SaludableOmaha: Development of a Youth Advocacy Initiative to Increase Community Readiness for Obesity Prevention

Leah Frerichs, MS; Jeri Brittin, MM, Associate IIDA; Catherine Stewart, MA; Regina Robbins; Cara Riggs; Susan Mayberger; Alberto Cervantes; Terry T-K Huang, PhD, MPH

Suggested citation for this article: Frerichs L, Brittin J, Stewart C, Robbins R, Riggs C, Mayberger S, et al. SaludableOmaha: Development of a Youth Advocacy Initiative to Increase Community Readiness for Obesity Prevention. Prev Chronic Dis 2016;http://dx.doi.org/10.5888/pcdexternal icon.

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Background

In the US, rates of overweight and obesity have reached epidemic proportions, and troubling impacts are well-established across a range of physical, social and economic consequences at individual and societal levels (1). Of particular concern, childhood obesity rates in minority populations continue to rise despite leveling (but persistent) national trends. From 2003–2007, the prevalence of childhood obesity among Latino children increased significantly by 24.3% compared with a non-significant 7.2% increase among white children (2).

Despite awareness of obesity as a public health issue and significant research and programming, effective and sustainable prevention strategies for obesity, particularly in youths, have been elusive (3). It is now recognized that a comprehensive, societal approach is needed to address childhood obesity where individuals, families and the community are simultaneously impacted (4). However, efforts to date have focused either on individually oriented interventions or environmental and policy factors. Little research has focused on how to create the demand for health in populations. Harnessing the power of advocacy systematically may help create a demand for a societal response to the obesity epidemic (5,6).

This case study describes the development of a pilot project anchored in an underserved Latino community in Omaha, Nebraska, designed to explore the potential of youth advocacy to enhance community awareness and capacity to generate both the demand for and supply of community-relevant, health promoting interventions. The project used the Community Readiness Model (CRM) as a tool to engage the community, assess community readiness, and guide the youth advocacy program training and program development. At the end of the case study, we propose a model to guide future work around building a sustainable social movement for childhood obesity prevention. The study was approved by the Institutional Review Board of the University of Nebraska Medical Center (UNMC).

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Interpretation

The CRM is an important tool to use when addressing issues such as childhood obesity in underserved communities since it provides a framework for matching interventions to a community. South Omaha was at a low level of readiness, which is not uncommon in minority communities where mainstream resources and communication fail to reach and engage stakeholder groups appropriately. Thus, efforts that do not consider these differences will likely neglect communities with lower readiness but higher need, and reinforces the need for public health interventions to tailor strategies to readiness. The CRM is also a beneficial way to effectively provide opportunities for community ownership. The knowledge gained through the interviews provides a platform for generating discussion about needs and priorities to create change. For this project, the CRM interviews also helped project partners learn about the community and established relationships that guided progress (eg, community leader interviewees later assisted with youth-led efforts).

The CRM was also helpful to inform the youth advocacy program and strategies. At the end of Phase 2, the youth planned two activities, both designed for low levels of community readiness and focused on increasing the awareness. Social marketing was also identified as important for addressing the low readiness. In Phase 3, enhanced marketing through social media tools such as Facebook are in development. These strategies have potential for increasing awareness in and engaging younger populations.

There are several challenges inherent to youth advocacy efforts, and many questions remain unanswered regarding best practices (6). The youth in South Omaha were largely disconnected and unfamiliar with leadership. Thus, projects such as this case study that focus on enhancing youth’s leadership ability to address social issues are needed, but also require more time and development to effectively address the disconnection identified. Youth participation in SaludableOmaha was key. The youths’ perceptions, attitudes, and experiences directly informed the development of the SaludableOmaha brand and strategies for cultural and social relevance (eg, the youth identified a location in the community to paint a mural with relevant cultural themes to depict the need to improve health). However, the continued growth and sustainability of the effort requires a process for continued engagement of new youth across time (ie, new freshman cohorts) potentially with different interests and skills to address evolving needs.

The low level of readiness from the CRM assessment reinforced the need for an intervention that could be dynamically tailored to community readiness. The intent of this pilot youth advocacy effort and creation of a Latino Health Movement brand was to explore possible mechanisms that create opportunity for ongoing growth and sustainability of health promoting environments and behavior change. Thus far, this effort created an infrastructure for communities to come together and address issues as they evolve at various levels. South High’s support of SaludableOmaha and key connections and resources were vital to the program’s success, and show potential for the future sustainability of the effort as it is institutionalized within regular school programs. However, a level of support and resources is still needed for sustainability and continued growth.

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Community Context

Omaha, Nebraska, the 42nd largest city in the US, is a growing metropolitan area of over 865,000 residents (7). Minorities represent nearly 20% of the population, including Latinos, who have more than doubled in the past decade. For the past 25 years, a significant number of Mexicans and other Latin Americans have settled in the southeast sector of Omaha (“South Omaha”), where between 32 to 55% of the population is Hispanic depending on the zip code (7).

The Latino population in Omaha has high rates of poverty; 30% with children under the age of 18, and 55% with a single female parent living at or below the 100% federal poverty line (7).

