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Community-Based Programs: How Does Information Help Them Achieve Their Goals?

Communities across the country are at the front line of efforts to reduce childhood obesity. Presenters in the first panel of the workshop are involved in local and regional efforts that work directly with children and adults on obesity prevention and other health-related goals. Understanding how organizations like theirs use and produce evidence provides insights into how to structure research that community groups can use effectively, as well as how to build and evaluate programs that respond to each community’s context and priorities.

In introducing the session, planning committee chair Patricia Crawford, Co-Director of the Center for Weight and Health, Cooperative Extension Nutrition Specialist, and Adjunct Professor, University of California, Berkeley, noted that the four presenters have different perspectives on the information needs of community programs and initiatives based on their diverse contexts and experiences—rural and urban settings, government agencies and private organizations, efforts targeting young children and adolescents. Despite this diversity, their presentations reflected some common messages with respect to how communities gather, use, and produce evidence:

  • Each location has unique characteristics that must be understood before programs or policies are developed. Each community has its own health-related concerns, eating preferences, and activity patterns, as well as socioeconomic conditions, opportunities, and constraints created by the built and natural environments. Presenters explained how they have drawn on different data sets, inventoried



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5 Community-Based Programs: How Does Information Help Them Achieve Their Goals? Communities across the country are at the front line of efforts to reduce childhood obesity. Presenters in the first panel of the workshop are involved in local and regional efforts that work directly with children and adults on obesity prevention and other health-related goals. Understanding how organizations like theirs use and produce evidence provides insights into how to structure research that community groups can use effectively, as well as how to build and evaluate programs that respond to each community’s context and priorities. In introducing the session, planning committee chair Patricia Crawford, Co-Director of the Center for Weight and Health, Cooperative Exten- sion Nutrition Specialist, and Adjunct Professor, University of California, Berkeley, noted that the four presenters have different perspectives on the information needs of community programs and initiatives based on their diverse contexts and experiences—rural and urban settings, govern- ment agencies and private organizations, efforts targeting young children and adolescents. Despite this diversity, their presentations reflected some common messages with respect to how communities gather, use, and pro- duce evidence: • Each location has unique characteristics that must be understood before programs or policies are developed. Each community has its own health-related concerns, eating preferences, and activity pat- terns, as well as socioeconomic conditions, opportunities, and con- straints created by the built and natural environments. Presenters explained how they have drawn on different data sets, inventoried 2

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0 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION existing programs, and talked with experts and community mem- bers to further their understanding of the local obesity problem, its causes, and potential solutions. In some cases, they noted that they would have benefited from more localized data than are currently available. • Obesity prevention fits within a broader context. All four presenters spoke of the need to define obesity prevention as a component of healthy living, rather than just as individuals’ attempts to lose weight. Obesity relates to issues as varied as public safety, edu- cation, and economic development. Successful approaches there- fore involve law enforcement agencies, planning agencies, schools, neighborhood associations, public health departments, and many other stakeholders. • Sustainability must be built into community-based obesity pre- vention efforts. While foundations and public entities focus vital resources and attention on the obesity problem, each presenter noted the need to look beyond such finite sources of funding. For example, the presenters reach out to churches and other commu- nity-based organizations, push to have public health departments integrate obesity prevention into their regular services, and provide targeted assistance in leadership development and other skills to nonprofit organizations that can carry on the work. They value receptive elected officials, but also recognize that they must estab- lish relationships that extend beyond the election cycle. • Obesity prevention is a long-term goal. As promising as many of these initiatives are, the presenters noted that eating and physical activity behaviors developed over generations will take many years to change. They stressed the need to view efforts to address the obesity epidemic as a movement and not a program with a narrow focus or fixed period for implementation. As summarized in this chapter, Gerardo Mouet, Executive Director, Parks, Recreation, and Community Services Agency, Santa Ana, California, discussed the challenges his agency faces in making maximum use of lim- ited open space to benefit city residents. Leslie Bernard, Director of Special Projects, Associated Black Charities, Baltimore, Maryland, spoke about a citywide partnership to reduce rates of obesity, especially among adolescents, and described how its “blueprint” was created. Genoveva Islas-Hooker, Regional Program Coordinator, Central California Regional Obesity Pre- vention Program (CCROPP), explained how a regional initiative has been more effective than eight separate jurisdictions competing against each other for funding and other resources. Finally, Canary Girardeau, Senior Program Associate, Summit Health Institute for Research and Education,

