As a result of a partnership between leaders in public health, out-of-school time, and human services in the city, Philadelphia, Pennsylvania, became the first city to develop and approve Healthy Living Guidelines (HLGs) for Out-of-School Time (OST) Programs. The goal of the guidelines is to create an environment where it easy for youth attending OST programs to develop and practice healthy behaviors and maintain a healthy weight. The key to this initiative’s success is its cross-sector, multidisciplinary, whole-system collaboration. Health Promotion Council (HPC) led The Healthy Kids, Healthy Communities Out-of-School Time Partnership Initiative (HKHC-OST) and applied the socio-ecological framework to assess and influence the Philadelphia OST system, including:
- The capacity of the system to provide nutritious foods and beverages, and time for daily physical activity.
- Environmental settings and policies;
- Systemic influences, such as system-wide policies and guidelines; and
- Social and cultural norms and preferences related to food, nutrition, and physical activity.
As a result of this initiative, 10 Healthy Living Guidelines are now in place for 200 OST programs in Philadelphia.
Body Mass Index (BMI) data from Philadelphia County schools show approximately 29% of youth grades K-6 are overweight or obese. A recent analysis has shown that 80% percent of children who are overweight at ages 10 to 15 are obese at 25 years old. Being overweight and or obese increases the risk of developing degenerative diseases like high blood pressure, diabetes, heart disease and cancer. Sixty percent of youth, ages 5 to 20 have one cardiovascular risk factor, like high blood pressure, and 25 % have two cardiovascular risk factors. A recent report found that the rates of type-2 diabetes and pre-diabetes among adolescents in America have skyrocketed from 9 percent in 2000 to 23 percent in 2008.
Today’s youth are tomorrow adults. If this trend continues, by 2030, it is projected that:
- 65 million more people in the United States will be obese,
- There will be 5.8 to 6 million cases of coronary heart disease or stroke, and
- Six to eight million more cases of diabetes will emerge.
Public health experts understand that parents and caregivers alone cannot bear full responsibility for their child(ren)’s weight. Communities and systems can be assessed to learn whether nutritious foods are available and affordable, and youth have opportunity and access to safe spaces to be physically active.
Out-of-school time programs serve many purposes, including providing a safe environment, social and educational support, and mentoring. Twenty thousand youth attend OST programs during after school hours and all day throughout the summer months in two hundred OST programs funded by the Philadelphia Department of Human Services (DHS), and managed by Public Health Management Corporation (PHMC). According to DHS demographic data , 65% percent of youth are African American, 10% Multiracial, 10% Caucasian, 9% undeclared, and 6 % are Asian; and 74% of the youth live in households at or below the poverty level. Approximately 60% of these programs are in Philadelphia public schools, the remaining are in community, recreational or faith-based centers. As integral parts of the communities they serve, these programs are ideally positioned to support solutions to the childhood obesity epidemic and help youth develop healthier habits.
Using a system-based lens, the HKHC-OST initiative asked “What makes it harder for youth to be healthy during OST, and what practices can be implemented in OST to make it easy to be healthy and maintain a healthy weight?” During a four and a half year period, HPC, an affiliate of PHMC, led a collaborative partnership to assess the health environment in the OST system. This partnership included PHMC, DHS, the Philadelphia Department of Public Health (PDPH), The Food Trust, the Out-of School Time Resource Center (OSTRC), the National Nursing Centers Consortium (NNCC), the University of Pennsylvania, and many OST programs. This collaboration resulted in the development and implementation of HLGs for the OST system.
Many assessments contributed to the development of the HLGs. All OST programs completed an OST Capacity survey measuring the physical capacity of sites for potential change. Reports on the status, policies, and best practices related to nutrition and physical activity in OST were developed. Community assessments gathered OST youth, parents and provider perspectives. , , ,
An OST Leadership Team, consisting of approximately 80 members representing City and nonprofit organizations, public health experts and the OST system, met over a period of six months to review and discuss the reports’ findings and lay the framework for the draft guidelines. The resulting evidence-based guidelines address best practices for nutrition and physical activity. Nine OST sites piloted the guidelines for up to a six-month period. Pilot sites were selected for diversity of place, age of youth, and represented the variety of food sponsors that provide food in the OST setting. The sites received training and technical assistance to assist with implementation of the guidelines.
