Loel Solomon

Approaches to Measuring the Extent and Impact of Environmental Change in Three California Community-Level Obesity Prevention Initiatives

Despite growing support among public health researchers and practitioners for environmental approaches to obesity prevention, there is a lack of empirical evidence from intervention studies showing a favorable impact of either increased healthy food availability on healthy eating or changes in the built environment on physical activity. It is therefore critical that we carefully evaluate initiatives targeting the community environment to expand the evidence base for environmental interventions. We describe the approaches used to measure the extent and impact of environmental change in 3 community-level obesity-prevention initiatives in California. We focus on measuring changes in the community environment and assessing the impact of those changes on residents most directly exposed to the interventions.

An Integrated Framework For The Prevention And Treatment Of Obesity And Its Related Chronic Diseases

Improved patient experience, population health, and reduced cost of care for patients with obesity and other chronic diseases will not be achieved by clinical interventions alone. We offer here a new iteration of the Chronic Care Model that integrates clinical and community systems to address chronic diseases. Obesity contributes substantially to cardiovascular disease, type 2 diabetes mellitus, and cancer. Dietary and physical activity interventions will prevent, mitigate, and treat obesity and its related diseases. Challenges with the implementation of this model include provider training, the need to provide incentives for health systems to move beyond clinical care to link with community systems, and addressing the multiple elements necessary for integration within clinical care and with social systems. The Affordable Care Act, with its emphasis on prevention and new systems for care delivery, provides support for innovative strategies such as those proposed here.

The Kaiser Permanente Community Health Initiative: Overview and Evaluation Design

We provide an overview of the Kaiser Permanente Community Health Initiative--created in 2003 to promote obesity-prevention policy and environmental change in communities served by Kaiser Permanente-and describe the design for evaluating the initiative. The Initiative focuses on 3 ethnically diverse northern California communities that range in size from 37,000 to 52,000 residents. The evaluation assesses impact by measuring intermediate outcomes and conducting pre- and posttracking of population-level measures of physical activity, nutrition, and overweight.

Menu Labeling Responsive to Consumer Concerns and Shows Promise for Changing Patron Purchases

This study evaluated a calorie labeling intervention in Kaiser Permanente Hospital cafeterias. Three cafeteria conditions were no labeling; calorie and nutrient labeling on posters only; posters plus point-of-purchase menu board calorie labeling. More respondents noticed calorie information at poster plus menu board sites than at poster-only sites (P < 0.05). Over 80% of patrons supported provision of calorie information. There was a significant increase in purchases of lower calorie side dishes (P < 0.0001) and snacks (P = 0.006) at the menu board site, compared with the no-labeling site. These findings support the premise that menu labeling can be useful in worksite wellness initiatives.

A Qualitative Exploration of Alternative Strategies for Building Community Health Partnerships: Collaboration- Versus Issue-Oriented Approaches

Broad-based community partnerships are seen as an effective way of addressing many community, health issues, but the partnership approach has had relatively limited success in producing measurable improvements in long-term health outcomes. One potential reason, among many, for this lack of success is a mismatch between the goals of the partnership, and its structure/membership. This article reports on an exploratory, empirical analysis relating the structure of partnerships to the types of issues they address. A qualitative analysis of 34 “successful” community health partnerships, produced two relatively clear patterns relating partnership goals to structurel membership: (1) “collaboration-oriented” partnerships that included substantial resident involvement and focused on broader determinants of health with interventions aimed at producing immediate, concrete community improvements; and (2) “issueoriented” partnerships that focused on a single, typically health-related issue with multilevel interventions that included a focus on higher-level systems and policy change. Issue-oriented partnerships tended to have larger organizations governing the partnership with resident input obtained in other ways. The implication of these results, if confirmed by further research, is that funders and organizers of community health partnerships may need to pay closer attention to the alignment between, the membership/structure of a community partnership and its goals particularly with respect to the involvement of community residents.

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 individuals 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 Permanentes 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 Permanentes 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.

Creating physical activity-promoting community environments: time for a breakthrough.

Increasing the amount of physical activity Americans get to recommended levels will require changes in community environments so that people can be more active as part of everyday life. Recent and pending federal legislation can provide the investments and other support necessary to make. These changes also positively address other major challenges we face as a nation, including climate change and the ailing economy.

A Community-Level Initiative to Prevent Obesity: Results From Kaiser Permanente’s Healthy Eating Active Living Zones Initiative in California

INTRODUCTION A growing number of health systems are leading health promotion efforts in their wider communities. What impact are these efforts having on health behaviors and ultimately health status? This paper presents evaluation results from the place-based Kaiser Permanente Healthy Eating Active Living Zones obesity prevention initiative, implemented in 2011-2015 in 12 low-income communities in Kaiser Permanentes Northern and Southern California Regions. METHODS The Healthy Eating Active Living Zones design targeted places and people through policy, environmental, and programmatic strategies. Each Healthy Eating Active Living Zone is a small, low-income community of 10,000 to 20,000 residents with high obesity rates and other health disparities. Community coalitions planned and implemented strategies in each community. A population-dose approach and pre and post surveys were used to assess impact of policy, program, and environmental change strategies; the analysis was conducted in 2016. Population dose is the product of reach (number of people affected by a strategy divided by target population size) and strength (the effect size or relative change in behavior for each person exposed to the strategy). RESULTS More than 230 community change strategies were implemented over 3 years, encompassing policy, environmental, and programmatic changes as well as efforts to build community capacity to sustain strategies and make changes in the future. Positive population-level results were seen for higher-dose strategies, particularly those targeting youth physical activity. Higher-dose strategies were more likely to be found in communities with the longest duration of investment. CONCLUSIONS These results demonstrate that strong (high-dose), community-based obesity prevention strategies can lead to improved health behaviors, particularly among youth in school settings. SUPPLEMENT INFORMATION This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Using Population Dose to Evaluate Community-level Health Initiatives

Successful community-level health initiatives require implementing an effective portfolio of strategies and understanding their impact on population health. These factors are complicated by the heterogeneity of overlapping multicomponent strategies and availability of population-level data that align with the initiatives. To address these complexities, the population dose methodology was developed for planning and evaluating multicomponent community initiatives. Building on the population dose methodology previously developed, this paper operationalizes dose estimates of one initiative targeting youth physical activity as part of the Kaiser Permanente Community Health Initiative, a multicomponent community-level obesity prevention initiative. The technical details needed to operationalize the population dose method are explained, and the use of population dose as an interim proxy for population-level survey data is introduced. The alignment of the estimated impact from strategy-level data analysis using the dose methodology and the data from the population-level survey suggest that dose is useful for conducting real-time evaluation of multiple heterogeneous strategies, and as a viable proxy for existing population-level surveys when robust strategy-level evaluation data are collected. SUPPLEMENT INFORMATION This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Investing in Obesity Treatment: Kaiser Permanente's Approach to Chronic Disease Management.

Kaiser Permanente, an integrated health care delivery system in the USA, takes a “whole systems” approach to the chronic disease of obesity that begins with efforts to prevent it by modifying the environment in communities and schools. Aggressive case-finding and substantial investment in intensive lifestyle modification programs target individuals at high risk of diabetes and other weight-related conditions. Kaiser Permanente regions are increasingly standardizing their approach when patients with obesity require treatment intensification using medically supervised diets, prescription medication to treat obesity, or weight loss surgery.