9

Promising Initiatives to Build Community Power and Improve Health

The fourth and final session of the July workshop highlighted examples of promising initiatives to build community power and improve health, and their application to obesity prevention and treatment efforts. Rebecca L. Pearl, assistant professor in the Department of Clinical and Health Psychology and Social and Behavioral Sciences at the University of Florida College of Public Health and Health Professions, moderated the session’s three speaker presentations, which were followed by a panel discussion, a wrap-up presentation, and closing remarks.

WAI‘ANAE ‘OHANA SOCIAL SERVICES AND PRODUCE PRESCRIPTION PROGRAMS

May Okihiro, associate professor and community researcher at the University of Hawaii John A. Burns School of Medicine and senior pediatrician and director of research at the Waianae Coast Comprehensive Health Center (WCCHC), discussed WCCHC’s integration of social service programs and its produce prescription program. Nearly half (48 percent) of families in Hawaii experienced food insecurity in 2021, she began, an increase of 50 percent since the start of the COVID-19 pandemic. She added that Hawaii also has the nation’s highest cost of living and among its lowest wages (Pruitt et al., 2021). Okihiro reported that in 2021, 19 percent of Hawaiian households were at or below the federal poverty level, and an additional 40 percent were designated ALICE—Asset Limited, Income Constrained, Employed (Aloha United Way, 2020).

Okihiro explained that food, especially fresh food, is expensive in Hawaii, and despite growth in the production of local produce, locally grown foods are costly and can be difficult to find. Hawaii imports more than 85 percent of its food, she noted, making it vulnerable to fluctuating shipping costs and natural disasters (Office of Planning, 2012). The COVID-19 pandemic illustrated this vulnerability, she recounted, disrupting Hawaii’s food supply chain such that store shelves were empty for weeks, and the simultaneous downturn in the tourism and restaurant industries left local farmers in a dire situation, with many being driven to bankruptcy. Okihiro stated that the intersection of Hawaii’s high cost of living, low wages, and the COVID-19 crisis elevated the need to strengthen community food systems and address health and wellness.

Communities along the Wai‘anae Coast of Oahu, where Okihiro’s team works, have some of the state’s highest rates of poverty and chronic diet-related diseases (Hawaii Health Matters, 2022). The community is also home to the largest concentration of native Hawaiians in the world, Okihiro observed, and has a strong culture and proud history. To illustrate this point, she explained that Native Hawaiians have long understood the importance of aina (land), ‘Ohana (family), and food, and historically inhabited complex communities called ahupua‘a that extended from the mountains to the sea and contained all the resources a community needed to thrive. Other cultural values include aloha (caring and mutual regard) and malama ‘aina (shared responsibility for taking care of the land). Yet despite their strong cultural values, Okihiro said, many Native Hawaiians living in poverty feel disempowered and disconnected, and those feelings have been amplified by Westernization and reliance on imported foods. She noted, however, that a cultural resurgence over the past 30 years has reignited a growing desire among many Native Hawaiians to return to traditions, including foods such as taro, a nutritious Hawaiian dietary staple.

Okihiro described WCCHC as the largest of the state’s 13 federally qualified health centers, as well as a major employer in the community. It is also the only safety net provider along the 15-mile western coast of Oahu, which she declared is important because two-thirds of its patients in 2019 lived at or below the federal poverty level. WCCHC provides accessible, affordable, patient-centered, culturally aligned services, Okihiro continued, for primary care as well as other services, such as dental; case management; transportation (to transport patients to and from services); eligibility coordination for health insurance and medication assistance; and other assistance, such as housing and referrals to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the SNAP (Supplemental Nutrition Assistance Program)-Ed program, and social security.

