United for health to improve urban food environments across five underserved communities: a cross-sector coalition approach.

BACKGROUND: Cross-sector coalitions can be a powerful vehicle to promote adoption and implementation of evidence-based programs and policies across diverse racial/ethnic communities with a high chronic disease burden. Few studies have examined coalition composition, function, or capacity to promote learning among members. METHODS: We used a mixed methods approach to examine the United for Health coalition's implementation of multiple food environment interventions across five low-income communities of color in Los Angeles, California (USA). At the coalition-level, key measures included the collaborative environment, membership characteristics, process and structure, communication, resources, strengths, challenges/barriers, and community impact. At the organizational- and individual-levels, we collected data on participation, leadership development, intraorganizational change, perceived benefits, and learning outcomes. FINDINGS: Overall, the United for Health coalition produced five community gardens, three pop-up produce markets, and one farmers' market; members also expanded Electronic Benefits Transfer (EBT) access at three existing farmers' markets. Findings indicate early coalition strengths included having a mutual purpose, which was maintained throughout the study period. Coalition participation and engagement was consistently high, while coalition and inter-organizational communication improved over time. Strengths were membership diversity and the availability of learning opportunities. Benefits included leadership development and strategic alignment across organizations. Members demonstrated an increased awareness of the importance of culturally adapted interventions and knowledge of community health planning topics. Key implementation challenges were a lack of resources and social context barriers. CONCLUSIONS: Examining coalition function and maturation in a real-world context reveals important lessons for scholars and practitioners committed to addressing nutrition-related health disparities in marginalized and historically underserved communities. Future work should investigate the sustainability of externally funded cross-sector coalitions after funding ceases.

Advocacy for Health Justice: An Innovative Pilot Course for MD and Master of Public Policy Students.

Problem: U.S. medical schools are searching for ways to address issues of health justice in undergraduate medical education. Physicians have not typically received training in how to be effective advocates for systemic change and individuals in policy fields are not usually equipped to understand the complex issues of health science and their intersection with the health system and society. To address this gap, medical school faculty partnered with school of public policy faculty on a collaborative learning model that engaged MD and Master of Public Policy students together to strengthen their collective knowledge of the healthcare landscape, and to build skills to work for health justice. Intervention: We hypothesized that pairing medical students with public policy students to learn about the intersections of health justice and advocacy could enhance the efficacy of each group and provide a new model of collaboration between medical and policy professionals. The students collaborated on a health justice advocacy project through which they provided consultation to an established community organization. Context: The 8-week course took place in the spring of 2021 in Los Angeles, California. Due to Covid-19 the course was taught online and included asynchronous learning modules and live Zoom sessions. The project also served as a pilot for the post-clerkship phase of a new longitudinal health justice curriculum for MD students that launched in August 2021. Impact: Analysis of student work products, course evaluations, partner interviews, and student focus groups showed that students valued learning through their interdisciplinary collaborative work which gave them new perspectives on health justice issues. The community partners indicated that the students consultative work products were useful for their initiatives, and that they found working with MD and MPP students to be a valuable way to think about how to build stronger and more inclusive coalitions to advocate for health justice. This project has the potential for national impact as it aligns with the Association of American Medical Colleges' renewed focus on the responsibility of academic medicine to partner with communities for health justice. The project also contributed to the national conversation on how to align health systems science education with the aims of health justice through our participation in the American Medical Association Accelerating Change in Medical Education Consortium. Lessons Learned: Leveraging faculty relationships with community partners was crucial for developing meaningful projects for students. Cultivating and expanding community partner networks is necessary to sustain and scale up this type of intervention. Centering the needs of communities and supporting their on-going work for health justice is essential for becoming an effective advocate. Learning communities that bring interdisciplinary students, healthcare providers, policy professionals, and community partners together to learn from one another can create key opportunities for ameliorating health inequities.

Catalyzing Implementation of Evidence-Based Interventions in Safety Net Settings: A Clinical-Community Partnership in South Los Angeles.

