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JANUARY / FEBRUARY 2015 :: 76(1)
Rural Health in North Carolina

This issue of the NCMJ discusses factors that influence the well-being of residents in rural communities in North Carolina. These include factors related to health care, such as physician recruitment and retention, the effects of hospital closures, and the need for behavioral health services, and factors beyond the health care sphere, such as child care, health behaviors, economic development, and access to health services.


Down East Partnership for Children Is Committed to Launching Healthy Learners

Henrietta Zalkind, Jamie Wilson

N C Med J. 2015;76(1):41-45.PDF | TABLE OF CONTENTS

Down East Partnership for Children is committed to launching every child in Nash and Edgecombe counties as a healthy, lifelong learner by the end of the 3rd grade. Our 20-year journey has leveraged various resources and brought together education and health to make the greatest impact on economic success.

Creating healthy change in 2 eastern counties in North Carolina is a key goal of the Down East Partnership for Children (DEPC). When the partnership was incorporated 21 years ago, the statistics for children and families in Nash and Edgecombe counties were bleak; graduation rates were low, and obesity rates were high and on the rise. Edgecombe County, especially, ranked low in health indicators such as poverty, infant mortality, low birth-weight infants, teen pregnancies, and child abuse and neglect. In 1999, after Hurricane Floyd and the ensuing flood, the twin counties saw an economic downturn that only made matters worse (See Table 1).

Thankfully, a cross-sector group of concerned community leaders had already begun to focus on children and child care as a way to make a long-term difference in the community. These leaders became the nucleus of what ultimately became DEPC, which incorporated in 1993 as a public-private partnership. At the same time, Smart Start was launched as a statewide early childhood initiative designed to ensure that all young children enter school healthy and ready to succeed. Smart Start was visionary and innovative. It created a locally controlled system of nonprofit organizations that could design and implement early childhood education systems and strategies based on local needs. One year after incorporating, DEPC became the Smart Start Partnership for Nash and Edgecombe counties. The Edgecombe-Nash community leaders understood that the only way to improve the quality of life in the 2-county area was to prevent problems before they occur by developing and changing systems of early care, education, and family support.

The mission of DEPC is to launch every child in Nash and Edgecombe counties as a healthy, lifelong learner by the end of the 3rd grade. We have worked in rural Eastern North Carolina for over 20 years to create a model of services designed to support children aged 0–8 years and their families. This model provides comprehensive strategies to meet varied needs, so that services are available for every child at a sufficient dosage over a long enough period of time to lead to long-term success on indicators for child and family well-being.

Healthy Kids Collaborative
In 2008, with support from the Kate B. Reynolds Charitable Trust, DEPC worked with a design team and local community leaders to create a more robust plan to support the healthy development of children from birth to age 8 years. Through these collaborations and with support from the Robert Wood Johnson Foundation (RWJF) in 2010, a new project emerged called the Healthy Kids Collaborative (HKC). The purpose of the HKC is 3-fold: to help individual organizations and agencies in Nash and Edgecombe counties identify and implement small shifts that will help achieve desired outcomes; to connect organizations and agencies so that they can achieve greater impact by working together; and to launch and support new initiatives requiring multiple partners for success. The HKC identified 6 enabling conditions essential to achieving the desired impact. First, parents and children’s guardians must value nutrition and physical activity. Second, child care providers must offer healthy food and opportunities for physical activity. Third, medical providers must talk to parents about the importance of a healthy diet and physical activity. Fourth, families must be able to conveniently access safe and affordable places to play. Fifth, healthy food must be both affordable and accessible. Finally, the entire community must value physical activity and healthy eating.

In 2011, the HKC became a regional hub for the Shape NC Initiative, funded by the Blue Cross and Blue Shield of North Carolina Foundation, which allowed it to have an even greater impact on healthy behaviors in child care centers. DEPC was also chosen as 1 of 50 RWJF Healthy Kids, Healthy Communities grantees nationally during the period 2010–2014. Today, the HKC has grown to include 70 partners and works through 5 subgroups: medical, outdoor learning environments, child care, physical activity and nutrition policy, and family engagement (See Table 2). The HKC continues to serve as a driving force in changing policy and practice to support healthier environments for young children.