Okihiro emphasized that WCCHC’s integration of social services and prioritization of food systems are important supports for patients’ health

and well-being. She highlighted WCCHC’s ‘Elepaio Social Services programs, which promote community self-direction and self-sufficiency, advocate for community health, and address social needs such as food insecurity. One of the program services is the Mākeke Wai‘anae community farmer’s market, the island’s first to accept SNAP electronic benefit transfer (EBT) card payments and the largest EBT/SNAP doubling program at a farmer’s market in the state (i.e., SNAP participants can double their benefit amounts spent to purchase qualifying items—fresh local produce, poi, honey, eggs, meat, and fish). Okihiro described how the ‘Elepaio team distributed thousands of pounds of food to community members in need during the COVID-19 pandemic, including thousands of pounds of fresh fruits and vegetables from local community farmers. She noted that these activities strengthened trust and relationships between community members and the health care system.

Okihiro next discussed the Wai‘anae ‘Ohana Produce Prescription (WOPRx) project, which recruits WCCHC patients who are Medicaid or SNAP participants and have a diet-related chronic disease(s), such as prediabetes, diabetes, or heart disease. According to Okihiro, the program aims to improve patient health and wellness and decrease food insecurity, strengthen community food systems, and gather data to demonstrate to policy makers and insurance companies that food is medicine. A future aim, she added, is to fully integrate WOPRx into the health care system so that health care and nutrition will not be separate entities. In 2021, she recounted, the program was awarded funding from the U.S. Department of Agriculture’s GusNIP (Gus Schumacher Nutrition Incentive Program) initiative, which aims to increase access to fruits and vegetables.

Okihiro elaborated on the program’s experience with enrolling health center patients to participate in the program. Primary care providers were invited to refer patients to WOPRx, but Okihiro explained that the slow rate of enrollment led the team to recognize that some patients did not understand what the program was about and did not answer phone calls from program staff. This made clear, she said, that other providers with more time to explain the program to patients should be able to make referrals, and program enrollment was then opened to all providers (e.g., psychologists, psychiatrists, dietitians, case management workers). The WOPRx team worked with WCCHC’s electronic medical record (EMR) department to add a button to EMR templates so that providers could refer patients to the program by clicking a check box, and then providing a short explanation for the referral and documenting the condition that made the patient eligible to participate in the program. WOPRx staff then call the patient to explain the program in more detail, obtain their consent for participation, and invite them to the Mākeke farmer’s market for full enrollment.

Okihiro explained that WOPRx program participants receive a $50/month voucher to purchase fresh produce at the market for up to 18 months,

noting that this duration was chosen in the hope that it would be long enough to make produce purchasing and preparation a habit. The WOPRx team created EMR templates to record all their encounters with program participants, an integration that she said allows health care providers and program staff to communicate throughout the program.

As part of data gathering to build the case for the idea that “food is medicine,” Okihiro said, the program is collecting baseline and quarterly measurements, including body mass index (BMI), blood pressure, and hemoglobin A1C (HA1C), and collecting results of a food insecurity survey. Providers are strongly encouraged to follow up with patients 3 months after they have enrolled in the WOPRx program, she added, to collect repeat measures. Participants’ pre- and postprogram HA1c and BMI measures will be compared, which Okihiro said she expects to indicate favorable outcomes.

Okihiro reported that retention in the program has been good during the few months since its launch, and that the program is undergoing continuous tailoring to better meet community members’ needs. For example, a second food pick-up location has been added on the WCCHC clinical campus so patients can come in the middle of the week to enroll and get produce; the program is working with farmers to offer cut vegetables that are ready to eat or cook; and an online ordering system and free delivery service are provided to serve participants who lack transportation or are homebound.

LOCAL MATTERS: PARTNERING FOR HEALTHY COMMUNITIES

Michelle Moskowitz Brown, executive director of Local Matters in Columbus, Ohio, discussed her organization’s work in food education, access, and advocacy. She explained that Local Matters was founded in 2008 with the belief that everyone has a right to affordable, accessible food that meets their cultural needs and preferences. The organization’s statement on diversity, equity, and inclusion declares that the outcomes of systemic racism prevent people from having equitable access to such resources as land, supermarkets, food business opportunities, and education, with the result that people of color experience disproportionately higher rates of poverty, food insecurity, and diet-related chronic disease. Ohio has the second-highest rate of Black infant mortality in the United States, Brown noted, adding that infants exposed to food insecurity in utero are at higher risk for infant mortality. She repeated further that Local Matters also endeavors to help turn the tide of diet-related disease through positive dietary changes.

