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Giles County Health Department

State: TN Type: Promising Practice Year: 2019

Giles County Health Department (GCHD) is one of thirteen health departments within the Tennessee Department of Health's (TDH) South Central Region (SCR). Located in Pulaski, the GCHD provides services annually to approximately 3,200 patients. The health department is open 5 days a week and provides care for residents of Giles County as well as surrounding counties as needed. GCHD provides a wide variety of patient and community services including, WIC, family planning, treatment of sexually transmitted diseases and health education. Residents of Giles County have a median household income of less than $40,000 per year. The income growth rate of the county is much lower than the state average. In regard to educational attainment for the county, roughly 43.8% of residents graduate high school with only around 9% obtaining a Bachelor's degree.

According to the Centers for Disease Control and Prevention (CDC), childhood development is an important determinant of health over the life of an individual. A child's academic success, health, and general well-being are directly impacted by early developmental opportunities. Preschool-aged children experience significant biological brain development and achieve ninety percent of their adult brain volume by age six. This physiological growth allows children to develop functional skills related to information processing, comprehension, language and motor skills. In keeping with the goals of the school system, Readiness Initiative for Success in Education (RISE) is geared toward specific learning targets that coincide with the Department of Education standards. Such standards include reading foundational skills, fine motor skills and counting and cardinality. The program activities correlate with the Ages and Stages questionnaire used by the Tennessee Department of Health's HUGS program. To grow and thrive, young children need strong families, good health, and positive early learning opportunities. Parent involvement is a critical component of the RISE program and supports healthy development for children. By actively involving parents in learning opportunities with their children the parents are empowered to use the skills they learn and practice them in the home setting. One of the most important things a parent can do is spend time with their child and let the child know they are loved, has a purpose in life, and identify trusted adults to go to if bad things happen. According to the CDC's information on ACEs, resiliency happens when the child has these ‘protective factors' as a shield to protect them from Adverse Childhood Experiences or ACEs. These protective factors for ACEs include parents who are strong, loving, supportive, and resilient and parents who read, rhyme, sing and talk to their children.

RISE focuses on school readiness for children ages three to five years old, in Giles County. RISE helps the parent know what school readiness skills are and how to teach them to their child. The program builds positive parent/child and peer relationships, confidence, school readiness skills, preparation for school structure, transition skills and social, emotional, and developmental skills. Tennessee's school readiness model emphasizes that the state's children will be ready to succeed in school only when families, communities, and schools work together on their behalf throughout the early childhood years. RISE engages families as partners in their child's development and education. Parent partnerships and involvement builds long-lasting collaboration among schools, families, and communities and promotes resilience.

In 2012, Tennessee Health Commissioner John Dreyzehner, MD, MPH, established Primary Prevention Initiatives (PPI) with the goal of implementing interventions before there is evidence of a disease or injury. As part of this initiative, health departments across Tennessee were charged with collaborating with community agencies to develop outreach activities surrounding primary prevention. In 2013, the Giles County Health Department was selected to serve as a beta county in the Commissioner's statewide initiative aimed at improving health outcomes. Following the development and implementation of various other local primary prevention programs, members of the health department staff began looking for new project ideas to begin in the new year. A proposal was developed by members of the health department staff along with input from representatives from the school. To mirror many of the same activities delivered through the health department's HUGS program, the staff made the decision to move forward with more planning and move to a more definite plan to begin the program. While the Giles County Health Department does not currently have a website, the Tennessee Department of Health's website is www.tn.gov.

RISE is the only preschool program of its kind in this community. Head start is not available in every community and there are only a few pre-K slots available in those that have it and it is based on income guidelines. RISE is not based on income guidelines so any family can participate. Tennessee's School Readiness Model emphasizes that the state's children will be ready to succeed in school only when families, communities, and schools work together on their behalf throughout the early childhood years. The model provides indicators of what ready children” know and are able to do across the birth-to-5 age span, but does not detail or overemphasize them. For readiness” is not seen solely as a condition of a child, but is a condition that exists when communities, schools, and families collectively create a nurturing environment for child development starting at birth. A ready community is one that holds high expectations for the organizations that provide services to protect young children's health and well-being, such as early childhood service agencies, social services agencies, health and mental health care services providers and other children's and family services agencies.

