Suzanne Rauzon

Exposure to a comprehensive school intervention increases vegetable consumption.

PURPOSE The current epidemic of childhood overweight has launched a variety of school-based efforts to address the issue. This study reports on the first 2 years of a 3-year evaluation of one school districts comprehensive intervention to transform school foodservices and dining experiences, offer cooking and gardening programs, and integrate nutrition and food systems concepts into the academic curriculum. METHODS This 3-year prospective study enrolled 327 4th and 5th graders in a mid-sized school district in California, and followed them into middle school. Intervention exposure was determined through interviews with school staff and student surveys. Student knowledge and attitudes were assessed annually by questionnaire, and student behavior was assessed annually by 3-day food diary. Household information was gathered by parent questionnaire. Changes in knowledge, attitudes, and behavior were compared by level of intervention exposure using analysis of covariance; pairwise differences were evaluated using Bonferronis test at a procedure-wise error rate of 5%. RESULTS After controlling for family sociodemographic background, students most exposed to the intervention increased their consumption of fruits and vegetables by nearly 0.5 cups (one standard serving), whereas students least exposed decreased their consumption by 0.3 cups (p < .05). Students most exposed to the programming also showed a significantly greater increase in preference for fruit and green leafy vegetables, compared to students least exposed to the programming (p < .05). CONCLUSIONS Future research is needed to better understand the relative importance of the different components of such a program, and their cost-benefits as well as health impacts.

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.

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

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

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

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.

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.

Improvements in Physical Activity Opportunities: Results From a Community-Based Family Child Care Intervention

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.

Changes in Nutrition Policies and Dietary Intake in Child Care Homes Participating in Healthy Eating and Active Living Initiative

INTRODUCTION Reaching preschool-aged children to establish healthy lifestyle habits, including physical activity, is an important component of obesity prevention efforts. However, few studies have examined family child care homes where nearly 1 million children receive care. STUDY DESIGN A pre- and post-intervention evaluation without a control group was conducted to evaluate what changes occurred in family child care homes that participated in the Healthy Eating and Active Living project, a multicomponent obesity prevention initiative, focused on community-driven policy and environmental change in neighborhoods within Kaiser Permanente service areas. SETTING/PARTICIPANTS From 2012 to 2014, a total of 17 family child care homes in Northern California participated in the intervention. INTERVENTION A physical activity workshop for child care staff and technical assistance to develop a policy to promote physical activity and other healthy behaviors. MAIN OUTCOME MEASURES Pre and post observations, questionnaires, and physical activity logs were completed to assess change in physical activity resources available in the family child care homes, the amount of child screen time offered, type and amount of physical activity offered to children, and implementation of physical activity best practices. RESULTS Between baseline and follow-up, providers significantly increased both the number of structured, adult-led activities (2.6 vs 3.2 activities per day) and the number of structured, adult-led minutes of activity in which children participated (49 vs 83 minutes per day). Providers also improved screen time practices and made improvements to the physical activity environment. CONCLUSIONS In this study, a community-based organization designed and implemented multicomponent strategies tailored for participating family child care homes. The successful implementation of the intervention likely contributed to implementation of practices that increased opportunities for physical activity for the young children attending these family child care homes. 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.