Communities Creating Healthy Environments to Combat Obesity : Preliminary Evaluation Findings From Two Case Studies

While there is growing faith in community organizing to influence policy as a way to improve the built environment and increase food or recreational equity, relatively little research is available examining the successes and challenges of community organizing in Latino communities attempting to reduce obesity. Using process and outcome evaluation data, we present preliminary findings from a study of two community-based organizations that are making efforts to increase access to physical activity and access to healthy foods in predominantly Latino areas. The organizations are part of Communities Creating Healthy Environments (CCHE), a national initiative of the Robert Wood Johnson Foundation (RWJF) to prevent childhood obesity. Both community-based organizations were able to achieve redistribution of public resources to advance their CCHE objectives. We discuss the study’s implications, including the need for public policy research around obesity that examines community organizing as an intervention. © 2012 Californian Journal of Health Promotion. All rights reserved.


Introduction
A growing public health literature examines community organizing as a means to influence public policy.There is also an increased call for policy research to combat obesity in Latino communities (Minkler, 2004;Ramirez, Chalela, Gallion, Green, and Ottoson, 2011).Community organizing helps neighborhoods pressure local government officials regarding land use policies, resources, services, and public infrastructure that make it difficult for children and families to make healthy choices or have healthy options.There is considerable intuitive wisdom regarding the capacity of community organizing to influence policy.However, relatively little research examines community organizing as a means to alter the built environment, to shift policies to increase food or recreational equity, or to address youth obesity and health disparities in communities of color.Philanthropy provides an opportunity to evaluate community organizing efforts aimed at making changes to built environments.One example of the efforts of philanthropic organizations is the Robert Wood Johnson Foundation (RWJF) Communities Creating Healthy Environments (CCHE) initiative.CCHE is a national initiative that aims to prevent childhood obesity by supporting local policy efforts aimed at increasing access to healthy foods and safe places to play in communities of color.CCHE supports 22 geographically and racially diverse 501 (c3) community-based organizations (hereinafter referred to as "grantees") and federally funded tribal nations.The grantees are required to utilize community organizing to increase access to healthy foods and safe places for recreation.The grantees receive 3-year grants of up to $225,000 to implement effective, culturally competent policy initiatives that address the local root causes of childhood obesity.Grantees vary in funding cycle, some receiving funding for 2010-2012 and others for 2011-2013.
The initiative supports community organizing campaigns that influence local policymakers regarding a host of outcomes, such as providing resources for increasing physical activity, and enacting zoning and land use policies that support healthy activity and access to nutritious food.The CCHE "theory of change" suggests that by focusing on policymakers, one can tackle root causes of poor health, which include "the land use policies, predatory marketing and underfunded public infrastructure that make it difficult for kids and families to make healthy choices in the first place" (ccheonline.org/overview).CCHE is part of RWJF's efforts to reverse the childhood obesity epidemic by 2015.
We present preliminary process and outcome evaluation findings from two community-based organizations seeking to increase recreational justice (increased access to physical activity) and food equity (access to healthy foods) in predominantly Latino areas.We compare and contrast the work of the organizations, pointing out commonalities and differences regarding key aspects that we believe are essential to effective advocacy campaigns.The organizations were purposively selected and are part of CCHE.

Obesity and Latinos
Childhood obesity is an epidemic in the United States; approximately one-third of children are obese or overweight (Galson, 2008).Latino children, a segment of the largest, youngest, and fastest growing minority group in the country, have the highest rates of obesity.Thirty-eight percent of Mexican-American children are obese or overweight, compared with 30.7% of non-Hispanic Whites and 34.9% of African Americans (Ogden and Flagal, 2008).
The root causes of obesity among children and youth in Latino communities are well documented.Latinos are less physically active than the general population, with disproportionate numbers living in low-income neighborhoods with environments that make it difficult for families to make healthy choices regarding exercise.These areas have few wellequipped, safe parks or other public open spaces for children to play and be active (Woodward-Lopez and Flores 2009;Lopez and Hynes, 2009).Relative to the neighborhoods inhabited by the general U.S. population, these places also have a disproportionate number of fast food outlets and grocery and convenience stores that offer limited affordable and nutritious foods and provide and an abundance of high fat and high sugar processed foods (Morland, Wing, Roux, and Poole, 2002;Bell and Rubin, 2007).
Increasing attention is now being given to policy research focusing on the built environment and the food environment in Latino communities.An impetus for this research is to provide community development and public health professionals with the necessary information to make evidence-based decisions regarding health improvements and community development (Erickson and Andrews 2011).The assumption is that such information would help mitigate "top down" decisions.Another reason for such research is that there is limited policy research on childhood obesity that is specifically focused on Latino lower-income neighborhoods (Kumanyika and Grier, 2006;Ramirez et al., 2011).In spite of greater attention to policy research in these areas, there is a need for evaluations of community efforts by groups of low income families of color because they experience the most health inequities.It is important to explore the efforts of groups that are organizing effectively and targeting public policies to change and improve the built and food-service environments.

