12/5/2015

Internship Plan
Final

Laura Rolke
UNC-GREENSBORO
HEA 648 Applied Program Planning

Part 1: Problem Definition and Description

Health Problem Identification
The physical activity and nutrition landscape in a community is crucial for residents to
make positive decisions about their health. Rockingham County Health and Human Services has
the challenge to promote physical activity and healthy eating habits to improve general health
and decrease the rates of obesity and chronic disease. In North Carolina, approximately 36.7% of
adults were overweight and 29.4% were obese in 2013 (Behavioral Risk Factor Surveillance
System [BRFSS], 2014). Unhealthy behaviors and risk factors were estimated to cost North
Carolina approximately $53.8 billion annually in 2010 in avoidable medical expenses, workers
compensation claims, and lost productivity (Be Active North Carolina, 2012). Excess weight
accounted for $5.77 billion of that annual burden, while physical inactivity accounted for $3.67
billion (Be Active North Carolina, 2012).
To maintain a healthy lifestyle, the CDC recommends at least 150 minutes of moderateintensity aerobic activity and two or more days a week of muscle-building activities for adults
(Centers for Disease Control [CDC], 2015). People who are physically active tend to have a
longer life span and have a lower risk for chronic diseases like heart disease, type 2 diabetes, and
some cancers (CDC, 2014). Cancer and heart disease are the leading causes of death in
Rockingham County; in 2014, 263 people died from cancer and 240 died from diseases of the
heart (North Carolina Center for Health Statistics, 2015). People who are inactive are also at a
higher risk for strokes and depression (CDC, 2014). In 2013, only 48.6% of adults in North
Carolina met the physical activity recommendation; 26.6% reported no leisure time physical
activity at all (BRFSS, 2013).
A healthy diet is a combination of what food are available in a community and the

individual ability to manage a balanced diet. The CDCs dietary guidelines for 2010 recommend
balancing caloric intake with physical activity to manage weight, consuming more nutrient rich
foods (like fruits, vegetables, whole grains, and seafood), and consuming fewer foods with
sodium, saturated fats, trans fats, cholesterol, added sugars, and refined grains (CDC, 2015). In
North Carolina, 40.8% of adults consume less than one fruit daily and 21.9% consume less than
one vegetable daily in 2011 (CDC, 2013). As part of the Community Health Action Plan 2013,
Rockingham County is working towards increasing the percentage of residents in the Piedmont
Region who consume the recommended 5 or more fruits and vegetables daily by 5% (21.2% to
26.2%) (Rockingham County Healthy Carolinians Partnership, 2013). Following these dietary
guidelines can help individuals maintain a healthy weight and prevent potential chronic diseases.

Non-health Problem Identification

Access to resources is an important problem that needs to be addressed in Rockingham
County. The built environment around physical activity and nutrition involves a variety of
factors; it includes families, worksites, schools, neighborhoods, policies, access to public
transportation and bike & pedestrian-friendly street designs (Harvard School of Public Health,
2012). This is a combination of social supports and environmental designs that affect how an
individual makes decisions. The role of local community health departments should be to
identify various data sources and analyze and interpret the relevant data. This information can
then be used to make economic and political decisions, as well as collaborate with community
partners and stakeholders. From this point, decisions about resources can be made to affect the
built environment around individuals.

To boost physical activity and nutrition levels, residents in Rockingham County need to
have better knowledge of what resources are available to them. Alterations to streets, parks, and
community design are expensive; while this is a goal to work towards, increasing knowledge of
current resources is a solution for now. The Health and Human Services department has already
identified many resources for physical activity and nutrition that exist within the county, but it is
important to make residents aware of what is available to them.

Agency Relevancy
The mission of Rockingham County Health and Human Services is to protect the health,
safety, and wellbeing of our customers by providing essential health and human services in the
most efficient manner (Rockingham County Health and Human Services, 2015). The issue of
physical inactivity and poor nutrition directly affects rates of obesity and chronic disease rates of
residents in the county. The organization is currently using various programs to make people
aware of health issues and the resources available to them. Rockingham County has a Local
Physical Activity and Nutrition (LPAN) workgroup that is seeking to to improve the health of
our community by encouraging Rockingham County citizens to improve nutrition and become
more physically active (Rockingham County Health and Human Services, 2015). The
workgroup is specifically targeting obesity and tobacco use, but both physical activity and
nutrition need to be addressed to affect obesity.
Some of the current programs and projects in place with the LPAN workgroup to
improve physical inactivity and nutrition in the county are African American Eat Smart Move
More, Faithful Families Eat Smart Move More, Chronic Disease and Diabetes Self-Management
Program, and Eat Smart Move More Weigh Less classes (Rockingham County Health and

Human Services, 2015). They also seek to support local farmers markets and community
screening events (Rockingham County Health and Human Services, 2015). The workgroup is
important to addressing access to physical activity and nutrition resources in the county.