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1 COMMUNITY-BASED PROGRAMS Inc. (SHIRE), Washington, DC, described work in the District of Columbia Ward 8 that targets young children in home-care settings. Through these four presentations and the discussion that followed, this session of the workshop highlighted various types of community-level initiatives across the country, explored their use of and need for evidence, and provided an on-the-ground perspective as new approaches are developed and refined. PROvIDINg OPPORTuNITIES FOR RECREATION IN DENSELy POPuLATED SANTA ANA, CALIFORNIA When Mr. Mouet became Executive Director of the Parks, Recreation, and Community Services Agency in Santa Ana, he led an effort to change the agency’s mission to include health and fitness. Mouet listed six agency goals that connect use of the park system with healthy living: 1. Increase places for youth to play sports, with expansion of joint-use areas (such as school fields) as a key approach. 2. Increase the effectiveness of programming on existing recreational open space, given that Santa Ana’s open space is very limited. 3. Encourage healthy eating at parks and recreational facilities. 4. Encourage healthy lifestyles in all Santa Ana homes through a variety of classes and other programs. 5. Maintain public safety at parks and recreational facilities. 6. Keep parks green, clean, and beautiful to encourage people to visit them. using Information to Promote Program goals The agency uses a variety of data to understand community character- istics and make changes to programs. Santa Ana, the largest city in Orange County, is very densely populated. Fully 76 percent of the population is His- panic, and a great percentage of these residents are foreign born. The median age is 26. According to the U.S. Census Bureau, 24 percent of Santa Ana children under age 18 live in poverty, double the average in the surrounding county. The state’s open space average is 3 acres per 1,000 residents, but it is less than one-third that amount, or 0.9 acres per 1,000 residents, in Santa Ana. According to data from the California Physical Fitness Test, 40 percent of fifth and seventh graders in the Santa Ana Unified School District are overweight or obese, compared with 29 percent in the rest of Orange County and 32 percent statewide, and fewer of these students meet the state’s six physical fitness standards than is the case elsewhere. Mouet said soccer is not only the most popular recreational sport in the city, but also an important support and information network for many

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2 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION Gathering and Using Information in Santa Ana • review of soccer team rosters revealed the extent of resident versus non­ A resident use of city facilities, which led to policy changes to give priority to local youth. • ark rangers and neighborhood associations serve as “eyes and ears” to P learn what is happening on park grounds. Without this monitoring, policies to promote the safe use of facilities by youth would not remain effective. • oundations not only provide needed funding, but also elevate the issue with F policy makers. people with limited English proficiency. Soccer leagues flourish, and the soccer fields are continually in demand. However, monitoring field activity and examining team rosters made clear that nonresident adults were the primary beneficiaries, often excluding Santa Ana’s youth. Mouet adjusted policies so local youth soccer organizations have first priority in obtain- ing field-use permits to encourage their physical activity. Yet because the fields are so limited in Santa Ana and elsewhere compared with demand, he admitted the reform process took “years and years of pain and agony and lots of politics.” Today, an estimated three-quarters of the 12,000 regular soccer players on the city’s fields, children and adults, are Santa Ana residents. Finding Information with Which to Run and Assess Programs Mouet said the agency takes many approaches to ensure that its pro- grams, many of which take place after school and on weekends, remain effective. Perhaps most valuable is having reliable “eyes and ears” on the ground to keep tabs on the parks and joint-use areas. Park rangers, many of whom are retired police officers, walk around the areas and file end-of- watch reports. They monitor what is being sold by vendors and concession stands and encourage them to offer healthier menu items. Mouet and his staff follow up on issues and complaints raised by neighbors near the fields and other members of the public. Otherwise, the primarily nonresident adult soccer leagues would again dominate use of the fields, and many public safety concerns would go unresolved. Fields and other recreational spaces on school property sit unused after school hours. The school district does not want to spend its budget on opening up its facilities after hours, so Mouet’s agency also manages these joint-use areas despite a severe budget crunch. The agency partners

