Healthier MO: From local programs to

regional policy and environmental change

April 26th -27th, 2010

Day 1: Objectives1. To provide an overview of the Prevention Research Center

including where we have been and where we are going

2. To provide an overview of evidence-based policy and environmental changes to increase physical activity and healthy eating

3. To provide an assessment of the health status of the region

4. To describe what has been done outside of and within MO

5. To understand some key areas of focus

What do people in your community need to

increase healthy eating?

What do people in your community need to increase physical

activity?

Where have we been?

April 26th

1-1:30 pm

Overview and History of the Prevention Research Center

We are part of a large and growing network

37 Prevention Research Centers in 2010

The Prevention Research Center in St. Louis

• Comprised of community, practice, and academic partners

• Been in existence since 1994 • Collaboration between Saint Louis University

School of Public Health and Washington University in St. Louis (Schools of Medicine and Social Work) 

• Mission: to prevent chronic disease and improve population health by adapting, implementing, evaluating, and disseminating evidence-based interventions.

PRC-StL Mission

“Prevent chronic diseases and improve population

health by adapting, implementing, evaluating,

and disseminating evidence based interventions”

PRC-StL Core Components

• Infrastructure• Community engagement and

partnership• Communication and dissemination• Training• Research• Evaluation

Healthier MO Communities

• PRC-StL Core Research Project for 2010-2014.

• The primary goal is: "To increase the dissemination of evidence-based environmental and policy interventions to improve physical activity and healthy eating in areas with high chronic disease disparities using a Community Based Participatory Research (CBPR) approach".

• The project includes partners from 12 rural communities in Southeast Missouri.

• Academically defined programs• Focus more on individual change and social

support for these changes:– Recipe books– Health Fairs– Calendars– Competitions – which person walks the most or

which church has the most walkers– Anti-smoking posters in schools

In the Past

A nurse takes the blood pressure of a Twin Towers resident during the Senior Health Fair

• We are focusing more on – Environmental changes

– Policy changes

• We have done some of this in the past but we are really focusing here now…to do this we needed to make some adjustments to the way we work with our communities

In the Present…

Environmental change for health is a change in the physical (natural or human-built), or social surroundings that make it easier for people to make healthy choices, especially for healthy food, physical activity and other behaviors.

Policy change for health is the creation or enforcement of laws and regulations that make healthy choices more available; unhealthy behaviors less available or illegal; and/or direct public and private resources into the support of healthy physical or social environments.

Environmental and Policy Change for Health

Breaking it down: Why environments and policies

• Since 1994 we have seen and been part of numerous projects to enhance healthy eating and physical activity

• Most have focused on individual and social factors…

• These are not sustainable without moving toward environmental and policy factors

Breaking it down: Which 12 counties and why?

• Pemiscot, Scott, Mississippi, Dunklin, Carter, Oregon, Reynolds, Shannon, Ripley, Howell, Wayne, Butler

• Rationale/understand: if move toward regional changes we may be able to benefit even more counties

Breaking it down: Why work regionally instead of one

county at a time?• Environmental and policy changes often

require support from regional partners

• Regional partners can encourage local changes even when there are local challenges

• Recognize still need to implement strategies locally

Breaking it down: What is CBPR

• Community based participatory research (CBPR) is an approach to doing research in which community, practice and academic partners work together to create and document changes– ideas for where to focus– planning, implementation, evaluation

Breaking it down: CBPR why do we think it is important?• Distance - need to plan and implement

here - not in St Louis• You know your communities and what will

work• You can sustain these efforts• CBPR makes it more likely that the

interventions will be the right ones and that they will make the desired differences

Principles of CBPR • Involves all partners in the design,

implementation, and evaluation of community-based efforts

• Builds programs on unique strengths and assets of local community

• Respects local beliefs and cultural norms• Takes community needs into consideration• Builds trust and respect to ensure that programs

will be maintained and enhanced over time

Where are we going?

Community-based participatory research

“A collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings.”

~ Community Health Scholars Program

Where are we going?

What will this really look like?

• Training - overview to share our perspective

• Prioritize strategies that you see as viable to address this this overall range of issues

• Committees to implement these strategies with funding and technical assistance from PRCSTL and others as needed

• Questions/Discussion

Where are we going?

What is evidence-based environmental and policy change?

April 26th

1:30-2:15pm

The Goals

1. What is evidence-based public health?

2. What are environmental and policy changes strategies that are evidence based?

“Public health workers (and community leaders)… deserve to get somewhere by design, not just by perseverance.”

--McKinlay and Marceau

What is “Evidence”?

What is “Evidence”?

Scientific literature Public health data Program evaluations Qualitative information

The words of community members Media/marketing data Word of mouth and personal experience

Objective

Subjective

Like beauty, it’s in the eye of the beholder…

Sometimes we do not connect the research evidence with policy

needs…

Where am I?