According to Brown, Local Matters, as a leader and community collaborator, works with health care institutions, schools, community centers, and housing organizations to help children and adults grow, cook, and access

affordable food and build a positive relationship with food and cooking. People of all ages, experiences, and abilities participate in the organization’s programs, she observed, which offer in-depth education and access points. Stressing the importance of these program services, she pointed out that a 24-week educational curriculum in preschools is less effective if parents cannot access the food the students are learning about, and efforts to provide healthy foods to community members are less beneficial if recipients do not know how to prepare them.

Brown elaborated on Local Matters’ educational Food Matters programs, which aim to impart age-appropriate skills and experiences to participants. She explained that youth education helps children develop positive relationships with food, introduces new foods using a multisensory and multicultural curriculum, and highlights the relationship between food and health. Teenagers learn food preparation skills and are introduced to such concepts as the food environment and food justice, she continued, and along with adults continue to build practical skills for cooking and budget management to support long-term health and food security. Brown emphasized that the organization’s educational programming uses a culturally appropriate, facilitated dialogue that draws out participants’ knowledge and experiences.

Brown moved on to highlight Local Matters’ efforts to equitably increase the availability and affordability of fresh, healthy foods. The organization has started to shift away from using the term “food deserts,” she remarked, which she said felt like a “catch-all” that is on the one hand easy to conceptualize but on the other hand is inadequate for addressing the embedded issues of poverty and structural racism. As an alternative, Local Matters has used the term “food apartheid” or provided a more thorough explanation to characterize a community’s food landscape.

Brown next described the veggie van, an access initiative to provide convenient, consistent availability of fruits and vegetables while supporting local small businesses and small-scale farmers. The van stops at the same locations each week and also provides delivery services, she explained, for $10 meal kits that come with recipes and can be purchased using SNAP, WIC, and Temporary Assistance for Needy Families benefits. It does not offer free food, she clarified, but it does provide equitable access for people who have food dollars and cannot easily obtain fruits and vegetables. The veggie van also provides dollar-for-dollar matching up to $25 per day to help families stretch their food budgets further and will soon begin participating in a produce prescription program with a local hospital. Brown described another access program—learning gardens—most of which are at recreation centers so they can reach children during both the school year and the summer. These and other access programs are designed to complement each other, she said, and to foster participation from multiple generations while addressing residents’ priorities.

Brown then turned to Local Matters’ efforts to advocate for policies that support community food access and education. She highlighted a new Community Advocates group that launched in January 2022 with 16 members. She explained that the group’s purposes are to provide ongoing feedback about Local Matters programs and discuss neighborhood needs, as well as to build group participants’ advocacy skills to prepare them to meet with elected officials and build power within the organization as they connect with the advocacy committee of the Local Matters board of directors. The Community Advocates group meets monthly over meals and receives transportation and child care support to facilitate their attendance.

Brown shared several closing thoughts to complete her presentation. Everyone has power, she submitted, and it is great to find ways to define purpose within a community and build power together. It has been said, she noted, that “every decision is made by the person who has power to make it.” She encouraged attendees to think about what decisions they have access to, who helps them make those decisions, and how they might allow some decisions to be influenced by people who they think have less power. She referenced Bryan Stevenson, founder of the Equal Justice Initiative, and his four components for effecting change: get proximate to the issues, change the narrative, be comfortable being uncomfortable, and remain hopeful. Lastly, she stated that collaboration moves at the speed of trust. Many health care systems have a great deal of power, she observed, and stated that as a community organization, Local Matters appreciates when partners such as health care systems are committed to long-term collaboration and to exploring the services local providers can offer.

