Neighborhoods Program

Healthy Neighborhoods began in 2012 after Metro Health assembled a diverse group of community stakeholders who identified eleven target neighborhoods throughout the city that were experiencing high risk factors for chronic disease, high rates of infant mortality, and high levels of youth violence. The group examined the social determinants of the target area, including income, affordable housing, single parent households, transportation, etc., as well as the presence of existing networks of community based assets such as churches, schools, and neighborhood associations that facilitated opportunities for health improvements. These eleven neighborhoods became the starting point for the Healthy Neighborhoods program – an innovative place-based childhood obesity prevention project in which CHWs serve as health educators, connectors, and community organizers who empower residents to become active voices of the community. The CHWs employed by Healthy Neighborhoods were recruited from the neighborhoods in which they work and are representative of the population within that neighborhood. CHWs are uniquely qualified to provide peer-to-peer education and culturally appropriate outreach to the communities they serve. It is important to consider that role of the CHW is inherently varied, challenging, and potentially emotionally taxing. CHWs often work long hours with irregular schedules that often include nights and weekends. It is important to make sure that the CHWs on the team are continuously motivated and supported by the entire team. Additionally, CHWs have broad scopes of work and are held accountable not only by program staff, but also by members of the community. Because of this, it is essential for any program replicating this model to carefully assess applicants for all the relevant positions. Losing a CHW from this model means losing institutional knowledge, potentially impacting the program reputation, and affecting key community connections which can have ripple effects on the entire program, especially if the CHW leaves the program due to conflict or is terminated. In the ongoing Healthy Neighborhoods Project, there have been many changes since the beginning. This has been due to results from formal needs assessment or from informally expressed needs by the community, due to changing skills and experience of the CHWs, and due to the availability of grants and various requirements. Currently, a CHW is assigned to each target neighborhood and supported by other team members. The families in that neighborhood continue to engage with the CHW in the locally appropriate health improvement strategies that aim to improve the nutrition and increase the physical activity of community members and especially the children. The focus of the Healthy Neighborhoods Project remains primary prevention of childhood obesity within the target neighborhoods by implementing evidence-based strategies both at the school and community levels. The project is aiming to increase community member engagement and use a community-school partnership approach where possible to improve the health status of children and families. Stakeholder Involvement & Project Design In each of the neighborhoods, the CHW from Metro Health has been working with local community members and other non-profit organizations to address childhood obesity prevention using environmental and policy change practices. The residents in the neighborhoods have been involved in assessment of the problems in the neighborhoods and in planning and implementation of strategies to address them with cooperation from other agencies working in the schools and communities. The CHW, with guidance from the Healthy Neighborhoods Project leaders, guide and support the planning and implementation of the strategies in the neighborhoods. It is noted that there is a complex interplay of factors that challenge the goal of achieving the nutrition and exercise requirements for a healthier lifestyle to reduce the disease burden in this vulnerable population. One of the mechanisms used to identify the needs and find solutions in the target neighborhoods is to engage the residents by using the ABCD framework. Here the community residents discuss the assets in the community, for example parks or libraries, to see how they can be used for obesity prevention strategies. Metro Health staff networked with residents, schools and other non-profit agencies within each neighborhood to engage families in the development of a targeted approach to community health improvement based on information from community surveying. Proposed strategies and interventions were presented and detailed at the neighborhood level. The interventions were based on reports of evidenced-based success with environment or policy changes to improve nutrition and promote fitness in similar neighborhoods in other locations. Community members were also involved in assessment, planning, implementation and evaluation activities