Community Nutrition Series

State: TX Type: Model Practice Year: 2012

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The jurisdiction of the Houston Department of Health and Human Services is the city of Houston, the 4th largest U.S. city, with a 2008 population estimated at 2,242,193. For this practice, the target population is the residents residing in the communities surrounding the 11 HDHHS multi-service centers. Chronic disease is an overwhelming problem in Houston/Harris County, leading to extensive suffering, disability, and 7 out of 10 deaths in 2008. The Community Nutrition Series is one of several efforts by the Department to impact chronic disease. Fresh fruits and vegetables are essential components of a healthy diet. The lack of access to sufficient amounts of fresh fruits and vegetables contributes to unhealthy diets, malnourishment, and chronic diseases. Poor health disproportionately affects minority and low-income populations, yet education opportunities and resources in these communities are limited. Since adequate nutrition is critical to good health and human flourishing, it is a vital component of community-based services.

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Houston Department of Health and Human Services
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Community Nutrition Series
The jurisdiction of the Houston Department of Health and Human Services is the city of Houston, the 4th largest U.S. city, with a 2008 population estimated at 2,242,193. For this practice, the target population is the residents residing in the communities surrounding the 11 HDHHS multi-service centers. Chronic disease is an overwhelming problem in Houston/Harris County, leading to extensive suffering, disability, and 7 out of 10 deaths in 2008. The Community Nutrition Series is one of several efforts by the Department to impact chronic disease. Fresh fruits and vegetables are essential components of a healthy diet. The lack of access to sufficient amounts of fresh fruits and vegetables contributes to unhealthy diets, malnourishment, and chronic diseases. Poor health disproportionately affects minority and low-income populations, yet education opportunities and resources in these communities are limited. Since adequate nutrition is critical to good health and human flourishing, it is a vital component of community-based services. The primary goal of the Community Nutrition Series, comprised of a Nutrition Program, Community Garden Program and Farmers’ Markets, is to assist limited-resource audiences acquire access to fresh produce and acquire the knowledge, skills, attitudes, and behaviors necessary to incorporate healthy diets with the intention of preventing or delaying the onset of chronic disease. In December 2007 the Nutrition Program, a 6 week program developed by a Registered Dietitian and funded by Departmental general funds, was offered to minority and low-income residents within the Houston area. The program empowers residents to make immediate healthy lifestyle changes regarding: grocery shopping, meal planning, food choices, portion control, cooking techniques, dining out and food label reading. To support the nutrition education offered to residents, it became critical to address the lack of access to fresh produce within low-income and underserved neighborhoods. As a result, the Community Garden Program was developed and offered to residents starting February 2009. The initial pilot site was funded by Departmental general funds and the expansion to 10 additional sites was grant supported by the Houston Galveston Area Council. This program offers a 5 week education component, developed by a Master Gardener, Health Educator and Registered Dietitian, focused on organic gardening, non-toxic pest control, site development, windowsill gardens, nutrition and physical activity. The Nutrition and Community Garden Programs have successfully helped to impact over 4,000 Houston area family homes to date. For residents who are unable to attend educational seminars or get involved with community gardens, HPEPD implemented the Get Moving, Houston Farmers’ Market in March 2011 in three underserved Houston communities also described as food deserts: Sunnyside, Magnolia and Fifth Ward. The famers’ markets have helped to reinforce the likelihood of participants making healthy food choices consistent with the most recent dietary advice as reflected in the Dietary Guidelines. The initiative was funded by the Texas Department of State Health Services Office of Obesity Prevention. Houston Department of Health and Human Services (HDHHS) Office of Health Planning, Evaluation and Program Development (HPEPD) houses and leads the Community Nutrition Series and is able to deliver a successful program with the support of Houston Parks and Recreation Department, Urban Harvest, Keep Houston Beautiful, Recipe for Success, Texas Agrilife Extension Program, Houston Galveston Area Council, Multi-Service Centers, Re-Entry Program, Community Health Statistics, Texas Department of State Health Services and Houston area residents.