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 COMMUNITY-BASED PROGRAMS with nonprofit organizations, churches, and others to continue recreational programming at these sites. In another effort to gather and use information, the agency commis- sioned a 1-year assessment of the lack of open space as a contributing factor to risks associated with problem behaviors in youth, including childhood obesity and gang involvement. The assessment is integrating surveys, focus groups, geographic information systems (GIS) mapping data, and other information. Mouet plans to share its findings with the mayor and city council, the school district, the planning agency, and others to demonstrate the impact of open space on the city’s youth. Linking Nutrition and Physical Activity to broader Community Priorities for Sustainability Working with policy makers, foundations, and neighborhood associa- tions helps link nutrition and physical activity with broader community priorities. Having the right policy maker in place makes a big difference. Mouet said that when he began his job in 2002, a city council member interested in health and fitness was in office and served as a champion for these issues. Mouet noted that foundations provide more than funding. When they select a grant recipient, they raise awareness of the issue with local pol- icy makers. Santa Ana’s grant from The California Endowment has built momentum and excitement with the mayor, the city council, and other officeholders. Even so, elected officials come and go, with differing priorities. Work- ing with neighborhood associations links obesity-related goals to broader priorities that outlast electoral changes. For example, complaints from a neighborhood association about graffiti in a nearby park led to a part- nership whereby the agency keeps the space safer. Since then, residents “I believe in civic engagement, have become more physically active getting the immigrant and help monitor park safety. This population involved, the soccer partnership serves as a model for the league organizations, … the agency’s work with other groups. neighborhood associations … Future plans include finding ways because policy makers come to work with the soccer leagues and and go, and funding cycles come with Mexican-area clubs (made up and go....” of people who come from the same —Gerardo Mouet Mexican state). Because of the com- munity’s high interest in both of these types of organizations, they have great potential to help with outreach and increase awareness of health and nutrition goals.

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 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION DEvELOPINg A CITyWIDE bLuEPRINT FOR HEALTH IN bALTIMORE Ms. Bernard discussed the Baltimore Blueprint for Healthy Outcomes in Children, a partnership to address childhood obesity. A grant from The Robert Wood Johnson Foundation enabled Associated Black Charities and the Association of Baltimore Area Grantmakers to bring together a diverse group of community partners, including neighborhood and youth-serving organizations, communities of faith, and health agencies, to understand and recommend how to reverse the rising trend toward childhood obesity in the city. The partners developed the Baltimore Blueprint to Reduce Community Obesity, which they released in spring 2008 at “Eat Right! Get Moving!,” a community summit attended by nearly 500 residents. In discussing the blueprint and related activities, Bernard stressed that she spoke on behalf of the many people involved in the effort. To develop an action plan to halt the rise in childhood obesity in Baltimore, the project formulated four objectives: 1. Define and describe the problem of childhood obesity in the city to understand contributing risk factors. 2. Identify innovative, evidence-based local and national approaches to increase healthy eating and physical activity. 3. Educate citizens and community leaders about childhood obesity and opportunities for its prevention to build informed constituen- cies that can serve as effective advocates. 4. Advocate for policies to decrease childhood obesity at the local and state levels. using Information to Promote Program goals Bernard said data from three main sources defined the scope of the problem in Baltimore: the Women, Infants and Children (WIC) program of the U.S. Department of Agriculture, the Youth Risk Behavioral Surveillance System (YRBSS) of the Centers for Disease Control and Prevention (CDC), and eight school-based health centers. These data revealed, for example, that 37 percent of Baltimore public high school students are or are at risk of becoming overweight, compared with 29 percent statewide. The data also demonstrated a significant gender component: more than 40 percent of the city’s female students are overweight or at risk, compared with 25 percent nation- and statewide. In addition to estimating the prevalence of obesity, the partnership researched why the problem exists. Five categories of risk factors that contribute to obesity prevalence in certain areas of the city were identified:

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 COMMUNITY-BASED PROGRAMS Some Lessons from Baltimore • ocus on obesity prevention as part of a movement for health equity, not a F separate program. • ngage youth (community residents, university interns, and others) in gather­ E ing evidence. As they learn, they also question and analyze. • earn from each other. Many positive efforts are already under way. A group L such as Associated Black Charities can forge connections among such efforts. (1) the local food environment, in which healthy food is more difficult to obtain and more expensive than less healthy options; (2) physical inactivity in schools without gyms or other facilities; (3) the built environment, including planning and transportation issues; (4) crime and safety concerns that influence the use of parks and other recreation facilities; and (5) socio- economic factors and racial disparities. Combining and mapping of data sets showed that neighborhoods with higher rates of poverty had higher rates of overweight and at-risk high school students (Figure 5-1). FIguRE 5-1 Community mapping in Baltimore linked the prevalence of obesity Figure 2-1.eps and overweight with poverty levels. SOURCE: L. Bernard, Associated Black Charities, based on U.S. Census and school bitmap image health center data.