RISE fills a gap for pre-K children and families who are not in a formalized early learning program. RISE sets them up for school success, providing a PPI component related to well-being. Results show a positive impact on families. This program does provide an innovative approach to address early learning as a social determinant of health. It also fills a gap for those children and families who may not be able to access other early learning opportunities. The program also engages parents in addition to the children.

Ideally, the target population for the project was children ages three to five years old that had not previously attended a head start program. According to the 2017 United States Census Bureau, only 5.7% of the total population of Giles County falls into the under five years of age group. Given the rural nature of the communities, each school has an estimated twenty Pre-k slots available. While the community populations are small, there's still a gap that needs to be filled within this age group. While there have been various programs to address school readiness for youth older than three to five years, RISE is the first of its kind to specifically target three-to-five-year-olds. The initiative is innovative in that it seeks to address a gap in rural communities where head start programs are unavailable. Additionally, it partners with local institutions such as the school and school board to support community buy-in and resource sharing. A ready community supports such organizations by working to assure them resources that strengthen their capacity to serve children's and families' changing needs. Ready communities, including businesses, faith-based organizations, early childhood service providers, community groups and local governments, work together to support children's school and long-term success by providing families with affordable access to information, services, high-quality child care, and early learning opportunities.

In striving to be a ready community, health department staff involved in the Help Us Grow Successfully (HUGS) program sought the opportunity to partner with the school system to deliver the RISE program. The Help Us Grow Successfully program is a targeted case management program that provides home-based intervention services to pregnant/postpartum women, children birth through the age of five (5) years and their primary caregivers. Care coordinators form a unique and voluntary relationship with a family. Care coordinators screen for and identify potential problems, provide education, and connect families with resources in their communities. The HUGS program seeks to prevent or reduce risks as well as promote health and wellness. Improving child development and maintaining or improving family strengths are a few goals of the program. According to the Environmental Scan of School Readiness for Health, health and learning are intertwined and in order to grow and learn very young children need a healthy beginning. The early years are a time of rapid growth and development and can be a time for establishing a healthy base for learning. Nutrition, physical activity, mental ability, and amount of stress, all interact to affect learning. Understanding the intertwined health, social development and learning requirements of young children can guide parents, practitioners, and policy-makers in planning for early childhood. Nurturing relationships, good nutrition, exercise, and rich environments enhances early brain growth and development. Learning language depends on conversations and interactions with a variety of people. Children are nested within families and families within communities. Information concerning young children's health, well-being and their active growth and learning benefits families and communities.

The RISE program impacts outcomes for individual youth and increases the health and well-being of the participants. As referenced in The Guide to Community Preventive Services related to early childhood development, these programs are designed to promote social competence and school readiness among children three to five years old. Early intervention programs, such as RISE influence readiness to learn in the school setting. School readiness, particularly among poor children, may help prevent the cascade of consequences of early academic failure and school behavioral problems. The referenced Perry Preschool program demonstrated a correlation between participation in early childhood development programs and improved educational and economic outcomes. As a result of the systematic review, early childhood development programs are recommended on the basis of strong evidence that they improve intermediate cognitive and social outcomes. All participants in the Giles County RISE program demonstrated an increase in knowledge which supports the need for creating and offering quality early childhood development programs in rural areas of the county where limited resources are available. In 2014, the Robert Wood Johnson Foundation Commission to Build a Healthier America recommended making investing in America's youngest children a high priority. Their recommendation was to create stronger quality standards for early childhood development programs and guarantee access by funding enrollment for all low income children under age five in programs meeting these standards by 2025. The Commission noted that only a small fraction of low income children are in high-quality programs. They aren't always available, and when they are, either space is limited or parents are unable to afford them.