Community Organizing and Obesity: An Emerging Agenda
Numerous community organizing models exist, and many trace their roots to a model proposed by Saul Alinsky (1972).The Alinsky model includes creating a pressure group from within neighborhoods and confronting the "enemy" that is contributing to inequities.The contention is that churches, ethnic groups, political organizations, and labor unions need to collaborate to politically educate and involve as many supporters as possible in change efforts.Some of the tactics Alinsky advocated include offering testimony in local government meetings, protesting, boycotting, staging marches and sit-ins, and circulating petitions (Gittell and Vidal 1998;Smock 2004).
Traditionally, the literature on community organizing and health has focused on environmental health hazards and risks such as alcohol and tobacco use (González et al., 2007;Wallerstein, Sanchez, and Velarde, 2005;Cheadle et al., 2001).The emphasis of the research has been describing organizing and developing models of community organizing.Less emphasis has been given to making links between community organizing and actual changes made to public policies regarding built environments and food access.Indeed, as Minkler and Wallerstein (2006) point out, "The lack of formal evaluation, coupled with the failure of many of those engaged in community organizing projects to write up and publish their results, have made it difficult to amass a literature of successful and unsuccessful organizing efforts and the hallmarks of each" (p.41).We seek to help address this gap in the health literature.
The study questions for this evaluation are as follows: 1) What are commonalities and differences in organizing between the two organizations?

2)
To what extent is community organizing an effective strategy for impacting public policy?3) community-based coalition.About a year later, however, the Coalition created a community survey that showed that crack cocaine was not the immediate concern of most community members, but instead a more important concern was an excess concentration of liquor stores and illegal activity around their premises (Gonzalez, 2006).The survey findings helped the Coalition to rethink how it defined community problems.The Coalition's mission is "to help transform the social and economic conditions in South LA that foster addiction, crime, violence and poverty by building a community institution that involves thousands in creating, influencing and changing public policy" http://www.cocosouthla.org/about/ ourmission).

Method
South LA is 60% Latino and 40% African-American (Community Coalition, 2010).The Coalition actively recruits South LA's African-American and Latino residents to become members and build multi-racial alliances capable of speaking and acting on their own behalf on a host of issues (Community Coalition, 2010).One issue that that Coalition works on is healthy food options.Healthy food options are scarce in South LA, which is marked by a disproportionately high number of fast-food chain outlets, liquor retail stores and smaller convenience markets that often sell processed, non-perishable items.Obesity is an issue in South LA.Almost 30% of its children are obese, compared to 17.6% in West LA and 23.3% in LA County.There are also inadequate numbers of safe places for children and families to play and exercise.Nationally, South LA ranks in the lowest quartile for park space available, with an average of less than an acre of park space for every 1,000 people.Compared to LA County as a whole, fewer residents in South LA (57%) believe their area is safe from crime compared to rates as high as 75% and 88% for other regions in the county (Los Angeles County Department of Public Health, 2009).

La Union del Pueblo Entero (LUPE): Hidalgo County, Texas
The late United Farm Workers (UFW) labor rights activist César Chávez founded LUPE in 1989.The original purpose was to serve lowincome Latino communities of California by providing social services such as income tax preparation, immigration services, and legal representation in small cases (La Union del Pueblo Entero, 2010).The organization continues Chávez' vision (¡Si Se Puede!) and over time, expanded to include communitybased organizing, leadership development, and advocacy.In 2003, LUPE assumed all UFW operations in South Texas and continued the labor rights traditions of the 1960s-1970s by "building stronger, healthier communities where people have the power to effect social change through community organizing and civic engagement" (http://lupergv.wordpress.com/).About 6,000 people enroll as LUPE members yearly and most are Latino and poor (La Union del Pueblo Entero, 2012).LUPE members pay dues and their main incentive to be members is services, such as income tax and immigration resources.Some members, however, also participate in LUPE in order to help make community-wide change.Through participation in member and house meetings, members discuss pressing political, economic, and rural issues and campaigns are planned.
Located in Texas in the U.S.-Mexican border County of Hidalgo, LUPE works from five offices embedded within 900+ colonias, rural, unincorporated, substandard community developed subdivisions.Colonias were developed over the last half century as families sought to purchase affordable property (La Union del Pueblo Entero, 2010).The vast majority of families in colonias is Mexican (95%), young, works in the service sector, and is unauthorized (about 80%) (La Union del Pueblo Entero, 2010).According to LUPE, substandard qualities of colonias stem from unregulated community development practices.For example, the average family purchased properties under a contract-for-deed arrangement from developers and buyers did not receive title to their land until final payment.The absence of strong building codes allowed residents to build their homes in stages.Until the 1990s, the State of Texas had passed few laws or codes to regulate this type of development and as a result, the vast majority of colonias were developed and remain without or inadequate potable water systems, sanitary sewage disposal systems, paved streets, mail services, electricity, streetlights and safe and open spaces.

