TeamWork: Leadership for Healthy States

CASE STUDY

OKLAHOMA
2015-2016

Team Members:

Dr. Terry L. Cline*

Chris Benge
Julie Cox-Kain
Joseph Fairbanks
Senator A.J. Griffin
Donald D. Maisch
Carol McFarland
Stephanie Uren
* Team Leader

For additional information, contact:

Dr. Terry L. Cline
Secretary of Health and Human Services and Commissioner of Health
Oklahoma State Department of Health
Phone: 405-271-4200 | Email: TerryC@health.ok.gov

The TeamWork: Leadership for Healthy States programpreviously known as the Excellence in State Public
Health Law Programstrengthens relationships within and across branches of government, builds
understanding of population health issues, and opens channels of communication and problem-solving that can
be used to address future population health challenges.
The Health in All Policies Vision

The Health in All Policies (HiAP) vision of the Oklahoma Team was to begin development of a
framework and tools to involve other agencies and cabinets in considering health impacts when
making policy decisions. The five key-elements of HiAP are: promoting health and equity,
supporting intersectoral collaboration, creating co-benefits for multiple partners, engaging
stakeholders, and creating structural or process change.

The strategies for achieving this vision included beginning with a Health Impact Assessment
(HIA) as a specific tool to provide recommendations on non-health policies, using the results of
the HIA to stress the importance of non-health policies on health outcomes, and selecting a
project that complements gubernatorial priorities. Specifically, the team chose a project that
includes the three priorities of the Governors second term (health, wealth, and justice) and
provided opportunities for collaborative work products with Oklahoma Works, an initiative
focused on quality jobs and education. The team also wanted to ensure the project could be used
to help launch Health 360, the Governors HiAP initiative, and be easily integrated into the
Oklahoma Health Improvement Plan (OHIP) 2020 and the Oklahoma State Department of
Healths strategic plan.

The Oklahoma team chose to demonstrate the importance of a Health Impact Assessment (HIA)
on the effects of early academic achievement on long-term outcomes of teenage pregnancy and
high school completion, simultaneously providing a model to engage other sectors in an HiAP
framework. Team discussions leading to the development of the HiAP vision helped the team
members to understand how health impacts can and should be assessed by other areas of
government, and that health considerations must be integrated into other sectors in order to
achieve significant improvements in health. Obstacles included identifying and scoping a quality
project, overcoming capacity and training issues on HIA, and the increasing strain of a deepening
budget crisis that continues to dominate the Oklahoma political landscape. The value of this
project is it is focused on integration of priorities rather than creating a stand-alone (and additive)
process. Continued conversation and evolution of ideas allowed this project to merge into a
single HIA that incorporated both an inter-sectoral state workforce initiative as well as
innovative approaches being implemented to improve early academic achievement in the
Choctaw Nation.

Over the course of the project, no lobbying took place with Robert Wood Johnson Foundation
funds.

Project Summary

The Oklahoma team chose to conduct an HIA of programs aimed at early academic achievement.
This project was chosen based on evidence available indicating that early academic failure is
associated with multiple downstream risk factors. Among associated risk behaviors, the team
chose to focus on school drop-out rates and teen pregnancy as they are relatively easy to measure
and evaluate. For this project, mandated third grade reading assessments are used as the measure
of early academic achievement. The following figure depicts the framework used for conducting
the HIA:
The key HIA team finding is that quality K-3 summer learning programs that include a focus on
reading have a significant positive impact on early academic achievement, and therefore a
potentially long-term positive impact on teen pregnancy and high school completion. The
specific program being evaluated by the HIA was summer school programs focused on reading
achievement. The Choctaw Nations Partnership of Summer School Education (POSSE)
program was chosen as a model for review because of its basis in the evidence and early
evaluation on the programs success at impacting academic achievement. Further, the Choctaw
Nation is implementing the program as a fully integrated model accepting any child at or behind
their academic level within the boundaries of the Choctaw Nation. The Choctaw Nation was
awarded Promise Zone status during the past administration, and is located in the area of the
state that suffers from high rates of poverty and health burdens.

