If We Build It, We Will Come: A Model for Community-Led Change to Transform Neighborhood Conditions to Support Healthy Eating and Active Living

Abstract

Neighborhoods affect health. In 3 adjoining inner-city Cleveland, Ohio, neighborhoods, residents have an average life expectancy 15 years less than that of a nearby suburb. To address this disparity, a local health funder created the 2010 to 2013 Francis H. Beam Community Health Fellowship to develop a strategic community engagement process to establish a Healthy Eating & Active Living (HEAL) culture and lifestyle in the neighborhoods. The fellow developed and advanced a model, engaging the community in establishing HEAL options and culture. Residents used the model to identify a shared vision for HEAL and collaborated with community partners to create and sustain innovative HEAL opportunities. This community-led, collaborative model produced high engagement levels (15% of targeted 12 000 residents) and tangible improvements in the neighborhood’s physical, resource, and social environments.

KEY FINDINGS

• ▪ The Healthy Eating & Active Living (HEAL) Model was developed to test the feasibility of a community-led approach to change neighborhood conditions and improve community health. The work proves that communities can come together to articulate a shared vision for their collective future and take strategic action to implement it with the community-led model for HEAL.

  • • Establish a community leadership with majority community representation.

  • • Gather community voice to identify values and priorities for the community’s future, and conduct neighborhood assessments to identify current assets and resources.

  • • Identify and prioritize opportunities for collaborative action that is community envisioned, implemented, and sustained.

  • • Form collaborative community working groups to develop and advance collaborative strategies.

• ▪ The role of the fellow as a facilitator and source of technical and theoretical assistance to the community, rather than as a prescriptive adviser, is critical to ensure successful community-owned strategies.

Neighborhoods, The places where we live, work, play, and age, affect health and life expectancy.¹ Residents of 3 adjacent Cleveland, Ohio, neighborhoods have average life expectancies 15 years less than residents of a suburb 8 miles away.² Factors influencing behaviors around healthy eating and physical activity are significantly linked to neighborhood conditions.³ The physical, social, and resource conditions of neighborhoods can promote or deter healthy eating and physical activity behaviors.⁴ Although some neighborhoods have fewer resources for making healthy choices, research shows that when residents take an active role in improving neighborhood conditions, a positive effect on health results.⁵

The Saint Luke’s Foundation of Cleveland, Ohio, funded and established the 2010–2013 Francis H. Bean Community Health Fellowship (housed at the Case Western Reserve University Center for Reducing Health Disparities) to engage the community in improving conditions, culture, and lifestyle around Healthy Eating & Active Living (HEAL) at the neighborhood level, as part of their ongoing 10-year neighborhood revitalization plan. The fellow functioned as facilitator, connector, and catalyst to create a model envisioned by, led by, and integrated into community, abandoning the usual community health approach that places manufactured health programs into communities.

DEVELOPMENT AND IMPLEMENTATION

The fellow used best practices for community engagement and health promotion to develop a place-based community health model around HEAL. This model is a dynamic, community-led process that continuously engages community members in identifying and prioritizing strategic opportunities for HEAL, building HEAL culture, and implementing and sustaining efforts that create opportunities for HEAL within the context of daily living in the neighborhood (Figure 1).

FIGURE 1—

Community-led model for Healthy Eating & Active Living (HEAL): Cleveland, OH, 2010–2013.

Community Leadership and Engagement

The HEAL Model elicits community involvement and resident leadership throughout the process. Community leadership begins with the HEAL Council, composed of 15 neighborhood resident leaders, supported by community partners and stakeholders. Of the HEAL Council members, 75% are in the neighborhood daily. The HEAL Council creates and guides the implementation of the HEAL strategic plan. Resident leaders ensure that HEAL work maintains fidelity to community voice, provide on-the-ground leadership to continuously increase community engagement, and advance the strategic plan.

