7

Community Obesity Assessment and Surveillance

Why: Why develop a Community Obesity Assessment and Surveillance Plan? Many recommendations from the report Accelerating Progress in Obesity Prevention (APOP) (IOM, 2012a) call for implementation of strategies at the community level, and many of the decisions affecting determinants of obesity are made at the local level. Accurate and timely knowledge of local obesity-related conditions and changes or trends over time are essential for planning and managing community obesity prevention initiatives.

What: What is a Community Obesity Assessment and Surveillance Plan? Complementary to the Community-level Obesity Intervention Monitoring and Summative Evaluation Plan (in Chapter 8), a Community Obesity Assessment and Surveillance Plan is a template to guide communities in describing the current status of and trends in obesity and its determinants in their community.

How: How should a Community Obesity Assessment and Surveillance Plan be implemented? A template to customize a plan for community assessment and surveillance contains guidance for (1) identifying a set of common indicators that measure impacts and outcomes of strategies recommended in the APOP report (IOM, 2012a) that can be measured, compared, and aggregated across multiple jurisdictions; (2) providing guidance for developing local capacity for these assessments; and (3) accommodating communities with varying resources and assets.

Accelerating progress in obesity prevention requires multi-level strategies at the federal, state, and local levels as recommended in the Institute of Medicine (IOM) Accelerating Progress in Obesity Prevention (APOP) report (IOM, 2012a). Unlike the previous chapter, which focused on more macro-level federal and state evaluation of obesity and related determinants, the next two chapters focus on evaluation of obesity prevention at the community or local level. Evaluation at the local level has two components: (1) assessment and surveillance of obesity status, its determinants, and the extent of obe-



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7 Community Obesity Assessment and Surveillance Why: Why develop a Community Obesity Assessment and Surveillance Plan? Many recommendations from the report Accelerating Progress in Obesity Prevention (APOP) (IOM, 2012a) call for implementation of strat- egies at the community level, and many of the decisions affecting determinants of obesity are made at the local level. Accurate and timely knowledge of local obesity-related conditions and changes or trends over time are essential for planning and managing community obesity prevention initiatives. What: What is a Community Obesity Assessment and Surveillance Plan? Complementary to the Community- level Obesity Intervention Monitoring and Summative Evaluation Plan (in Chapter 8), a Community Obesity Assessment and Surveillance Plan is a template to guide communities in describing the current status of and trends in obesity and its determinants in their community. How: How should a Community Obesity Assessment and Surveillance Plan be implemented? A template to customize a plan for community assessment and surveillance contains guidance for (1) identifying a set of common indicators that measure impacts and outcomes of strategies recommended in the APOP report (IOM, 2012a) that can be measured, compared, and aggregated across multiple jurisdictions; (2) providing guidance for developing local capacity for these assessments; and (3) accommodating communities with varying resources and assets. A ccelerating progress in obesity prevention requires multi-level strategies at the federal, state, and local levels as recommended in the Institute of Medicine (IOM) Accelerating Progress in Obesity Prevention (APOP) report (IOM, 2012a). Unlike the previous chapter, which focused on more macro- level federal and state evaluation of obesity and related determinants, the next two chapters focus on evaluation of obesity prevention at the community or local level. Evaluation at the local level has two components: (1) assessment and surveillance of obesity status, its determinants, and the extent of obe- 183