You’re 30 yards above the

ground in a balloon

You must be a researcher Yes. How

did you know?

Because what you told me is

absolutely correct but completely

uselessYou must be a policy maker

Yes, how did you know?

The problem

And so the lessons…

• We might speak different languages

• The evidence in some areas and/or populations may be limited

• We may need to design new approaches

A simple definition

- “Evidence-based public health is the process of integrating science-based interventions with community preferences to improve the health of populations.”

• Today, the evidence we have gathered on what might work in SE MO for promoting healthy eating and physical activity

The purpose of environmental and policy change is to

“Make the healthy choice the easy

choice”

In the Past

• Focus more on individual change and social support for these changes:– Recipe books– Calendars– Competitions – which person walks the

most or which church has the most walkers

– Anti-smoking posters in schools

In the Present…• We will focus more on

– Environmental changes (physical and/or social environments)

– Policy changes

• We have done some of this in the past but we are really focusing here now…to do this we need to make take some new approaches

• We are especially interested in regional approaches and bringing new partners to the table

• We want to select projects with the biggest impact

Environmental and Policy Change for Health

Environmental change for health is a change in the physical (natural or human-built), or social surroundings that make it easier for people to make healthy choices, especially for healthy food, physical activity and other behaviors.

Policy change for health is the creation or enforcement of laws and regulations that make healthy choices more available; unhealthy behaviors less available or illegal; and/or direct public and private resources into the support of healthy physical or social environments.

Environmental Changes

• Building walking trails• Turning empty lots into gardens• Making fruits and vegetables more

available at local grocery stores

Policy Changes

• Cities allow gardens on vacant lots• School Boards make policy for healthier

school lunches and vending machines• Schools allow school property for

community physical activity• Smoking bans in schools, workplaces,

businesses

A few examples(access with social

marketing and school PE)

One important effort for knowing what works:

The Guide to Community Preventive Services

(the Community Guide)

Example:

What are effective interventions for promoting

physical activity?

Enhanced access to places for physical activity + outreach

Strongly Recommended

bphotoonelane.jpg

Trivial pursuit:

What is the famous line from the “Field

of Dreams”

If you build it, they (he) will come--Field of Dreams, 1989

Outreach: Social Marketing

Social Marketing Steps

• Select target behaviors and audiences

• Conduct marketing research• Develop and test program

materials• Implement• Evaluate

A community campaign using paid media to encourage walking among sedentary older

adults

Bill Reger, EdD Adrian Bauman,PhD Linda Cooper, MSW Bess Marcus, PhD

Steven Booth-Butterfield, EdD Susan Middlestadt, PhDHolli Smith, MA, MSW Felicia Greer, PhD

To get the word out and

motivate physical activity on trails among

SEDENTARY ADULTS, we apply

(social) marketing strategies

like McDONALDS and FORD

TIME

ENERGY

Message Development

Our research indicated that our most effective message needed to focus on:

WHEELING WALKS Overview

Print ad: woman

Examples: ENVIRONMENT and POLICY lessons

• community advisory committee helped plan campaign

• including local clubs, government, schools, press, businesses, medical society, other stakeholder

• engaged city agencies—mayor, streets, highways, parks, law enforcement, planning

• involved local physicians—prescriptions for walking

• Mayor designates on-going Walkable Wheeling Task Force

School-based PE Curricula and Policy

Another Community Guide recommendation

Coordinated Approach To Child Health

CATCH

Peter Cribb, MEdUT-Houston

School of Public Health

512.346.6163

CATCHTexas.org CATCHInfo.org

Classroom Curriculum

Food Service

Physical Education

Family

The 4 CATCH Components

Observable Changes in Schools

Summary: What we are looking for…

Examples of Env/Policy Change

NOT Env/Policy Change

Walking trails (environment) Health fairsCommunity gardens (environment)

Teaching cooking classes

School physical education requirements (policy)

Health provider counseling

Healthy vending machine requirements (policy)Social marketing campaigns (social norms)

Questions to ponder…

• What are the priorities in this region?

• How do we link evidence-based approaches to strengths in your communities?

• What will have the largest, regional impact?

• What is feasible?

“Getting a new idea adopted, even when it has obvious advantages, is often very difficult.”

-- Everett Rogers, Diffusion of Innovations

Assessment of the region

April 26th

2:30-3:00pm

Death rate from heart disease in 2007

Age-adjusted heart disease mortality, Missouri, 1996-2004

Combined death rates for heart disease, cancer, and diabetes

Age-adjusted chronic disease mortality, Missouri, 1999-2005

Age-adjusted mortality (per 100,000) from breast cancer, uterine cervical cancer, lung cancer, colorectal cancer, coronary heart disease, stroke, diabetes, chronic obstructive pulmonary disease, and hepatic disease/cirrhosis

% of obese and overweight adults

% of adults who do not participate in leisure-time physical activity

% of adults who eat fewer than 5 servings of fruits and vegetables per

day

What has been done in this region?