to ensure the appropriateness of specific strategies and interventions in the particular neighborhood and the also in the process of their implementation. Costs & Participant Criteria The Healthy Neighborhoods program is one of six Metro Health projects that focus on improving San Antonio community health using funding from the Medicaid Program 1115 Waiver called the Texas Healthcare Transformation and Quality Improvement Program.” Texas received federal funding for this Medicaid waiver to test new or existing ways to deliver and pay for health care services in Medicaid and the Children's Health Insurance Program (CHIP). The Texas Health and Human Services Commission (HHSC) divided Texas into 20 Regional Healthcare Partnerships (RHPs) to implement this waiver. Bexar County and 19 other counties comprise RHP 6 and the University Health System serves as its anchor organization. All waiver providers throughout the RHP work to implement projects aimed at improving healthcare through simultaneous pursuit of the triple aim”: improving the experience of care, improving the health of populations, and reducing the per capita costs of health care. Healthy Neighborhoods uses the 1115 Medicaid Waiver funds to prevent health problems among Medicaid eligible and low-income uninsured people living in San Antonio. However, this model of obesity prevention can be used in any population if it is tailored to the audience and culturally relevant. There are tangible and intangible costs associated with building a successful community health worker-led program similar to Healthy Neighborhoods. The larger the geographic reach and program impact, the higher the costs. The first year costs for implementing a program similar to Healthy Neighborhoods with a team of six CHWs is approximately $550,000. This amount includes all relevant start-up costs including: salary and benefits for personnel including one program coordinator ($70,000), a data analyst/assistant coordinator ($60,000), and six CHWs (6 * $45,000 = $270,000); office costs such as rent, printing, marketing ($60,000); supplies such as uniforms, technology, furniture ($30,000); travel including mileage reimbursement, training, and conferences ($40,000); and funding for projects such as food for nutrition demonstrations and supplies for various community activities ($20,000). The total cost is scalable depending on the size of the staff, the geographic spread of the program, and the type of community projects being implemented. In additional project years, we recommend budgeting additional contractual costs for an external evaluator. In this model, half of the program costs are dedicated to personnel and staffing. This is because the strength of the program comes from the CHWs on the team. This is in contrast to other programs targeting environmental and policy change that often allocate a high proportion of their budget to the project materials themselves (such as building robust infrastructure). Additionally, we wanted to note that originally the CHWs on the staff were hired as temporary contracted employees. As of December 2018, all eleven staff members have been converted to full-time City of San Antonio employees who are entitled to benefits such as a city pension, health insurance, and paid sick time. Many of the CHWs have said that this is the first time they have had a job that offers benefits. Since the people power of this program is extremely important, it is crucial to recognize the value of the CHW role by offering competitive compensation and benefits for all staff. There are also intangible costs and considerations associated with a program similar to Healthy Neighborhoods. The biggest intangible cost associated with a successful similar program is time – it takes a lot of time, sometimes even a couple years, for the CHWs to develop mutual trust with the community. This is especially true among communities of color or other marginalized groups who may be wary of new programs or groups. It is crucial to be aware of the time required to build community connections and rally community support while using this model otherwise the program will not be successful. Goals & Objectives The goal of Healthy Neighborhoods is to prevent childhood obesity by addressing root causes of obesity and creating environmental and policy changes for sustainable changes that promote active lifestyles and healthy eating habits. There are three main objectives for the program related to the three main functions the CHWs serve: improve the neighborhood environment to promote healthy living through implementing evidenced-based interventions to promote health; improve nutrition and physical activity habits among community members through education and connecting people to local resources; and amplify the voice of the community and supporting participation by community members in public input sessions and grassroots advocacy. The activities related to these objectives will vary dramatically depending