Health Issues The Community Nutrition Series addresses three main public health domains: chronic disease, community involvement and health disparities. In addressing chronic disease, the Department has chosen to address the risk factors that cut across most chronic diseases: poor nutrition, physical inactivity, tobacco use and alcohol use. According to the National Center for Chronic Disease Prevention and Health Promotion 2009 data, only 22.7% of the Harris County adult population age 18 years and older consumed fruits and vegetables daily; 65.5% of the adult population within Harris County age 18 years and older are overweight or obese in comparison to the US national average of 64%. In addition, only 44.3% of adults greater than 18 years of age within Harris County get the recommended amounts of physical activity daily. Additionally, a Health Disparities Data Report released March 2008 by the City of Houston states the following: (a) over 60% of the Houston population is made up of Hispanic or Latino, Black or African American, and Asian residents; (b) the Hispanic or Latino population experiences worse outcomes for some health indicators, such as diabetes, obesity and kidney disease, than other non-Hispanic or Latino groups in Houston; (c) the Black or African American population experience worse health for a wide-range of health indicators, such as overweight or obesity, diabetes, HIV/AIDS and heart disease, than any other racial or ethnic group in Houston. In order to determine the relevancy of the public health issues noted above for Harris County residents, local and national data was further examined and compiled. Beginning in 2006, Houston Department of Health and Human Services implemented an Assessment, Intervention and Mobilization Tool (AIM) within the six city regions: North, Northeast, South, Southwest, Southeast and Central West. Data was compiled into Community Health Profiles which highlight important health issues facing the residents of geographically-defined areas. These areas are defined socio-politically, as Super Neighborhoods, and city council districts, and for purposes of public health administration (public health regions) and resource needs (such as medically-underserved areas and populations). The aggregate of data demonstrate a lifestyle shift for Harris County residents which are evidenced by the leading causes of mortality: heart disease, cancer and stroke. Secondly, the Bureau of Health Promotion and Education hosted community meetings with local neighborhood leaders, associations, civic clubs, multi-service centers and non-profit organizations to gauge interest and relevancy of the Community Nutrition Series to the specific region. In efforts to help address the issues highlighted above, the Community Nutrition Series aims to empower and enable residents by providing ongoing nutritionally and culturally relevant education through classroom, hands-on, interactive and demonstrative sessions led by Registered Dietitians, Senior Health Educators, Master Gardeners and Professional Culinary Chefs. The idea is to help guide the integration of positive healthy practices into residential homes and transform behavioral approaches to food, fitness, chronic disease and community involvement in order to build healthier communities benefiting everyone while leveraging limited resources. Equally important is access to affordable, quality, nutrient dense foods within neighborhoods. Farmers’ Markets provide residents with the opportunity to translate classroom education and hands-on garden training into daily practice. During each market, nutritionally sound recipes and cooking demonstrations prepared by a Registered Dietitian were delivered to attendees. Innovation The Community Nutrition Series is an inventive use of existing tools and/or programs. HPEPD reviewed case studies, Centers for Disease Control and Prevention (CDC) and Institute of Medicine (IOM) literature, as well, implemented the Assessment, Intervention and Mobilization (AIM) and Mobilization for Action through Planning and Partnerships (MAPP) tools in order to determine that the inventive creation of the Community Nutrition Series was relevant, applicable and effective for Houston community residents. A case study titled “Cultivating Community Gardens: The Role of Local Government in Creating Healthy, Livable Neighborhoods,” highlight a Sacramento neighborhood of Del Paso Heights, an ethnically diverse, low-income community with limited access to healthy foods. The case study goes on to state that the success of the community was due to coordinated efforts of community and local government organizations. In July 2009, CDC released “Recommended Community Strategies and Measurements to Prevent Obesity in the United States: Implementation and Measurement Guide,” identifying community gardens and farmers’ markets as resources for residents to have access to healthy and affordable foods. In a brief report released September 2009 by IOM titled “Local Government Actions to Prevent Childhood Obesity,” states that local governments are ideally positioned to promote behaviors that will help children and adolescents reach and maintain healthy weights. Following demonstrates evidence of innovation: 1. Certificate of Promising Practice presented by the National Association of County and City Health Officials (NACCHO) in recognition of outstanding contributions in local public health practice in 2011; 2. the Garden team has