Program goals continue to remain the same even in the third year of offering the program.   

By the end of the school year, members of the RISE team will deliver at least two ninety-minute educational sessions per month for participating youth and parents. Participation assists in creating relationships and experiences with caring adults and offers opportunities for everyday challenges such as learning to get along with others, sharing and being in new environments.

By the end of the school year, a minimum of 45% of the program participants will demonstrate increased knowledge of key school readiness skills as measured by comparing outcomes on the pre-post content assessments. The more knowledge and skills a child has upon entering school, the more prepared they will be for kindergarten. RISE also allows for increased opportunities for social interaction.

By the end of the school year, books will be provided at each session in order to increase parent opportunities to read to their child. Reading together provides parents a chance to bond with their child.

By the end of the school year, enroll a minimum of ten students in the RISE program in Giles County. The local Pre-K program is limited and can only accept twenty students each year. With no local head start program serving several of the local schools, RISE provides an opportunity for these children who otherwise would not be given the chance to participate. By attending a program within the walls of the school they will eventually attend, children are able to become more familiar with the facility and school personnel.

By the end of the school year, provide a minimum of five read-a-loud activities for children and their parents. A copy of each book read during the RISE session is given to each family. This allows parents to read at home and reinforce the story from the session. Planning meetings were arranged between members of the staff and the school system.

During the first two years of the program, the HUGS social counselor, health educator, and county director were involved in the initial discussions about the RISE program startup. The health educator presented the plans for the program to the local health council, which routinely serves as an oversight committee for related projects. Members of the health council have varying degrees of expertise including early childhood and education. Serving as an oversight committee for nearly twenty years, this group of stakeholders has a wealth of experience when it comes to providing support for such a project. Information about the program was made available at the local schools and details were also shared through the use of informational flyers designed by members of the planning group. Children ages three to five years who were not able to participate in a head start program or the Pre-k program were the primary group targeted to participate in the program. Initially, project planning for the RISE initiative began in November 2016, as a result of an effort to expand an existing community partnership with the local school system. Members of the early literacy PPI team at the health department were instrumental in taking the initial steps leading to the creation of a plan with Minor Hill School to deliver the program.

The first year of offering the program, meetings were arranged between health department staff and representatives from the school during the months of December 2016 and January 2017. In February 2017, the first session of the program was held at Minor Hill School. Two ninety-minute sessions were offered each month thereafter through the month of May.

The program was offered again in 2017-2018 at the Minor Hill School and followed a very similar time frame for delivery.  

During the month of September, participants began the program and will once again conclude with post-testing during the month of May. At the last session, school personnel took participants and their parents on a tour of the school. During the tour, parents have the opportunity to meet school personnel and become familiar with school administration. Teachers discuss what a typical day is like and briefly cover classroom expectations for children and their parents. The Giles County Health Department has a long history of partnering with Giles County Schools. Representatives from the school system have consistently promoted health department activities and programs. In particular, Minor Hill School has been involved with various health department initiatives. Since May 2012, the school system has been a recipient of Project Diabetes funding from the Tennessee Department of Health. School personnel, including the Coordinated School Health Director, provided oversight on the standards and appropriate activities for the target age group and served as a key partner in planning the RISE program. School representatives took a hands-on approach by actively recruiting youth to participate in the program. A program flyer was created to share with other local agencies serving youth. A contact with the school system's central office served as a liaison with the school board and during the month of February, a school board member attended a RISE session in order to learn more about the program. Also a vital partner in helping deliver health-related programs in the community, the Giles County Public Library was instrumental in the success of RISE. As part of their service to the public, the library provided information for parents about gaining access to the online library. The local library has provided guidance in regard to appropriate reading materials for the RISE students.