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sity prevention activities and (2) monitoring and summative evaluation of the quality and effectiveness of obesity prevention interventions. The prominence of local prevention activities implies that evaluating progress in obesity prevention must include knowledge of changes in obesity and its determinants at the local level and of the effectiveness of locally implemented strategies (IOM, 2007). Therefore, local evalu- ation includes both community assessment and surveillance (CAS)1 and community program and initia- tive monitoring and summative evaluation (e.g., evaluation of interventions, including programs, systems, policies, environmental changes, services, products). This chapter addresses the former. The subsequent chapter (Chapter 8) focuses on community program and initiative (or intervention) monitoring and sum- mative evaluation. Goals of CAS Compared to Intervention monitoring and summative Evaluation Community assessment, surveillance, and intervention monitoring and summative evaluation are distinct sets of activities with complementary goals. The goal of community assessments is usually a first- time assessment of status or trends overall. Surveillance provides repeated or continuous assessments of progress over time, whereas intervention monitoring and summative evaluation seeks to establish and share “what works.” The combination of first-time assessment and ongoing surveillance (or CAS) can document, at the local level, associations of the status or trends in obesity prevalence with behaviors, ­ social factors, environments, or interventions. Linking these with the monitoring of implementation of interventions becomes the main sources of data for evaluation. Intervention summative evaluations seek to move beyond association to determine whether observed changes in outcomes can be associated with and, ideally, attributed to the intervention or combination of interventions. These two purposes—assessing status or progress and evaluating whether interventions are w ­ orking—require different types or levels of evidence. When assessing status or progress, evidence of cur- rent levels or trends in obesity and its determinants (e.g., behaviors, environments, programs, systems, and policies) can be sufficient, without necessarily attributing cause. Causal assumptions will be inevitable because some determinants are found to be above state or national averages, suggesting that interventions need to be developed with those determinants as targets. For implementers of community initiatives, this information can help them to decide whether their approaches are on target or need adjustment. For local efforts that need to show progress to constituents or funders, evidence of progress may be sufficient for accountability. In contrast, when evaluating interventions, the strongest evidence possible is desirable, and this means place-based experiments usually including a comparison or control condition, or the strongest feasible quasi-­ xperiments (see Chapter 8). e CAS and intervention monitoring and summative evaluation interact and share some similarities. Intervention monitoring and summative evaluation can use data generated by CAS and can suggest topics for inclusion in data collection and vice versa. Combining CAS data across communities can contribute data to multi-site assessment designs. Both can incorporate community engagement and participatory research methods. 1  This chapter focuses on a plan for conducting community assessments and surveillance for obesity prevention efforts as defined. The Committee deliberately uses community assessments or CAs when referring to this aspect only and uses community assessments and surveil- lance or CAS when referring collectively to both aspects. 184 Evaluating Obesity Prevention Efforts

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Why Measure STATUS OR Progress at the Community Level Many of the factors that determine obesity rates—and the decisions to change those factors—are local and, therefore, so are many of the APOP strategies (IOM, 2003, 2012a). In communities, for example: • planning and land use decisions create built environments that support walking and biking and increase access to better food choices and limit exposure to unhealthful foods; • schools provide better food choices and more opportunities for physical activity; • organizations provide and support community programs designed to increase physical activity; • local governments, organizations, and institutions adopt comprehensive strategies to reduce overconsumption of sugar-sweetened beverages and to implement nutritional standards for foods and beverages available at government and public sites; • health care providers improve practices for prevention, screening, diagnosis, and treatment of overweight and obesity; and • employers encourage active living and healthful eating at work. At the local level, people can be more creative and innovative than at the federal or state level. Local communities, in short, can provide direct services, implement policy, change environments, and c ­ reate systems changes. localITY-SPecific and diverse Data Not every strategy enumerated by APOP’s recommendations (IOM, 2012a) can be expected to be appropriate to the specific circumstances of each community. Because local challenges and assets vary widely across America’s communities, selection and adaptation of evidence-based strategies may be most appropriately decided in each community. Local communities across the nation vary widely with respect to population size; cultural, racial and ethnic diversity; and impact of obesity. Local capacities for assess- ment and surveillance are also highly variable, with a wide range of skills and resources for developing and using health and other data. The Committee tried to account for this heterogeneity by developing a tiered set of guidance suitable to diverse communities and initiatives of varying scales and intensities with differing levels of resources for community assessment and surveillance. Because it is possible for local assessors to connect directly with community organizations, and in some cases residents, the potential for community engagement and use of community-based participatory research (CBPR) methods is greater for CAS than for assessment of progress nationally. Overview of Community Assessment and SuRveillance Community assessment2 is a process that involves the systematic collection of data over time at the community level for the purposes of describing current health status and determinants of health at points in time and trends over time (Cibula et al., 2003). Community assessment and surveillance may be global 2 Community assessment as defined by this chapter is focused on assessments of obesity prevention efforts. Community health assessment is commonly used in the field as a way to assess overall health of a community, which can include obesity. Community Obesity Assessment and Surveillance 185