Measures and Procedures
We report on one year of process and outcome data, both qualitative and quantitative, from the first year of project implementation for both grantees (January 1, 2011-December 31, 2011).We conducted four telephone interviews with members of each organization, spaced 3 months apart (a total of eight interviews) using an indepth structured interview protocol that included qualitative and quantitative questions.The questions focused on the CCHE Change Model and Evaluation Frame (Figure 1).Grantees selfselected at least one staff member that was most intimately involved with the community organizing/policy activities of the CCHE project to complete the interviews.Typically, PARC interviewed two staff per grantee simultaneously, and most often the staff members were lead organizers, project coordinators, or directors.Interviews lasted oneand-a-half hours, on average.We also reviewed archival documents for each grantee, such as grant documents, newsletters, quarterly CCHE reports, and related documents in order to better understand the background of the grantees and to supplement interview data.------------------(

Efforts of the Two Grantees to Reduce Obesity Coalition
For the CCHE campaign, the Coalition seeks to use a grassroots community organizing strategy, coupled with leadership development and capacity building, to implement two direct action campaigns aimed at improving the recreational and social environment in the King Park neighborhood: (1) abating nuisances in and around liquor stores as well as a smaller goal of converting one liquor store into a small fresh food market; and (2) securing resources for the implementation of recreation programs at King Park.
The organization is pursuing these objectives in the context of broader challenges to service and social environments, such as the presence of residential motels and recycling centers that fuel the drug trade, prostitution, and gang wars that overrun the King Park neighborhood and diminish social, cultural, and recreational services.
To increase safety and recreational usage of the park, the Coalition will use its proven nuisanceabatement strategies to shut down businesses and/or convert them to beneficial community land uses, (e.g., stores that offer fresh and healthy food options) and implement a King Park pilot program where residents will be mobilized to secure year-round activities at the park and advocate for funding from the City's Summer Night Lights program, an anti-gang initiative that keeps parks open after dark.If the city turns this park into an eligible site for sports and cultural programming, additional gang prevention and intervention funds could be another source of support.This type of investment could mean full programming into the evening hours during peak crime hours.In turn, the increased safety of the park for noncriminal activities could result in reduced crime and gang activity and increased usage of park facilities for recreation, play, and exercise.LUPE LUPE's CCHE campaign seeks to channel community development resources to colonias.LUPE's CCHE policy-change goal is to ensure that there is "equitable allocation of Hidalgo County CDBG funds to promote safe and healthy communities and address recreation equity through the creation of parks and implementation of streetlights in the colonias" (LUPE CCHE Workplan, p. 1, 2011).Their aim is improving the built environment and services across six colonias.This includes access to new, improved, and safer recreational spaces and development infrastructure, as well as access to public works services.In part, these efforts are an attempt to secure resources that the Texas Legislature gave county governments to install street lights; many colonias have yet to receive any street lights.
LUPE is trying to improve some of the root causes of obesity.While there is no obesity data for South Texas, the Texas Department of Health Services consistently reports significantly higher rates of overweight and obese Latino children and adults compared to other racial and ethnic groups (La Union del Pueblo Entero, 2009)

Commonalities and Differences of Process Policy Goals
The organizations differ in their long-term policy goals (Table 1).The Coalition is focused on changing land use policies (nuisance abatement to increase public safety and winning community-driven needs-based prevention programs to increase recreation activities) that will ultimately impact residents' ability to burn more calories while consuming fewer nonnutritional calories.LUPE's policy focus is to make it easier for residents to burn calories via availability of health promoting environments, such as lighted streets and walking trails.Both organizations use multiple and diverse campaign strategies to help them achieve their long-term policy change goal of creating communities where people can safely and openly go out and walk or play, and even get involved in formal recreation programs tailored to their community's needs.Both groups target support from decision makers at varying levels, from the mayor and city planning department for the Coalition to county commissioners and the county judge for LUPE.

