAMP trains all staff                                 
                                         7. Social worker works                                      
                                         with families and child


                                                                                                           42
                                                                      STEPS to a Healthier Hillsborough


                                    8.Nurse and guidance                                      
                                    counselor work with
                                    contact teachers
                                    7. Teen Talk (SAAMP)                                     
                                    8. Collect data from                                      
                                    parents, teachers,
                                    nurses, students, and
                                    social worker &
                                    counselor
      Need             Objective             Activities         Yr1       Yr2    Yr3     Yr4     Yr5
Increased         Increase healthy  1. Collect baseline         
percentages of    choice items sold cafeteria sales data
overweight as     in the school     2.Nutrition Diner in        
children get      cafeteria         elementary schools
older                               3. More Health in all                                    
                                    schools
                                    4.Faculty and food                                       
                                    service personnel
                                    training ( in groups of
                                    10-12 schools )
                                    5.Parent training                                        
                                    6.Heallthy foods                                         
                                    marketed in cafeteria
                                    7. Data collection                                       
                                    8. Marketing concept to                                  
                                    parents and students
                                    (web, newsletter,
                                    morning show)
Increased         Reduce % of 1.Collect Baseline BMI            
percentages of overweight/obese 2.Notify parents                                             
overweight as children              3. Refer at-risk students                                 
children      get                   to health care
older                               4.Referral follow up with                                 
                                    community health
                                    5.Staff development (in                                  
                                    groups of 10+ schools)
                                    6. Daily movement for                                     
                                    children
                                    6 Challenge with                                          
                                    Pinellas
                                    7.Parent and staff                                        
                                    activity opportunities.




                                                                                                     43
                                                                         STEPS to a Healthier Hillsborough


                                          8. Tracking and data                                  
                                          collection: School
                                          Health Index, YRBS,
                                          YPAN, and a
                                          Nutritional/physical
                                          activity questionnaire.
Decline in          Reduce the % of       Incorporate community                                 
support for         high school           SWAT efforts in the
tobacco             students using        targeted schools
prevention          tobacco products


J. Financial Contributions (See support letters in Appendices 2-4)

Agency                         Resource                    Cash Commitment              In-kind value
American Heart                 Various programs: Jump                                   $25,000
Association                    for Heart, CPR,
                               professional medical
                               education programs, web-
                               based programs
Asthma and Allergy             Validated education and                                  $42,200
Foundation of America          support programs,
                               volunteer services,
                               residential asthma camp
                               for children
Partnerships In Prevention     In-Kind media match                                      $37,500
                               Cash Match from corporate $37,500
                               partners
University of South Florida,   Consultation for evaluation
College of Public Health       Graduate student Interns                                 $10,000
                                                                                        $10,000
Community Health               Health professional                                      $45,000
Advocacy Partnership           services
                               Facilities use                                           $25,000
                               Health risk assessments                                  $5,000
St. Joseph’s Hospital          Zap Asthma program                                       $18,000
Children’s Advocacy            Youth health education                                   $70,000
Center                         Staff time                                               $1,000
Tampa Metropolitan Area        Lead staff to STEPS                                      $15,000
YMCA                           Facilities use                                           $25,000
                               Training and certification                               $ 5,000
                               YMCA membership
                               scholarships                                             $50,000
Florida Medical Quality        25 train-the-trainers tools                              $ 625
Assurance, Inc. FMQAI
University of Florida          Dietitians, classes,                                     $50,000

                                                                                                        44
                                                                            STEPS to a Healthier Hillsborough


                              materials
Hillsborough County           Office space, equipment,                                      $50,000
Health Department             support staff
School District of            Office space and supplies                                     $75,000
Hillsborough County           for SWAT Coordinator,
                              School nurse support staff


The total value of the cash commitments is $37,500 and the in-kind commitment is $559,325 or a total

match contribution of $596,825. In addition we will ask partners to track the contributions on an on-going

basis, as in-kind contributions are often under-reported.

K. Evaluation and Monitoring

Risk factor surveillance data is currently collected and utilized for program planning and monitoring in

Hillsborough as well as Florida. The 2002 BRFSS included 499 adults from Hillsborough County, making

data available on the risk-factors and health conditions this project targets. The 2002 BRFSS data is used

as baseline for this project and will continue to be used every year to measure change in risk factors or

health condition. Additional adult county level data, including age-adjusted death rates (AADR) per