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assessments of the health of a community or focus specifically on chronic diseases, or more specifically on obesity. An obesity-focused community assessment and surveillance can draw attention to obesity as a priority health concern and include more obesity-related information than a broader CAS. In both cases, they should include indicators that assess progress in obesity prevention, such as obesity prevalence3; o ­ besity-related behaviors such as physical activity and food and beverage consumption; features of the environment that influence behaviors such as accessibility of healthful foods, walkability, or places for physical activity; policies that shape environments and behaviors, nutrition, and physical activity pro- grams; other interventions such as media campaigns or food retail promotion of healthier foods; levels of funding for obesity prevention initiatives; transportation systems; and social assets (e.g., groups with a history of working together to promote health, community leadership and champions, and political will). CAS also may include information on community contextual factors that influence obesity (Fawcett et al., 2011), such as demographics of the community, and social determinants of health leading to differential exposure and vulnerabilities (e.g., education and unemployment, income inequality, racism/discrimination, social norms, social capital, residential proximity to walkable areas, and “food deserts”). Ideally, they also describe policies that shape environments and behaviors such as menu labeling or pedestrian master plans, as well as the interactions of sectors and institutions in addressing obesity from a systems analysis perspective, although data and methods for these domains are just emerging (see Chapter 9). CAS displays and disseminates data through reports, presentations, and websites using a variety of data description and visualization methods (e.g., maps of available community parks and supermarkets). The general tasks of CAS in the context of this report are to describe the current state of obesity- related and contextual indicators and track them over time. The information gathered from CAS can identify areas that need improvement, monitor the implementation or emergence of policies, programs, or other interventions, and track changes in contextual influences. These provide various forms of data to facilitate planning for future actions and to examine the effects of interventions over time. CAS systems can range from simple reports of generally available indictors easily accessed on the Web to intensive projects that involve a combination of primary and secondary data collection, sophisticated qualitative and quantitative data analysis, and advanced dissemination and visualization techniques. This chapter describes uses of CAS in the context of this report, commonly used indicators and some innovative ones, sources of data for these indicators, methods for conducting CAS, examples of typical and exemplary CAS, gaps in current CAS indicators and methods, and recommendations for obesity-focused CAS. Box 7-1 provides an actionable plan to implement a community obesity assessment. The rest of the c ­ hapter provides support and guidance for implementing each step with specific attention to different needs for larger and smaller communities. This support and guidance includes where possible the identi- fication of existing tools, resources, and methods for consideration framed around assessing the environ- mental and policy strategies recommended in the APOP report (IOM, 2012a). Define community boundaries The Committee defines community level as activities conducted by local governmental units (e.g., cities, counties), school districts, quasi-governmental bodies (e.g., regional planning authorities, housing authorities) and private-sector organizations (e.g., hospitals, businesses, after school programs). In this 3  Incidence data would be preferable, but these are generally not available at the local level. 186 Evaluating Obesity Prevention Efforts

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context, community is defined as people sharing a common place (e.g., city, neighborhood); they may also share a common experience (e.g., living in a neighborhood with few grocery stores or parks or living in poverty) or interest (e.g., working together to promote better nutrition or active living) (IOM, 2012b). A community may also be defined as a group of people who identify themselves as sharing a common inter- est or culture, but this interpretation is only applicable here to the extent that such a common-interest community is local. Geographic community definitions can be based on jurisdictional boundaries (e.g., city, county, school district, hospital district), census-defined boundaries (e.g., census places or metropolitan/­ micropolitan statistical areas), or customized boundaries (e.g., aggregations of census tracts or ZIP codes). The choice of geographic boundaries often depends on availability of data for the area of interest. CAS can describe and track health inequities among different groups; for example, those sharing race/ethnicity, gender, sexual orientation, income, and geography. By displaying indicators stratified by demographic and geographic strata, it becomes apparent whether progress in preventing obesity is occur- ring equitably (see Figures 7-1 and 7-2 for examples). The boundaries of the community must be explicit to help to clarify the conditions of that particular community and to identify the appropriate set of indica- tors (McIntyre and Ellaway, 2000). Engage community members and other key stakeholders Collaborative approaches to CAS involving government, community organizations, and private-sector stakeholders have gained recent recognition for addressing the complex set of factors associated with popu- lation health. Engaging community members and private-sector stakeholders in planning and sense-making is essential to understanding, implementing, and sustaining community assessments and surveillance and health improvement efforts (IOM, 2003). Interested stakeholders include community organizations and coalitions, hospitals, local public health agencies, human service agencies, schools, business, and commu- nity health centers. Meaningful participation extends beyond physical presence of community members to include their active engagement in generating ideas, contributing to decision making, and sharing responsi- bility for taking action (NIH, 2011). Stakeholders can engage during some or all phases of CAS, including • Review/revise community definition, participating stakeholders; • Assess stakeholder priorities for focus/topics, for assessment/surveillance, and to engage in plan- ning the assessment; • Determine resources and capacities among participants (e.g., staff, technical skills, data, fund- ing, etc.) available for conducting assessment/surveillance; • Make community participation and involvement easier (i.e., enhance access by arranging meet- ings at times and places convenient for community members, with language/physical access, transportation, child care, and other necessary accommodations); and • Include community members in data collection and interpretation of results, and disseminate findings (detailed throughout this chapter). The extent and type of end-user engagement should be appropriate to the scale and scope of each specific community assessment or development of surveillance capacity. Community Obesity Assessment and Surveillance 187