Locales and Community Members
The two organizations are targeting different types of locales and community members.For the Coalition, the focus is on one neighborhood, while for LUPE the focus is six different colonias, some adjacent to each other and others miles apart.There are also slight variations in the demographics of the targeted community members.The Coalition is organizing adult residents of all ages and junior and high schoolaged youth, most of whom are students, both African-American and Latino, and mainly Mexican immigrant and Mexican-American.On the other hand, LUPE is organizing adult residents and young families, the vast majority of whom are Mexican immigrant and women.

Strategies and Tactics
Both organizations share similar organizing strategies and tactics, which include personal visits, door knocking, neighborhood, apartment building, or house meetings, phone banking, and to a lesser extent, use of social media.These strategies, along with public education, are used to build their community resident base and develop their resident leaders.The CCHE evaluation defines an "active community resident base" as people who "attend activities/events off and on and can count on them to come to important actions, but aren't regulars."Leaders are defined as residents who "received formal leadership development and involved with the grantee organization on a regular ongoing basis."Typical types of leadership development would include formal training (small group or one-on-one political education and skills development) and "in-thefield" practice of their new skills and knowledge.
This includes mobilizing the community to participate in large events, actions, or protests; outreach via door-to-door visits or telephone; neighborhood/house meeting preparation and facilitation; strategy development; public speaking with media or decision makers; and creation/development of materials or propaganda to raise political consciousness.

Base and Leaders
Both organizations had a significantly larger number of resident base members than leaders.LUPE's parent/ resident base was 476, and 67 of these were leaders.For the Coalition, the numbers are much smaller given the relatively small area of the target neighborhood, with a parent/resident base of 223, of which 30% are youth (n=45), and 8 are leaders, most of whom are parents/residents.

Allies
The grantees also differ in the type and nature of support they receive from like-minded groups or organizations.The Coalition has eight allies.The most typical way allies provide support is by sharing or agreeing to share resources (e.g., staff, monetary, expertise), followed by allowing the grantee to use the ally's name as a supporter to the CCHE campaign, participating in strategic planning, or leveraging outside resources for the grantee.In contrast to the Coalition, LUPE has not engaged allies on this particular campaign, though it has an active network of allies from previous campaigns that it can count on if needed.

Political Education
The grantees also conducted political education activities in the broader community, with similar purposes and goals.In general, grantees provided educational meetings or trainings to the general community and existing parent leaders to increase awareness of the CCHE campaign and to build their resident base and thereby increase their strength to fight on behalf of the issue.For example, the Coalition held the Freedom School program, a six-week summer literacy program series for South LA elementary and middle school children, that utilizes a progressive curriculum grounded in the Civil Rights Movement and empowers children to become active citizens and agents of social change.This training also targeted the parents of the participating children to engage them in the CCHE campaign and introduce them to the Coalition.Leadership activities also include involving the organization's youth leaders in door-to-door outreach to recruit parents/residents to the campaign and the organization.LUPE's community trainings were used to expand both the parent/resident base and the leadership base.It trained residents in Power Analysis, an assessment of how much support the organization had from key local government officials and other sectors as well as how much political and economic influence each had in the area; educated them about county budgets and funding for lights and parks in local precincts; and trained them with public speaking and other skills to engage with decision-makers around any budget injustices.The training also included "action" whereby the organization mobilized a resident delegation to the Commissioner's Court, where selected leaders spoke publically to government officials about their personal living conditions and the CCHE campaign.

Tactics and Strategies
Community organizing can include an array of tactics and strategies, each selected strategically to advance a campaign agenda in ways that resonate with the socio-political context of the target community.LUPE and the Coalition reflected this, as each organization carried out different types of activities designed to advance unique purposes.For instance, the Coalition carried out "investigation research," coupled with routine and systematic documentation of nuisance activity associated with particular businesses, with plans to formally and publicly submit this data to the city's planning department during their hearings on nuisance businesses.LUPE mobilized a resident delegation to go before the Commissioner's Court, where selected leaders spoke publically to government officials about their personal living conditions and the CCHE campaign.

