1. The State Health Agency’s Role in Increasing Access to Drinking Water
Notes to the Presenter:
Purpose - The purpose of this PowerPoint presentation is to educate state agency staff and partners about the importance of incorporating water access strategies into their state public health efforts and garner support to implement this strategy collaboratively with partners in their state.
Audience - The intended audience for this PowerPoint presentation is state health agency staff and other public health practitioners working on water access in their state. State agency staff funded by CDC cooperative agreement DP may find this presentation especially useful.
Definition - In this presentation, water access refers to increasing access to drinking water in key settings, including communities, worksites, government agencies, schools, and early care and education.
How to Use this PowerPoint Presentation - You should first download and review this presentation. Then, if needed, you may choose to adapt the slides to fit your context or situation. For example, you may want to add specific information about programs and activities in your state related to water or initiatives already underway that might be relevant to a water access strategy. You might also use the document DNPAO Implementation Guidance and Resources for Cooperative Agreement DP (which includes definitions, references, and resources related to cooperative agreement 1305 strategies) to incorporate additional content or speaker notes into your PowerPoint.
If you only need a small portion of this information, you can copy and paste the language from selected slides into a simple 1-page document to use as an education or communication tool with partners.   
Once you develop the slides or handouts to suit your specific state’s needs, you may share the information at meetings, coalitions, workgroups, and other settings where you want others to understand the importance of incorporating water access strategies into your existing state efforts. The content from these slides may elicit ideas from colleagues about water access and help garner support for this strategy.
The intent is for this PowerPoint resource to be relevant to your situation, and to “meet you where you are,” so feel free to customize to suit your needs.

2. Why is drinking water important?
Drinking water instead of sugar-sweetened beverages helps to reduce intake of excess added sugars and calories.
Drinking water is also important in preventing dehydration and may improve cognitive function in children and adolescents.

3. Why is drinking water important?
Drinking fluoridated water can help prevent cavities by providing fluoride and reducing acid in the mouth.
One way to encourage children and adults to drink enough water is to make safe drinking water widely available in schools, healthcare institutions, worksites, communities, public places, and early care and education (ECE) settings.

4. What are schools and ECE providers in your state required to do around water access?

5. Water Access in Schools
United States Department of Agriculture (USDA) requires schools participating in the National School Lunch Program (NSLP) to make plain (i.e., no flavoring, additives, or carbonation) drinking water available to students at no cost during the lunch meal periods at the locations where meals are served
Schools must also make drinking water available during the School Breakfast Program when breakfast is served in the cafeteria
Schools that participate in the Afterschool Snack Program are encouraged to provide drinking water when snacks are served

6. Actions for Schools to Increase Water Access and Consumption
Schools can:
Offer water filling stations or water jets
Provide cups at water filling stations and/or allow students to bring and use reusable water bottles
Allow students to bring clear water bottles to class
Offer water pitchers and cups on lunch tables
Place signage near and at water fountains and dispensers
Promote the safety of tap water

7. Actions for Schools to Increase Water Access and Consumption (cont.)
Schools can:
Promote the environmental and cost benefits of drinking tap water over bottled beverages
Include messages about the health and environmental benefits of water in classroom lessons and in materials sent home to parents
Ensure the school is in compliance with plumbing codes regarding the minimum number of drinking fountains based on the number of students
Establish cleaning standards for all water access points
Complete the needs assessment and planning tools in the CDC Increasing Access To Drinking Water in Schools toolkit to determine additional action steps

8. Actions for State Health Agencies to Support Schools in Water Access
State health agency staff can:
Help school districts incorporate water access into their local wellness policies
Provide schools and districts with best practices and scientific evidence of the benefits of drinking water
Create education or media campaigns to promote the benefits of water consumption
Ensure schools and districts are aware of the safety of tap water in their area
Provide technical assistance and troubleshooting help to schools that may want to address water access
Provide training on the CDC Increasing Access To Drinking Water in Schools toolkit to schools and school districts

9. Water Access in Early Care and Education (ECE)
The federal Healthy, Hunger-Free Kids Act of 2010 requires child care centers, family day-care homes, at-risk afterschool programs, and shelters participating in Child and Adult Care Food Program (CACFP) to make water available to children throughout the day, including at meal times, and upon request
In addition to federal law, at least 42 states (as of 2012) have separate licensing regulations that discuss the provision of water in ECE
In many states, CACFP nutrition requirements apply to non-CACFP centers and family day-care homes

10. Actions for Early Care and Education to Increase Water Access and Consumption
ECE providers can:
Make drinking water readily available indoors and outdoors
Train staff members about the federal requirement that water be available to children throughout the day
Offer water filling stations or water jets
Provide cups at water filling stations and/or allow students to bring and use reusable water bottles
Offer water pitchers and cups on lunch tables, in classrooms, and on playgrounds
Clean and sanitize water pitchers, dispensers, and reusable drinking cups daily