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BOX 7-1 Components of a Community Obesity Assessment and Surveillance Plan Purpose: To provide accurate and timely knowledge of local obesity-related conditions and relevant changes or trends over time as a result of implementing strategies in the Institute of Medicine Accelerating Progress in Obesity Prevention (APOP) report (IOM, 2012a). 1. Define community boundaries. a. Create specific geographic areas that reflect jurisdictions, key stakeholders, and community members’ perceptions of geographic boundaries. 2. Engage community members and other key stakeholders. a. Include stakeholders, to the extent possible, in defining community, identifying priorities, planning assessments, collecting data, interpreting and sense-making of results, and disseminating the findings. 3. Plan assessment/surveillance and include stakeholders and community members. a. Identify lead agency or agencies responsible for conducting assessment/surveillance. b. Clarify goals of assessment/surveillance. c. Define audience and the information that will move it to action. d. Define topics to include in assessment/surveillance. e. Identify sub-populations and small areas disproportionately affected by obesity, and develop approach to collecting information about them. f. Select local data to be included about context, assets, interventions, barriers, and social determinants, and which data to schedule for ongoing surveillance. The principles and methods developed for conducting CBPR are well-suited for promoting commu- nity engagement in assessment and surveillance of the assets of the community; identifying local concerns; designing and conducting the assessment/surveillance; interpreting, disseminating, and translating the find- ings; and sustaining and evaluating partnerships that act on the assessment/surveillance findings (Fawcett et al., 2003; Israel et al., 2013; Minkler and Wallerstein, 2008). CBPR methods can contribute to assuring accurate findings that describe true conditions in the community because they bring diverse perspectives and knowledge bases into the assessment/surveillance process. CBPR contributes to bringing together 188 Evaluating Obesity Prevention Efforts

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4. Collect data. a. Obtain existing data from web-based platforms or published reports. b. As resources permit, add other sources of data. c. Create an inventory of local obesity prevention interventions. 5. Analyze and interpret the data. a. Include trends over time. b. Present data for infants, children, adolescents, adults, and special populations. c. Describe variation in indicators (e.g., across race/ethnicity/socioeconomic status/small areas). d. Include comparison to benchmarks, state rates, and peer communities. e. Compare extent of existing interventions identified to those recommended in the APOP report (IOM, 2012a). f. Share data with community members and other stakeholders for their interpretations and suggested implications for action. g. Visualize, or illustrate, data (see Figures 7-1 and 7-2). 6. Disseminate findings. a. Prepare reports, websites, infographics, and other dissemination tools. b. Share findings with stakeholders and engage them in interpretation of findings. c. Present findings at community meetings for further interpretation. d. Implement a media advocacy strategy to gain media coverage. e. Consider using social media to further increase awareness of findings. assessment/surveillance professionals and the community “to establish trust, share power, foster co-learn- ing, enhance strengths and resources, build capacity, and examine and address community-identified needs and health problems” (Israel et al., 2013, p. 14), especially in communities affected by health inequities. Box 7-2 summarizes some key aspects. An example of the application of participatory methods to community obesity assessment and surveillance comes from the work of Faith Leaders for Environmental Justice in New York City (see Box 7-3). Community Obesity Assessment and Surveillance 189

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Indicator: Percent of Adults Who Are Obese, Health Reporting Areas, King County, 2007-2011 Legend Adult obesity rate 29% - 35% 23% - 28% 17% - 22% 10% - 16% ­ 0 1.5 3 6 9 12 Miles Rate = Percent of adults with Body Mass Index >=30 Source: Washington State Department of Health, Center for Health Statistics, Behavioral Risk Factor Surveillance System supported in part by Centers for Disease Control and Prevention Cooperative Agreement Produced by: Public Health-Seattle & King County Assessment, Policy Development & Evaluation 3/13/2013 Path: S:\WORK\CoreIndicators\2011-2012\HRAdata for maps\Obese Map 3.mxd FIGURE 7-1  Example of illustrating community health indicator data—map. SOURCE: Used with permission from Public Health–Seattle & King County (King County, 2013b). Obese by Household Annual Income Obese by Race/Ethnicity among King County adults age 18+ among King County adults age 18+ 2006-2010 Combined 2006-2010 Combined FIGURE 7-2  Examples of illustrating community health indicator data—bar chart. NOTE: AN = Alaskan Native; PI = Pacific Islander. SOURCE: Used with permission from Public Health–Seattle & King County (King County, 2013c). Figure 7-2.eps 2 bitmaps, titles retyped 190 Evaluating Obesity Prevention Efforts