Community engagement is the core of the HEAL Model. Guided by the principle “Do Nothing About Me Without Me,”⁶ resident leaders and the community-at-large are empowered throughout the process to create changes they envision in their neighborhood. The HEAL Model places the power to identify and determine how to address priorities into the hands of the community rather than the institution or grant-making organization. This power shift positions the fellow, community partners, and stakeholders to support, rather than drive, the community’s agenda.

Community voice was elicited with a comprehensive engagement strategy that included focus groups, appreciative inquiry, stakeholder interviews, the arts, and large group visioning forums. Equal resident participation across neighborhoods was sought. A complementary HEAL asset assessment identified existing neighborhood resources and opportunities for healthy food and active living (Table 1).

TABLE 1—

Summary of Healthy Eating & Active Living (HEAL) Actualized in Community Across 3 Neighborhood Environment Domains: Cleveland, OH, 2010–2013

	Neighborhood Environment
HEAL Priority	Physical	Resource	Social	Evaluation
Affordable accessible food	Gardening	Education	Support networks	Food retail scans
	Neighborhood garden network (192 backyard gardens, 13 community gardens, 1 urban farm and orchard, 3 school-based gardens)	Hands on gardening training and support led by residents and organizations	Garden mentor network	Food access surveys
	Retail		Garden leader network	Garden evaluation to assess change in skill, capacity, and diet
	Produce in corner store
Opportunities for active living that build relationships	Space	Group exercise activities	Leadership	Tracked repeat participation, retention, and growth of class size and number offered
	5 community centers, 1 church, 3 parks host free exercise activities	Year-round free exercise classes (≥ 40 volunteer-led activities/week for all ages)	Exercise classes and walking groups led by resident volunteer instructor (80% of instructors are from the neighborhood)
	Silver Sneakers gym
	3 marked walking routes
Hubs and safe spaces	Space		Connectedness	Resident surveys: change in community connectedness
	Established 6 community hubs		1 hub in each neighborhood
			Strong relationships between neighbors
			Safety in numbers
Opportunities to learn and practice healthy living skills	Space	Cooking classes	Resident-initiated efforts	Assessed satisfaction, change in knowledge, skill, and intent among participants
	Hands-on learning community kitchen	Year-round healthy cooking courses for adults and youths	Walking groups and events
	Neighborhood walking routes with route markers and maps	Adult and youth healthy weight, healthy lifestyle clinical coaching	Health forums in salons and barbershops
			Resident-led healthy cooking and snack demonstrations
Intraconnected and interconnected communities	Space	Communication	Leadership	Counts of reach and response rate for flyers, Web, etc.
	Kiosk at library	Multimedia neighborhood communications: flyers, mailers, Web, mobile application, video, and social media	Established HEAL Council with resident leaders from each neighborhood
			Cross-neighborhood community planning and workgroups
			Semiannual HEAL focused community planning and resource events
Branding and awareness	HEAL cobranding	Communication	HEAL events	Brand awareness survey
	Signage connecting partner programs and establishments	Interactive HEAL Web site and social media	HEAL and the arts  HEAL wristbands  HEAL partner events

Collaborative, Community-Led Strategies

Considering community-identified priorities and existing assets, the HEAL Council identified actionable areas of opportunity to build infrastructure for healthy living and develop a culture of health in the neighborhood. The council used the resulting plan, the Community Vision for Healthy Living, to engage the larger community in creating, implementing, and participating in strategies for each priority area.

Project Description

Healthy Eating & Active Living (HEAL) engages residents of 3 adjacent inner-city Cleveland, Ohio, neighborhoods in transforming their community to make healthy food and exercise a part of the culture and daily living in these neighborhoods. Since its inception in 2010, HEAL has grown into a community movement, empowering residents, producing high levels of resident engagement, and creating tangible changes in neighborhood culture and environment to support healthy living.

