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

⏐ FFIELDI ACTION REPORT ⏐

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

| Vedette R. Gavin, MPH, Eileen L. Seehozer, MD, MS, Janeen B. Leon, MS, RD, LD, Sandra Byrd Chappelle, MA, and Ashwini R. Sehgal, MD

Neighborhoods affect health. In 3 adjoining inner-city Cleveland, Ohio, neighborhoods, residents The Saint Luke’s Foundation have an average life expectancy 15 years less than that of a nearby suburb. To address this dispar- of Cleveland, Ohio, funded and ity, a local health funder created the 2010 to 2013 Francis H. Beam Community Health Fellowship established the 2010–2013 to develop a strategic community engagement process to establish a Healthy Eating & Active Living Francis H. Bean Community (HEAL) culture and lifestyle in the neighborhoods. The fellow developed and advanced a model, Health Fellowship (housed at the engaging the community in establishing HEAL options and culture. Residents used the model to Case Western Reserve University identify a shared vision for HEAL and collaborated with community partners to create and sustain Center for Reducing Health innovative HEAL opportunities. This community-led, collaborative model produced high engagement Disparities) to engage the com- levels (15% of targeted 12 000 residents) and tangible improvements in the neighborhood’s physi- munity in improving conditions, cal, resource, and social environments. (Am J Public Health. Published online ahead of print April culture, and lifestyle around 16, 2015. doi:10.2105/AJPH.2015.302599) Healthy Eating & Active Living (HEAL) at the neighborhood level, as part of their ongoing 10-year NEIGHBORHOODS, THE neighborhood revitalization plan. places where we live, work, The fellow functioned as facilita- KEY FINDINGS play, and age, affect health and tor, connector, and catalyst to life expectancy.1 Residents of create a model envisioned by, The Healthy Eating & Active Living (HEAL) Model was developed to test 3 adjacent Cleveland, Ohio, led by, and integrated into com- the feasibility of a community-led approach to change neighborhood neighborhoods have average munity, abandoning the usual conditions and improve community health. The work proves that commu- life expectancies 15 years less community health approach that nities can come together to articulate a shared vision for their collective than residents of a suburb 8 places manufactured health pro- future and take strategic action to implement it with the community-led miles away.2 Factors influenc- grams into communities. model for HEAL. ing behaviors around healthy • Establish a community leadership with majority community repre- eating and physical activity are DEVELOPMENT AND sentation. significantly linked to neighbor- IMPLEMENTATION • Gather community voice to identify values and priorities for the hood conditions.3 The physical, community’s future, and conduct neighborhood assessments to social, and resource conditions of The fellow used best practices identify current assets and resources. neighborhoods can promote or for community engagement and • Identify and prioritize opportunities for collaborative action that is deter healthy eating and physi- health promotion to develop a 4 community envisioned, implemented, and sustained. cal activity behaviors. Although place-based community health some neighborhoods have fewer model around HEAL. This model • Form collaborative community working groups to develop and resources for making healthy is a dynamic, community-led pro- advance collaborative strategies. choices, research shows that cess that continuously engages The role of the fellow as a facilitator and source of technical and theoretical when residents take an active community members in identi- assistance to the community, rather than as a prescriptive adviser, is role in improving neighborhood fying and prioritizing strategic critical to ensure successful community-owned strategies. conditions, a positive effect on opportunities for HEAL, building health results.5 HEAL culture, and implementing

Published online ahead of print April 16, 2015 | American Journal of Public Health Gavin et al. | Peer Reviewed | Field Action Report | e1 ⏐ FIELD ACTION REPORT ⏐

