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 impact health. In three adjoining inner-city Cleveland neighborhoods, residents have an average life expectancy 15 years less than that of a nearby suburb.¹ To address this disparity a local health funder created a Fellowship to develop a strategic community engagement process to establish a Healthy Eating and 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. Using the model, residents identified 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.

Background

Neighborhoods, the places where we live, work, play, and age, impact health and life expectancy.¹ Residents of three adjacent Cleveland neighborhoods have average life expectancies fifteen years less than residents of a suburb eight 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 While some neighborhoods have fewer resources for making healthy choices, research shows that when residents take an active role in improving neighborhood conditions, there is a positive impact on health.⁵

The Saint Luke's Foundation established a 3-year Fellowship to engage the community in improving conditions, culture, and lifestyle around healthy eating and 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, led by, and integrated into community, abandoning the usual community health approach that places manufactured health programs into communities.

Methods

Developing the HEAL Model

Using best practices for community engagement and health promotion, the Fellow developed a place-based community health model around HEAL. This model is a dynamic, community-led process that continuously engages community 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).

Community Leadership and Engagement

The HEAL model elicits community involvement and resident leadership throughout the process. Community leadership begins with the HEAL Council, comprised of fifteen neighborhood resident leaders (RLs), supported by community partners (CPs), and stakeholders. 75% of HEAL Council members are in the neighborhood daily. The HEAL Council creates and guides the implementation of the HEAL strategic plan. RLs ensure HEAL work maintains fidelity to community voice, provide on-the-ground leadership to continuously increase community engagement, and advances the strategic plan.

Community engagement is the core of the HEAL model. Guided by the principle “Do Nothing about Me without Me”⁶, RLs 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, CPs and stakeholders to support, rather than drive the community's agenda.

Community voice was elicited using a comprehensive engagement strategy including 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 HEAL Actualized in Community across 3 Neighborhood Environment Domains.

HEAL Priority	Neighborhood Environment			Evaluation
	Physical	Resource	Social
Affordable Accessible Food	GARDENING: Neighborhood garden network (192 backyard gardens, 13 community gardens, 1 urban farm & orchard, 3 school based gardens) RETAIL: Produce in corner store	EDUCATION: Hands on gardening training & support led by residents and organizations	SUPPORT NETWORKS: Garden mentor network Garden Leader network	Food retail scans Food access surveys Garden evaluation to assess change in skill, capacity, and diet
Opportunities for Active Living that Build Relationships	SPACE: 5 community centers, 1 church, 3 parks host free exercise activities Silver Sneakers gym 3 marked walking routes	GROUP EXERCISE ACTIVITIES Year-round free exercise classes (40+ volunteer led activities/week for all ages)	LEADERSHIP: Exercise classes and walking groups led by resident volunteer instructor (80% of instructors are from the neighborhood)	Tracked repeat participation, retention and growth of class size and number offered
Hubs and Safe Spaces	SPACE: Established 6 community HUBS		CONNECTEDNESS: 1 Hub in each neighborhood Strong relationships between neighbors Safety in numbers	Resident surveys - change in community connectedness
Opportunities to Learn & Practice Healthy Living Skills	SPACE: Hands-on learning community kitchen Neighborhood walking routes with route markers and maps	COOKING CLASSES: Year round healthy cooking courses for adults & youth Adult & youth healthy weight, healthy lifestyle clinical coaching	RESIDENT INITIATED EFFORTS; Walking groups and events Health forums in salons and barber shops Resident-led healthy cooking/snack demos	Assessed satisfaction, change in knowledge/skill and intent among participants.
Intra- & Inter Connected Communities	SPACE: Kiosk at library	COMMUNICATION: Multi-media neighborhood communications: flyers, mailers, web, mobile app, video, and social media	LEADERSHIP: Established HEAL council with RLs from each neighborhood Cross-neighborhood community planning & work groups Semi annual HEAL focused community planning & resource events	Counts of reach and response rate for flyers, web etc.,
Branding & Awareness	HEAL CO-BRANDING: Signage connecting partner programs & establishments	COMMUNICATION: Interactive HEAL website and social media	HEAL EVENTS: HEAL & the arts HEAL wrist bands HEAL partner events	Brand awareness survey

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.

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 using 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. The HEAL Tree - Model to Develop and Implement Community-led HEAL Strategies.

Implementation

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

HEAL Strategy Highlight – 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 four 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 CWG to create a Free Summer Outdoor Exercise Series. Using personal relationships, the CWG recruited volunteer activity leaders and exercise instructors from the neighborhood to lead 8 activities at 3 neighborhood parks for 12 weeks. First quarter had 400 regular participants. Within 2 years, 40 weekly volunteer-led activities were offered each quarter, averaging 300 monthly participants. The HEAL Council and residents also worked together to construct two 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 implemented change in neighborhood conditions around healthy food and exercise. The six HEAL priority areas were evaluated to assess change created in three neighborhood domains: physical, resource, and social environments (see Table 1). Change indicators for each environment were measured using 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 residents (1,800) in the focus population (Figure 3) in 2 years.

Figure 3. HEAL Community Engagement Flow Chart.

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 setting(s) 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.

Sidebars.

Healthy Eating & Active Living (HEAL) engages residents of 3 adjacent inner-city Cleveland 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.

Demographics: 3 Neighborhoods, 1 Place

While Buckeye, Larchmere & Woodland Hills are neighboring communities 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% from in 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, barber shops and eateries

• Woodland Hills - predominantly public housing; few commercial businesses

Demographics	Δ in pop.	Race		% Renter Occupied	% Below Poverty
		%AA	%White
Buckeye	-24%	80%	16%	67%	32%
Larchmere	-20%	71%	21%	70%	10%
Woodland Hills	-26%	97%	2%	70%	43%

Source: NEO CANDO system, Center on Urban Poverty and Community Development, MSASS, Case Western Reserve University (http://neocando.case.edu).