HEAL strategies create change in the neighborhood’s physical, social, and resource environments. HEAL strategies align community voice and assets, providing opportunities for residents and partners to work together to innovatively co-create the changes outlined in the Community Vision for Healthy Living. The strategies were built with the HEAL core value of “community connectedness,” whereby relationship building is the primary driver for garnering resources, aligning strategy, and building necessary infrastructure to create change at a scalable level. The fellow modeled this concept in the visual of a Buckeye Tree (Figure 2).

FIGURE 2—

Healthy Eating & Active Living (HEAL) Tree: model to develop and implement community-led HEAL strategies: Cleveland, OH, 2010–2013.

The HEAL Council formed community working groups that connected and engaged resident leaders, lay residents, and community partners in developing and advancing strategies for priority areas (Table 1).

Example: Creating Opportunities for Exercise

In the Community Vision for Healthy Living, residents identified “opportunities for active living that build relationships” as essential for a healthy, thriving neighborhood. The HEAL resources assessment showed few organized opportunities for active living. One recreation center, shared by 4 neighborhoods, operated at maximum capacity with limited hours and activities. Fifteen neighborhood parks and green spaces were identified as community assets. Considering community voice, available resources, and opportunities for action, the HEAL Council led a community working group to create a free summer outdoor exercise series. The community working group used personal relationships to recruit volunteer activity leaders and exercise instructors from the neighborhood to lead 8 activities at 3 neighborhood parks for 12 weeks. The first quarter had 400 regular participants. Within 2 years, 40 weekly volunteer-led activities were offered each quarter, averaging 300 monthly participants.

Demographics: 3 Neighborhoods, 1 Place

Although Buckeye, Larchmere, and Woodland Hills are neighboring communities in Cleveland, Ohio, sharing the same schools, library, recreation center, and other amenities, they differ demographically and have distinct identities. In 2010, the combined neighborhood population was 21 059 (down 22% since 2000). Hit hard by the foreclosure crisis, vacant homes, blighted structures, and unemployment presented serious challenges for Buckeye and Woodland Hills, with the population shrinking by 24% (2000–2010).

• • Buckeye: largest neighborhood; housing primarily renter-occupied duplexes; struggling commercial corridor

• • Larchmere: smallest and most economically vibrant; anchored by a strong commercial corridor of antique shops, salons, barbershops, and eateries

• • Woodland Hills: predominantly public housing; few commercial businesses

		Race
Demographics	Change in Population, %	% Black	% White	% Renter Occupied	% Below Poverty
Buckeye	−24	80	16	67	32
Larchmere	−20	71	21	70	10
Woodland Hills	−26	97	2	70	43

Source. Welcome to NEO CANDO. Case Western Reserve University. Available at: http://neocando.case.edu. Accessed February 1, 2014

The HEAL Council and residents also worked together to construct 2 community gym spaces and created a community exercise certification program, providing scholarships for instructor certification to residents who, in return, provide free instruction hours to the community to sustain this infrastructure for active living.

EVALUATION

The fellowship focused primarily on the feasibility of successfully developing and implementing a model for community-envisioned and community-implemented change in neighborhood conditions around healthy food and exercise. The program evaluator (J. B. L.) and evaluation intern (Erica Chambers, MPH) evaluated the 6 HEAL priority areas to assess change created in 3 neighborhood domains: physical, resource, and social environments (Table 1). Change indicators for each environment were measured with varied data collection methods.

Engagement was evaluated for reach and authenticity according to the definition, core values, and 10% participation goal set by the HEAL Council at the onset of the work. The HEAL Model exceeded the goal, engaging 15% of the residents (1800) in the focus population (Figure 3) in 2 years.

FIGURE 3—

Healthy Eating & Active Living (HEAL) community engagement flowchart: Cleveland, OH, 2010–2013.

NEXT STEPS

The next key steps are to (1) support continued use of the model to evaluate long-term sustainability and engagement for HEAL activities, and (2) replicate the model in other neighborhood settings to establish proof of concept.

Future evaluation should include measures to understand and validate the community engagement process, describe changes in relationships and behaviors associated with implementation of the work resulting from the model, and assess changes in neighborhood health associated with the work.