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 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION Finding Information with Which to Run and Assess Programs In addition to quantitative data, the partnership gathered information through a literature review of best practices; an inventory of the work of local organizations; a risk-factor assessment conducted by interns at the health department; meetings with youth, faith-based, and other organiza- tions; and meetings with experts. This information was also disseminated at the 2008 community summit mentioned above. Drawing on this experi- ence, Bernard offered the following insights on gathering and building on evidence: • Leveraging existing expertise and knowledge of promising approaches provides important ideas. For example, the partnership learned about the value of a food policy council in other cities in addressing systemic problems and is now working to establish such an entity in Baltimore. • Assessing organizational capacity is key because community-based programs often have staffing deficits. By discussing these deficits openly, the grantmakers at the table learned about situations in which even small grants could make a big difference. • Using assessment tools, including community mapping performed by students, uncovered important information, such as the food offerings in corner stores. • Committing to continuous improvement means letting go of pro- grams that do not work, or figuring out why they do not work and doing something different. • Building a movement versus a program means focusing on health equity, with people becoming their own advocates and organiza- tions such as Associated Black Charities serving as a catalyst to jumpstart efforts. Linking Nutrition and Physical Activity to broader Community Priorities for Sustainability Related to the idea of building a movement rather than implementing a specific program, Bernard stressed the importance of linking nutrition and fitness with broader priorities. She shared the socioecological model used by Associated Black Charities (Figure 5-2), which shows how individual knowledge, attitudes, and skills fit within interpersonal, organizational, community, and public policy contexts. The most effective interventions, she said, affect multiple levels, recognizing the health implications that underlie educational, housing, land use, and zoning policies. Examples

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 COMMUNITY-BASED PROGRAMS FIguRE 5-2 A socioecological model that links individuals with a broader context. SOURCE: L. Bernard, Associated Black Charities. include engaging the community to understand how the prevalence of corner stores in lower-income communities is a land use and zoning issue, working with schools to enforce wellness policies and serve healthier food, and changing traffic patterns to improve accessibility. Community-based groups have the will and spirit to succeed, Bernard said, but many of them need targeted assistance to sustain their efforts: organizational capacity in the areas of funding, staffing, and community con- “We are all about building tacts; strategic partnerships; enhanced a movement, with all kinds communication and information shar- of advocates for change, ing; and the ability to enlist diverse educating kids that you can stakeholders. have an impact, you can make A website and community direc- a difference.” tory have helped sustain Baltimore’s —Leslie Bernard efforts and enabled diverse stake- holders to share what they are doing. In closing, Bernard emphasized that building an informed constituency and sharing evidence are keys to long- term sustainability.

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 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION COLLAbORATINg ON A REgIONAL LEvEL IN CENTRAL CALIFORNIA Ms. Islas-Hooker began her presentation by describing the large area within California covered by CCROPP: almost 300 miles from one end to the other, with a population of 3.8 million people expected to more than double by 2050, and with high rates of unemployment and family poverty, particularly in the rural, primarily Latino communities. Although central California is one of the richest agricultural regions in the nation, many local families struggle to put food—especially healthy food—on the table. Dire health conditions and persistent poverty plague the region despite the prosperity generated by the agriculture industry. Central California’s obesity rates are the worst in the state. One of every three children under age 12 and 15.5 percent of adolescents aged 12−17 are overweight. Rates of adult obesity and diabetes also are significantly higher than state averages. Islas-Hooker recounted that from her early years, she served as an interpreter at medical visits for family members and friends who did not speak English. She once assumed educating them about healthier choices would save them from negative health consequences, but “the reality is that was only half the equation . . . [the other half] is the environment.” A program to prevent obesity must take into account the region’s poverty, languages, rural−urban mix, and lack of transportation, among other envi- ronmental factors. CCROPP, which is funded by The California Endowment and The Robert Wood Johnson Foundation, was formed when public health direc- tors from six (now eight) different jurisdictions came together in a regional initiative. The program’s advantages include collective decision making and planning, pooled resources, and collaborative implementation. The partners have also found it easier to pursue resources collectively rather than com- pete against each other. Islas-Hooker is Regional Program Coordinator, but stressed that the initiative is community driven, and people on the ground carry out the work. CCROPP’s interventions fall within two large categories: (1) increas- ing access to healthy food, such as through greater acceptance of electronic benefit transfer (EBT) payments at farmers’ markets and conversion of small stores to selling healthier food; and (2) increasing opportunities for safe places to play, such as through park improvements and greater joint use of facilities with schools. CCROPP has already had successes, including an effort by Latina women in Bakersfield that resulted in improvements to a local park and a zoning change in Fresno to facilitate the establishment of more farmers’ markets.