on the input of the community. Project Examples Three examples of projects that exemplify how the ABCD & CHW model can be applied to childhood obesity prevention include the Sarah King Elementary Walking School Bus, the Palo Alto Skateboard Clinic, and the Highland Park Farmers' Market. One childhood obesity strategy, a walking school bus' where children walk together to school in a group with adult support, was implemented during 2018 in the Avenida Guadalupe neighborhood. The objective was to enable children to walk safely to Sarah King Elementary School from the Cassiano Apartments; the longest distance between home and school for these children is about half a mile. The Sarah King Walking School Bus was very popular since children could walk to school safely, with friends and escorted by adults from different agencies like Metro Health, University of Texas San Antonio, San Antonio Police Department, Animal Control, and Alamo Area Metropolitan Planning Organization. The neighborhood is a safer place now without the children having to fear stray dogs or threatening persons. The children can play when they like, and all children can walk to school. This is a necessity when parents cannot take them and bus facilities are not available. The children have fun when they walk to school with the adults who socialize with them, talk to them, and learn about their studies and career goals. The Walking School Bus encourages neighborhood unity, positive attitudes toward school and friends, and useful physical activity. For the children, walking to school is not only a time of physical activity but also a time to learn values and attitudes that, as they grow up, will help them become healthy adults. The Skateboard Clinic was implemented in the Palo Alto neighborhood as an intervention to increase physical activity among neighborhood children by leveraging their interest and enthusiasm for learning to skateboard at the local park. The clinic and its curriculum were carefully designed to cover safety, skateboarding maintenance, basic skills, advance maneuvers, manners, team spirit, healthy diet, hydration, and responsible community care. The training was organized into six weekly sessions of three hours each on Saturday mornings. The Skateboard Clinic was possible though the contributions and collaborations of several organizations, as well as the local resource of an existing skateboard park adjoining the Palo Alto Park. This brought in community volunteers to teach and mentor them and many parents to provide healthy snacks or lunch and to cheer on the participants. Local authorities cleared the graffiti in the park to provide a very attractive venue. This also gave the participants the desire to protect the park as a community resource and to show their pride in ownership and determination to continue to protect and help maintain community assets and public places such as the parks. Almost all the participants said that they would continue to use the skateboard for fun and exercise, use helmets, teach siblings, and find other parks where they can skateboard as it was a new skill for some. Almost all of them replied that they plan to drink more water and eat healthy food. They expressed confidence in their new skills and in their ability to help take care of the parks and environment. The skateboard clinic helped the participants to learn to be physically active, eat healthy food, change behavior, and also grow in self-confidence and communication. They all learned how to care for the parks, surroundings, and environment. They enjoyed being physically active in the outdoors and wanted to follow the example of adult mentors for whom skateboarding had been a part of staying active throughout their lives. The 2018 Highland Park Farmers Market was organized and held monthly from May to October to increase availability of local healthy food options and to create a community celebration of healthy living. Each market had vendors who provided a range of wares: fresh vegetables and fruit, herbs, cooking utensils, and ready-to-eat food and beverages, as well as other items such as crafts and used books. Small baskets heaped with zucchini, eggplant and tomatoes, or with Fredericksburg peaches, beautiful natural wood cutting boards, healthy green plants, and colorful homemade crafts all made a very attractive sight. With nice weather and a lovely setting on the lawn under the Bode Center's beautiful trees, the community members came together, some as families, some individually, and had a great time.” They enjoyed the healthy cooking demos and tasted the healthy veggie recipes, printed on cards for them to take home. They could socialize with neighbors and try out a yoga class while the children had fun in organized activities and just playing out in the open. All of these healthy activities and attitudes could have longer-term effects on the health of local families if repeated over time and could in this way help prevent childhood obesity.