April 26th

3:00- 3:30pm

Walking trails in the Ozarks

Community Gardens in the Bootheel

Building walking trails

Turning empty lots into gardens

Making fruits and vegetables more available at local grocery stores

Environmental Changes

Smoke-free areas are being established in the Ozarks

• Smoking bans in schools, workplaces, businesses

• Cities allow gardens on vacant lots

• School Boards make policy for healthier school lunches and vending machines

• Schools allow school property for community physical activity

Policy Changes

Other examples from the group?

Brainstorm….

• What are the strengths in your community or region around nutrition and physical activity?

• Mass Media Campaigns• Point of Prompt –Stair use for physical

activity• Social Support for physical activity -

establishing walking groups• School based programs for nutrition

and physical activity

Nutrition and Physical Activity – promising

evidence based interventions

Point of Prompt –Stair use for physical activity

Brainstorm…what are some things we can

focus on?

April 26th

3:30-4:30pm

Physical activity strategies

Tell us about the strategy.

What strengths does it build on?

Could this be done locally, regionally or both?

What partners might need to be at the table?

Nutrition strategies

Tell us about the strategy.

What strengths does it build on?

Could this be done locally, regionally or both?

What partners might need to be at the table?

Opinion generators

April 26th

4:30-5:00

Healthier MO training

Day 2: April 27th

Day 2: Objectives

1. To understand how to prioritize ideas from the brainstorming.

2. To describe the action planning process that will occur

3. To discuss key principles of partnership development

4. To describe how we will move the proces forward

How do we prioritize issues and

approaches?

April 27th

8:30 -9:30am

The Goals

1. What are sources of information to help us in prioritizing?

2. How might we do this?3. Review ideas from

brainstorming session

Some sources of evidence

• What other communities have found successful

• Recommendations from health authorities like the CDC

• Local knowledge• Published literature

Scale for assessing feasibility

• “Good”: You and your partners should have considered most of the supporting questions and have taken some action to address them

• “Fair”: You and your partners may have considered some of the supporting questions and have brainstormed ways to work on them

• “Poor”: You and your partners may have not considered most of the issues and still have some work to do before you can answer the questions

Feasibility scale (examples) 1. The level of support we have from those who

will be affected by the intervention is… Good Fair Poor

Before you answer, have you and your partners considered or addressed the following?

Who will be affected (family members, coworkers, neighbors, community members)?

Have we taken steps to describe or get to know our community of interest?

Has our population expressed an interest or concern

about the issues your intervention will address?

2. The level of political support we have from key-decision makers is… Good Fair Poor

Before you answer, have you and your partners considered or addressed the following? Who are the key decision-makers (organizational, administrators, legislators, or advocacy groups?)

Have we identified these individuals; interests and how to appeal to them?

Have we talked to these individuals about the intervention or asked for their opinions on what might work?

3. The amount of funding we have for planning and implementing the intervention is… Good Fair Poor

Before you answer, have you and your partners considered or addressed the following?

What is our current budget for the intervention? Will it be sufficient?

How long do we want to sustain the intervention? Do we need more funds?

4. The resources we have readily available to plan and implement the intervention are… Good Fair Poor

Before you answer, have you and your partners considered or addressed the following?

What are our space and equipment needs?

What are our technology needs?

5. Our team’s level of skills and expertise to plan and implement the intervention is… Good Fair Poor

Before you answer, have you and your partners considered or addressed the following?

What are the skills and expertise on our team?

What are our training needs?

Will we need to bring in other outside help (e.g., consultants or contractors)

6. The strength of our team’s leadership is… Good Fair Poor

Before you answer, have you and your partners considered or addressed the following?

Do the leaders motivate and support the team?

Do we have shared leadership? How do we define leadership roles?

Does our team respond favorably to the leaders?

Policy and Program Planning Options*

More Important

Less Important

More Feasible Highest priority Low priority

Less Feasible Priority for innovative programs (evaluation is essential)

No intervention program

Example, Changeability table:Diabetes prevention in Rio Grande Pueblo communities

More important Less important

More feasible

Sustaining community support for healthy living with diabetes Availability of resources for healthy eating and exercise Image of diabetes from one of hopelessness to one that engenders hope Some stories of diabetes reveal poor outcomes, rather than success Food choices at celebrations or feasts

Ideal body weight

Less feasible

History that led to social, environmental, and physiological changes Social, work, and family obligations

Local adaptation• Scientific evidence is a starting point• Realize that ALL programs need some level

of adaptation• Limits of scientific evidence should be

noted– Local history– Local strengths– Work on lifestyle changes that are

consistent with history and culture• Seek out other forms of evidence, such as?