The Oklahoma Team outlined short-term, intermediate, and long-term goals to support a Health
in All Policies vision in Oklahoma:
Short-Term: Conduct a Health Impact Assessment on Implementing Summer Learning Programs
Use Choctaw Nations POSSE summer school as model program
Develop guidance or recommendations between the Oklahoma State Department of
Health and the Oklahoma State Department of Education based on evidence gathered
through the HIA to guide school district decision making
Disseminate HIA findings and recommendations via Key Economic Networks (KENs);
Oklahoma Turning Point Coalitions (regional health improvement coalitions) will
communicate HIA findings to influence local school districts decision making regarding
summer learning program implementation
Intermediate: Integrate Health Impact Assessment within local Turning Point Coalitions
Bring in HIA experts to train Turning Point Coalition staff on conducting HIAs
Turning Point Coalitions will integrate HIAs into their decision making process for
programs and policies. This will be required through individual performance appraisals
and supported through an agency-developed HIA Community of Practice (CoP)
Regional Partnership Consultants will utilize KENs and local Turning Point Coalitions
for ongoing development and implementation of HIA and dissemination of findings

Long-Term: Integrate Health Impact Assessment as a Tool within a Health in All Policies
Framework
Institutionalize HiAP and HIA as a framework to integrate health across the Governors
three key initiatives:
o Wealth Generation
o Health Improvement
o Justice Reform
Conduct HIA on strategies identified to achieve key outcome goals in Oklahoma Works
and Justice Reform plan
Institutionalize HiAP as the framework for the Governors Health Delivery model
utilizing an intersectoral approach

Progress to date, Short-Term update at cohort end: The team completed the HIA in the fall of
2016 and continued to disseminate findings and information about the partnerships gained
through the process by presenting to various audiences, including Oklahomas American Indian
Data Community of Practice.
Progress to date, Intermediate update: HIA training was conducted for approximately 40
Turning Point Coalition staff, other Oklahoma State Department of Health personnel, and
individuals from other agencies, including the Oklahoma State Department of Education, the
Oklahoma Department of Mental Health and Substance Abuse Services, the Oklahoma City
Planning Department, the Oklahoma Department of Transportation, and Choctaw Nation health
staff.
Turning Point Coalition staff have begun developing rapid HIAs within their local communities.
The Oklahoma State Department of Health is also developing an infrastructure to prioritize,
standardize, and disseminate HIAs completed at the agency.
Progress to date, Long-Term update: Executive leadership from the Oklahoma Department of
Human Services, the Oklahoma Health Care Authority, the Oklahoma Department of Mental
Health and Substance Abuse Services, and the Oklahoma State Department of Health attended an
initial Health 360 planning meeting in mid-June 2016 to discuss the HiAP framework and decide
on initial priorities. Health 360 officially launched in December 2016 with a larger, inter-sectoral
group. The first meeting was an opportunity to discuss the initial health priority of obesity and
next steps for gathering data from state agencies. The work of the initiative is currently focused
on developing a statewide inventory of publicly funded obesity-related programs and developing
an assessment tool using a compendium of evidence based practices. The purpose of the
inventory and assessment tool is to help evaluate the best investment of state dollars across
sectors to prevent and reduce obesity in our state and measure population impact. The cross
sector workgroups will continue and make decisions regarding policy and programming that has
the best potential to reduce obesity statewide.

Cross-Sector Collaboration

Team members were selected primarily based on ability to form new partnerships and deliver
improved outcomes. However, over time team members have also collaborated around shared
values, innovation, and cost savings as joint education, health, and workforce efforts were
identified and discussed. The identification of cross-agency initiatives has emphasized and
supported the view of health as a shared goal, with the continued need for discussions about
health outcomes that involve multiple sectors and cabinets. Data sharing between the agencies
was identified as a barrier at the midterm TeamWork meeting. The inclusion of the Oklahoma
State Department of Education on the team has also led to a request for a data sharing agreement
with the Oklahoma State Department of Health. The data sharing agreement is being established
and will include seven Health and Human Service Agencies, the Department of Corrections and
the Oklahoma Department of Education.

The Benefits of TeamWork

Among the benefits of TeamWork for the success of Team Oklahoma:
Active learning philosophy
Team project time
Diversity of members and their perspectives
Technical assistance on HIAs
Convening stakeholders
Relationship building, across multiple sectors within government and with local
school superintendents and tribal governments
HIA training for staff and other partners, providing them with basic understanding in
order to influence policy decisions at a local level and conduct assessments using
HIA
In the midst of a state budget crisis, reinforcement of the importance of integrating
public health efforts through multiple sectors of government

For a summary of Oklahomas HIA, see the following page.