Evaluation is the key component of any successful program and Healthy Neighborhoods has benefited from collaborating with researchers to better quantify the impact of the program. As stated previously, the objectives of the Healthy Neighborhoods program are to: improve the neighborhood environment to promote healthy living through implementing evidenced-based interventions to promote health; improve nutrition and physical activity among community members through education and connecting people to local resources; and amplify the voice of the community and supporting participation by community members in public input sessions and grassroots advocacy. The impact that Healthy Neighborhoods has on the neighborhood environment is assessed through the evaluation of the community impact projects. In project year 2018, the team had a goal of completing at least 30 community impact projects and they exceeded this process goal by completing 33 (3 per neighborhood). In order to assess the outcome of these projects, we partnered with Dr. Mary Thomas, a public health researcher, and her team to conduct a health impact evaluation on twenty of these projects and develop case study reports. In these studies, Dr. Thomas collected qualitative and quantitative data to evaluate the outcomes of these projects. A similarly designed evaluation was performed in fall of 2017 by Dr. Adelita Cantu. Dr. Cantu performed interviews with key stakeholders to assess the program as well as analyzed quality of life survey data the team had collected from community members. Dr. Thomas' evaluation of the projects included the following steps: (1) study the current status and interim results of the Healthy Neighborhoods Project in each target neighborhood; (2) compile and analyze data provided by the department and collected by the staff on visits and interactions in the neighborhoods; (3) organize data, analysis, summaries, feedback, and comments into a case study for each target neighborhood which will be updated throughout the evaluation project; (4) use each case study as a resource for further study of that target neighborhood and for selecting its health outcome impact stories to be written and presented to community members for feedback; (5) provide each story upon completion to the department for distribution within the neighborhoods. The purpose of the evaluation was to develop a set of community health impact stories that accurately documented achievements and celebrated contributions of community leaders/members in order to inspire and motivate them and others in their neighborhood to continue, and even expand their efforts towards improved nutrition and physical activity. These stories also included the voices of community members. The case studies also included the current outcomes and the projected long-term outcomes based on review of literature which have documented other similar disparity neighborhoods that implemented similar interventions. All twenty of the projects Dr. Thomas' team evaluated were successful in making a positive impact on the neighborhood environment based on the feedback of participants that Dr. Thomas collected in interviews. The Sarah King Elementary Walking School Bus, the Palo Alto Skateboard Clinic, and the Highland Park Farmers' Market are all examples of community impact projects that Dr. Thomas evaluated. The walking school bus evaluation, for example, found that participants increased from about ten regular student participants in January 2018 to over 50 regular student participants in May 2018. The stakeholder interviews indicated that safety in the area has improved because of fewer stray animals this is largely due to Healthy Neighborhoods' collaboration with Animal Care Services to reduce stray animals on the path to school. Participants in the walking school bus also reported higher levels of pedestrian safety understanding. The Palo Alto skateboard clinic was successful in similar ways. Of the 13 elementary school age participants in the six week clinic, 100% reported they will use their skateboard for fun and for exercise after the clinic ends. 13 out of 13 reported learning how to properly wear a helmet while 12 out of 13 reported always using a helmet. Almost all of the participants (12 out of 13) reported drinking more water instead of sugary drinks after the clinic. Lastly, the farmers' market demonstrated a positive impact on the Highland Park community because it brought the community together to learn about healthy cooking as well as to purchase affordable produce. Dr. Thomas' team interviewed or surveyed 39 attendees of the market nearly half reported that they purchased fresh vegetables and most reported that they would attend if the market was held twice a month (instead of just once a month). The participants indicated that they enjoyed the market and were able to buy healthy foods that were not sold in some of the local stores. Healthy Neighborhoods evaluates the extent to which nutrition and physical activity habits are improved among program participants. The process measures for this are the number of educational nutrition classes that are conducted in the year. These nutrition classes use the curriculum from Metro Health's Viva Health nutrition education campaign. In project year 2018, the team had the goal of teaching 110 education classes reaching at least 750 adults. The Healthy Neighborhoods team exceeded this goal by teaching 316 nutrition classes that reached 3,513 adults. The outcome results of these nutrition classes are evaluated using a pre- and post-test that evaluates change in knowledge, behavior, awareness, and attitudes in participants regarding nutrition. The results of these evaluations indicated that the nutrition classes are effective. For example, in the Prospect Hill neighborhood on the west side, a survey of 160 students who received nutrition education classes once a week for six week indicated the following: 14% increase among participants who reported cooking meals at home with their family in the past week; 24% increase among participants who reported eating fruit on most days of the week; 18% increase among participants who reported eating vegetables on most days of the week; and a 41% increase among students who reported using a salad size plate instead of a large dinner plate during meals. Finally, Healthy Neighborhoods seeks to amplify the voice of the community and support participation by community members in public input sessions and grassroots advocacy. This was achieved by providing 36 trainings ABCD to a variety of audiences including schools, community groups, churches, and more. The Healthy Neighborhoods team also sought to capture the voice of the community by conducting a quality of life survey. The team surveyed people from over 300 randomly generated addresses within their neighborhood boundaries to assess quality of life including overall health, physical health, mental health, and the impact of poor health on daily activities. This is an example of primary data collection performed by Metro Health. These surveys indicated that, of the people surveyed, 60% described their general health as good”, very good”, or excellent”. Survey participants reported that in the past month, their physical health was not good for an average of 4.3 days and their mental health was not good for an average of 3.9 days. Poor health restricted everyday activities like going to work or school for an average of 3.4 days among survey participants. These results indicate that poor health continues to affect the target neighborhoods so ongoing health promotion activities are necessary.