Following evaluation of the pilot, partners modified the guidelines slightly. PDPH subsequently adopted the HLGs for full implementation in all OST program sites. Three of the guidelines became mandatory in the 2013 fiscal year, and all became mandatory in fiscal year 2014. All OST programs are now required to provide a minimum of 30 minutes of physical activity per three hours of program; ensure drinking water is available; limit screen time; serve foods that follow the United States Dietary Guidelines; encourage healthy eating behaviors; provide safe, equitable opportunities for youth to be active; and use credible materials for nutrition education.
HKHC-OST offered a variety of resources to OST program staff to support implementation of the HLGs, including: professional development and technical assistance for OST program staff, created the Healthy Living Guidelines for OST Toolkit, short student-acted videos, and Geographic Information Systems (GIS) maps with community resources like farmers’ markets and parks for each planning analysis area of Philadelphia.
Distinction in approach
Philadelphia is unique in adopting system-wide guidelines to support the health of youth attending OST programs. The ten HLGs were developed with an understanding of what OST programs can control. Compliance data since implementation show that 95% of sites report complying with the initial three guidelines for water, screen time and sugary drinks. Data about adherence will be gathered after a full year of implementation.
HKHC-OST resulted out of a dialogue between HPC and PHMC about using a system-based approach to improve health outcomes for youth in the OST setting. This initiative utilized collaborative dialogue techniques with public health, education, and social service partners to facilitate health promotion practices in the OST community/organizational setting. All parts of the OST system were included throughout the process. The expertise and contribution of the Leadership Teams were crucial to the development of the HLGs and informing potential challenges during implementation, resulting in few surprises during piloting and implementation. This inclusive and collaborative approach requires significant time and facilitation expertise; as a result it is not often used enough in public health policy planning.
The Philadelphia Department of Parks and Recreation established their own guidelines for their unique system after participation in the HKHC-OST initiative. HKHC-OST also led to a collaborative working group of the Pennsylvania Department of Education certified food sponsors that provide food to OST programs, and increased collaboration between experts in physical activity programming and OST staff. Finally, many OST staff has reported personal behavioral and health changes as a result of involvement in the process and an increased consciousness about the value of a healthy lifestyle.
As the Philadelphia guidelines were being developed, HKHC staff was in communication with the National Institute on Out-of-School Time (NIOST) who was recommending national best practices similar to the Philadelphia Guidelines for OST.
Ten OST Healthy Living Guidelines were developed in a collaborative public health initiative. OST programs following the HLGs will make the OST environment more conducive for youth and staff to develop and maintain healthy behaviors. HKHC-OST is a partner in the DHS-OST system to carry on and support OST sites for HLG implementation.
Other public health policy programs can use a whole system collaborative approach, like the one used in this initiative, to review best practices and system-change options in local or national settings. A commitment to process will result in a richer understanding of a system, inform potential challenges, and foster opportunities for positive change and further collaborations.
HPC thanks the following funders for supporting this initiative: The Robert Wood Johnson Foundation; the Centers for Disease Control and Prevention, Communities Putting Prevention to Work; U.S. Department of Health and Human Services and Get Healthy Philly, an initiative of the Philadelphia Department of Public Health; the Public Health Fund; St. Christopher’s Foundation for Children; the United Way of Greater Philadelphia and Southern New Jersey; and the United States Department of Agriculture Supplemental Nutrition Assistance Program. HPC is extremely appreciative of the in-kind support from the PHMC, DHS, OSTRC, the OST Leadership Team, NNCC, food sponsors, and many OST providers.