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). Collaborative, Community-Led Strategies Considering community- identified priorities and existing assets, the HEAL Council identified actionable areas of opportu- nity 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, im- FIGURE 1—Community-led model for Healthy Eating & Active Living (HEAL): Cleveland, OH, 2010–2013. plementing, and participating in strategies for each priority area. HEAL strategies create and sustaining efforts that create maintains fidelity to community create changes they envision in change in the neighborhood’s opportunities for HEAL within voice, provide on-the-ground their neighborhood. The HEAL physical, social, and resource the context of daily living in the leadership to continuously in- Model places the power to environments. HEAL strategies neighborhood (Figure 1). crease community engagement, identify and determine how to align community voice and as- and advance the strategic plan. address priorities into the hands sets, providing opportunities for Community Leadership and Community engagement is of the community rather than residents and partners to work Engagement the core of the HEAL Model. the institution or grant-making together to innovatively co-create The HEAL Model elicits com- Guided by the principle “Do organization. This power shift the changes outlined in the munity involvement and resi- Nothing About Me Without positions the fellow, community Community Vision for Healthy dent leadership throughout the Me,”6 resident leaders and the partners, and stakeholders to Living. The strategies were built process. Community leadership community-at-large are empow- support, rather than drive, with the HEAL core value of begins with the HEAL Council, ered throughout the process to the community’s agenda. “community connectedness,” composed of 15 neighborhood resident leaders, supported by community partners and stake- Project Description holders. Of the HEAL Council members, 75% are in the Healthy Eating & Active Living (HEAL) engages residents of 3 adjacent inner-city Cleveland, Ohio, neighborhoods neighborhood daily. The HEAL in transforming their community to make healthy food and exercise a part of the culture and daily living in these Council creates and guides neighborhoods. Since its inception in 2010, HEAL has grown into a community movement, empowering residents, the implementation of the producing high levels of resident engagement, and creating tangible changes in neighborhood culture and HEAL strategic plan. Resident environment to support healthy living. leaders ensure that HEAL work

e2 | Field Action Report | Peer Reviewed | Gavin et al. American Journal of Public Health | Published online ahead of April 16, 2015 ⏐ FIELD ACTION REPORT ⏐

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 Gardening Education Support networks Food retail scans accessible food Neighborhood garden Hands on gardening training Garden mentor network Food access surveys network (192 backyard and support led by gardens, 13 community residents and organizations Garden leader network gardens, 1 urban farm and Garden evaluation to orchard, 3 school-based gardens) assess change in skill, Retail capacity, and diet Produce in corner store

Opportunities for active living Space Group exercise activities Leadership Tracked repeat that build relationships 5 community centers, Year-round free exercise Exercise classes and participation, retention, 1 church, 3 parks classes ( 40 volunteer-led walking groups led by and growth of class size ≥ host free exercise activities activities/week for all ages) resident volunteer instructor and number offered (80% of instructors are from Silver Sneakers gym the neighborhood)

3 marked walking routes

Hubs and safe spaces Space Connectedness Resident surveys: Established 6 community hubs 1 hub in each neighborhood change in community Strong relationships connectedness between neighbors Safety in numbers

Opportunities to learn and Space Cooking classes Resident-initiated efforts Assessed satisfaction, practice healthy living skills Hands-on learning community Year-round healthy cooking Walking groups and events change in knowledge, kitchen courses for adults and youths Health forums in skill, and intent among Neighborhood walking routes Adult and youth healthy weight, salons and barbershops participants with route markers and maps healthy lifestyle clinical coaching Resident-led healthy cooking and snack demonstrations

Intraconnected and Space Communication Leadership Counts of reach and interconnected communities Kiosk at library Multimedia neighborhood Established HEAL Council response rate for flyers, communications: flyers, mailers, with resident leaders from Web, etc. Web, mobile application, video, each neighborhood and social media 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 Interactive HEAL Web site and HEAL and the arts and establishments social media HEAL wristbands HEAL partner events

Published online ahead of print April 16, 2015 | American Journal of Public Health Gavin et al. | Peer Reviewed | Field Action Report | e3 ⏐ FIELD ACTION REPORT ⏐

