Community Approaches to Preventing Obesity in California

The risks of obesity are well known: life-threatening and chronic illnesses that strain an already stretched health care system, shortened life spans, and reduced quality of life—especially in low-income communities of color.

For The California Endowment, designing effective obesity-prevention strategies, particularly among underresourced, diverse communities, is a deep commitment. Over the past decade, The California Endowment has recognized that building healthy communities requires addressing the underlying causes of poor health rooted in social, economic, and physical conditions that determine an individual's health risks and opportunities. In the mid-2000s—using health disparities research, extensive experience with community-level prevention programs, and evaluation findings—The California Endowment pioneered community-scale efforts aimed at preventing obesity among school-aged children by using environmental and policy change strategies to increase physical activity and promote healthy eating. Two programs were developed in communities across California with high rates of obesity, poverty, and health disparities: the Healthy Eating Active Communities (HEAC) program and the Central California Regional Obesity Prevention Program (CCROPP).

The HEAC program, located in six low-income communities, is built around collaborative partnerships between a community-based organization, a school district, and the local public health department. The partnerships strive to improve nutrition and physical activity environments and policies in five settings: neighborhoods, schools, after-school programs, health care, and marketing and media. They engage local governments and nongovernmental entities and forge relationships with new partners within transportation, public safety, and urban planning. HEAC collaborations work, for example, to educate city councils on the benefits of incorporating health considerations into their development plans.

CCROPP aims at increasing the reach of the environmental and policy change approach in eight agricultural Central Valley counties. Working with public health departments and community organizations, CCROPP communities work, for example, to establish farmers’ markets in neighborhoods that have no access to fresh fruits and vegetables and to open schoolyards for community use after hours. HEAC and CCROPP grantees receive technical support from experts in nutrition, physical activity, community and youth organizing, communications, and health policy.

At the same time, Kaiser Permanente prepared to launch its Community Health Initiative (CHI). Kaiser Permanente wanted to explore what could be done to combine the power of a prevention-oriented delivery system with community activism and a focus on community conditions to significantly improve health in Kaiser Permanente's communities.

Faced with high and rising rates of obesity—and mounting research and clinical experience indicating that clinical prevention alone is not enough to address the problem—Kaiser Permanente focuses its CHI on Healthy Eating, Active Living, or HEAL. The framework for this initiative emphasizes a multisectoral approach; a focus on practice, policy, and environmental changes; strategies that employ both community and Kaiser Permanente's own assets; long-term partnerships and investments; and a commitment to using evidence where it is available and building the evidence base where it is lacking.

After testing the CHI model in other Kaiser Permanente regions, the organization brought the initiative to three low-income communities in northern California in 2004: Modesto, Richmond, and Santa Rosa. CHI communities first developed community action plans that provided a roadmap for specific interventions. The plans focused on four settings: schools, neighborhoods, workplaces, and health care. Interventions fielded by CHI communities included getting more fresh fruits and vegetables into local stores, working with community providers to implement evidence-based clinical prevention strategies, planning safe routes for kids to walk or bicycle to school, and incorporating health considerations into planning and development decisions. Although the particular strategies vary considerably, the sites are connected to each other and 37 other Kaiser Permanente–supported CHIs in five other states through a common logic model and national evaluation framework.

CALIFORNIA CONVERGENCE

The California Endowment and Kaiser Permanente next sought to leverage their initiatives and connect grantees to build a statewide movement focused on policy and environmental change. Meanwhile, community leaders and advocates were expressing a desire to share lessons, provide peer support, advance a shared policy agenda, and cultivate a “common identity.” Consequently, The California Endowment and Kaiser Permanente, along with the California Department of Public Health, the Robert Wood Johnson Foundation, the W. K. Kellogg Foundation, and the Centers for Disease Control and Prevention, established California Convergence.

California Convergence, supported by staff at the Public Health Institute, now includes more than 40 communities and connects community-based obesity-prevention and advocacy efforts across the state. It is a learning community and a conduit to state-level policy advocacy organizations.