Challenges in Organizing
Both organizations experienced challenges in their organizing or policy campaigns.The Coalition lost two organizers, and that interrupted day-to-day organizing tasks at different times during the year.Moreover, the Coalition continues to face what it describes as "uphill battles" with a local decision-maker who does not support the Coalition's work to improve local urban health and related conditions.LUPE's challenge was expanding and maintaining a base and leadership while it kept pushing for commissioners to fulfill their stated commitments.Because the organization was organized in multiple colonias, it had different rates of success with base building, due to having a stronger history and relationship in some colonias and more recent contact in others, and to some extent because it also had to replace an organizer mid-year.Moreover, the organization spent some time researching where it could leverage private funding to help match local government funding.

Grantee Specific Outcomes
LUPE and the Coalition achieved public and social policy outcomes, specifically related to resource allocation.For instance, the Coalition obtained funding for needs-driven recreation programs from the City's Parks and Recreation Department (e.g., Summer Night Lights), despite local and national trends of cutting recreation programs if not entirely eliminating parks and their programs.This was a significant victory, particularly because the resources were allocated to King Park, an area with high crime rates that was originally on the chopping block in budget discussions.The organization was also able to obtain political support from the local city supervisor and secure private funding for the Freedom School program, which provided educational and recreational services to youth from the King Park neighborhood.These efforts did not entirely begin at the start of CCHE, but CCHE funding helped boost organizing that was already happening around this campaign.LUPE secured funding from three commissioners who had committed to installing solar powered streetlights in five colonias and obtained a commitment by a chief administrator to a commissioner for a walking trail in one colonia.The funding stems from a federal grant and amendments to the county budget.

Discussion
Community organizing is in part about the redistribution of power and resources for greater equity across resourced and under-resourced communities.Community organizing for health is about reducing health disparities by changing policies that expose some groups to built environments that make it difficult to practice health-promoting behaviors.Given the growing recognition of obesity inequity in working-class Latino communities, and in poor and ethnic minority communities in general, we can expect to see an increase of community organizing for altering public policy in these areas.
We described a frame for documenting the process that community-based organizations undertake to change policy.In our case studies, both community-based organizations were able to achieve redistribution of public resources to advance their CCHE objectives.Both community-based organizations carried out community organizing activities that are established in the literature, but the specific activities for each were different.The Coalition is gathering research on local nuisance business and plans to submit the data to the city's planning department.LUPE, on the other hand, has mobilized a resident delegation to speak before the commissioner's court in order to advocate for streetlights.Both organizations are trying to improve safety, but for different immediate reasons (reducing prostitution and drug activity vs. increasing pedestrian safety).LUPE wishes to see relatively immediate results, such as increased walking and general extracurricular activity, while it is unclear how long it will take for the Coalition to see healthier food options in local businesses.
Both organizations also reported barriers to pursuing their work.For the Coalition, the main barrier is obtaining support from a key political official, while for LUPE, the issue is more practical, in that it had lost a key organizer and this slowed down the work somewhat in some colonias.
Another commonality is that both communitybased organizations are organizing in predominantly Latino areas with sizable numbers of recent and unauthorized immigrants.Nonetheless, neither site reported encountering barriers to organizing unauthorized immigrants due to potential fear of contesting local governments.In recent years, there has been an increase in local and statewide policies criminalizing unauthorized immigrants, who are seen as drains on local resources.LUPE has been quite strategic in researching potential private funds to help leverage resources secured by local officials--the idea is to help reduce the public perception that Latino residents are draining public resources and/or not securing their own.

Limitations
Our study has three limitations.First, we provided one year's worth of preliminary data.This limits our documentation of actual policy implementation.It could very well be that any one of the community-based organizations may achieve additional policy victories and/or experience unfulfilled promises by local officials.The initiative-wide evaluation helps address this limitation by evaluating all grantees for all three years of funding.A second limitation to our study relates to our sample.While the community-based organizations were selected purposively, they nevertheless represent a group of highly skilled organizations.CCHE grantees constitute a selective group of organizations that RWJF believed had the capacity to carry out the goals of the CCHE initiative.Our findings, therefore, stem from community-based organizations with high organizational capacities.Third, the evaluation frame may have not captured all activities for each organization that may have been making a difference.We can only assume, though with a high degree of confidence, that the evaluation findings capture the most essential factors contributing to successes and challenges in each organization.

Implications
The CCHE initiative and our study have implications for future policy research.We believe that the evaluation frame guiding our study could be useful for examining similar community-based organizations attempting to alter public policy for health promotion.The frame is timely, particularly given the country's shrinking budgets around redevelopment and growing interest among health philanthropies for interventions targeting community development and public health sectors (Williams and Marks, 2011).Interventions will probably include a mix of strategies, including community organizing.It is our hope that our study and the evaluation frame are useful to researchers interested in publishing the results of community organizing and health policy efforts.