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BOX 7-2 Increasing Participation in Community Assessment and Surveillance (CAS) 1. Identify those community members and groups, including those experiencing health disparities, that have a stake in community health improvement and conducting a CAS. 2. Invite members of the community to participate through public announcements and connectors—those with trusting relationships and credibility with members of diverse communities. 3. Make community participation and involvement easier by addressing logistical and cultural barriers to participation. 4. Make community participation and involvement more rewarding • Assure that the “6 Rs” are incorporated into the group’s meetings and activities, including ——Recognition—Recognize people for their contributions. ——Respect—Respect and consider people’s values, culture, ideas, and time. ——Role—Give each person a clear and meaningful role through which they can contribute. ——Relationships—Provide opportunities for people to establish relationships and build networks. ——Reward—Ensure that the rewards of participating in the group outweigh the costs. ——Results—Work to achieve results that are linked to outcomes of importance to the community. 5. Assess and enhance the cultural competence of the community assessment/surveillance initiative by considering the local customs and values of the community, designing the assessment/surveillance with the participation of people from diverse cultures within the community, and assuring that minority groups have the power and voice to express their concerns and ideas. 6. Assure open communication of draft plans/findings and opportunities for review and feedback from the whole community. SOURCE: Adapted from Fawcett et al., 2011. Plan assessment/SURVEILLANCE Planning a CAS includes identifying a lead agency responsible for conducting it; clarifying its goals; defining the target audience and what information will move them to action; defining topics to include in the assessment/surveillance; identifying sub-populations and small areas disproportionately affected by o ­ besity; developing approaches to collecting information about them; and selecting local data about con- text, assets, interventions, barriers, and social determinants. Community Obesity Assessment and Surveillance 191

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BOX 7-3 Community-Based Participatory Research: The Faith Leaders for Environmental Justice The Faith Leaders for Environmental Justice (FLEJ), a group of individuals and organizations in New York City with interest in mobilizing communities around environmental justice issues, was interested in influencing public policy focused on the issue of food access. This group brought together community residents to help to identify priority problems in their communities, document problems associated with the food environ- ments, elicit experiences on the Supplemental Nutrition Assistance Program and other food access–related policies, and identify existing policies that may relate to their policy goals and interests. The work of this group illustrates the utility of a community-based participatory approach and to policy advocacy work. The FLEJ used the Everyday Democracy’s “dialogue-to-change” process (http://www.everyday-democracy. org, accessed November 11, 2013), which involved bringing together a cross-section of community resi- dents to share their views and experiences through structured facilitated conversations in small groups. For this dialogue process, local food and health experts and Everyday Democracy developed a guide. Trained individuals facilitated “dialogue circles” during a 2-day summit, with the materials helping to guide the conversation. Each circle was tasked to identify three action ideas. The information collected from the group conversations identified a list of the most popular ideas and helped form working groups in which the com- munity residents would participate in developing the necessary data and interventions. The working groups were Business Outreach; Community Engagement; Farm Bill; Food; Voter Education; and Healthy Incentives. These working groups then developed a targeted approach to tackling their particular issue. SOURCE: Tsui et al., 2013. Valuable resources are available for conducting CAS. The Community Tool Box, Centers for Disease Control and Prevention (CDC), National Association of County and City Health Officials, state health departments, and others offer guidance on methods for conducting CAS. Box 7-4 provides a list of exam- ple tools and resources that are available for planning CAS. Identifying a Lead Agency Responsible for Conducting the Assessment and Surveillance Identifying a lead agency (or agencies) for the assessment promotes accountability for completing the CAS. The choice of which agency or agencies are best suited to lead the CAS depends on community context and agency assets. A lead agency should have the capacity to convene and manage the CAS process, access ­ to the data needed for the assessment, skills in data analysis, and resources for communicating and dissemi- nating findings. If a lead agency does not have these assets, then collaboration with others is an alternative. In participatory CAS, the engaged stakeholders choose or endorse the lead agency early in the process. In other cases, such as the production of routine assessments as part of a local health department’s responsibili- ties, the lead agency may initiate and conduct the CAS, engaging stakeholders in a more limited capacity. ­ 192 Evaluating Obesity Prevention Efforts