been privileged to work with a Harvard University graduate in starting a documentary about Hiram Clarke’s Community Garden over a 6 month period. Below is the link to the Community Garden Program documentary, unfortunately never came to fruition due to lack of funding. http://growingseasonmovie.com/; 3. University of Texas School of Public Health facilitated the implementation and process evaluations – additional details provided in later sections; 4. TALHO poster presentation during March 2011 Senate session reflects programmatic outcomes from implementation in 2009 through completion in end of 2010; 5.poster presentation at the Inaugural Texas Obesity Research Center Conference on April 9 – 10, 2009; 6. National Public Radio broadcast of the Get Moving, Houston Farmers’ Markets. HDHHS built community gardens on City owned Multi-Service Center properties. This approach ensures accessibility and does not cost residents any direct membership fees or dues. HDHHS promotes community ownership of the gardens by requiring participants to attend education classes prior to hands-on involvement in the garden. In addition, HDHHS does not sell or ask for donations of harvested items. In addition, HDHHS provides all materials and supplies necessary to grow a successful seasonal garden. Residents take full ownership of the gardens because they are primarily responsible for the maintenance of safety of each site. The Community Garden Program is similar to Community Gardening by Williamson County and Cities Health District; however, HDHHS does not require residents to adopt a plot because the emphasis is equal community involvement and accountability. Therefore, all residents who are active participants of the Garden teams take equal ownership of the entire garden area.  
Primary Stakeholders Houston Department of Health and Human Services (HDHHS) community residents local community based organizations (identified below) Role of Stakeholders/Partners Collaborative efforts with key stakeholders are: (a) HPARD – onsite Horticulturalist provided consultations and resources for the gardens. In exchange, the Registered Dietitian and Senior Health Educators delivered nutrition education to youth attending after-school and summer programs; (b) Urban Harvest – staff of Master Gardeners aided in the consultation and building of Community Gardens. Both HPEPD and Urban Harvest will implement and deliver Farmers’ Markets to low-income and underserved neighborhoods; (c) Texas AgriLIFE Extension Program – overall collaboration on a Departmental level to help address needs of the residents related to nutrition, food access and program sustainability; (d) Houston Re-Entry Program – provides volunteers to help build community gardens who are in need of community service; (e) Recipe for Success – provides professional Culinary Chefs who lead cooking demonstration sessions during the nutrition and garden programs. HPEPD invited Recipe for Success to be a part of the HGAC grant which enabled them to expand afterschool services and summer camps to three multi-service centers and procure additional resources to continue at their existing school sites; (f) Community Health Statistics – provides current and relevant health data; (g) Houston Galveston Area Council (HGAC) - HDHHS was the grant recipient and the goals were to deliver nutrition education and community gardens to residents affected by Hurricane Ike. Under this grant HPEPD was able to deliver education classes to over 2,000 Houston residents as well as build nine community gardens; (h) HDHHS Multi-Service Centers – the primary site which offers nutrition education and houses the community gardens. HPEPD staff was approached by these centers to offer ongoing nutrition education and garden services due to residential interest and commitment. HPEPD was able to deliver services of interest that ultimately aided the centers in achieving site goals and enhancing resident ownership; (i) Texas Department of State Health Services – HPEPD was the grant recipient to deliver Farmers’ Markets; (j) Keep Houston Beautiful – supplied garden equipment during build at no cost. HPEPD aims to expand the garden program into on-site composting, a goal for Keep Houston Beautiful. LHD Role The Houston Department of Health and Human Services is the primary stakeholder and principal investor vested in sustainable and effective implementation of evidence based programs to help decrease the prevalence of chronic disease, food insecurity and obesity. A pivotal factor to being able to meet programmatic goals was by intentionally matching key partners with their defined organizational goals to the Community Nutrition Series programmatic goals. For example, Recipe for Success offers a Seed to Plate curriculum geared towards elementary school aged children during the summer and after-school, however did not have a safe and accessible location with a community gardens and within neighborhoods. HDHHS welcomed Recipe for Success to offer summer and afterschool programs at six Multi-Service locations (Southwest MSC; Northeast MSC; Kashmere MSC; Denver Harbor MSC; West End MSC; and Sunnyside MSC). All eleven Multi-Service Centers were not chosen as a site for Recipe for Success due to low youth participation and response, minimal staffing availability of Recipe for Success instructors and language barriers. Another example is illustrated by local farmers’ requesting an opportunity to sell produce at affordable