100,000, behavioral risk factors, hospitalizations, health resource availability, socio-demographics, and

other information, available through Florida CHARTS, a system that provides GIs mapping of selected

health conditions in the intervention area. To better understand chronic disease burden and trends, related

risk factors and the effects of STEPS, in 2004-2005, some components of BRFSS (modified to fit project

targets) will be administered in partnership with USF, among 1,500 – 2,000 adults from the intervention

area. On-going implementation of BRFSS will continue to be administered every year locally in partnership

with DOH and CDC to retrieve on-going surveillance data. In addition, starting on 2004 and continuing

through this grant period, the Hillsborough Health Care Program (HCHCP) will continue to gather treatment

recommendation follow up and attendance at a community-based program for patients with diabetes,

asthma and obesity from the intervention area’s networks. The community-based programs that will follow-



                                                                                                            45
                                                                               STEPS to a Healthier Hillsborough


up on these patients will maintain a record on each patient indicating compliance/non-compliance and other

relevant information that will help in tracking prevalence and incidence rates of diabetes, asthma, and

obesity. In addition, specific interventions will each have some form of process, outcome, or impact

evaluation.

      The YRBSS 2003 was administered in 32 states and 19 local communities. Hillsborough was among

those local communities. On-going implementation of the YRBSS by CDC will be used to measure

changes in risk-factors for obesity/overweight, asthma, and diabetes among students grades 9-12. HC

School District (HCSD) will work with CDC to develop the appropriate sampling frame and do over-

sampling in schools located in the intervention area. This will provide for more accurate data for monitoring

and evaluation.

      The Florida Youth Tobacco Survey (FYTS) will be implemented every other year, as long as funding

is available, by the DOH. Results of this survey have been used since 1998 to determine county-level rates

in teen tobacco use, exposure to second-hand smoke, and other tobacco-related information.

      The Florida Youth Physical Activity and Nutrition Survey (YPANS) has recently started

implementation to determine nutrition, overweight, lifestyles, and risk-factors for the conditions targeted

among middle school students. Although the YPANS provides statewide data only, the HCSD is exploring

the possibility of getting data specific to the intervention area so that local data on middle school students is

available.

      To capture risk-related data on elementary school students, two measurements will be used: First,

starting during school year 2004, BMI data will be determined for all 3 rd graders in the intervention area. It

is the plan to expand data collection to 6th and 9th grades in upcoming years. This will allow for long-term

outcome determination since interventions are planned for 3rd graders, who will become 6th graders during

the implementation of this project. The second measurement will be done through a local

nutritional/physical activity questionnaire developed by USF, in conjunction with the Coordinated School
                                                                                                              46
                                                                                STEPS to a Healthier Hillsborough


Health Program. This survey was implemented in 2003-2004 but data is not yet available. Because of

being a local effort, survey items will be modified as appropriate to meet the data needs for the STEPS

project. To determine actual Vs. self-reported nutritional food choices, the school district will start

maintaining a count of food choices based the line item sales list for the school cafeteria, which provides

month-to-month food choice data. This data can be compared to non- STEPS schools to measure program

impact. Students’ visits to school clinics will be another medium that will be used to track data on students

with asthma, diabetes, or obesity.

        HCHD and the STEPS Consultant will bring their expertise to establish a common set of core

performance measures for STEPS. The evaluation team will use standard methodology to assure these

essential elements are tracked throughout the project period:  Number and types of persons served by

various interventions  Achievement of related short-term, intermediate and long-term objectives  Link

between program activities and the achievement of the initiative’s overarching goals  Selected ―Healthy

People 2010‖ objectives  Comprehensive evaluation plan  Participate in an independent, external

evaluation to examine and document the effectiveness of the cooperative agreement  Examining and

acting on successes/barriers/failures  Gathering and submitting data on selected outcome and

performance measures  Participating in other evaluation activities including regular debriefings,

descriptive case studies  Special analysis and mid course adjustments.

Comprehensive evaluation plan: Using a participatory approach, an evaluation team will be formed to

include the evaluator, project staff, USF students, and consultant as needed. The Hillsborough team will

participate fully in the national evaluation of STEPS. The Consortium will participate at various levels of

the evaluation process. The Leadership Team will utilize logic models to document explicit outputs,

outcomes, and impact of STEPS. The evaluation plan is structured to demonstrate and document




                                                                                                              47
                                                                               STEPS to a Healthier Hillsborough


measurable progress toward achieving the stated Health People 2010 project goals, ongoing program

monitoring of interventions, specific outputs, and sustainability.

Community Consortium Evaluation: The evaluation will include: a) annual member surveys to assess the

decision making process and the perceived impact of the project in the community b) a review of board

meeting minutes to assess member involvement. Findings will be shared with the consortium as part of the

quality assurance process. Time Frame: Development of interviews and surveys: Nov 2004-Feb 2005

Evaluation of Collaborations/Partnerships: An annual Leadership Team survey will be conducted to

assess partner participation and their relationship with the lead agency. Time Frame: Survey development:

Dec 2004-March 2005; Implementation: April 2005

Staff Satisfaction: Project staff will be surveyed annually to assess perceptions of program implementation

and processes. It will also assess staff perceptions of the program impact. Time Frame: Survey

development: Dec 2004-March 2005; Implementation: April 2005

Evaluation of Program Administration: The overall implementation of the project will be assessed through

tracking of outcome indicators, quality assurance and improvement activities, and contract

monitoring. Each contractual partner will prepare a report summarizing activities at least quarterly.