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BOX 7-4 Example Tools and Resources for Planning Community Assessment/Surveillance National Resources • Association for Community Health Improvement: Community Health Assessment Toolkit—http://www. assesstoolkit.org • Catholic Health Association: Assessing and Addressing Community Health Needs—http://www.chausa. org/communitybenefit/printed-resources/assessing-and-addressing-community-health-needs • Community Health Assessment and Group Evaluation (CHANGE): Building a Foundation of Knowledge to Prioritize Community Needs—http://www.cdc.gov/nccdphp/dch/programs/healthycommunitiespro- gram/tools/change.htm • Community Health Needs Assessment—http://www.chna.org • Health Education Curriculum Analysis Tool (HECAT)—http://www.cdc.gov/HealthyYouth/HECAT/index.htm • Indian Community Health Profile Toolkit—http://www.npaihb.org/images/resources_docs/Toolkit_Final.pdf • Mobilizing for Action through Planning and Partnerships (MAPP)—http://www.naccho.org/topics/ infrastructure/mapp • Protocol for Assessing Community Excellence in Environmental Health (PACE EH)—http://www.cdc.gov/ nceh/ehs/CEHA/PACE_EH.htm • Resource Center for Community Health Assessments and Community Health Improvement Plans— http://www.naccho.org/topics/infrastructure/CHAIP/chachip-online-resource-center.cfm • Some Recommended Practice Areas for Enhancing Community Health Improvement. Work Group for Community Health and Development, University of Kansas—http://ctb.ku.edu/sites/default/files/site_ files/recommended_practices_for_enhancing_community_health_improvement.pdf • School Health Index (SHI): Self-Assessment and Planning Guide—http://www.cdc.gov /HealthyYouth/SHI • The Community Tool Box—http://ctb.ku.edu/en/default.aspx State Resources • New York State Department of Health—http://www.health.ny.gov/statistics/chac • Minnesota Department of Health—http://www.health.state.mn.us/divs/opi/pm/lphap/cha/howto.html • North Carolina Department of Health and Human Services—http://publichealth.nc.gov/lhd/cha NOTE: Web addresses accessed November 11, 2013. Community Obesity Assessment and Surveillance 193

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TABLE 7-6  Community Health Issues Identified Using a Mix of Community Assessment Methods (Douglas County, Kansas, 2012) Health Concern Focus Status Community Health Issue Survey Group Interviews Report Photovoice Lack of access to affordable healthy foods • • • • • Limited access to dental services • • • • Insufficient access to health care and other services • • • • Poverty/too few job opportunities • • • • Limited access to safe,* affordable housing • • • • Frequent abuse of alcohol (including binge drinking and drinking and driving) • • • • Lack of access to health insurance coverage • • • • Disparities in health outcomes and quality of life • • • Inadequate recognition of mental health issues and access to mental health services • • • Limited knowledge of available health and other services • • • Lack of physical activity • • • Inadequate transportation linking people to services, jobs, and recreation • • Prevalence of abuse and intimate partner violence • • * Safe housing includes absence of environmental toxins, including mold and lead. SOURCE: Collie-Akers and Holt, 2012. with the widespread availability of software applications and user-friendly websites for data visualiza- tion. For example, www.healthydane.org provides an interactive website to view the health status of Dane County, Wisconsin. It is available for use by the entire community. Mapping, facilitated by the increasing availability of geocoded data and sophisticated software, has emerged as a powerful tool for displaying geographic variability of indicators and time trends in geographic patterning.14 Storytelling can bring data to life and create a compelling case for action (Work Group for Community Health and Development and University of Kansas, 2013a). Collecting stories in a story bank so that relevant ones can be accessed in a timely fashion facilitates their use. 14  For examples, see http://­ childhealthdata.org/browse/rankings; http://www.cdc.gov/obesity/data/adult.html; http://www.­ community commons.org; http://www.countyhealthrankings.org (accessed November 11, 2013). 212 Evaluating Obesity Prevention Efforts