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 Buck- eye Tree (Figure 2). 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, thriv- ing neighborhood. The HEAL resources assessment showed FIGURE 2—Healthy Eating & Active Living (HEAL) Tree: model to develop and implement community-led few organized opportunities for HEAL strategies: Cleveland, OH, 2010–2013. active living. One recreation center, shared by 4 neighborhoods, operated at maximum capacity with limited hours and activities. Fifteen neighborhood parks and Demographics: 3 Neighborhoods, 1 Place green spaces were identified as community assets. Consider- Although Buckeye, Larchmere, and Woodland Hills are neighboring communities in Cleveland, Ohio, sharing ing community voice, available the same schools, library, recreation center, and other amenities, they differ demographically and have distinct resources, and opportunities for identities. In 2010, the combined neighborhood population was 21 059 (down 22% since 2000). Hit hard by action, the HEAL Council led the foreclosure crisis, vacant homes, blighted structures, and unemployment presented serious challenges for a community working group to Buckeye and Woodland Hills, with the population shrinking by 24% (2000–2010). create a free summer outdoor • Buckeye: largest neighborhood; housing primarily renter-occupied duplexes; struggling commercial corridor exercise series. The community • Larchmere: smallest and most economically vibrant; anchored by a strong commercial corridor of antique working group used personal shops, salons, barbershops, and eateries relationships to recruit volunteer • Woodland Hills: predominantly public housing; few commercial businesses activity leaders and exercise instructors from the neighborhood Change in Race % Renter % Below to lead 8 activities at 3 neighbor- Demographics Population, % % Black % White Occupied Poverty hood parks for 12 weeks. The Buckeye −24 80 16 67 32 first quarter had 400 regular Larchmere −20 71 21 70 10 participants. Within 2 years, 40 Woodland Hills −26 97 2 70 43 weekly volunteer-led activities Source. Welcome to NEO CANDO. Case Western Reserve University. Available at: http://neocando.case.edu. Accessed February 1, 2014 were offered each quarter, aver- aging 300 monthly participants. The HEAL Council and residents also worked together to

e4 | Field Action Report | Peer Reviewed | Gavin et al. American Journal of Public Health | Published online ahead of April 16, 2015 ⏐ FIELD ACTION REPORT ⏐

FIGURE 3—Healthy Eating & Active Living (HEAL) community engagement flowchart: Cleveland, OH, 2010–2013.

construct 2 community gym neighborhood conditions around of the work. The HEAL Model and validate the community en- spaces and created a community healthy food and exercise. The exceeded the goal, engaging gagement process, describe exercise certification program, program evaluator (J. B. L.) and 15% of the residents (1800) in changes in relationships and be- providing scholarships for in- evaluation intern (Erica Cham- the focus population (Figure 3) haviors associated with imple- structor certification to residents bers, MPH) evaluated the 6 in 2 years. mentation of the work resulting who, in return, provide free in- HEAL priority areas to assess from the model, and assess struction hours to the community change created in 3 neighbor- NEXT STEPS changes in neighborhood health to sustain this infrastructure for hood domains: physical, re- associated with the work. active living. source, and social environments The next key steps are to (1) (Table 1). Change indicators for support continued use of the About the Authors EVALUATION each environment were mea- model to evaluate long-term sus- Vedette R. Gavin is with Case Center for sured with varied data collection tainability and engagement for Reducing Health Disparities at Metro- The fellowship focused methods. HEAL activities, and (2) replicate Health and the Saint Luke’s Foundation, Cleveland, OH. Eileen L. Seeholzer is with primarily on the feasibility of Engagement was evaluated for the model in other neighbor- the Center for Healthcare Research and successfully developing and reach and authenticity according hood settings to establish proof Policy and Department of Medicine, the implementing a model for to the definition, core values, and of concept. MetroHealth System, and Case Western Reserve University School of Medicine, community-envisioned and com- 10% participation goal set by Future evaluation should in- Cleveland, OH. Janeen B. Leon is with the munity-implemented change in the HEAL Council at the onset clude measures to understand Center for Healthcare Research and Policy,

Published online ahead of print April 16, 2015 | American Journal of Public Health Gavin et al. | Peer Reviewed | Field Action Report | e5 ⏐ FIELD ACTION REPORT ⏐