The prevalence of childhood obesity in South Omaha closely mirror national rates in the Hispanic population. A phone survey of a random sample of Omaha households found that 31% of adolescents in South Omaha were overweight or obese, compared with only 20% in North-west and Southwest Omaha (primarily white residents) (8). In Nebraska, when compared with the white population, Latino adults have a higher prevalence of obesity (33% vs 25%) and type 2 diabetes (13% vs 7%) (9). These adult health disparities may widen if the high prevalence of Latino childhood obesity persists.

The South Omaha Community Care Council (SOCCC) and the Omaha South High Magnet School collaborated with the UNMC College of Public Health to develop the project. UNMC provided expertise in public health research and access to obesity prevention scientific knowledge. SOCCC, a community-based organization with the mission to provide a strategic infrastructure to enhance services for and well-being of the community, provided connections to key individuals and organizations within the community. The school provided connections to many students and parents.

This project’s goal was to explore the potential for a community-based and youth-led approach to generate a social movement by empowering a new generation of Latinos to transform their family and community environments. The beginning phases trained an initial cohort of youth advocates who created and launched a Latino Health Movement brand (http://saludableomaha.com/). SaludableOmaha is now the brand for the youth advocacy program and its initiatives. The CRM provided a multi-faceted tool to identify gaps in community readiness and capacity, guide strategies of social marketing and youth initiatives, and will provide a useful measure of supply and demand for health to assess future social change.

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Assessing Community Readiness

CRM Background

The CRM provides a theoretical framework and method for measuring community readiness to address obesity prevention (10). The CRM has been used successfully to address numerous public health issues in diverse populations by determining the most appropriate program or intervention given a community’s current level of readiness (13–20). Rarely does one-size-fit-all in community-level health promotion and disease prevention strategies, because communities vary in their needs (11). The CRM includes six dimensions: presence of community efforts, community knowledge of these efforts, leadership support, community climate, community knowledge about the issue, and availability of resources (12). These dimensions provide a proxy measure of whether a community is demanding change around an issue (eg, via leadership support, community climate and knowledge) and the current supply of resources and contextual support (eg, via presence of efforts and resources). The CRM assessment involves semi-structured qualitative interviews with key informants, scored using anchored rating scales along each dimension and averaged for an overall quantitative readiness score that corresponds to one of nine stages (see Appendix). The tool has been shown to be reliable (reporting agreement between scorer ratings 92% of the time) (12), and involves a process of expert rating with anchored rating scales (10). This project used the model to assess the baseline level of readiness of the South Omaha Latino community to take action on childhood obesity, so that activities taken on by youth advocates could match current needs.

CRM Methods

Two subgroups of key informants were identified for CRM interviews: community leaders and parents. The South Omaha community partners prepared a list of approximately 30 potential community leaders connected to the issue of childhood obesity either by occupation or known general health interest. Project partners worked together to narrow this list to ten priority leaders representing sectors considered most relevant and influential in regards to childhood obesity, including schools, medical professions, social service organizations, and recreational facilities. In addition, South Omaha community partners generated a list of potential parent interviewees. Similar to community leaders, the parents were considered based on their interest in childhood obesity and health. The parent interviewees needed to self-identify as Hispanic/Latino, live in South Omaha, and have children under the age of 19 years.

South Omaha project partners from the community agencies made first contact with potential interviewees and connected them to UNMC study personnel trained to conduct CRM interviews for the project. All interviews were completed in-person and audio-recorded. The interviewer provided a brief introduction to the project and followed the standard CRM interview questions. Ten community leaders and eight parents completed interviews, which ranged from 20–45 minutes (six individuals are recommended by CRM methodology). Nine community leader and six parent interviews were conducted in English; the remainder were in Spanish.

The audio-recordings were transcribed verbatim. Two evaluators (UNMC study personnel trained in CRM analysis for the project) scored the interview transcriptions independently. For each parent and community leader interview, the six dimensions were rated using the CRM anchored scales. The evaluators compared scores and in the case of disagreement, established reliability by reaching a consensus rating. To compute the total CRM score for each respondent, the ratings of the six dimensions were averaged. A separate CRM score was determined for the community leaders and parents by averaging all respective respondent scores. The stage of readiness was determined for each subgroup of respondents by rounding down the average score to the lower CRM stage.

CRM Outcomes

The findings indicate that the South Omaha community is at a low stage of readiness to address childhood obesity. The community leaders scored at stage 2, “Vague Awareness,” indicating that childhood obesity was felt to be a local issue, but there was no significant effort to take action within the community. Parents scored at stage 3, “Denial/Resistance.” Overall, they felt while some individuals identify childhood obesity as a problem, the community as a whole does not recognize it as a local concern.

The average dimension scores were fairly consistent (see Table 1). The average score ranged between 2–3 for both community leaders and parents with the exception of the dimension of “efforts,” which was slightly higher. The participants indicated many different types of physical activity and nutrition related programs and strategies available. However, none specifically targeted childhood obesity or appeared effectively coordinated across the community, indicating a gap in programming that actively targets individuals at risk or systematically addresses the complex factors of obesity prevention.