Working With Child Care Centers
DEPC is working with child care centers to promote best practices for nutrition and physical activity. Through the Nutrition and Physical Activity Self Assessment for Child Care (NAP SACC) and the Shape NC Initiative, the importance of healthy living in all environments where children play and learn is becoming more apparent in the community. Shape NC centers, including the Model Early Learning Center at Nash Community College Child Development Center, have significantly increased daily fruit and vegetable consumption and daily physical activity opportunities. These initial successes have led to a phase II expansion of Shape NC, with an additional 120 new centers statewide participating over the next 3 years.

Access to Fresh Fruits and Vegetables
Increasing farmers’ markets, community gardens, and community agriculture boxes remains a key strategy of the HKC. DEPC also hosts Produce and Play Days at its Family Resource Center each week during the growing season. During these events, activities are available for children, while families receive tips on how to shop at a farmers’ market and how to cook fresh foods. As a result of the HKC advocacy efforts, the local transit system added a bus stop at the Rocky Mount Farmer’s Market. Future advocacy efforts will focus on acceptance of supplemental nutrition assistance program (SNAP) benefits at local farmers’ markets and utilization of the Women, Infants, and Children (WIC) Farmers’ Market Nutrition Program.

We continue to seek resources to support child care providers in serving healthier options to children in their care. The next step is working through the network of community partners to devise a food distribution system that moves food from the fields of local farmers and community gardens to the kitchens of child care providers and families.

Access to Places to Play
National research, as well as our own experience, tells us that healthy children are more successful learners and that early nutrition and physical activity matter greatly to school readiness and success [8-15]. Research also proves that early learning happens best through play [16-18], and playing outdoors exponentially expands those opportunities, even in poor rural areas. Therefore, enhancing outdoor learning environments is a priority of DEPC. This year we will see a total of 6 existing playgrounds in Nash and Edgecombe communities get renovated as outdoor learning environments. We are grateful to our generous partners—including the PNC Foundation, Shape NC, Cummins–Rocky Mount Engine Plant, and the Rocky Mount Community Foundation—who helped us open Discovery Play and Learning Park, a model outdoor learning environment designed by North Carolina State University’s Natural Learning Initiative. This park is located at the DEPC office in Rocky Mount and is open to the public during daylight hours.

In addition, thanks to a grant from the Kate B. Reynolds Charitable Trust, DEPC will transform existing playgrounds into outdoor learning environments at 5 elementary schools in 2 school systems: Nash–Rocky Mount Public Schools and Edgecombe County Public Schools. An outdoor learning environment is a type of playground that provides more natural elements, gathering settings for outdoor classrooms, and intentional opportunities for learning, such as gardening or loose part manipulation. The HKC is supporting the school districts in implementing shared-use agreements, policies, and procedures that will allow the community to access these enhanced environments during non-school hours in order to increase student physical activity, to improve family engagement, and to smooth children’s transition to school.

Communities are now coming together to design and create learning environments that allow students to explore nature, engage in physical activity, and have opportunities for hands-on learning. The outdoor learning environments will not only increase the learning and physical activity opportunities for students, but it will also provide increased community involvement at every location.

Finally, DEPC created a “Places to Play” map, highlighting all of the publically accessible parks in the 2 counties, which is available both on DEPC’s website ( and as a hard copy. Community garden sites are also recognized on the map. Adding to and increasing utilization of these resources continues to be a key strategy for improving early health outcomes.

The Role of Medical Professionals
The HKC is supporting the role of physicians and other medical professionals in improving literacy and preventing obesity by providing tools for families that need preventive and intervention services. For example, DEPC participates in Reach Out and Read, a program that works with area medical providers to deliver new, culturally and developmentally appropriate books to children during their well-child visits, while discussing the importance of reading and parent-child interactions with parents. Last year 1,834 children benefitted from this program, with almost 2,400 books being delivered [19].

HKC’s Childhood Obesity Prevention Toolkit provides easily accessible childhood obesity screening tools and community resources for families at well-child visits [20]. The toolkit gives medical providers information to share with families on fast food, Healthy Family food policies, Healthy Kids/Healthy Plates, and tips and local resources. Some practices have made this information available to patients on their websites in addition to providing copies onsite. The HKC will continue to assess the training needs of area providers through the state’s Area Health Education Centers.