the MetroHealth System, and Case West- to create environments, neighborhood Harvey Rice K-8 School, Cleveland html&ei=rxDvUvH_DcPiyAGagYGYB ern Reserve University School of Medicine. amenities, and programs that support Public Library, Boys & Girls Club, Q&usg=AFQjCNFwh4qwb4TZA_cbI- Sandra Byrd Chappelle is with the Saint healthy living. Cleveland Botanical Gardens, Cleve- 8dfRG27iBJDg&bvm=bv.60444564,d. Luke’s Foundation. Ashwini R. Sehgal is Our thanks to the HEAL Council land City Planning, and the Cuyahoga aWc. Accessed February 1, 2014. with the Case Center for Reducing Health for their dedication, commitment, and Place Matters Team. Disparities at MetroHealth and Depart- hard work. Members include Lynn 3. PolicyLink and The California En- ment of Medicine, Case Western Reserve Alfred, Anthony Benson, Ali Boyd, dowment. Why Place Matters: Building University School of Medicine. Vera Brewer, Marilyn Burns, Bianca Human Participant Protection a Movement for Healthy Communities. Correspondence should be sent to Butts, Erica Chambers, Freddy Col- This project did not include human par- 2007. Available at: http://www.policyl- Vedette Gavin, MPH, Center for Reducing lier Jr, Monica Dumas, Stephanie ticipant research; therefore, institutional ink.org/sites/default/files/WHYPLACE- Health Disparities, 2500 MetroHealth Dr, Fallcreek, Jackalyn Fehrenbach, Julia review board approval was not sought. MATTERS_FINAL.PDF. Accessed Cleveland, OH 44109 (e-mail: vgavin@ Ferguson, Kim Fields, Marka Fields, February 1, 2014. metrohealth.org or [email protected]). Kimberly Foreman, Keisha Herbert, 4. Robert Wood Johnson Foundation Reprints can be ordered at http://www. Tamika Herndon, John Hopkins, References 1. Wenger M. Place Matters: Ensur- Commission to Build a Healthier Amer- ajph.org by clicking the “Reprints” link. Sheen Jeffries, Kevin Kay, Jessica ing Opportunities for Good Health for ica. Neighborhoods and Health. 2011. This article was accepted January 20, Kayse, DeAngelo Knuckles, Mary All. September 2012. Available at: Exploring the Social Determinants of 2015. Ellen Lawless, Kimalon Meriwether, http://www.coloradotrust.org/attach- Health Series; Issue Brief 8. Avail- Jackie Mills, Jealene Pardon, Kathryn ments/0002/0258/JCsummary.pdf. able at: http://www.rwjf.org/content/ Plummer, Joyce Rhyan, Jose Sanchez, Accessed February 1, 2014. dam/farm/reports/issue_briefs/2011/ Candace Smith, Nakia Smith, Robert Contributors rwjf70450. Accessed February 1, Smith, Tearra Smith, Ron Soeder, 2. CommonHealth Action. Place Mat- All authors collaborated in designing 2014. the project and writing and revising the Chris Stocking, Tanesha Tate, Damien ters Design Lab Thirteen: Determining article. Ware, and Robert White and in lov- the Public’s Health: Implications of the 5. Ludwig J, Sanbonmatsu L, Gennetian ing memory of Rayshawn Armstrong Economy, Housing, and Employment. Oc- L, et al. Neighborhoods, obesity, and di- and Gloria Moose. Thanks are also tober 27–29, 2010; Cuyahoga County. abetes—a randomized social experiment. Acknowledgments extended to our many community Available at: http://www.google.com/ N Engl J Med. 2011;365(16):1509– The project was generously supported partner organizations: Buckeye Shaker url?sa=t&rct=j&q=&esrc=s&frm=1& 1519. by the Saint Luke’s Foundation, Cleve- Square Area Development Corpora- source=web&cd=3&ved=0CDcQFjA land, OH. Residents and community tion, Shaker Area Development Cor- C&url=http%3A%2F%2Fwww.com- 6. Delbanco T, Berwick DM, Boufford partners also contributed significant poration, Fairhill Partners, Cuyahoga monhealthaction.org%2Fcomponent% JI, et al. Healthcare in a land called social capital and raised more than County Metropolitan Housing Author- 2Fk2%2Fitem%2Fdownload%2F17_0 PeoplePower: nothing about me without $50 000 in grants and sponsorships ity, Neighborhood Progress Inc, df8d0bb0c2d7b4c31d5865ccbfff403. me. Health Expect. 2001;4(3):144–150.

e6 | Field Action Report | Peer Reviewed | Gavin et al. American Journal of Public Health | Published online ahead of April 16, 2015