11. Actions for Early Care and Education to Increase Water Access and Consumption (cont.)
ECE providers can:
Ensure drinking fountains that are too tall for children are accessible by placing a sturdy stool to reach them
Promote the safety of tap water
Promote the environmental and cost benefits of drinking tap water over bottled beverages
Ensure compliance with plumbing codes
Establish cleaning standards for all water access points
Complete the needs assessment and planning tools in the CDC Guide for Increasing Access to Drinking Water and Other Healthier Beverages in the Early Care and Education Setting (to be released in 2014) to determine additional action steps

12. Actions for State Health Agencies to Support ECE in Water Access
State health agency staff can:
Inform ECE providers of federal and state requirements
Inform ECE providers of the best practices and scientific evidence of the benefits of drinking water (Caring for Our Children: National Health and Safety Performance Standards Guidelines for Early Care and Education Programs
Ensure water access is part of state licensing regulations for ECE providers
Ensure providers are aware of the safety of tap water in their area
Provide technical assistance and troubleshooting help to providers that may want to address water access
Provide training to ECE providers on the CDC Guide for Increasing Access to Drinking Water and Other Healthier Beverages in the Early Care and Education Setting (to be released in 2014)

13. How does water access fit within CDC cooperative agreement DP13-1305 funding?

14. What is CDC Cooperative Agreement DP13-1305?
In 2013, CDC awarded funding for 5 years to state health departments to reduce the risk factors associated with childhood and adult obesity, diabetes, heart disease, and stroke.
Name of cooperative agreement: State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity, and Associated Risk Factors and Promote School Health DP (or just “1305”)
All 50 states health departments and DC are funded
Funding was awarded for four domains
Epidemiology, surveillance, and evaluation to inform, prioritize, and monitor diseases and risk factors and the delivery of interventions.
Environmental strategies that reinforce healthful behaviors and expand access to healthy choices.
Health systems interventions to improve the delivery and use of clinical and other preventive services.
Clinical and community linkages to better support chronic disease self-management.
Water access as a strategy fits within the environmental strategies as described in Domain 2.

15. Where does water access fit within 1305 funding?
1305 Domain 2 Strategies and Sub-Strategies Relevant to Water Access
 Increase access to healthy foods and beverages
Provide access to healthier food retail
Create supportive nutrition environments in schools
Promote and implement nutrition standards where foods and beverages are available
Implement nutrition standards/food service guidelines in priority settings (early care and education (ECE), worksites and communities)
This slide provides the strategies and sub-strategies under Domain 2 that might be relevant to water access. “Provide access to healthier food retail” is a sub-strategy under increasing access to healthy foods and beverages that could include water access. For example, a state might be working with a group of corner stores within their state and could provide them technical assistance on how to move the placement of water to a more appealing location in their retail venue. The strategy about nutrition environments in schools includes allowing students to have access to drinking water. Also included in the list of strategies is the use of food service guidelines or nutrition standards. We will discuss how water access fits into this in more detail on the next slide.

16. How does water access fit within food service guidelines/nutrition standards?
What are food service guidelines (FSG)?
The 2010 Health and Sustainability Guidelines are food, beverage, and operations standards for institutional food service.
What settings are included?
Federal, state, and local government agencies
Healthcare institutions
Worksites
Parks and recreation
ECE
FSG specifically includes water requirements for cafeterias
“Drinking water, preferably chilled tap, must be offered at no charge at all meal-service events.”
In the context of 1305, we define this strategy to mean increasing the use of food service guidelines by state and local governments, businesses, non-governmental organizations, park and recreation, and food services (cafeterias, vending, and snack bars) in worksites. Food service guidelines or nutrition standards are guidelines for organizations or programs to create healthy eating and drinking environments in cafeterias, vending machines, and snack bars. Additionally, guidelines may also promote healthy dietary choices by using pricing incentives, food placement architecture, or be used to improve the sustainable practices of food service operations. This strategy also includes ensuring that ECE facilities serving 0 – 5 year olds, including preschools, child care centers, day care homes (also known as family child care), and Head Start and pre-kindergarten programs, meet national nutrition standards.

17. Additional Ways to Increase Water Access and Consumption in Various Settings
Provide free drinking water (with attractive presentation) at meetings and conferences
Offer water filling stations or jets
Provide information on the safety of tap water
When available for sale, offer water at a reduced price compared to other beverages
There are a number of other ways to address water access as per the food service guidelines and nutrition standards in government buildings, worksites, healthcare institutions, parks and recreation, schools and ECE.