rates to underprivileged and underserved communities. A list of interested farmers were provided by Urban Harvest, after detailed farm inspections were completed, to the Programs Manager for Get Moving Houston Farmers’ Markets. As a result, Get Moving Houston hosted over 30 markets in totality serving as an opportunity for local farmers to sell affordable and fresh produce to the target population of low income residents residing within food desert area. Lessons Learned Several community based organizations expressed strong interest in supporting efforts surrounding community gardens, farmers's markets and nutrition education however lacked sufficient funding for material reproduction costs and personnel costs. Similarly, additional community based organizations expressed an interest in involvement during weekend hours when HDHHS MSC facilities are limited in operations. Finally, residents expressed an interest to sell the harvests yielded from the community garden to help offset personal economic burdens. Future opportunities to collaborate on lot allocated community gardens are within the horizon. Implementation Strategy Gardens: Successful implementation and delivery of evidence based classes prior to building a garden; building garden sites with volunteer residents and organizations; maintaining each under supervision of a Master Gardener Farmers’ Markets: Determine legal framework and City regulations to comply with in order to establish market sites; identify key local farmers willing to vend produce at a affordable rate to underserved populations; maintain consistency in offering markets monthly; identify community based organizations that share the vision of improving residents’ access to fresh and local produce. Community Nutrition Program: Develop the full curriculum; obtain all necessary supplies for execution of the curriculum; and identify those agencies interested in the program. Gardens: The timeframe for each garden is estimated at about 7-9 weeks. The classes (5 weeks) must be completed before garden building begins. Once classes are completed, then materials must be ordered and the building and planting scheduled. Ordering of supplies as well as building and planting takes an additional 2-4 weeks for a total of 7-9 weeks per garden. It is possible to expedite these activities and complete a garden in 6 weeks, if various activities are completed simultaneously. Farmers’ Markets: The timeframe for complete development and execution of each market is approximately 4 months. Sufficient time must be allocated to developing relationships with farmers, community stakeholders and consumer health staff; ordering all the necessary supplies for the markets; developing the appropriate marketing strategies; and providing the necessary training for farmers. Community Nutrition Program: The Community Nutrition Program is fully developed and can be implemented as soon as a request is received. The Program itself is 6 weeks in length.  
Process & Outcome Objective 1: To build a community garden within each City region (6 regions total and 13 HDHHS Multi-Service Centers as potential sites) and reach 7,500 households by 2010. Performance Measure(s): Total number of actual gardens built within the Multi-Service Centers identified. Total number of residential households reached within the six defined City regions. Data: physical count of actual number of gardens built; number of residents attending garden classes; number of residents participating during the build of a garden; number of residents continually engaged in maintenance of the garden; total harvest yield at each site. Evaluation: The Community Garden program implementation team and involved stakeholders observed opportunities for improvement such as: additional funding to support marketing and advertising materials, recruitment of residents, preparation for seasonal fluctuations as related to weather, fertilizer and irrigation. The primary objective to build 13 community gardens was successful and yielded actual construction of 11 community gardens at 11 Multi-Service sites and within 6 City regions. Two locations were deemed structurally unfit to house a community garden since they lacked a water source within close proximity and handicap accessibility for residents. In addition, a total of 5,000 residential households were reached. Feedback: Findings and recommendations were delivered directly to the HDHHS internal program management team. Suggestions were inclusive of: development of a website, continual promotion and advertisement, expand communications with local school districts, place a sign within the Southwest Multi-Service Center and implement a full health and economic impact evaluation. In response to the recommendations made by UTSPH, HDHHS has developed a website (www.houstontx.gov/health/community/garden.html) and posted notices for volunteer opportunities via social media outlets; conducted three television interviews related to community gardens and one NPR radio interview for the farmers’ markets; interviewed for four newspaper articles related to gardens and farmers’ markets; formed a Garden Club consisting of neighborhood residents and built a school garden at Lyons Elementary School. Objective 2: To conduct monthly farmers’ markets in three Houston food desert communities–Fifth Ward, Magnolia, and Sunnyside. Performance Measure(s): Total number of markets held within the three defined food desert communities. Data: Farmers’ market manager; consumer health permits obtained; total dollars earned by market vendors. Evaluation Results: The farmers’ markets staff learned that there are various things that must be considered when implementing farmers’ markets such as: liability insurance and the financial burden that may place on farmers; seasonal variation in weather and its impact on produce availability; and the need to attract multiple local farmer vendors. The HDHHS successfully implemented the activities necessary to support the farmers’ markets. Presentations were continually conducted to attract additional vendors. Educational assistance was provided to farmers on how to obtain the necessary liability insurance. Assistance from the Department’s Office of Public Information was provided to market the Farmers’ Markets on the appropriate media outlets. Objective 2 was achieved and actually surpassed. Monthly markets were to be held at 3 sites from March through August 2011, for a total of 18 markets. There were actually 21 markets held at those three sites. We added an additional site and held an additional 16 markets at that additional site. Feedback: The evaluation results were received by the Farmers’ Markets Manager and the funding source – the Texas Department of State Health Services. Lessons learned and modifications suggested as a result of the data findings included: Lack of farmer participation due to distance, lack of labor to “man” the markets, misconceptions about safety and profitability. Solution: In the future, the program would like to develop a micro-grant process whereby successful farmers/ vendors would receive funding for: liability insurance; mileage costs to and from market; and labor costs for someone to “man” the market booths. With respect to misconceptions about safety and profitability, have the successful farmers who participated in markets at all three sites, talk with other farmers regarding profit and experience at inner-city markets. Volunteers: Need more committed consistent volunteers. Solution: Reach out to area civic associations, colleges and high schools in a more formalized way. Marketing: People cannot participate in the market if they don’t know about it. Solution: Establish relationships with area news outlets that are culturally embraced by the market neighborhoods, including TV news stations, newspapers, websites, blogs, etc. Weather: We endured extreme climate conditions that made it very hard to enjoy and facilitate markets. Solution: At the beginning, our community had suffered an uncharacteristic freeze so there was not a great variety of produce available at our first market. For this problem, perhaps having a one or two month break between seasons. At the end (the last 3 monthly markets at each of the 3 sites) we were experiencing extremely hot weather-over 100 degree temperatures. For these extreme temperatures, porta-coolers must be purchased to provide a cooler atmosphere in the immediate market area for community participants. Objective 3: To offer the Community Nutrition Program two times per quarter, total of 8 per year, underserved populations with a high prevalence of chronic disease. Performance Measure(s): Total number of classes successfully implemented. Data: Number of residents attending nutrition classes Evaluation: Lead Registered Dietitian offering the full nutrition curriculum observed the need to measure and monitors any long term behavior modifications associated with the information presented during class. A total of 3 nutrition programs in its entirety were offered and successfully implemented. Feedback: A long term evaluation was not constructed or implemented for distribution to residents due to lack of funding and insufficient staff. Future efforts are to focus on solidifiying funding opportunities to implement a long term behavioral study or to solidify partnerships with academic institutions interested in obtaining similar data.
Gardens: The Community Garden Program has had a longer lifespan than the other Community Nutrition Series’ programs. As such, sustainability efforts are much more varied and include the following:  MOU with Texas AgriLIFE for assignment of Master Gardeners to HDHHS gardens;  Implementation of “Adopt a Site” between Texas AgriLIFE and MSC’s for additional Master Gardeners and a similar implementation with community based organizations to help with resident recruitment, marketing, advertising and long term sustainability  Implementation of Train the Trainer for both the garden education curriculum and nutrition curriculum. Continue to update the garden website. Farmers’ Markets: The sustainability efforts for the farmers’ markets include the following: Develop a monthly “Farmers’ Pulse” Newsletter for distribution among area residents and community based organizations. Continue to conduct presentations at meetings of local farmers to continue to recruit vendors for the markets. Continue holding markets at Multi-Service Centers that have captive audiences as well as captive organizations interested in markets and local produce. Community Nutrition Program: Develop a fee schedule for delivery of the program, particularly among agencies that have wellness programs (agencies such as METRO and other community-based/faith-based organizations) or health ministries. Continue to market the program to community –based organizations that have organized constituent groups.
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