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 COMMUNITY-BASED PROGRAMS What Has Worked in Central California • oin forces to collaborate and attract more funding, rather than compete for J limited funding. • eframe the issue from obesity prevention to social equity and justice. R • se a variety of methods to learn about community choices and preferences. U Finding and using Information to Promote Program goals Islas-Hooker said that historically, obesity has been addressed through interventions aimed at individuals, so few data have been collected about the impact of the community environment. Information is needed to better understand access issues related to food and physical activity environments, utilization issues related to community choices and preferences, and obe- sity and chronic disease rates for specific target locations. Relevant policy models from geographic areas with similar demographics also are necessary. Islas-Hooker quoted a CCROPP program lead, who said that framing the obesity problem in terms of the need for a series of local, environmental, and policy changes has made the problem easy for people to grasp and mobilize around, particularly when they see how these changes relate to the health and future of children. Islas-Hooker listed the many sources of information CCROPP has drawn on, including the California Health Interview Survey (CHIS); Com- munities of Excellence in Nutrition, Physical Activity and Obesity Pre- vention (CX3), which covers some of the region; the California-based study Designed for Disease, authored by UCLA Center for Health Policy Research, the California Center for Public Health Advocacy (CCPHA), and PolicyLink; and evaluation data. Methods used to gather information have included GIS satellite mapping, PhotoVoice documentation, interviews, focus groups, polling, and walkability assessments. In one county, polling consisted of choosing among photos of potential park amenities—a simple but powerful tool for low-literacy residents to express their preferences for their local park. Linking Nutrition and Physical Activity to broader Community Priorities Islas-Hooker reiterated a theme expressed throughout the workshop when she said, “Policy and environmental change work is not program work in the traditional sense.” Instead, it involves engaging the community,

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0 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION advocating, and building relationships over a period of time. It also requires new ways of looking at implementation and evaluation. CCROPP reframes obesity prevention within the context of larger issues of social equity and justice. For instance, promoting the sale and consump- tion of more fruits and vegetables is connected to economic development. “Promoting the sale and Increased access to space for physical consumption of more fruits and activity is linked to greater community vegetables is linked to economic cohesion and community ownership, development in our region. . . . thus engaging law enforcement and Increasing access to physical planning officials, among others. activity space is linked to greater Islas-Hooker noted that commu- community safety, increasing nity empowerment and engagement community cohesion, and lead to sustainability beyond funding community ownership. Using cycles. She elaborated on three ways this frame has been helpful in engaging nontraditional partners.” in which CCROPP hopes to sustain —Genoveva Islas­Hooker its efforts: • Leadership development within community organizations, which CCROPP is undertaking with a grant from The Robert Wood Johnson Foundation’s Healthy Kids Initiative; • Reorganization of public health departments to be involved in (and fund) chronic disease prevention; and • Smart redistribution of resources to match changing community needs. In many communities, said Islas-Hooker, the need for nutrition educa- tion is not as strong as the need to build capacity for work toward policy and environmental changes. She urged that federal funding reflect these changing needs. FOCuSINg ON AN uNDERSERvED WARD IN WASHINgTON, DC Ms. Girardeau was the final speaker on the community-based panel. Her organization, SHIRE, works with communities, government agencies, educational institutions, and foundations to identify inequities and galva- nize grassroots groups to address issues of access to health care and quality of care among the underserved, particularly people of color. SHIRE became involved in the obesity issue upon learning about the District of Columbia’s high rates of overweight and obesity in children. With a grant from the Kaiser Foundation Health Plan, SHIRE is focusing on young children in home-care settings in the city’s Ward 8, a community with a particularly high incidence of obesity and other chronic diseases.