18. What are some examples of roles state health departments are playing in water access?

19. Kansas
Just Add Water intervention and media campaign in Shawnee County, Kansas
Implemented by Kansas Department of Health and Environment
Pilot project funded by CDC in
Aimed to raise awareness among mothers of children 8-10 years of age about the benefits of water and the health risks associated with the consumption of too many sugar sweetened beverages (SSBs)
Partners: local universities, local/regional health care, communication sectors, and media and television outlets
Just Add Water commercials presented on 5 broadcast and 22 cable channels with an estimated coverage for the target audience of 94.9%
Also included billboards, social media, website, and posters
Approximately 25% of those exposed to the 8-week campaign stated they made significant attitude and behavioral changes in their approach to SSBs.

20. Kansas: Keys to Success
Engaged a broad partnership which provided diversity and expertise (through a Media Advisory Committee)
Be clear and up front to establish budget, roles, expectations, and timeline
Researched the audience early to provide data that was used in a timely manner to inform the development of the campaign

21. Minnesota
MN Department of Health serves as convener of mutually-interested partners to develop and provide evidence-based resources to increase access to and consumption of healthier beverage options
Target audiences are State Health Improvement Plan (SHIP) and Community Transformation Grant (CTG) grantees working on strategies to reduce SSBs in hospital and clinical settings
Internal partners include Health Promotion and Chronic Disease Division/Cancer, Office of State Health Improvement Initiative, and Oral Health
External partners include Minnesota Cancer Alliance (MCA), Public Health Law Center, Institute for a Sustainable Future, and participating healthcare institutions
MCA priorities include reducing consumption of SSBs and MCA promotes the Institute for a Sustainable Future, which resulted in 5 MN hospitals phasing out SSBs in their facilities.
Funding comes from a cancer policy grant

22. Minnesota
Developed several tip sheets for healthcare institutions and A Guide for Developing Healthy Beverage Programs (which includes specific content on how to promote tap water)
Presented webinars and provided technical assistance to grantees
As of early 2014, MN legislature refunded SHIP for $35 million, which provides enough to fund all county health boards to implement a strategy to increase access to water for those that proposed it in their applications

23. Minnesota: Keys to Success
Included external partners, such as MCA and Public Health Law Center
Worked with hospitals and health care facilities because they have a mission to promote health
Started with hospitals to “soften the ground” for working on reducing SSB consumption in other settings
Spent a great deal of time to build relationships with hospital staff, management, and state hospital associations
Emphasized the community benefits and encouraged hospitals to use a healthy beverage policy in their hospital as part of their community health improvement plan under the Affordable Care Act
MN Dept of Health contracted with the Law Center to create the toolkits (creating the toolkit required time and resources)

24. Mississippi
2008: MS Department of Health beverage guidelines state that no SSBs should be sold during school hours nor be available in vending machines.
April 2013: MS Department of Health made revisions to the MS childcare regulations that water is to be served with all meals and snacks and readily available throughout the day, which applies to any center licensed through the MS Department of Health (~1900 centers)

25. New York: Child Care Child care regulations
NYS Dept of Health administers the Child and Adult Care Food Program (CACFP) and established the Healthy Child Meal Pattern. NY CACFP Healthy Child Meal Pattern recommends providers to serve water with snacks when no other beverage is being served, and the menu must specify when water is served at a snack
Also working on a new regulation that would limit beverages served in childcare programs to only water, 100% fruit juice and skim or 1% milk for children over 2 years
Dept of Health worked closely with several partners to pass the standards, and are providing technical assistance and training to child care providers and staff in the NYS Office for Children and Family Services

26. New York: Media Campaign
Between February and August 2011, NYS Dept of Health conducted a media campaign in four counties called iChoose600 to encourage residents to order meals with less than 600 calories in restaurants
One message included in the campaign was to save calories in fast food restaurants by ordering water instead of SSBs
Target audience: low income, minority women with children
Ads were posted on billboards, buses, and malls. Also created a Facebook page
Evaluation showed that fast food customers who recalled seeing the ‘iChoose600®’ campaign were more likely to notice and use posted calorie labels when ordering

27. Utah
UT Dept of Health manages program for child care providers called Targeting Obesity in Preschool and Childcare Settings (TOP Star)
TOP Star targets obesity in preschool and childcare programs and assists providers in improving nutrition and physical activity environments through assessment, goal-setting, training and technical assistance
Partners: UT Department of Health Bureau of Child Development, Professional Development Institute at the UT State University, and the UT Department of Health Environment, Policy, and Improved Clinical Care
Providers receive an endorsement from the TOP Star Program if they complete all program components and achieve a score of ≥ 90
Drinking water is on the assessment and the childcare providers receive 1 to 3 points per strategy depending on how they complete the questionnaire
If the provider gets 3 points then the Department of Health considers this a best practice. The following items receive 3 points:
Drinking water outside the building is easily visible and available for self-service
Drinking water inside is easily visible and available for self-service