DEPC is now launching Triple P (Positive Parenting Program) across the 2 counties and will use the medical provider network to reach families seeking support with everyday parenting issues. The HKC will play a critical role in the implementation of Triple P Healthy Lifestyles to provide families with a local childhood obesity intervention program. This partnership with the medical community is making a difference by integrating family support and medical practice recommendations to create environments and opportunities for families that will help prevent future chronic health problems.

Increasing Well-Child Visits
In 1993, 63% (Edgecombe) and 58% (Nash) of children aged 0–5 years who were eligible for Medicaid received a well-child visit. In 2013, 70% (Edgecombe) and 77% (Nash) of children eligible for Medicaid received a well-child visit [21]. While this indicates that great improvements have been made over the past 20 years, the last few years have seen a decline in the total number of well-child visits, especially among 2–3-year-olds. DEPC is working with local health departments, medical providers, and families to determine the root cause of this decline and to develop interventions with HKC partners that will get us back on a trajectory of improvement.

Working with Families
In the fight against childhood obesity, engaging a diverse network of community partners is just as important as engaging families. The Shape NC Initiative has brought a tremendous resource to North Carolina—the ABLe Change Framework from Michigan State University. This model provides simultaneous attention to the content and process of the work, ensuring effective implementation and the pursuit of systems change [22]. The ABLe Change Team is helping DEPC take the HKC to the next level by more deliberately seeking family input in order to address the root causes of the obesity problem. This year we will launch the Family Coalition to engage families at every level of the community change process. The Family Coalition will start with addressing nutrition and physical activity needs, and we hope it grows to become the definitive community resource for family input into decision making across sectors.

Today we are seeing the impact of the work undertaken by DEPC, and we know that prevention practices and health collaboration are changing the culture of our communities. The impact of these services is significant. DEPC has been able to improve educational opportunities by integrating evidence-based health strategies into bundled services while also building the capacity of families to support their children’s growth and development.

According to 2012 data from the North Carolina Nutrition and Physical Activity Surveillance System, obesity rates for young children have started to decline after steady increases in previous years (See Figure 1) [23]. There is now a growing awareness in our community and region of the strong connection between health, early education, and economic success. More people are eating healthy and staying active. More child care centers are instituting healthier practices. Community gardens are growing. Local physicians are handing out books to children and integrating family support into their practices. Slowly but surely, we are digging out of the bleak health statistics and economic downturn (See Table 3). However, the shift to a healthy culture is a long-term process with many variables. Thus, we will continue to engage the community in efforts to launch every child in Nash and Edgecombe counties as a healthy, lifelong learner.

The Down East Partnership for Children acknowledges all the supporters of the Healthy Kids Collaborative Initiative, including the North Carolina Partnership for Children, the Kate B. Reynolds Charitable Trust, the Robert Wood Johnson Foundation, the Blue Cross and Blue Shield of North Carolina Foundation, the PNC Foundation, the Cummins-Rocky Mount Engine Plant, the Nash Health Care Foundation, and the Rocky Mount Community Foundation.

Potential conflicts of interest. H.Z. and J.W. have no relevant conflicts of interest.


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19. Down East Partnership for Children. Learning is Everywhere! 2014 Annual Report. Accessed December 16, 2014.

20. Healthy Kids Collaborative. Pediatric resources. Website of Boice-Willis Clinic, PA. Accessed December 16, 2014.

21. North Carolina Division of Medical Assistance. Health Check (EPSDT) Program Year-to-Year Comparison Report: Number of Medicaid Enrolled Children and Health Check Participation. Accessed December 16, 2014.

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23. Eat Smart, Move More North Carolina (ESMMNC). Data on children and youth in North Carolina. ESMMNC website. Accessed December 16, 2014.

24. Feeding America. Map the Meal Gap 2014: Child Food Insecurity in North Carolina by County in 2012. Accessed December 23, 2014.

25. Kids Count Data Center. Children in poverty. Kids Count Data Center website.,4973/false/868,867,133,38,35/any/12873,4680. Accessed December 23, 2014.

Henrietta Zalkind, JD executive director, Down East Partnership for Children, Rocky Mount, North Carolina.
Jamie Wilson, MA research and development director, Down East Partnership for Children, Rocky Mount, North Carolina.

Address correspondence to Ms. Henrietta Zalkind, Down East Partnership for Children, PO Box 1245, Rocky Mount, NC 27802 (