 Exploring the Connection Between Reading Achievement and Health:
Health Impact Assessment on K-3 Summer Learning Programs

Overview
An inter-agency team has developed a Health Impact Assessment (HIA) that examines the potential impact of early
academic achievement in reading (supported through summer learning programs) on long-term outcomes related
to teenage pregnancy and high school completion. The HIA focuses on a life course approach to health, with the
underlying assumption that when children experience academic success early in life, it reduces the risk of negative
health behaviors and results in more positive outcomes in adolescence and adulthood.

Choctaw Nation POSSE Program

In Oklahoma, a comprehensive summer learning program is currently operating in the southeastern part of the
state. An initiative of the Choctaw Nation, the Partnership of Summer School Education (POSSE) program operates
in 10 counties for children in kindergarten through 3rd grade who are below or slightly above average for their
grade level on their mid-year reading assessment. The program serves a high proportion of American Indian and
Hispanic students, as well as students who participate in the free or reduced lunch program. The Choctaw Nation
POSSE program involves 1,700 students at 14 locations, with plans for expansion.
The program collects a number of educational
performance data before and after a childs STAR Reading Results, Grades 1-3, Summer 2015
participation in the program. Initial data
show positive outcomes related to reading.
The figure at right shows results for children
in grades 1-3 who participated in the 2015
program. It indicates that the children, as a
group, showed improvement after the
program in their STAR reading scores. The
majority of students also exceeded the
expected progress standard for both the
STAR Reading and STAR Math assessments.
Additionally, over 90% of students showed
gains in sight word and letter recognition
assessments.
Given its early success and foundation in
research, as well as reading-focused
elements, the HIA utilizes the Choctaw
Nation POSSE program as a model program
on which Oklahoma can build.
Source: Choctaw Nation Partnership of Summer School Education Program
Findings
Using both evidence in the literature and the Choctaw Nation POSSE program data, the HIA team finds that
quality K-3 summer learning programs have a significant positive impact on reading achievement and a
potentially long-term positive impact on teenage pregnancy and high school completion.
While there are limitations to the data and evidence gathered, the following can be said with confidence:
Quality summer learning programs have a short-term positive effect on reading achievement for
academically at-risk children.1
Children, as a group, who participated in the 2015 Choctaw Nation POSSE program improved
performance in reading and math assessments after completing the program. The majority of students
also exceeded the expected progress standard for both the STAR Reading and STAR Math assessments.2
There is some evidence of a relationship between low literacy and teenage pregnancy.3
Though inconclusive, several studies indicate favorable effects of summer learning programs on high
school completion and participation in post-secondary education.1
The HIA impact analysis is provided below.

Impact Analysis: K-3 Summer Learning Programs

Initial Academic Direction and Likelihood Distribution Quality of Evidence
Outcome Extent of Effect
Reading Likely Low-income
achievement students and Many studies that
Significant
academically at-risk support a direct
impact on a high
students are relationship;
proportion of
impacted more1 supporting local data
participants
Potential Long- Direction and Likelihood Distribution Quality of Evidence
Term Health Extent of Effect
Outcomes
Teen pregnancy Possible Hispanic and African
American adolescent At least one study that
Small impact on a
women are strongly supports an
high proportion
impacted more3 indirect relationship
of participants
High school Possible Hispanic and African
completion American children, More than one study
Small impact on a
as well as low- that supports a direct
high proportion
income children, relationship but results
of participants
may be impacted are inconclusive
more4

1. Knopf, J.A., et al. (2015). Out-of-school-time academic programs to improve school achievement: A Community Guide health
equity systematic review. Journal of Public Health Management Practice, 21(6), pp. 594-608
2. Choctaw Nation Partnership of Summer School Education program. (2016). Program data.
3. Bennett, I.M., Frasso, R., Bellamy, S., Wortham, S. & Gross, K. (2013). Pre-teen literacy and subsequent teenage childbearing in a
US population. Contraception 87(4): pp. 459-464.
4. Hernandez, D.J. (2012). Double Jeopardy: How Third-Grade Reading Skills and Poverty Influence High School Graduation. Research
brief. Baltimore, MD: The Annie E. Casey Foundation.
Recommendations
Invest in early education summer learning programs.
Evidence supports the idea that early interventions, since they put students on a trajectory to experience
success and become more engaged in school, are not only effective but contribute to long-term outcomes for
school completion. Furthermore, evidence shows that reading-focused programs are effective only for
students in grades K-3 1 which could be due to the fact that third grade is the crucial point at which reading
must be mastered.