This study is a process evaluation of a clinical-community partnership that implemented evidence-based interventions in clinical safety net settings. Adoption and implementation of evidence-based interventions in these settings can help reduce health disparities by improving the quality of clinical preventive services in health care settings with underserved populations. A clinical-community partnership model is a possible avenue to catalyze adoption and implementation of interventions amid organizational barriers to change. Three Federally Qualified Health Centers in South Los Angeles participated in a partnership led by a local community-based organization (CBO) to implement hypertension interventions. Qualitative research methods were used to evaluate intervention selection and implementation processes between January 2014 and June 2015. Data collection tools included a key participant interview guide, health care provider interview guide, and protocol for taking meeting minutes. This case study demonstrates how a CBO acted as an external facilitator and employed a collaborative partnership model to catalyze implementation of evidence-based interventions in safety net settings. The study phases observed included initiation, planning, and implementation. Three emergent categories of organizational facilitators and barriers were identified (personnel capacity, professional development capacity, and technological capacity). Key participants and health care providers expressed a high level of satisfaction with the collaborative and the interventions, respectively. The CBO's role as a facilitator and catalyst is a replicable model to promote intervention adoption and implementation in safety net settings. Key lessons learned are provided for researchers and practitioners interested in partnering with Federally Qualified Health Centers to implement health promotion interventions.

Transforming the urban food desert from the grassroots up: a model for community change.

Confronted by continuing health disparities in vulnerable communities, Community Health Councils (CHC), a nonprofit community-based organization in South Los Angeles, worked with the African Americans Building a Legacy of Health Coalition and research partners to develop a community change model to address the root causes of health disparities within the community's African American population. This article discusses how the CHC Model's development and application led to public policy interventions in a "food desert." The CHC Model provided a systematic approach to engaging impacted communities in support of societal level reforms, with the goal to influence health outcomes.

Use of research evidence in state health policymaking: Menu labeling policy in California.

Addressing the translational gap between research evidence and state health policy requires an understanding of the current use of research evidence in the state policymaking process. In this study, we explore the use of research evidence to inform the legislative debate about restaurant nutrition labeling policy in California. In 2008, California was the first state to enact a mandatory menu calorie labeling policy in the U.S. Using a qualitative approach, we examine data sources and types of evidence used in legislative documents (n = 87) related to six menu labeling bills introduced in California's state legislature between 2003 and 2008. Federal- and state-level government agency reports were the most frequently cited sources of technical knowledge. Advocacy coalition members who were active participants involved in the policy debate were also cited as experts. Five of the six bills included evidence in related legislative documents. While documents included considerable evidence on the magnitude and severity of the obesity problem to justify policy enactment, there were a limited number of statements referring to policy effectiveness and only one statement identified attesting to implementation context and acceptability. Reference to evidence on related policy suggests policy precedence may also play an important role in policy decision making. There is a need to improve the dissemination of obesity policy effectiveness and implementation studies in a politically time sensitive manner to influence state health policy debates. Strategies are discussed to effectively integrate the use of research evidence in the state health policymaking process.

Intrapersonal and Environmental Barriers to Physical Activity Among Blacks and Latinos.

OBJECTIVE: To understand perceived barriers and facilitators to physical activity (PA) among at-risk African American and Hispanic adolescents and adults in a low-income community. DESIGN: Qualitative research was conducted in 2014-2015 using focus groups and a sociodemographic survey. SETTING: Three high schools in South Los Angeles, California. PARTICIPANTS: Eight high school-aged adolescent focus groups (n = 64) and 8 adult focus groups (n = 47). PHENOMENON OF INTEREST: Perceived barriers and facilitators to PA among predominantly obese and overweight African American and Hispanic adolescents and adults. ANALYSIS: Groups were audio recorded, transcribed, coded, and analyzed using an inductive approach. RESULTS: Participants reported that PA resources were available on school campuses (eg, sports teams) and in the community (eg, sidewalks, local parks, fitness classes). Key barriers to PA were intrapersonal (lack of motivation and time constraints) and environmental (safety concerns), whereas facilitators included interpersonal factors (social support). Participants provided valuable insights, including recommendations to increase noncompetitive programs at schools, develop shared-use agreements, and address safety concerns at local parks and public recreational spaces. CONCLUSIONS AND IMPLICATIONS: The findings suggest that future efforts to promote PA among at-risk minority groups should address intrapersonal and social environmental factors. Community-based programmatic and policy recommendations are provided.