This project has received attention from local leaders and continues to gain interest from other agencies outside of Giles County. Minor Hill School was contacted by the State of Tennessee Department of Education, about possibly sharing information about the project with statewide leadership. In December 2017, the RISE Initiative was named a statewide Gold Standard Bright Spot project by Commissioner John Dreyzehner for being innovative, successful and replicable. Highlighted as a best practice within primary prevention, the RISE initiative was selected following an application process and panel review. Various projects across the state of Tennessee were considered for this honor with only a select few being chosen.

The Giles County Health Council has been a key partner in many health department initiatives. Various members of the council were involved in the program startup and program planning.  Several members of the health council have served as volunteer facilitators.  As far as resources, program supplies were purchased through the local Giles County Health Department budget earmarked for primary prevention initiative programs. For this project, PPI funds were utilized to purchase supplies such as crayons, scissors, pencils, and glue. These items were distributed to students in backpacks designed specifically for the program. Minor Hill School has been instrumental in the success of the program by providing a space to deliver the sessions in addition to other supplies such as paper, pencils, and books. Through a successful and continued partnership between the health department and the local school board, participating schools in Giles County have access to resources such as books and other supplies that can be used with the program.

RISE provides a service that fulfills a need in rural communities where resources are limited. The RISE program is currently serving youth for the third year in Giles County. For communities in which head start programs are not available, RISE meets the needs of these children by filling the educational gap. Most services that pertain to development end at age three. Likewise, schools typically only offer a limited number of pre-k slots that are primarily based on income guidelines. Because RISE is not based on income guidelines, the program is able to meet the need for children who otherwise would not be eligible.

At this time, RISE is the only program of its kind serving youth in this age group in the Giles County community. Knowing they can have a positive influence on their child's development, members of the RISE team intentionally involve parents at each of the learning sessions. Parents remain alongside their children and staff purposefully involves them in activities. Developing parental commitment to help their children learn is also a program goal. Through this community of parents who share in the responsibility of helping their children learn, youth benefit from the increased interaction during the program.

Results for the first two years include the following: 

YEAR ONE OUTCOMES: 

  • Student Assessment - The average pre-score for all participants were 61.4%. At the conclusion of the program, these tests were repeated with an average score of 73.7%. The results demonstrated an average of 12.3% increase in scores with 100% of participants demonstrating some level of improvement.
  • Parent Survey - According to a parent satisfaction survey, 87.5% of parents agreed that the program assisted in teaching them how to better prepare their child for school. Likewise, 100% of those surveyed indicated parents found participation beneficial for themselves, as well as their child. Parents were asked if they would recommend the program to other parents with 100% agreeing that they would.

YEAR TWO OUTCOMES: 

  • Student Assessment - The average pre-score for all participants was 36.8%. At the conclusion of the program, this test was repeated with an average score of 60.2%. The results demonstrate a 23.4% increase in score with 100% of participants demonstrating some level of improvement.
  • Parent Survey - According to a parent satisfaction survey, 100% of parents agreed that the program assisted in teaching them how to better prepare their child for school. Likewise, 100% of those surveyed indicated parents found participation beneficial for themselves, as well as their child. Parents were asked if they would recommend the program to other parents with 100% agreeing that they would.

YEAR THREE OUTCOMES:

  • Student Assessment- The average pre-score for all participants was 32.7%. The program is on-going this school year and results are yet to be determined.

Parental support for the RISE program has been strong each year. When asked what they liked most about the program, one parent commented, "Each part played an important role in what he has learned. It was all beneficial." Another stated, Allowing the child in the school to see what it's like, teaching upper and lower case letters, numbers, and shapes and working one on one with each child is a crucial part in learning." Pre-test survey data was collected from participants upon beginning the program. Recognition of basic items such as name, colors, and shapes as part of the data collected. Members of the school system team and health department staff were responsible for giving and collecting the survey instruments.

Health department staff tallied all pre-test surveys and maintained a written listing of each child's name and basic information. Following the sessions, health department staff delivered post-test surveys to all children and analyzed results. A comparison was made and results calculated to determine if there were changes during the program. At the beginning of the program, all children were asked to take a pre-test which measures academic, cognitive, physical, and language development.