ADVANCING A PROGRESSIVE OBESITY AGENDA

Brian C. Castrucci, president and CEO of the de Beaumont Foundation, asserted that obesity is one of the last diseases that society views almost solely through an individual lens (i.e., regarding it as the result of an individual’s poor choices). It is still acceptable, he observed, to create entertainment, such as televised weight loss competitions, at the expense of people with excess weight. Such shows perpetuate the simplistic narrative that obesity results from failed lifestyle choices, he contended, and promote weight stigma and bias. He stressed that weight gain and loss reflect complex systems that involve interactions between genetic predispositions and environmental exposures, as well as metabolic and physiologic adaptation.

Castrucci voiced his concern about the use of BMI as a diagnostic measure for obesity. He shared his view that BMI does not necessarily work well for characterizing an individual’s position relative to a broad population group, nor does it account for muscle mass or frame size. He observed,

moreover, that BMI is sometimes used singularly to characterize health without consideration of other relevant indicators, such as blood pressure, cholesterol, and glucose. Weight is a complex and fluid number, he said in summary, and thus should be diagnosed with more dynamic, sophisticated measures.

A narrow focus on individual behavior as the cause of obesity is problematic not just because it medicalizes obesity and perpetuates weight bias and stigma, Castrucci maintained, but also because it fails to consider the role of social determinants of health or equity—that is, environments and policies. He called for community conditions that enable residents to make healthy lifestyle choices, recognizing that such conditions are often determined at the policy level. As an example of an upstream determinant he cited housing prices, illustrating this example by noting that his residential proximity to work allows him more time to prepare a nutritious meal and to be physically active after the end of his workday. He suggested solutions to other upstream determinants, such as stiffer penalties for propagating medical misinformation (e.g., “miracle cures” for obesity) and easily accessible, culturally relevant food retail options in communities that meet residents’ needs.

In closing, Castrucci urged consideration of a broader set of metrics when characterizing health. He called for a shift in mindset from weight loss to improving health and wellness, and from medicalizing obesity to recognizing its structural and social determinants.

PANEL AND AUDIENCE DISCUSSION

Following their presentations, the three speakers engaged in a moderated discussion and answered participants’ questions. They first commented on how the content of their presentations is relevant to efforts to prevent or treat obesity, then touched on individual versus systemic obesity solutions, tips for sustaining community health programs, and Local Matters’ Community Advocates group.

Connecting the Speaker Presentations to Obesity

Okihiro explained that her work in obesity research began with a focus on individual-level, clinical solutions and has expanded to community and systems solutions. She suggested that connecting work on obesity solutions with other efforts that leverage community empowerment strategies is likely to yield greater success than focusing on obesity prevention and treatment alone.

Brown shared Local Matters’ belief that a key component of preventing diet-related disease is the integration of nutrition education into the

curricula in schools, provided across children’s elementary and secondary years and not only in optional programs such as farm-to-school initiatives.

Castrucci asserted that a narrow focus on specific disease states can lead to overlooking common social- and political-level contributors to health, such as poverty and education. He mentioned cityhealth.org as a good example of a package of health-promoting policies and commented, “If you think of our world as a fish tank, we need to spend less time thinking about the fish and more time thinking about changing the water and cleaning the tank.” He called on funders to consider the interrelationships and intersectionality between diseases as they structure their awards, noting that some funding entities focused on specific chronic diseases can end up at odds with each other as to how funding should be distributed despite working to influence similar root causes of disease.

Individual versus Systemic Obesity Solutions

Castrucci contended that both individual-level and systemic obesity solutions are needed, adding that an individual’s efforts to improve health will likely have limited effectiveness in the absence of a supportive environment. With respect to environments, he shared his perspective on changing the narrative of shaming and blaming individuals for their obesity, calling on media to stop perpetuating weight stigma and emphasizing the importance of educating clinicians on appropriate ways to care for individuals with excess weight.