SWOT Analysis
The following SWOT analysis highlights some of the positive and negatives of physical
activity and nutrition promotion for Rockingham County Health and Human Services. Overall,
the agency has consistent funding for health initiatives, but it is limited and grant funding is
needed to supplement. There are a lot of projects going on to reach many populations affected by
a variety of issues; while this is a positive, it means there is a high level of multitasking among
limited staff members. There are also bureaucratic processes for approval and funding that may
slow down progress. The education services department has collected many health promotion
resources for the county to use and this has a lot of potential to reach residents provided they
have interest in and time for improving their health. Also, so far there has been interest in larger
businesses for worksite wellness programs so there is potential for new partnerships with smaller
businesses.

Internal

External

Positive
Strengths
Consistent funding for
programs provided by the
county and taxpayers;
supplemented by grants
Diversity in the projects to
reach many population subsets
Opportunities
Many existing resources for
fresh foods and physical
activity in the county.

Negative
Weaknesses
Limited funding
Limited staff overseeing many
diverse programs to address
issues
Potential for slow moving
processes because of bureaucratic
procedures
Threats
Limited time and interest of
residents

Interest in worksite
promotion programs and
policies; potential for new
partnerships

Potential difficulties to mobilize a

rural community

Ethics
Community health departments have a duty to do what is best for a population and
abiding by social justice. The overall goal is to produce benefits for the community while
preventing health harms. It can be difficult balancing the distribution of health benefits fairly,
respecting individual autonomy, and respecting confidentiality when dealing with critical health
issues. One potential dilemma is identifying resources for people with certain diseases or
conditions because of their privacy. Awareness of the Health Insurance Portability and
Accountability (HIPPA) regulations is crucial for protecting the personal information for people
in the county. Another ethical dilemma is building and maintaining trust with community
members. To address issues, they need to trust that decisions are being made are in their best
interest. Community health organizations do the best they can to develop relationships and steer
residents towards wellness; ideally all the programs currently implemented are serving the
community to the best of their abilities.

Part 2: Problem Analysis

Analysis through SEM
Both physical inactivity and poor nutrition habits are unhealthy behaviors on the
individual level that can lead to poor health and chronic disease. However, policy, community,
and interpersonal relationships all have an affect individual health. In order for Rockingham

County Health and Human Services to address these issues, the problem can be analyzed through
a social ecological framework. In the below diagram, the various levels are color coded so they
can be distinguished.

Physical activity and nutrition habits on the individual level are key to addressing to
change obesity and chronic disease rates at the community level. A study that looked at physical
fitness with Spanish adults found that, self-efficacy and perceived barriers were the most
important individual factors in obtaining physical activity (Serrano-Sanchez, 2012). In order to
participate, individuals need to believe in their ability to accomplish their tasks and be able to
overcome any perceived barriers. Self-efficacy and perceived barriers are linked to all of the
individual and interpersonal factors.
Some individual factors that have a large impact on self-efficacy and perceived barriers
are demographic identifiers (age, gender, race, and ethnicity), health knowledge, and current
health status. Existing conditions can change how people view their current health status and
affect their likelihood of engaging in healthy behaviors. Beyond these, education and income

play a large role in wellness behaviors. Understanding the benefits of physical activity and the
knowledge of opportunities influences physical activity level. Nutrition knowledge and skills can
involve understanding nutritional content of foods (more than just by the number of calories),
being able to read food labels, or cooking skills (Fitzgerald, 2009). Income influences what
resources a person can buy or get access to. Individual factors have the most direct influence on
behaviors.
In this diagram, social support is linked to both self-efficacy and perceived barriers, but
also interacts with most of the individual factors. Social support can be in the form of familyinfluence, friendship, role models, peer pressure, cultural norms, or physician influence (to name
a few). Successful interventions alter programs to suit individual needs, account for fitness
levels, allow for personal control of the activity and its outcomes, and provide for social support
by family, peers and communities (Seefeldt, 2002). Also, adolescents who have a role model,
volunteer, participate in organizations outside of school, or experience high levels of teacher or
other adult support at school are more likely to participate in physical activity and are more
likely to have a healthy weight (Babey, 2015). Interpersonal relationships also impact individual
food and nutrition decisions. The social context in which meals are consumed can affect the
types of foods a person eats and the total caloric intake of a meal (Herman, Roth, & Polivy,
2003). Especially with youth, family habits impact what and how much they eat; it is important
to reach children and parents in successful. This oftentimes plays into time and cost availability
due to employment; having more food options at home and having family meals are associated
with having a healthier diet (Neumark-Sztainer, Wall, Perry, & Story, 2003).
The community level is mostly comprised of available resources and access to these
resources. These can be in the form of general community resources or ones found at institutions

