Pamela M. Schwartz

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.

Promoting Policy and Environmental Change Using Photovoice in the Kaiser Permanente Community Health Initiative

Creative ways must be found to engage both community residents and political leaders around policy and environmental solutions to public health issues. Photovoice is a community-based, participatory approach to documentary photography that provides people with training on photography, ethics, critical discussion, and policy advocacy. Photovoice projects have been implemented across the nation as part of Kaiser Permanente’s Community Health Initiative—a community-based obesity prevention effort. This article focuses on the first Photovoice project implemented in three communities in Colorado. Photovoice themes related to healthy eating and active living include a lack of access to healthy food choices in stores and schools, unsafe street crossings and sidewalks, and the need to redevelop certain areas to encourage safe recreation. The involvement of policy leaders in the project combined with several dissemination activities has contributed to healthier food offerings in schools and neighborhoods and city planning efforts that emphasize walkability and access to healthy food, and park revitalization.

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.

Kaiser Permanente's Community Health Initiative in Northern California: evaluation findings and lessons learned.

Purpose. To describe the evaluation findings and lessons learned from the Kaiser Permanente Healthy Eating Active Living–Community Health Initiative. Design. Mixed methods design: qualitative case studies combined with pre/post population-level food and physical activity measures, using matched comparison schools for youth surveys. Setting. Three low-income communities in Northern California (combined population 129,260). Subjects. All residents of the three communities. Intervention. Five-year grants of

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

1.5 million awarded to each community to support the implementation of community- and organizational-level policy and environmental changes. Sectors targeted included schools, health care settings, worksites, and neighborhoods. Measures. Reach (percentage exposed) and strength (effect size) of the interventions combined with population-level measures of physical activity (e.g., minutes of physical activity) and nutrition (e.g., fruit and vegetable servings). Analysis. Pre/post analysis of population level measures, comparing changes in intervention to comparison for youth survey measures. Results. The population-level results were inconclusive overall, but showed positive and significant findings for four out of nine comparisons where “high-dose” (i.e., greater than 20% of the population reached and high strength) strategies were implemented, primarily physical activity interventions targeting school-age youth. Conclusion. The positive and significant changes for the high-dose strategies suggest that if environmental interventions are of sufficient reach and strength they may be able to favorably impact obesity-related behaviors.

Using the Concept of “Population Dose” in Planning and Evaluating Community-Level Obesity Prevention Initiatives:

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

When planning and evaluating community-level initiatives focused on policy and environment change, it is useful to have estimates of the impact on behavioral outcomes of particular strategies (e.g., building a new walking trail to promote physical activity). We have created a measure of estimated strategy-level impact—“population dose”—based on our work in evaluating obesity prevention initiatives that uses elements of the RE-AIM method of combining reach and effectiveness to estimate the impact of a strategy on risk behaviors within a target population. We provide a definition and examples of measuring population dose, discuss measurement options in the face of uncertainty about key parameters, review ways of increasing population dose, and illustrate how the concept of population dose has been used in the Kaiser Permanente Community Health Initiative.

Using Photovoice as a Participatory Evaluation Tool in Kaiser Permanente’s Community Health Initiative

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.

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

Photovoice is a community-based participatory research method that provides participants who traditionally have little voice in community policy decisions, with training in photography, ethics, critical dialogue, photo captioning, and policy advocacy. Photovoice has been used primarily as a needs assessment and advocacy tool and only rarely as a pre-/postintervention evaluation method. This article describes the use of Photovoice as a participatory evaluation method in the Community Health Initiative, a 6-year, multisite community-based obesity prevention initiative, sponsored by Kaiser Permanente. Fifty community participants (including six youth) from six Community Health Initiative communities used photos and captions to identify, from their perspective, the most significant accomplishments from the initiative at both baseline and follow-up. Accomplishments identified included increased access to fresh/healthy food in local neighborhoods; policy changes supporting a “healthy eating, active living” community; increased access to physical activity; changes to the built environment creating increased neighborhood walkability/safety; and leadership development.

Using Population Dose to Evaluate Community-level Health Initiatives

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.