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BOX 7-7 Assessing Health Inequities and Disparities Contra Costa Health Services uses small-area analysis to identify health disparities within the Contra Costa county in California. With this information Contra Costa created a 5-year plan to reduce health and health care disparities. This includes efforts to improve its service delivery system to address health dispari- ties (e.g., through culturally and linguistically appropriate services) and efforts to partner with local commu- nity and public agencies (e.g., education, housing, transportation, community development, land use plan- ning) to address physical and social environmental factors that underlie health inequities. Website: http:// cchealth.org (accessed November 12, 2013). Alameda County Public Health Department in California is addressing the social conditions that lead to poor health through participation in the Joint Center for Political and Economic Studies, Health Policy Institute National Place Matters Initiative. Alameda County closely tracks inequities in health and uses data on social determinants of health to inform community health improvement efforts. Public health officials in Alameda County use compelling data to raise awareness about inequities and the importance of addressing conditions for health at a fundamental level, and they underscore the need for capacity-building to address these systemic issues. Website: http://www.acphd.org (accessed November 12, 2013). Disseminate findings Community measures of obesity and its determinants are useful to the extent to which they are used to increase awareness of the issue, implement or improve interventions, and track progress (or lack thereof). Therefore, dissemination of findings to end users is an essential component of the assessment and surveillance process. Most commonly, findings are assembled into a report that is posted on a website or distributed to interested parties. Summarizing key findings in an infographic can help users to quickly understand the key messages. A few larger health departments have interactive data analysis or visualiza- tion tools on their websites to allow end users to customize their information (Communities Count, 2013; Los Angeles County, 2013; New York City Department of Health and Mental Hygiene, 2013a). Briefings of decision makers and policy makers can increase the likelihood that findings will shape policies, b ­ udgets, and programmatic decisions, especially if efforts are made to engage them in interpreting and making sense of the data. Using media advocacy methods to earn media coverage allows the findings to reach a larger audience (APHA, 2000; Wallack et al., 1999). Social media channels can augment coverage and reach more diverse audiences. Hosting community meetings to discuss and make sense of the data can engage residents in devising and implementing interventions and can build support for obesity prevention. Community Obesity Assessment and Surveillance 213

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Current Practice in Community Assessment AND SURVEILLANCE This chapter concludes with an overview of what communities across the United States are doing with respect to obesity-focused CAS. To locate CAS examples, the Committee consulted with experts and organizations that provide technical assistance for conducting CAS and used Internet search engines to identify and review existing CAS. Table 7-7 identifies indicators reported in the sample of CAS reports the Committee was able to identify and does not represent the wide-ranging set of obesity-related indicators measured in CAS across the country. The table aims to illustrate indicators that are reported from CAS in more than one community. Each community reported a number of other obesity-related indicators in its CAS, such as overweight low-income infants and children, use of outdoor recreational areas, safety of cyclists, adults who have been advised by a health care professional to lose weight, and gaining insight into the community’s obesity-related norms and attitudes, such as the accessibility to affordable healthy foods and effectiveness of the health care system (see Appendix G). summary Community assessments are intended to assess the current status, and surveillance systems are intended to assess progress overall in a community. They involve the collection of data at a point in time and over time at the community level for the purpose of describing current health status and determinants of health at points in time and over time. Specific to obesity, these data can describe the current state of obesity-related intended impacts and outcomes (see Figure 3-1) as well as contextual factors that influence obesity (e.g., demographics, social determinants). Although the chapter identifies several resources available to aid communities across the country, ­ there is no consensus guidance for what indicators to measure or what methodologies to use when con- ducting obesity-focused CAS. Based on a review of the current infrastructure for conducting obesity- focused CAS, the Committee found • a lack of data available at the local level for indicators relevant to measuring progress of APOP strategies (IOM, 2012a). Especially needed are data for preschoolers and elementary school s ­ tudents and systematic descriptions of determinants of obesity (e.g., environments, policies, other interventions, norms, and attitudes). Additional sources of data at the local level may exist in multiple sectors, such as health care, planning, and schools; and • a need to increase sample size of existing surveillance systems, add data on missing indicators, and develop new systems for policy, environmental, and intervention indicators, and for report- ing data by race and socioeconomic status to the extent possible and by small areas affected by inequity in larger communities. Other important findings include the following: • There is a lack of a common set of indicators to allow cross-community comparisons and aggregation; • Engaging stakeholders/community in assessment process is valuable; • Capacity to develop assessments varies widely across communities; and 214 Evaluating Obesity Prevention Efforts