Sustainability for the Healthy Neighborhoods project is multifaceted and is addressed by project leadership at the grassroots level, the organization level, and the systems level. At the grassroots level the project works to co-create environmental changes that can be sustained by the community that it was created within. The lessons learned from the grassroots sustainability level are that people in the communities served by the project are of low income status and are often working to just meet basic human needs such as food and shelter therefore having an expectation upon them that requires time or financial resources is not always appropriate or may take much longer than a similar project that was implemented in an affluent area of the city. Similarly, non-profit organizations and school systems in these neighborhoods are also often struggling to obtain adequate resources. That said, it is always the goal to pass ownership of an environmental change project to the community and that can be seen in the three stories that we have highlighted throughout this submission. The CHW organizing the Highland Park Farmers Market is working in her neighborhood to build the capacity of local leadership to sustain the market. This means inviting people to participate in the planning, organizing, and promotion of the events in order to build the sense of community ownership. Two organizations, the Baptist Temple Church and the Highland Park Neighborhood Association have both increased their responsibilities with the market this past season and will be invited to take even larger roles next year. The CHW who co-organized the Walking School Bus with JobsPlus and Sarah King Elementary School is actively building capacity with City Year volunteers and leadership in order for a hand-off within the next year to them and the ultimate goal being to increase parent engagement and participation in the program. At the Palo Alto Skateboard Park, the CHW works to build leadership skills with the parents of the skateboarders. This year, the parents will be participating in Adopt a Park with the City of San Antonio Parks and Recreation Department as a way to reclaim space and stay on top of graffiti issues that arise. At the organizational level, sustainability is tied to funding. The project works to be fiscally responsible and build up reserve funds in order to prolong the length of funding of the project. While the majority of funding for chronic disease prevention projects is grant-funded, the value of this model was recognized by a council district and one CHW position within the project is funded through general funds. This partnership between the project and council districts may be a way to increase the amount of public funds in the future that supports the program and diversifies funding streams. Another way the project works to create sustainability is to pursue additional grant funding that supports the work of community health workers in chronic disease prevention. A recent win for the project was being awarded a 5-year grant from the CDC addressing Racial and Ethnic Approaches to Community Health. This grant will build on the strength and innovation of the Healthy Neighborhoods project while also expanding our scope of work to include tobacco and lactation strategies. At the systems level, it is critical to share the success of combining the CHW and ABCD models to implement evidenced-based chronic disease prevention strategies. The project seeks to inspire other organizations, educational institutions, and leaders to adopt similar models to address health and equity issues at the grassroots level to lead change. In order to share our work, we have presented to a diverse mixture of organizations and conference attendees, including: Texas Cities Connecting Children in Nature, the Cultural Inclusion Conference, TACCHO Health Equity Workgroup, the Healthier Texas Summit, UT Health Science Center Community Service Learning Conference, IIMS Community Engagement Symposium, and the Texas Public Health Association Annual Conference. Additionally, applying for awards such as this one in order to be recognized on the national stage is another strategy to achieve this systems level sustainability of the model. Whether or not this project exists far into the future, everyone benefits if community health workers continue to be recognized as the agents of change they are and we all promote the use of seeing people and community as assets, rather than users of services.

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