(workplaces, schools, churches, etc). The Guide to Community Preventive Services

recommends increasing walkability of an area to increase physical activity; this can be attained
through community-scale urban design, street-scale urban design, and improving access to places
for physical activity (the Task Force on Community Preventative Science, 2002). Currently,
Rockingham County is focusing on the last recommendation by increasing awareness of active
areas with their Be Healthy mobile app. This also helps with access to healthy foods and
vegetables. The Community Guide strongly recommends using community-wide campaigns
because of their effectiveness to utilize social networks and encourage individual
participation. Interventions in workplaces can use a variety of tactics, including face-to-face
counselling, telephone counselling, counselling and fitness testing, individual and group
counselling, group-based behavioral skills training and gym membership, counselling and mutual
activity sessions, a peer support program and tailored online magazines, and motivational health
promotion classes to encourage wellness (Malik, 2014). Many worksite programs involve action
planning, goal setting, and barrier identification/problem solving (Malik, 2014). Prevention
Partners, a NC non-profit seeks to create healthy built environments through these locations to
encourage people to engage in healthy behaviors. The county is currently working to recruit
businesses to join the WorkHealthy America program.
Community resources and their availability are often influenced by higher level factors
like funding, taxes, urban design, and media/awareness. Typically, health departments strive to
create interventions that utilize informational, behavioral, and social support strategies while
impacting policy and the physical environment (Brownson, 2007). A study of state health
departments found that the most important factor related to physical activity decision making
was the availability of adequate resources, like money, staff, and a supportive state legislature

(Brownson, 2007). Funding is one of the most important parts to creating change because it can
alter who all is working on a project and how the project happens. Taxes can be in place to make
unhealthy behaviors less favorable; an example of this would be a higher tobacco tax or a sugar
tax. Urban design increases availability of resources and helps develop opportunities for active
transportation. Media and awareness can help people be more aware of the issues and what is
currently available. Policy changes will be out of the scope of the internship, but it is important
to recognize how important of a role it has in decision making.
This internship will be looking to address the non-health problem of access to resources.
This will involve identifying information about the current state of resident health and helping to
market information about what resources already exist.

Part 3: Internship Activities Plan

The internship with Rockingham County Health and Human Services encompasses three
main activities with supplementary exposure to some of the other programs in the county. Local
health agencies are expected to cover a wide variety of topics, including chronic disease
prevention, mental health, access to services, health education, etc, with minimal resources and
staff. As part of the internship, I will be working on the Community Health Assessment,
marketing the Be Healthy Rockingham County mobile app, and recruiting local businesses for
Prevention Partners.
Community Health Assessment
Every four years, Rockingham County is required to complete a Community Health
Assessment (CHA) to identify the health needs of the community. Per the standards provided by

the North Carolina Department of Health and Human Services, there are eight phases to
completing a CHA (North Carolina Department of Health and Human Services [NCDHHS],
2015). First, a CHA team must be established (Step 1) (NCDHHS, 2015). For Rockingham
County, this is made up of Katrina White and Beverly Scurry of the Health Education Services
division. Following this, primary (Step 2) and secondary data collection (Step 3) occurs so that
the information can be analyzed and interpreted (Step 4) (NCDHHS, 2015). The analysis helps
with determining what the health priorities in the county will be (Step 5); these are issues that
will later be addressed through a community action plan (NCDHHS, 2015). Once the health
priorities are determined, the CHA document is written to share the assessment results and plans
with community members and stakeholders (Step 6) (NCDHHS, 2015). Sharing the CHA (Step
7) and developing the community action plan (Step 8) complete the assessment process
(NCDHHS, 2015). During the course of the internship, I will be assisting with steps 2-6 (data
collection, data analysis, health priority identification, and section writing).
In North Carolina, there are two types of primary data that are required to be collected in
these assessments- an inventory of health resources and community opinion collected through a
health opinion survey or small group discussions (NCDHHS, 2015). Rockingham County is
completing primary data collection through focus groups with the community. Most of the focus
groups were completed in the fall of 2015, but they have been having difficulty reaching specific
target group participants. I will be helping complete these focus groups in December and January
before the next stage of the CHA can begin. Typically, primary data collection is the most time
consuming portion of the assessment, so it is not uncommon for organizations to spend more
than 3-5 months collecting this data (NCDHHS, 2015).