Getting your input

• Opinion Generators– Develops instant feedback from the whole

group

• Example: Ratings a series of possible interventions for importance and feasibility

Partnership

April 27th

9:30-10:30am

What to we mean by partnership?

• Intentional relationships between two or more individuals, groups or organizations

• Committed to pursuing an agenda or goal of mutual benefit

• May be for information exchange, input, or joint planning and implementation

Why partner for regional policy and environmental change?

• Accomplish something that one organization cannot accomplish alone

• Bring people together that are interested in similar cause or outcome in the region

• Pool resources – time, talent, networks

• Reduce duplication of effort

Together we can make a difference

Think of an experience with a group or partnership when things went

well. What are the three things that contributed to the success of that

group?

What makes a partnership successful?

Characteristics of successful partnerships

1. Community readiness – right issue, right time

2. Community history – turf issues, leadership

3. Membership – diversity, representation4. Relationships – trust, respect

Characteristics of successful partnerships

5. Shared vision and mission6. Resources – skills, money7. Leadership and staffing –

committed, inclusive8. Structure and organization –

defined roles, responsibilities, processes

9. Ability to take action

• What are the rights and responsibilities of each partner?

• Who has decision making power?

• Is there respect for all voices/concerns?

• What is the expectation of engagement in various activities needed accomplish goals?

Different ways of engaging partners

• a collaborative approach to research• equitably involves all partners in the

research process and recognizes the unique strengths that each brings.

• begins with a research topic of importance to the community,

• combine knowledge with action and achieving social change to improve health outcomes and eliminate health disparities.

Community-based participatory research

Prevention Research Center in St. Louis Example

1. We are committed to equity, collective decisions, and collective action

2. We are committed to high quality, ethical research

3. We are committed to addressing social inequalities that affect health and those that constrain participation

4. We are committed to maximizing opportunities for learning within environs of the local community

Develop trust: show respect, follow through, attend to each other’s interests and needs

Provide leadership: shared leadership, delegation, task/maintenance functions

Develop processes for shared power and influence: equity, mutual influence, co-learning, balance of power

Things to consider when building regional partnership

Address conflict: necessary part of group process, identify reasons for conflict, establish norms for conflict management

Establish shared decision-making processes: determine how decision s will be made and enable all members of the group to be engaged as appropriate

Choose a fiscal agent – determine which organization will be responsible for administering funds and a process for making financial decisions as a group

Things to consider when building regional partnership

• Poor communication and language differences

• Lack of shared understanding of financial requirements and structures

• Differences in values and mission

• Deadlines

• Different learning and action styles- email vs. phone/in person

• Undeclared agendas

Potholes…what to look out for once you decide to take the

plunge…

Action Planning

April 27th

10:45am-11:45am

Action planning

• Structured process to move from

– Goal or Vision.. to

– Objectives - what do you need to achieve to accomplish your vision..to

– Activities or action steps that need to be taken to accomplish your objectives

How action planning will occur

• Action planning committees – Each will focus on a different strategy-

priority from earlier– Sign up for issue(s) of interest– Each member of the committee will be

asked to do some specific tasks between meetings to help move things forward

– Each member of the committee may be asked to garner local support for desired changes

Action planning committees

• Once issues are chosen PRC staff will provide additional assessment data for these issues

• Work together – to identify any work already underway– to determine how best to complement existing

interventions – To maximize use of existing resources and

opportunities (e.g., if there is any financing issue already on the books)

Action planning committees

• Technical assistance will be provided by PRC staff in St. Louis and locally

• Time frame- – planning meetings over the summer; – technical assistance to move toward these

plans during the fall

• Funding– will be determined by the way the issues are

defined and the strategies chosen

Outline Plan for moving forward

April 27th

11:45am - 12:00pm

Moving forward

• Sign up for committee(s) of interest– PRC will contact you for next meetings– Go through action planning steps– Consider who else needs to be at the table

• PRC will provide technical assistance and support - if need training on advocacy will provide this

• Identify communication plan- prefer to email…if this is a problem please let us know a better way to contact you

Who else needs to be at the table for regional

policy and environmental change to address

nutrition and physical activity in southern

Missouri?

Things to consider when engaging policy-makers

• Provide compelling data• Listen to their needs• Understand their issues of interest• Find win-win issues

Committee meetings

• Next meeting will be in smaller groups

• Committees will meet monthly

• First meeting will discuss how the group members will work together and determine partnership principles

PRC St. Louis Website: http://prcstl.wustl.edu

PRC St. Louis General Email: prcstl@wustl.edu

PRC St. Louis General Phone: 314-362-9643

Contact the Prevention Research Center in St. Louis