Local families and residents help maintain an organic community school garden at a monthly garden workday in exchange for fresh produce. This initiative was developed by the Healthy Eating, Active Communities program. Photo by Tim Wagner for Partnership for Public's Health. Available at http://www.twagner.com. Printed with permission.

During the 2008 California Convergence Conference, The California Endowment and Kaiser Permanente convened an evaluation roundtable for evaluators and funders of multisectoral obesity-prevention initiatives in California. Participants recommended sharing what has been learned from the HEAC, CCROPP, and CHI initiatives with a wider public health audience. Reflecting our shared value of collaboration and interest in building the collective knowledge, this issue of the Journal contains a series of articles sharing lessons and challenges from an evaluative perspective.

EVALUATION

Evaluating the impact of any community-based program is difficult, and measuring the effect of an obesity-prevention intervention presents special challenges. First, environmental and policy changes are long term, and changes in behavior (and obesity levels) tend to occur well after interventions end. Determining attribution or even contribution is challenging in community settings. How, for example, does the installation of a new bike path affect community obesity rates? Also, communities are hardly static; people move in and out all the time.

Moreover, when HEAC, CCROPP, and CHI began, there was little precedent on evaluating the impact of comprehensive, multisectoral obesity-prevention initiatives. From the beginning, evaluators had to develop tools that would measure both process and short- and long-term impact.¹

Through the development of logic models and a series of evaluation methods, HEAC and CCROPP evaluators are tracking program implementation and changes in the community environments that affect nutrition and physical activity.^2,3 CHI evaluators have adopted similar methods, focusing on documenting the implementation, reach, and impact of community change efforts.⁴ With communities now having four or more years of experience, results from midpoint evaluations are becoming available, such as adherence to California's school nutrition standards.⁵ Our evaluation teams also surfaced emerging issues requiring further attention from concerned community residents, including violence and unsafe neighborhoods, public transportation, and land-use planning.⁶

CONCLUSIONS

As the Institute of Medicine recently concluded, it is vital, given perceived gaps in the evidence base and the urgency of the obesity epidemic, that comprehensive community-based obesity initiatives like HEAC, CCROPP, and CHI build the evidence base and learn by doing.⁷ The evaluations of these programs are helping inform the field about the feasibility and impact of the environmental and policy approach—an approach that was novel when the initiatives were first launched.

These evaluations have yielded important findings thus far. Among the most important are that policy and systems change at the local level holds promise for fostering sustainable improvements in health and quality of life for residents; a multisectoral approach can be effective, although this approach takes time and can diffuse resources; to produce measurable, population-level behavior change, all those involved must collaborate to deliver interventions of sufficient reach and impact (i.e., “dose”), while developing evaluation systems that can track long-term outcomes; community-based organizations, residents, and advocates can effectively work across sectors; and community residents are effective advocates for broad-based systems change at the local, regional, and statewide levels. The evidence has helped to shift the focus from a relatively narrow set of behavioral and health outcomes (e.g., obesity rates) to indicators of community change that reflect broader community priorities such as land use, violence, and food insecurity.

The evaluations have also raised a number of questions: What are the most promising strategies to address the emerging community issues connected to obesity prevention? How can impact best be measured? Evaluators have made considerable headway in developing tools to measure community changes, but measuring the contribution of specific interventions to changes in obesity rates is still a challenge. How can community improvements be sustained and how can efforts be spread? What is the right amount of outside technical assistance for community-based efforts?

The communities we have had the honor of working with are at the leading edge of transformative change. Our collective initiatives have informed the White House Task Force on Obesity, the First Lady's Let's Move Campaign, and Governor Schwarzenegger's 2010 Summit on Health, Nutrition, and Obesity. The evidence is coming in, and we are encouraged by what we see. And still, we know that there is more to do and more to learn. Using environmental and policy approaches to obesity prevention, we plan to support communities in their efforts to create health equity and address underlying structural causes of obesity. As a matter of equity as well as economic necessity, we seek to create opportunities for improved health where these challenges are greatest. We are committed to continued learning and the continued effort of fostering this community change. Justice demands it. The future of our next generation depends on it.