Secondary data, or data initially collected by a third party, is most commonly in the form
of statistics. North Carolina CHAs are required to contain discussions of population
demographics, socioeconomic factors, environmental factors, health indicators, health care
facilities and provides, parks and recreational facilities, and smoke-free facilities (NCDHHS,
2015). This portion of the data collection will take place once the primary data stage is
complete, likely in January and February. The secondary data collection is guiding by NC CHA
guidebook, which identifies which state statistics databases to use for particular issues.
Once primary and secondary data collection is complete, the next stage is pulling it all
together into a cohesive document. I will be helping to analyze, but also write assigned portions
of the CHA. The data will be analyzed to determine what is important to state and note as a
health priority. The 2012 Rockingham County CHA identified social determinants- education,
access to healthcare, and physical activity & nutrition as their healthy priorities so it will be
interesting to see if these change with the updated data (Rockingham County Health and Human
Services, 2013). It is likely that I will be helping to identify possible health priorities that will be
chosen as the main priorities by community members and stakeholders at a later date.

Be Healthy Rockingham County

In the fall of 2015, the LPAN workgroup had a soft launch for their Be Healthy
Rockingham County app. This mobile application is designed to increase access to wellness
opportunities by providing information about resources. The app has listings for healthy places
like playgrounds, rivers, farmers markets, roadside stands, recreation centers, community
gardens, trails, and walking tracks with turn-by-turn directions to get there. It also has a directory

of healthy recipes and active living tips, as well as listings of upcoming events. The mobile app
is designed to be a complete guide to living a healthy life in Rockingham County. The app is still
very new and one of the biggest steps moving forward is helping to market it so that more
residents and community members are aware of it. Beverly Scurry, who helped create the app, is
planning to meet with the Tourism Department in early December to discuss marketing the app.
As part of the internship, I will assess what the current marketing strategy and research
marketing tactics from other community resource apps. From the research I complete, we will
develop a feasibly marketing strategy and attempt to implement it. However, with the timeline of
the internship, it is unlikely that everything will be implemented by the end of the internship.
Currently, little is known about the effectiveness of a community resource mobile app in
improving individual physical activity and nutrition behaviors. Most literature reviews of mobile
apps look at ones that target individual behaviors (like exercise logging, food diaries, goal
setting, etc) rather than community resource apps. One of the most successful mobile resource
apps is Its Time Texas Choose Healthier app that has engaged the local government,
businesses, schools and other organizations in Austin, Texas to create a comprehensive list of
healthy opportunities (Its Time Texas, 2014). It is possible that similar strategies used to market
this app can be used with the Be Healthy Rockingham County app.
Prevention Partners Program
The third activity of the internship will be helping to recruit businesses to the Prevention
Partners Healthy Together NC Initiative and WorkHealthy America program (Prevention
Partners, 2015). Prevention Partners is a North Carolina nonprofit that seeks to build healthier
communities through intervention materials targeted at schools, workplaces, hospitals, and
clinics to address the leading causes of preventable disease: tobacco use, poor nutrition, physical

inactivity, and obesity (Prevention Partners, 2015). The Healthy Together NC initiative seeks to
recruit 10 of the largest businesses in each North Carolina county in order to reach about 20% of
the overall workforce (Prevention Partners, 2015). The first phase of this partnership involved
recruiting ten large businesses in Rockingham County to participate in the WorkHealthy
America program. The next phase will involve recruiting 40 smaller businesses to participate in
the program. I will be helping to assist the Education Services team as they reach out to these
businesses. It is unknown at this time if there is a particular recruitment goal during my
internship, but it is likely that recruitment will last through the year.
Timeline of Activities
Internship Activities
Pre-Internship Planning
meetings
Help with focus groups (Primary
data collection)
Secondary data collection from
state statistics sources
Data analysis
Identify potential health
priorities
Write assigned sections of the
CHA
Identify current marketing
strategy plans for the app
Research marketing strategies
for mobile resource apps
Develop marketing strategy
Implement marketing strategy
Evaluate marketing strategy
Help with recruitment of 40
smaller businesses to the
program

December

2015
X

January
2016

February

2016

March
2016

April
2016

May
2016

X
X

X
X

X
X*

Community Health Assessment

X
X
X

X
Be Healthy Rockingham County App
X
X
X

X
X

Prevention Partners Recruitment

X
X

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