Contract monitoring will be accomplished annually according to Grants Management requirements with a

written report maintained in the contract file.

Evaluation Plan: During the first 8 months of STEPS (planning phase), a specific evaluation plan will be

developed by the evaluation team and Consultant. The plan will incorporate baseline performance goals of

each STEP activity listed under this project for physical activity, obesity, nutrition, tobacco, diabetes, and

asthma, to ensure performance goals directly link program activities to the achievement of STEPS

overarching goals.

Data-Based Decision Making: Intervention strategies and the Community Action Plan are based on data

obtained from various sources listed in this document. As more data is collected in Yrs. 2-4, the action plan
                                                                                                                 48
                                                                             STEPS to a Healthier Hillsborough


strategies will be modified to reflect findings. If needed, the budget and subcontractors will be amended

based on the data. Technical assistance, through an evaluation Consultant or contracted services, will be

available to help collect data that drives decision-making. The structure of the STEPS committee will

evolve as data is collected and the action plan strategies modified. CDC may utilize all reports for

purposes of national evaluation.

L. Communications Plan

The Communications Plan for this project is designed to target three groups: 1) coalition and leadership

team members, 2) the community at large and other partners, and 3) other STEPS sites and national

project officer. Communication with coalition and leadership team members will occur during meetings held

at times and places determined to be convenient for most members, especially consumers. The coalition

will meet quarterly and leadership team meeting will be held monthly. A meeting agenda and reminders will

be sent along with minutes of the previous meeting to members prior to each meeting. Between meetings,

conference calls will be organized as needed. Telephone, e-mail, and FAX will be the primary method of

communication between the coalition, leadership team, and project staff although regular mail also will be

used. Quarterly newsletters will summarize project activities and feature special events. A bulletin board

for feedback, input and information sharing will be developed on the project’s website. Coalition training

and development workshops will be held at least twice yearly. Communication with the community -at-large

and other partners will be primarily through the major media campaign described in detail in other sections

of this application. Other methods of communication will include a project website, which will include a

STEPS resource center. This section will host a calendar of events, educational information, and links to

other Internet sites targeting the areas of concern. A new local cable access television show on

Hillsborough County Government’s Cable TV station will promote health events and increase consumer

awareness for quality health care. Hillsborough County’s 24 hour 2-1-1 help line will include STEPS health

resources, sites, and services. Newspapers, Tampa Tribune, minority-based and other local city and
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                                                                             STEPS to a Healthier Hillsborough


neighborhood publications will regularly promote health messages. Brochures and flyers, an important

vehicle for health messages to the public and will be available at multiple businesses, churches and public

service organizations. Mobile health awareness messages such as car magnets and shirts will be worn

by ―Health Ambassadors‖. Leadership Team members will have quarterly meetings with the Pinellas

County Leadership team to coordinate on projects and media activities. Project Coordinator and Leadership

Team members will participate in regional and national meetings, including evaluation meetings to establish

common performance measures, face-to- face, via satellite, or by conference call. Information, including

lessons learned and best practices, will be shared through workshops, publications, email, FAX, Internet

bulletin boards, conference calls, and site visits to and from other STEPS sites. Problem-solving techniques

will include ―Ask a Colleague‖ (Ask a STEPSister City). Project reports will be submitted as required.

M. Letters of Support and MOU

        Key partners providing written support to this project include  4 Mayor’s Offices  local health

agencies/health center networks (in addition to the health department – lead agency) local education

agency  key community health care (voluntary, professional) organizations  business, community and

faith-based leaders. A total of 24 agencies have committed to STEPS through their letters of support

(Appendices 2-4). In addition HCHD already has ongoing signed MOU with the School Board, the

County Government, and St. Joseph Hospital (see Appendix 5). Specific information about each

participant’s specific role, responsibilities and resources is provided in table #8, located under Community

(H) section.

Organization                          #   Organization             #   Organization                   #
Voluntary/Community Org.              4   Mayor’s Offices          2   Schools /Child Care            2
Professional Health Care Org.         4   Academic/Research        2   Community Partnerships         1
Community Business Leaders            2   State Agencies           1   National Organizations         2
Faith-Based Organizations             1   County Government        1
Hospitals and medical facilities      1   Media groups             1



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