Ending Cervical Cancer Screening in Low-Risk Women After Age 65: Understanding Barriers to Adherence With Evidence-Based Guidelines Among Primary Care Providers.

BACKGROUND: Current evidence-based cervical cancer testing guidelines recommend that screening of low-risk women ceases after age 65. Despite this, research suggests that continued testing by primary care providers remains common and represents unnecessary patient discomfort, cost, and consumption of valuable primary care resources. OBJECTIVE: To understand why primary care providers might knowingly ignore consensus evidence-based screening guidelines for cervical cancer in low-risk women of this age-group and to identify barriers to adherence with best practice recommendations. METHODS: A survey tool to identify barriers to adherence with current guidelines for cervical cancer screening in low-risk women older than age 65 was mailed to 4929 randomly selected primary care providers throughout California. Providers were asked to indicate the predominant reason(s) they might knowingly continue cervical cancer screening in women older than 65 years, despite evidence-based recommendations to the contrary. RESULTS: Qualified surveys were received from 1259 (25.5%) of those surveyed, representing primary care providers of all types, practicing in areas of vastly different demographics. Despite published reassurance to the contrary, many providers retain fear that discontinuation of testing in low-risk women after age 65 may result in missed invasive cervical cancer. Even among health-care providers who agree that cessation of screening is safe, other circumstances prompt their recommendation to continue cervical screening. CONCLUSION: Although the data from this study suggest areas of policy intervention to lessen unnecessary cervical cancer screening, the broader implication is that advancement of evidence-based medicine will be of little value in improving the quality and cost of health care if barriers to guideline adherence are poorly understood and addressed.

Advocacy coalitions involved in California's menu labeling policy debate: Exploring coalition structure, policy beliefs, resources, and strategies.

Advocacy coalitions often play an important role in the state health policymaking process, yet little is known about their structure, composition, and behavior. In 2008, California became the first state to enact a menu labeling law. Using the advocacy coalition framework, we examine different facets of the coalitions involved in California's menu labeling policy debate. We use a qualitative research approach to identify coalition members and explore their expressed beliefs and policy arguments, resources, and strategies by analyzing legislative documents (n = 87) and newspaper articles (n = 78) produced between 1999 and 2009. Between 2003 and 2008, six menu labeling bills were introduced in the state's legislature. We found the issue received increasing media attention during this period. We identified two advocacy coalitions involved in the debate-a public health (PH) coalition and an industry coalition. State organizations acted as coalition leaders and participated for a longer duration than elected officials. The structure and composition of each coalition varied. PH coalition leadership and membership notably increased compared to the industry coalition. The PH coalition, led by nonprofit PH and health organizations, promoted a clear and consistent message around informed decision making. The industry coalition, led by a state restaurant association, responded with cost and implementation arguments. Each coalition used various resources and strategies to advance desired outcomes. PH coalition leaders were particularly effective at using resources and employing advocacy strategies, which included engaging state legislators as coalition members, using public opinion polls and information, and leveraging media resources to garner support. Policy precedence and a local policy push emerged as important policymaking strategies. Areas for future research on the state health policymaking process are discussed.

Perceived Barriers and Facilitators to Healthy Eating and School Lunch Meals among Adolescents: A Qualitative Study.

OBJECTIVES: We explored how perceived barriers and facilitators influence healthy eating and investigated the acceptability of changes to school lunch meals among adolescents after implementation of the Healthy, Hunger-Free Kids Act of 2010. METHODS: We conducted 8 focus groups with adolescents (N = 64) at 3 South Los Angeles high schools. Data collection instruments included a semi-structured guide and questionnaire. Two researchers independently coded transcripts. RESULTS: Most participants believed fruits and vegetables were available in their community and reported high relative cost, poor quality, and lack of motivation as barriers to consumption. Many said school meals were an important source of healthy food and were aware of recent changes to the school lunch program. A primary facilitator to eating school lunches was access to fresh food items (eg, a salad bar). Perceived barriers included long cafeteria lines, time constraints, lack of variety, and limited quantities of preferred items. Adolescents viewed off-campus food establishments near the school as competition to school meals. CONCLUSIONS: Our findings suggest the need to measure perceived and actual barriers to healthy eating among adolescents and to examine the effect of these barriers on dietary behavior. We provide programmatic and policy recommendations.

