Partners for a Healthy City: Implementing Policies and Environmental Changes Within Organizations to Promote Health

Abstract

Current research has suggested that obesity prevention efforts should promote policy and environmental changes. The Partners for a Healthy City project, implemented in Douglas County, Nebraska, focused on collaborating with local organizations to help them select and implement 1 or more policies that promoted healthy eating and physical activity. Of the 346 organizations participating in the project and completing the follow-up assessment, 92% implemented at least 1 new policy or expanded an existing policy related to healthy food and drink options and physical activity, totaling 952 individual policy changes. Common policies included providing water as the primary beverage and installing bike racks to support active commuting to and from work. These findings suggest widespread support for policy changes that promote community health.

Obesity is a growing problem for communities throughout the United States. In 2010, 28% of US adults were obese, and an additional 36% were overweight.¹ There is increasing consensus among experts that environmental factors are driving the obesity epidemic.^2,3 Examples include limited availability of affordable healthy foods, overabundance of cheap unhealthy foods, lack of support for active transportation, and limited physical activity during the workday. As a result, recommended strategies for preventing overweight and obesity among adults largely focus on policy and environmental changes to address these issues.⁴ Although the literature supports community-wide implementation of these strategies, workplaces are considered an ideal setting.⁵

Focusing community efforts on implementing evidence-based strategies in innovative ways has great potential to both combat the obesity epidemic and build the evidence base. Partners for a Healthy City was developed in Douglas County, Nebraska, with those goals in mind.

PROMOTING POLICY CHANGES WITHIN ORGANIZATIONS

The prevalences of obesity (26%) and overweight (37%) in Douglas County are similar to national averages.¹ Beginning in 2003, the Douglas County Health Department in Omaha, Nebraska, and Live Well Omaha, a local nonprofit focused on improving the health of Omaha residents, have intentionally combined forces through common branding, communication, and vision to spearhead a community-wide movement addressing health and health disparities. In 2010, with funding from the Centers for Disease Control and Prevention’s Communities Putting Prevention to Work initiative, Live Well Omaha and the Douglas County Health Department created Live Well Omaha: Douglas County Putting Prevention to Work. This community initiative aimed to prevent obesity by expanding existing policy, systems, and environmental changes with particular focus on making healthy eating and physical activity opportunities accessible and desirable. One of the projects implemented was Partners for a Healthy City (PHC).

Building on recommended strategies,^4,5 PHC was designed to facilitate the initiation or enhancement of policy and environmental changes in faith-based organizations, businesses, physician offices, and ethnically diverse agencies to foster healthier lifestyle choices. Project activities included developing a partner engagement kit, recruiting community trainers, and providing technical assistance to help guide organizations to identify, implement, and sustain policy and environmental changes to support healthier lifestyles.

Above: Partners for a Healthy City logo.

Right: Farm to Work photo taken in a local business park. Photo taken and granted permission by Malone & Co. Released July 27, 2011.

The PHC team consisted of 4 full-time and 6 part-time community trainers. A full-time project director provided oversight of community trainers, maintained reports, and assisted with the implementation of the project. The community trainers were recruited on the basis of their health promotion experience, including their ability to engage specific target populations. Each community trainer was responsible for contacting local organizations to generate interest in the PHC project. To do so, trainers used the Partner Engagement Kit (Box 1). On average, 2 interactions were required per organization to secure participation in the project. Additionally, once an organization agreed to participate, the community trainers spent an average of 5 hours providing technical assistance. Policy implementation support, incentives to promote new policies, and networking sessions were common technical assistance strategies.

Partner Engagement Kit Contents

1. Letter to potential partner

2. Introductory brochure

3. Policy menu

4. Letter of intent

5. Policy assessment

6. Window cling

7. Trainer business card

Note. For more information about the Partners for a Healthy City engagement kit please visit: http://www.partnersforahealthycity.org.

Baseline policy implementation was tracked with an online assessment tool. The tool measured implementation of 9 types of targeted policies:

1. offering healthy food options,

2. supporting local agriculture,

3. increasing access to physical activity,

4. developing an active workplace,

5. providing breastfeeding support,

6. reducing screen time,

7. nutrition labeling,

8. body mass index tracking, and

9. prompts and signage.