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TABLE 7-7  Examples of Indicators Reported in Broader Community Health Assessment Reports Small Counties (50,000 residents) Contra Lawrence- Cherokee Hill McKean Costa Dutchess Douglas County, County, Lincoln, County, County, County, County, Lee County, Indicator Topic  NCa MTb MAc PAd CAe NYf KSg NCh Overarching                 Obesity (adult) • • • • • Overweight (adult) • • Overweight/obese (adult) • Obesity (child) • Overweight (child) • Overweight/obese (child)         • •     Goal Area 1: Physical Activity Environmenti Adults leisure time physical activity • • • Adult physical activity • • Goal Area 2: Food and Beverage Environmenti Adults consumption of fruits and vegetables •   •     •   Access to affordable healthy foods • • Goal Area 3: Message Environmenti Goal Area 4: Health Care and Worksite Environmenti Goal Area 5: School Environmenti Other: Norms/Attitudes, obesity-related Perceived priorities/assets/issues/needs of the community (obesity-related) • • • • • • • SOURCES: a County of Cherokee (2008); b Larson (2013); c Community Opportunities Group, Inc. (2010); d Center for Rural Health Practice and University of Pittsburgh at Bradford (2005); e Contra Costa Health Services Public Health Division (2010); f Center for Governmental Research (2009a,b); g Collie-Akers and Holt (2012); h Lee County Public Health Assessment Team and LeeCAN (2010). i These are goal areas identified in the Accelerating Progress in Obesity Prevention report (IOM, 2012a). 215

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• Improving the accessibility and dissemination of assessment data through multiple channels will improve their use for decision makers, media, and the public. The Community Obesity Assessment and Surveillance Plan (see Box 7-1) provides guidance for local communities to identify and use a set of common indicators that measure impacts and outcomes of strategies recommended in the APOP report (IOM, 2012a). It also provides guidance for developing local capacity for these assessments, including common use and understanding of assessment protocols, descrip- tions of health disparities, community engagement, oversight, and public reporting on progress. The plan was developed not only to accommodate communities with varying resources and assets (i.e., large and small communities), but also to provide a common set of indicators that can be measured, compared, and aggregated across multiple jurisdictions. Given the existing gaps in the current infrastructure for CAS of APOP strategies identified by the Committee, Chapter 10 provides seven recommendations (and a set of potential actions and actors) to support the successful implementation of the components of the Community Obesity Assessment and Surveillance Plan. References AHRQ (Agency for Healthcare Research and Quality). 2013. Medical expenditure panel survey: State-level medical expenditures. http://meps.ahrq.gov/data_stats/quick_tables_results.jsp?component=1&subcomponent=0&year= 2010&tableSeries=8&searchText=&searchMethod=1&Action=Search (accessed March 20, 2013). APHA (American Public Health Association). 2000. APHA media advocacy manual. Washington, DC: APHA. Arterburn, D. E., G. L. Alexander, J. Calvi, L. A. Coleman, M. W. Gillman, R. Novotny, V. P. Quinn, M. Rukstalis, V. J. Stevens, E. M. Taveras, and N. E. Sherwood. 2009. Body mass index measurement and obesity prevalence in ten U.S. health plans. Clinical Medical Research 8(3/4):126-130. Baum, F. 1995. Researching public health: Behind the qualitative-quantitative methodological debate. Social Science and Medicine 40(4):459-468. Beebe, J. 2001. Rapid assessment process: An introduction. Walnut Creek, CA: Altamira Press. Beierle, T. C. 1999. Using social goals to evaluate public participation in environmental decisions. Policy Studies Review 16(3/4):75-103. Braveman, P. A. 2003. Monitoring equity in health and healthcare: A conceptual framework. Journal of Health Population Nutrition 21(3):181-192. Brookmeyer, R., and D. F. Stroup. 2004. Monitoring the health of populations: Statistical principles and methods for public health surveillance. New York: Oxford University Press. Brownson, R. C., C. J. Newschaffer, and F. Ali-Abarghoui. 1997. Policy research for disease prevention: Challenges and practical recommendations. American Journal of Public Health 87(5):735-739. Brownson, R. C., R. A. Housemann, D. R. Brown, J. Jackson-Thompson, A. C. King, B. R. Malone, and J. F. Sallis. 2000. Promoting physical activity in rural communities: Walking trail access, use, and effects. American Journal of Preventive Medicine 18(3):235-241. CDC (Centers for Disease Control and Prevention). 2010. 10 essential public health services. http://www.cdc.gov/ nphpsp/essentialservices.html (accessed March 20, 2013). CDC. 2011. SMART: BRFSS city and county data. http://www.cdc.gov/brfss/smart/technical_infodata.htm (accessed July 12, 2013). CDC. 2013. Diabetes public health resource. Diabetes interactive atlas. http://www.cdc.gov/diabetes/atlas (accessed May 30, 2013). 216 Evaluating Obesity Prevention Efforts

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