Assessing resource environments to target prevention interventions in community chronic disease control.

The recent emphasis in public health and medicine on the environmental determinants of chronic illness has created the need for a more comprehensive way to assess barriers and facilitators of healthy living. This paper reports on the approach taken by a Centers for Disease Control and Prevention (CDC)-funded project whose goal is to reduce disparities in diabetes and cardiovascular disease in Los Angeles' African American communities. Findings from this community-based participatory research project suggest that while location is an important variable in evaluating nutritional and physical activity resources, quality and price considerations are at least as useful. We argue that every community or neighborhood is located within a resource environment for medical care, recreation, food, and other health-promoting or health-compromising goods and services that affect the lives and health of its residents.

Putting promotion into practice: the African Americans building a legacy of health organizational wellness program.

A Los Angeles REACH demonstration project led by Community Health Councils, Inc. adapted and implemented an organizational wellness intervention originally developed by the local health department, providing training in incorporating physical activity and healthy food choices into the routine "conduct of business" in 35 predominantly public and private, nonprofit-sector agencies. A total of 700 staff, members, or clients completed the 12-week or subsequently retooled 6-week curriculum. Attendance and retention rates between baseline and postintervention assessments were improved substantially in the shortened offering. Feelings of sadness or depression decreased significantly (p = .00), fruit and vegetable intake increased significantly (+0.5 servings/day, p = .00), and body mass index decreased marginally (-0.5 kg/m(2), p = .08) among 12-week participants. The numbers of days in which individuals participated in vigorous physical activity increased significantly among 6-week participants (+0.3, p = .00). This model holds promise for extending the reach of environmentally focused work-site wellness programming to organizations and at-risk populations not traditionally engaged by such efforts.

Discontent and Confusion: Primary Care Providers' Opinions and Understanding of Current Cervical Cancer Screening Recommendations.

BACKGROUND: In 2012, new cervical cancer screening guidelines were published by three widely recognized entities which advocate delayed onset of testing, fewer screenings, selective use of human papilloma virus co-testing, and no further screening in women over age 65 years. Early observations report that these recommendations are not being followed and overscreening is common. This study seeks to understand why primary care providers might not adhere to these new 'best practice' health policy protocols. METHODS: A total of 4,909 randomly selected primary care providers (physicians, nurse practitioners, and physician assistants) practicing in California were mailed a study questionnaire. Participants were asked if they consider current published screening guidelines to be authoritative, reliable, and/or clinically appropriate. Clinical vignettes captured individual provider beliefs on timing and method of cervical cancer screening in women within the four key age groups embedded in current screening guidelines. RESULTS: Of the 4,909 surveys mailed, 1,268 (25.8%) qualified responses were received. Fundamentally, 35.0% of all primary care providers do not believe current guidelines are clinically appropriate, with 58.6% of obstetrician/gynecologist physicians having this same skepticism. Even among those who affirmatively believe current guidelines are authoritative, reliable, and clinically appropriate, only 15.3% recommend screening intervals and methodology of testing in women of four differing ages consistent with that of current policy guidelines. CONCLUSION: Among the primary care providers surveyed, distrust and confusion likely limit adherence to current evidence-based cervical cancer screening health policy recommendations, and contribute to the current high rates of overscreening that have been observed.

Work group IV: Future directions for measures of the food and physical activity environments.