Make reading instruction the first priority for summer learning programs.
However a program is implemented, it should include a reading focus as a first
priority for early childhood. Reading-focused programs were more effective than
general or minimal academic programs at improving reading achievement.1

Focus on children who are at risk for academic failure.

Summer learning programs are shown to be effective for children who are
academically at-risk,1 and focusing on at-risk children may decrease the need for
more intensive interventions later.

If you must choose, invest in summer learning programs over after-school programs.
Summer learning programs have been shown to be more effective at improving reading achievement.1
Summer learning programs may also be especially beneficial to students in low-income households, as they
may have fewer academic resources available to them.

Keep class sizes small. An extensive body of evidence

Supported by the research and implemented in the Choctaw links educational achievement
Nation POSSE program, small class sizes increase programs
and attainment to lifelong health
effectiveness.5
outcomes through 3 interrelated
Identify other strategies to support reading achievement at pathways: (1) development of
an early age. psychological and interpersonal
Summer learning programs are one strategy to support strength, such as a sense of
reading achievement, but there are others ways that control and social support,
communities and programs can support these efforts. There which, in turn, contribute to
may be some strategies that are simple and relatively healthy social interactions; (2)
inexpensive (e.g., providing books in clinics), and may problem-solving abilities and the
enhance and complement larger efforts. ability to pursue and maintain
productive work and adequate
Engage parents.
Summer learning programs, while valuable, are one part of a income, and the health benefits
childs environment. Engaging parents about ways to they provide; and (3) adoption of
promote reading skills outside of the classroom during the healthy behaviors.1
summer can help the child be more successful.

Build partnerships with entities that can support summer learning programs in your community.
The Choctaw Nation POSSE program has expanded rapidly over just a few years. This initiative partners with
school districts, several colleges and universities, and other public entities to build and maintain the program.
Building partnerships can increase community buy-in, make the program more sustainable, and reduce the
burden of resources on schools.

5. Cooper, H., Charlton, K., Valentine, J.C., Muhlenbruck, L. & Borman, G.D. (2000). Making the most of summer school: A meta-
analytic and narrative review. Monographs of the Society for Research in Child Development, 65(1), pp. i-vi+1-127
Implementation Strategies

In consultation with a variety of stakeholders, the HIA team developed the following strategies:

Public Health Professionals

Communicate regularly that reading and health are connected
Partner with local schools to learn about and support efforts to
improve reading achievement for young children
Leverage opportunities the currently exist to engage young
children and their parents about literacy (e.g., home visitation
programs, clinic visits)
Educate yourself about local and statewide literacy and learning
initiatives

School Personnel
Assess the best investment for helping children get on track for reading by the third grade
Engage your community to see what existing efforts (e.g., library programs) could be leveraged to
support reading achievement for young children
Engage higher education, tribes, businesses, and other partners who may support the infrastructure
necessary to implement a summer learning program
Engage parents to better understand what needs young children have to increase reading
achievement at school and at home
Ensure that school administrators are included in the planning and development of programs
Be aware of possible stigma associated with summer school programs

Parents
Ask staff at your childs school about summer learning and reading programs
Advocate for programs that are designed to meet your needs and the needs of other parents (e.g.,
length and timing of instruction, transportation)
Talk to your childs teacher(s) about ways to promote reading skills at home to complement efforts at
school

Community Partners
Engage your local school district and health department on ways you can partner to support early
reading achievement and health
Consider the positive contributions summer learning programs can have for children, parents,
employers, and communities

State Agencies
Find ways to support reading achievement for young children within current programs
Work together: Positive outcomes for children represent a joint vision across agencies and cabinets.

For more information contact: James Allen, Director, Partnerships for Health Improvement at JamesA@health.ok.gov or

Melissa Fenrick , Health Planning Coordinator at MelissaDF@health.ok.gov