28. Vermont
VT Department of Health developed school policy guidelines in 2008; one of the five priorities is to remove sugar sweetened beverages from school environments and provide easy access to drinking water
Key role of state health department is to build awareness about the connection between good health and academic achievement, aligned with messages from the State Department of Education
Partners are the health promotion division, child health division, and coordinated school health
No dedicated funding for obesity prevention therefore VT leverages funds from cancer, prevention block grant, maternal and child health, CTG, and other federal funds

29. Vermont
Health department provides support to school liaisons who are present in each school district to provide onsite technical assistance at various points in the school year
Health department annually recognizes schools through a School Wellness Award. All VT public schools are eligible (~350).
To be eligible, schools must complete a questionnaire. One question asks if they have “free, fresh drinking water available all day”
In 2013, 57 out of 64 school applicants answered “yes” to this question.
VT also included a water question in their middle and high school 2013 YRBS survey
“During the past 7 days, how many times did you drink a bottle or glass of plain water? (count tap, bottled, and unflavored sparkling water).”

30. What are key roles or action steps state health agencies can take to increase access to water?

31. Key Roles for State Health Agencies
Conduct a scan of your state or local policies, regulations, or licensing around drinking water access or plumbing codes in schools, child care, hospitals, worksites, restaurants, parks, or public venues and events (e.g., festivals, stadiums).
Identify and convene partners and stakeholders that are "ready to go" or that already have mission statements that coincide with implementing a water strategy
In addition to partners that have an interest in nutrition/physical activity, consider other agencies in your office such as oral health, heart disease, or cancer staff
Also consider working with private industry, academic, or legal institutes to assist in data collection, legal advice, and communication strategies
Engage decision-makers such as senior management, funders, and/or key stakeholders

32. Key Roles for State Health Agencies
Facilitate discussions with stakeholders. Work to gain an understanding of their priorities, needs, and assets. Be ready to answer questions.
Educate stakeholders on the importance of water access and replacement of caloric intake from sugar-sweetened beverages as a key strategy in obesity prevention efforts
Educate your own staff and partners on the ease of incorporating water into existing funded efforts such as nutrition standards, food service guidelines, fluoridation
Ensure that “water” and “healthy beverages” are words that are consistently added onto phrases such as “increase access to healthier foods” in your documents and guidance
Provide stakeholders with best practices and evidence-based resources. 

33. Key Roles for State Health Agencies
Educate school and ECE providers on federal regulations (and relevant state regulations) on water access and the importance of compliance
Conduct a water access assessment in targeted settings or venues. Locations may include schools, child care, hospitals, worksites, restaurants, parks, public spaces, or public venues and events (e.g., festivals, stadiums). Consider the following themes in your assessment:
Is the tap water clean and safe?
Where is the source of water located?
How much does the water cost, or is it free?
If bottled, what is the impact on the environment?
In schools and ECE, what is the source of the water, and is it appealing in taste, smell, and color?

34. Key Roles for State Health Agencies
Showcase local success and learn from them. Local health departments might have already implemented water access strategies that should be highlighted at a broader level and might even be applied to the state level. (For example, they might have made progress in vending, procurement, building assessments, installing water fountains, providing price advantages to water, installing bottle filling stations in public buildings, or instituting healthy meeting policies.)
Track your progress. Data collection, analysis, and presentation are key to telling a story and advancing your priorities.
Celebrate achievements, large and small.

35. Acknowledgements
This presentation was developed by Joan Atkinson from the Association of State Public Health Nutritionists (ASPHN) for CDC’s Division of Nutrition, Physical Activity, and Obesity (DNPAO).
A special thanks to the following state health department staff who provided input on the content of this presentation:
Arizona Department of Health Services - Karen Sell
California Department of Public Health - Suzanne Haydu and Betty Sun
Iowa Department of Public Health - Doris Montgomery and Carol Voss
Kansas Department of Health & Environment - Sandy Perkins and Anthony Randles
Minnesota Department of Health - Lisa Gemlo, Donna McDuffie, and Michelle Strangis
North Carolina Division of Public Health – Michelle Futrell
North Dakota Department of Health - Deanna Askew
Oklahoma Department of Health - Miranda Manning
Utah Department of Health - Patrice Isabella
Vermont Department of Health - Susan Coburn and Todd Perry
West Virginia Bureau for Public Health - Denise Ferris