Much progress has been made in the past 5 to 10 years in measuring and understanding the impact of the food and physical activity environments on behavioral outcomes. Nevertheless, this research is in its infancy. A work group was convened to identify current evidence gaps and barriers in food and physical activity environments and policy research measures, and develop recommendations to guide future directions for measurement and methodologic research efforts. A nominal group process was used to determine six priority areas for food and physical activity environments and policy measures to move the field forward by 2015, including: (1) identify relevant factors in the food and physical activity environments to measure, including those most amenable to change; (2) improve understanding of mechanisms for relationships between the environment and physical activity, diet, and obesity; (3) develop simplified measures that are sensitive to change, valid for different population groups and settings, and responsive to changing trends; (4) evaluate natural experiments to improve understanding of food and physical activity environments and their impact on behaviors and weight; (5) establish surveillance systems to predict and track change over time; and (6) develop standards for adopting effective health-promoting changes to the food and physical activity environments. The recommendations emanating from the work group highlight actions required to advance policy-relevant research related to food and physical activity environments.

African Americans' access to healthy food options in South Los Angeles restaurants.

OBJECTIVES: We examined availability and food options at restaurants in less affluent (target area) and more affluent (comparison area) areas of Los Angeles County to compare residents' access to healthy meals prepared and purchased away from home. We also considered environmental prompts that encourage the purchase of various foods. METHODS: We designed an instrument to assess the availability, quality, and preparation of food in restaurants. We also assessed advertisements and promotions, cleanliness, and service for each restaurant. We assessed 659 restaurants: 348 in the target area and 311 in the comparison area. RESULTS: The nutritional resource environment in our target area makes it challenging for residents to eat healthy away from home. Poorer neighborhoods with a higher proportion of African American residents have fewer healthy options available, both in food selections and in food preparation; restaurants in these neighborhoods heavily promote unhealthy food options to residents. CONCLUSIONS: Environment is important in understanding health status: support for the healthy lifestyle associated with lower risks for disease is difficult in poorer communities with a higher proportion of African American residents.

Leading by example: a local health department-community collaboration to incorporate physical activity into organizational practice.

A multisectoral model promoting sociocultural environmental change to increase physical activity levels among African Americans in Los Angeles County, California, was developed and implemented. This model represents a true collaboration between a local health department and a community lead agency. Community organizations serving targeted areas of the county participated in one or more interventions incorporating physical activity into routine organizational practice, which centered around modeling the behaviors promoted ("walking the talk"). In the current study, level of organizational support for physical activity integration was assessed, as reflected in the extent of organizational commitment associated with each intervention. Individual-level data, characterizing the sociodemography, health status, and health behaviors of organization staff, members, and clients, are presented to document the average risk burden in the targeted population. Nearly half of the more than 200 participating organizations actively embraced incorporating physical activity into their regular work routines, with more than 25 percent committed at the highest level of involvement. Broad capacity and support for organizational integration of physical activity was demonstrated, with the observed level of commitment varying by organization type. Similar to the successful evolution of tobacco control, some of the responsibility ("cost") for physical activity adoption and maintenance can and should be shifted from the individual to organizational entities, such as workplaces.

Improving the nutritional resource environment for healthy living through community-based participatory research.

OBJECTIVES: To build health promotion capacity among community residents through a community-based participatory model, and to apply this model to study the nutritional environment of an urban area to better understand the role of such resources in residents' efforts to live a healthy life. DESIGN: A multiphase collaborative study that inventoried selected markets in targeted areas of high African-American concentration in comparison with markets in a contrasting wealthier area with fewer African Americans. SETTING: A community study set in the Los Angeles metropolitan area. PARTICIPANTS: African-American community organizations and community residents in the target areas. INTERVENTIONS: Two surveys of market inventories were conducted. The first was a single-sheet form profiling store conditions and the availability of a small selection of healthy foods. The second provided detailed information on whether the store offered fruit, vegetables, low-fat dairy products, dried goods and other items necessary for residents to consume a nutritious diet. RESULTS: The targeted areas were significantly less likely to have important items for living a healthier life. The variety and quality of fresh fruit and vegetable produce was significantly lower in the target areas. Such products as 1% milk, skim milk, low-fat and nonfat cheese, soy milk, tofu, whole grain pasta and breads, and low-fat meat and poultry items were significantly less available. CONCLUSIONS: Healthy food products were significantly less available in the target areas. The authors conclude from these results that the health disparities experienced by African-American communities have origins that extend beyond the health delivery system and individual behaviors inasmuch as adherence to the healthy lifestyle associated with low chronic disease risk is more difficult in resource-poor neighborhoods than in resource-rich ones.