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1 COMMUNITY-BASED PROGRAMS What SHIRE Has Learned in Ward 8 • eaching rather than changing behaviors can be easier—thus the focus on T young children. • t a certain point, communities grow tired of being the subject of research A when they see no improvements in conditions. • hurches with large memberships, strong leaders, and buildings for meetings C and activities are among the community assets with which to work. Girardeau said the emphasis on young children stems from the observation, expressed by New Hampshire First Lady and physician Susan Lynch, that it is easier to teach than to change a behavior. Initial priorities include raising community awareness of the effects of obesity and obtaining community buy-in to prevent it, increasing access to healthy food, and increasing opportunities for physical activity. The Early Childhood Obesity Prevention (ECOP) Collaborative serves as SHIRE’s “think tank” and recommends policies and programs. ECOP grew from 30 members in 2006 to more than 120 in 2009. Its members include health care providers, community leaders, government representatives, parents, faith leaders, child care providers, and others. With the goal of halting and reversing childhood obesity trends and promoting healthy living, ECOP developed a “healthy living opportunity tree” (see Figure 5-3) to illustrate how partners and programs can work toward healthy living, obesity pre- vention, and supportive policy initiatives. using Information to Promote Program goals SHIRE, like the other organizations represented on the panel, needs various types of information to implement initiatives. Demographic data have come from the National Urban League’s Environmental Scan, funded by The Robert Wood Johnson Foundation. The scan showed, for instance, that Ward 8 has a population of 71,000 people, more than 99 percent of whom are African American. For 12 years, it had no supermarket (it now has one), and it now has one farmers’ market (down from two). Other information gathered included an understanding of the ward’s key politicians, conveners, and opinion leaders, as well as its gathering places. Community members spoke about what they consider to be the causes of childhood obesity, and about the level of willingness and community assets to work on the problem.

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42 FIGURE 5-3 Early Childhood Obesity Prevention Collaborative’s healthy living opportunity tree. NOTE: DOH = DC Department of Health; HK/HC = Health Kids, Health Communities; HSC = Health Services for Children; MarPat = The MARPAT Foundation; OMH = Office of Minority Health; RWJF = The Robert Wood Johnson Foundation. SOURCE: C. Girardeau, SHIRE.

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 COMMUNITY-BASED PROGRAMS Finding Information with Which to Operate and Assess Programs SHIRE has also obtained information from literature and Internet searches, as well as from asking questions of ECOP members and focus groups. Parents, child care providers, health care providers, and government representatives have offered input. At community meetings, churches, and community centers, the goal was to listen, rather than to “talk about what we want to accomplish.” The Ward 8 Heath Council has become strong, and as Girardeau noted, it is beginning to question why so many agencies are funding research in Ward 8, but the statistics show no change. Assessment is important to this project and will encompass pre- and post-surveys, telephone interviews, and other strategies. An outside evalu- ator will help SHIRE distill significance and guide future efforts through its documentation and assessment. Linking Nutrition and Physical Activity to broader Community Priorities for Sustainability Girardeau said ECOP’s message is about healthy eating and active liv- ing, not just losing weight. The question to people becomes, “What in your community prevents or helps you eat healthy and be active?” This question “What in your community stimulates responses that highlight prevents or helps you eat healthy the relationship between obesity pre- and be active? What would vention and the larger environment: you like to change? What are food outlets that sell outdated prod- you willing to do to get those ucts, unsafe parks and playgrounds, changes? These questions vendors selling unhealthy food. By stimulate conversations.” stimulating conversations within the —Canary Girardeau community on how to improve health, ECOP is helping community members contribute to the development of a citywide obesity action plan. SHIRE is seeking to sustain its efforts by producing data that show program effectiveness, determining entrepreneurial possibilities for com- munity members, providing education and support to institutionalize poli- cies, collaborating with other agencies and stakeholders to keep resources flowing, determining entities that can incorporate SHIRE programs into their ongoing activities, and sharing lessons learned. Girardeau expressed gratitude to foundations and agencies that have helped fund SHIRE’s work, particularly the Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., which recognize that behavior change takes time.