After completing the policy assessment, organizations were asked to identify policies that could be implemented and integrated into the culture of the organization. Letters of intent were signed to signify the organizations’ commitment to becoming a PHC and to implement at least 1 policy related to increasing access to healthy food and drinks, physical activity opportunities, or both. Several months after the initial assessment, community trainers completed a follow-up assessment with each organization to evaluate policy implementation.

POLICY SELECTION AND IMPLEMENTATION

Over a 2-year period, 640 organizations were educated about the PHC initiative. Of the organizations educated, 390 (61%) signed a letter of intent to commit to implementing at least 1 healthy eating or physical activity policy (Table 1). Of the 346 organizations that completed the follow-up assessment, 317 (92%) implemented at least 1 new policy or expanded on an existing policy related to healthy food and drink options, physical activity, or both, totaling 952 individual policy changes. On the basis of the number of people in each organization, estimates are that the PHC initiative had an impact on more than 84 000 individuals.

TABLE 1—

Partners for a Healthy City Policy Implementation

Objective/Outcome and Indicator	No.
Organizations contacted and educated
Businesses	320
Faith-based organizations	175
Community-based organizations	49
Human services organizations	11
Physician groups	85
Total organizations	640
Signed letters of intent to implement ≥1 policy
Businesses	167
Faith-based organizations	98
Community-based organizations	38
Human services organizations	8
Physician groups	79
Total organizations	390
New or expanded polices
Total no. of organizations that completed a follow-up assessment	346
Total no. of organizations implementing new or expanded policies	317
Total no. of new or expanded policies	952

Although each organization implemented policies that were unique to its site, the majority of organizations chose policies related to offering healthy food and drink options (e.g., decreasing consumption of sugar-sweetened beverages by installing a water cooler or pitcher), increasing physical activity (e.g., supporting active transportation by installing a bike rack), or both. Community trainers worked closely with the organizations to provide the needed assistance and support to implement these policies. For example, the community trainers collaborated with a local water company to provide water coolers for organizations committed to decreasing sugar-sweetened beverage consumption. The water company agreed to provide a discount for the water coolers and the monthly water fees. The community trainers also worked closely with the city of Omaha’s bike pedestrian coordinator to ensure best placement of bike racks and installation.

Another successful piece of PHC was the Farm to Work initiative. Local farmers partnered with several organizations within 1 mile of each other to sell produce over the lunch hour. This served the dual purpose of supporting local agriculture and increasing access to fresh produce for employees. The farms involved with this effort were identified through the Farm to School initiative, which was another Live Well Omaha: Douglas County Putting Prevention to Work project. It is estimated that the Farm to Work initiative increased access to fresh produce for 1860 people. Additional success stories are described in Box 2.

Partners for a Healthy City Success Stories

An architecture firm paid for employees’ food Co-op fees.

Four organizations partnered to provide Farm to Work.

A physicians group implemented multiple policies at their 36 clinics such as walking meetings, mandatory healthy food/beverage options whenever food was provided, and on-site exercise equipment for staff.

A university environmental service team implemented a walking group twice a week.

Although the PHC project did not examine behavior change, information from the existing literature has suggested that the PHC strategies have the potential to have an impact on behavior change.⁵ For example, research has suggested that workplace physical and cultural supports for active transportation (e.g., perceiving that coworkers actively commute; presence of bicycle parking and storage policies) predict employee utilization of active transportation.⁶

LESSONS LEARNED

The PHC initiative was clearly successful at engaging a large number of diverse organizations in the adoption and implementation of health-promoting policies. Several factors contributed to this success. First, the community trainers were carefully selected on the basis of their existing community ties and ability to effectively engage with organizations. Second, organizations were offered a range of policies from which to choose, which increased the likelihood that at least 1 policy would meet their needs. Third, the community trainers focused on aligning the PHC initiative with other wellness initiatives implemented in the organizations. Last, incentives directly related to the policies being implemented as well as promotional materials such as reusable shopping bags, lunch bags, and posters were provided. Partners were also recognized on the PHC Web site and in local newspapers.

Stair promotion poster.

The PHC initiative illustrates the potential for implementing policies throughout various organizations to increase access to healthy food and drink options and support for physical activity. Although implementation of policies to support healthy food and drink options and physical activity increased dramatically, further research is needed to provide evidence of behavior change. Nonetheless, the recent experience in Douglas County suggests that community support for policy and environmental changes to improve health is widespread.