Castrucci shared personal experiences in clinical settings, including one in which a provider asserted that he needed to be at a certain weight before the provider assessed his overall health or discussed the topic with him. He also recalled an experience from his childhood when a pediatrician labeled him “fat.” These kinds of experiences linger in people’s memories for a long time, he insisted, and can lead patients to view the health care system as an adversary instead of a partner in pursuing health.

Sustaining Community Health Programs

Okihiro explained that WCCHC is trying to demonstrate to funders, especially insurance companies, the effectiveness of community programs that break down silos and address health equity in a broader way than, for example, focusing only on diabetes or obesity management. To foster the sustainability of programs, she suggested, it is important to meet the needs of the community; meaningfully partner with community members and organizations in program development, implementation, and evaluation; share program data with people who influence policy; and uplift stories of people affected by policies.

Local Matters’ Community Advocates Group

Asked to elaborate on Local Matters’ Community Advocates group, Brown replied that during the group’s 6 months of operation, it has been iterative and participant driven. The group is weighing in on such issues as the veggie van’s route and the ease of use of its app, which she said could lead to changes that would improve the user experience and better tailor the program to certain populations, such as older adults. Local Matters will continue to make the group a priority, she predicted, because the input it provides is a critical support to the organization’s ability to deliver programs effectively.

WORKSHOP WRAP-UP AND CLOSING REMARKS

Leah D. Whigham, founding director of the Center for Community Health Impact and associate professor at the University of Texas Health Science Center at Houston School of Public Health in the Department of Health Promotion and Behavioral Sciences, summarized a series of key takeaways from the workshop (see also the “Highlights from the Presentations of Individual Speakers” boxes at the beginning of Chapters 6, 7, 8, and 9). She began by highlighting the point that obesity is a complex disease with multiple causes and contributors that should be targeted comprehensively in interventions. Power, she added, influences the availability of, access to, and uptake of interventions.

Another key takeaway, Whigham continued, is that coordination of evidence-based treatment for both obesity’s causes and contributors can be expected to drive the greatest impact at the community and population levels. Access is a challenge for evidence-based treatment of causes, she continued, citing the need to better equip primary care providers to address obesity in light of the relatively low numbers of obesity specialists. She highlighted the speakers’ emphasis on centering and uplifting the voices of community members targeted by strategies for addressing the causes of or contributors to obesity when those strategies are being developed and on evaluating an intervention’s desired outcomes.

Whigham emphasized that communication and framing can either perpetuate misconceptions about obesity or reframe and correct false narratives. As an example, she stated that conflating contributors to and causes of obesity can unintentionally fuel the bias that people with obesity choose to have excess weight because they do not eat healthy food or exercise enough.

The bottom line, Whigham proposed, is that two strategies are essential: integration of individual strategies that are scalable and available regardless of a person’s geographic location, income, or race/ethnicity; and systems changes that make those individual strategies available and sustainable. She appealed for advancing the two strategies in tandem, working collectively, and focusing on the interaction of both contributors to and causes of obesity.

Bruce Y. Lee, professor of health policy and management at the City University of New York Graduate School of Public Health and Health Policy and executive director of the PHICOR (Public Health Informatics, Computational and Operations Research) initiative and the Center for Advanced Technology and Communication in Health, provided closing remarks and recapped how this second workshop fit into the broader context of the workshop series. He pointed out that the three workshops in the series were all rooted in the foundational understanding that obesity is the result of complex systems that in many cases are broken or need to be redesigned. The dangers of not recognizing or appreciating that obesity is a systems problem, he posited, are that the resulting solutions are unsustainable “Band-Aids” that often have unintended consequences; worsen existing disparities; introduce bias; and consume inordinate time, effort, and resources in a process of trial and error. The second workshop, he recounted, had highlighted that communities are complex systems, and that power dynamics within them are key. Communities need to be empowered to effect change, he maintained, instead of simply being engaged in discussions to listen and provide input but not being afforded decision-making capacity.

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