These results demonstrate that the program is effective and supports data previously discussed relating to school readiness and overall health outcomes. The RISE program pre-post test results correlate with Brigance testing results used in Giles County for children entering kindergarten. Brigance testing provides a screening of skills that are critical predictors of school success, including physical development, language, academic/cognitive, self-help, and social-emotional skills. The RISE pre-post assessments indicated the child's ability to recognize their name, count to ten, recite the alphabet, and identification of letters, basic colors, shapes, as well as proper use of scissors.

Another measure of success would be the availability of a program like RISE for children that otherwise would not be exposed to the activities of the program at such an early age. Children in this area are several miles from the county seat of Pulaski. While Pulaski offers various opportunities for children, the availability of such resources in most communities is limited. The RISE program has met the educational and social needs of the participating children and their parents.

The RISE initiative has continued to be heavily dependent on the input and ability of local partners to put forth not only time but resources and facilities for the project. Consequently, the success of the initiative was contingent on the commitment of community partners and was not viable without their support. Latching on to existing partnerships has led to increased success for RISE. The local health department formerly served as the primary driver of this program in conjunction with the schools. Initially, while the schools might have been able to adopt the program, it was doubtful that would happen due to the lack of time and resources needed to deliver the program. With staff time designated toward the implementation of primary prevention activities, there were increased opportunities for local health departments to replicate the RISE program. Strong community partnerships are a must to successfully implement this program.

During the third and current year of the program, the local school system has initiated the implementation of the RISE program at not one but two new schools in Giles County. School board personnel are more heavily involved in the planning process during the current school year. They have recruited and trained school personnel and volunteers to deliver the program to students. Health department staff is now serving as a resource for the local school system when it comes to the RISE program. Year three for the RISE program has been a turning point in how the program is being implemented. The primary role of health department staff is helping gather and interpret program data for the school. In the past, their involvement was critical whereas, now, their function is to assist. Staff was involved with community partners in the development of outreach activities, therefore, providing a means for replication. County health departments with strong community ties are typically always at the greatest advantage when it comes to the delivery of a successful program. Partnerships with agencies such as school systems and libraries are vital components.

With the assistance of volunteers such as local health council members, a community might also initiate a successful program. Most, if not all, local health councils are composed of the most influential, active and vested members of any particular county. Since the inception of health councils, these groups are accustomed to lending support and assistance to a variety of projects. Many times, these projects are geared toward improving health outcomes for youth. With over twenty years of experience in carrying out health-related activities, health councils are likely an important partner. Retired teachers might also serve as volunteers. If targeting families in the more rural areas of a county, lack of transportation could be a barrier when it comes to participation.

Counties should likely explore any transportation barriers prior to participation and discuss with school personnel in the early planning stages. Adequate space to hold this type of program could be limited at some schools depending on current enrollment and the school schedule. Leaders with the Minor Hill project developed a plan to utilize the cafeteria area following the conclusion of lunches. The option of organizing various learning stations was possible in the cafeteria due to the arrangement of tables and general layout of the room made Minor Hill School an ideal location.

Sustainability in a community choosing to offer the RISE program is dependent on the willingness and ability of local partners to put forth time and resources. Health departments bring tremendous assets to the table, however; the ultimate success of any local project is dependent on the level of commitment and participation by partners outside of the health department. Partnerships are effective in rural communities for sharing scarce human and capital resources. Increasing involvement among community agencies would be beneficial and provide additional adults to assist in program delivery. This might also increase the availability of local resources which could be used to help with the program.

According to the Office of Disease Prevention and Health Promotion, in cases where community health promotion activities are initiated by a health department or organization, organizers have a responsibility to engage the community. Realizing the vision of healthy people in healthy communities is possible only if the community, in its full cultural, social, and economic diversity, is an authentic partner in changing the conditions for health.

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