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 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION DISCuSSION At the end of each panel, workshop attendees had the opportunity to ask questions of the presenters. Among the topics raised in this first session were the following: • Stimulating community action with little funding. Crawford launched the discussion by asking presenters how they would sug- gest that organizations without foundation or other funding start to engage the obesity problem. Mouet said that in a city gov- ernment setting, grassroots involvement, such as speaking at city council meetings, brings an issue to the forefront. Islas-Hooker noted the “six degrees of separation between obesity prevention and everything else”; thus, supporting healthy eating and physical activity is related, for example, to violence prevention and safety. Bernard agreed that advocacy efforts can accomplish a great deal with little money. • Role of bMI data. When an audience member asked the pre- senters about the priority of using local BMI data to measure the outcomes of their interventions, the responses varied. Islas- Hooker said CCROPP hoped desired behavior changes would lead to lower BMIs, but local BMI data were not available as a baseline. Although having BMI data would be helpful to communicate with decision makers, the fact that the focus of the program is on envi- ronmental and policy-level change makes these data less necessary. In Baltimore, according to Bernard, collection of BMI data has not emerged as a high priority. In contrast, Mouet said it was essential for Santa Ana to show progress over the course of the 10-year effort funded by the California Endowment; thus measuring and hoping to improve upon BMI percentages is a higher priority. Girardeau said the Washington, DC, community with which SHIRE is work- ing is resistant to using BMI data. In four separate focus groups held by SHIRE, residents stated their belief that the BMI charts are not applicable to the African American community because they are based only on a white population. Girardeau also observed that changes in BMI would take a long time to show. • gender considerations in encouraging physical activity. A partici- pant asked Mouet, who had spoken about the role of soccer in encouraging more physical activity, whether girls are as likely as boys to become involved, especially as they reach middle school and older ages. Mouet agreed that a gender gap persists, although more young girls are now playing soccer. Islas-Hooker said a preliminary assessment in central California’s Latino community showed a high

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 COMMUNITY-BASED PROGRAMS level of interest, but few programs, in folkloric dance. She noted that physical activity is not just about sports, and dance and other arts-related programs are physical activities that merit support. • Working with small stores to offer healthier food. Islas-Hooker was asked how CCROPP has worked with small stores to stock health- ier food. She said the process involves engaging storeowners, who are worried about the risk of perishable food that may go unsold. CCROPP is surveying residents to see what kinds of produce they would buy at what prices. The program is also working with the California Association of Family Farmers to create a distribution mechanism that would encompass a local market for the region’s small farmers. Finally, Islas-Hooker noted that storeowners need business plans and marketing strategies to sell produce. • Need for long-term, sustainable support. A participant underscored the need for interventions to take place over the long term, since time is needed to build trust, produce results, and reverse many years of poor eating habits. She asked how funding institutions could be encouraged to commit to longer time frames. Bernard agreed with the need for long-term funding, but also stressed the importance of diverse streams of funding to avoid an overdepen- dence on one or two foundations. Another avenue of sustainability is to work closely with city agencies so they will institutionalize the work begun under a grant or other special funding. • Working with planners. Planners, noted one participant, think in long-range terms. She asked presenters about the challenges and opportunities they have faced in working with planning agencies. Mouet said collaboration is critical, although it can be frustrat- ing. Bernard said Baltimore’s planning department is rewriting the zoning code for the first time in 30 years, which she termed an opportunity to promote healthier communities. The commissioners of the planning department and the health department co-lead a food policy task force. • Role of nutritionists and others in educating about healthier eating. Agreeing with the need for environmental changes, a nutritionist in the audience urged the organizations represented by the presenters to consider individual and group counseling, cooking and meal- planning education, and other ways to improve eating. Girardeau noted that a focus group of Washington, DC, children said their family members should cook more. Bernard reported that some participants in Baltimore focus groups said that removing home economics from the school curriculum had led to a generation of parents not knowing how to cook. The Baltimore Blueprint includes nutrition education in its recommendations. Another way

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 COMMUNITY PERSPECTIVES ON OBESITY PREVENTION to increase demand is to hold cooking demonstrations in corner stores, farmers’ markets, and other locations. Islas-Hooker noted that time pressures often prevent people from cooking, even in cultures that traditionally emphasize cooking. • Access to WIC data. The panelists were asked whether they thought community groups were aware of and had access to WIC data, which contain real-time BMI numbers. Bernard said her group began to share this information with community groups, but sen- sitivity is necessary, particularly with parents whose children are overweight. Mouet said it takes time to enable the community to have access to and understand the data.