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Generating a Youth-Driven Response to the Community

The youth advocacy component of this project is intended to create upward momentum in the South Omaha community through the levels of readiness to address childhood obesity. While it is increasingly recognized that community ownership is critical to the long-term success of community programs, it has been more the exception than the rule to involve youth directly in the design and implementation of efforts (5). By using a youth-driven approach, this project generated community-relevant solutions, and improved sustainability via creation of a new generation of community activists to champion the cause long-term.

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Youth Advocacy Program Methods

The Omaha South High School provided connection to a pool of potential high school students (and their parents) who became the initial cohort of youth advocates. Several South High faculty members identified a list of potential applicants with a range of perspectives and skills defined by the project team as important to building infrastructure for the program (eg, graphic art and media skills, communication skills). In addition, the project partners held two informational events for parents and youth to present the need for obesity prevention, the concept of youth-advocacy, and a tentative schedule of workshops and student expectations. Application forms were distributed to youth, which the school helped collect and schedule interviews. One South High faculty member and a UNMC project consultant completed 15–30 minute interviews with all students who applied. A total of 22 students were selected from approximately 45 applicants, of whom 17 accepted and 14 participated in the program through the first two phases described below.

The youth advocates participated in a series of trainings, workshops, and activities over the summer of 2011. This included two core phases (1,2) that incorporated elements of the 6 CRM dimensions that armed youth with advocacy skills and guided them to develop and launch a Latino Health brand (eg, a conceptual framework and corresponding imagery that would resonate with the community regarding healthy lifestyles). A third phase subsequently developed that consisted of partnership growth and institutionalization.

Phase 1 (Basic Training) consisted of a series of four to five hour workshops over one month. Workshops included obesity, nutrition, and physical activity education as well as leadership styles, team work, and communication. Different formats encouraged active learning (eg, hands on cooking demonstrations and group discussion). This phase also engaged the youth in brainstorming and creative processes to develop their own unique brand for the movement.

Phase 2 (Brand Development and Launch) took place over a 4 week period and guided the youth to actively connect with their community around childhood obesity. The project facilitators identified potential roles (eg, public relations, creative agency, project coordination, etc.) for the students based on discussions with youth during Phase 1 regarding their interests and strengths. At the end of phase 2, the youth developed the infrastructure, framework, and strategies as well as a logo for their Latino Health Movement, SaludableOmaha. The culmination of their efforts was to create awareness and discuss their proposed strategies with the community during two events: a community wide health fair and a formal dinner for community leaders and parents.

As of the spring of 2012, SaludableOmaha was in Phase 3 (Institutionalization). During this phase a cohort of new youth advocates became involved and successfully led a school-based healthy eating initiative that demonstrated potential for the movement to take root and grow. The project was selected by youths given the low readiness of the community as a whole, and to increase awareness within their own school environment. South High began to institutionalize the youth advocacy program within their regular curricula and a local partnership with Live Well Omaha Kids (LWOK) (21), the youth component of a community-based coalition for greater Omaha (www.livewellomaha.org), developed in parallel. This resulted in a natural collaboration of two youth groups (1): LWOK Youth Advisory Committee (YAC) (student leaders representing high schools throughout Omaha) and (2) South High Character in Action (CIA) (a service learning class leading the SaludableOmaha effort). The groups began an initiative, “Green is Go,” to advocate for no-to-low cost changes to the Omaha South school cafeteria to improve healthy eating. Based on evidence of social network influence of health and health behaviors (22), the “Green is Go” initiative utilizes social marketing and media. For example, students plan to post pictures and stories (eg, images of healthy lunch trays) on the SaludableOmaha Facebook page for peer-to-peer networking and discussion.

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Opportunities for an Integrated Model

Youth advocacy for obesity prevention is a new area, and this pilot project is one of the first to begin to illustrate how youth advocacy can potentially be harnessed to promote normative change at the community level.

Figure 1provides an initial model that future research can build upon as underlying mechanisms for creating community demand for change are identified. The model includes processes and strategies discovered critical to the success of this pilot effort and those identified as needs.

Figure 1. Model for a Horizontally and Vertically Integrated Social Movement

This figure, based on the experiences of SaludableOmaha, provides a proposed model to guide further research on the potential underlying mechanisms of such a social movement. It proposes a central youth advocacy approach with horizontal and vertical integration.

The youth advocacy approach is central to the health movement at a local level. Horizontal integration involves support from community groups and metro area partners to assist the youth to engage in “On the Ground” activities (eg, “Green is Go”). The local partners provide a variety of support; however, local investment (eg, school in-kind support of space) combined with Metro Partner logistical support (eg, connection to nutrition expertise) are vital. Vertical integration via linkage to state, regional, and national networks supported by public and private partners could grow the effort locally and create pathways to diffuse the movement to additional communities. This includes various support at both national and local levels (eg, research organization funding for a centrally coordinated national network and local “chapters”). Private partners operational support is instrumental for growth as well (eg, communications firms maintenance of social media and marketing).

Local expansion and outward growth creates a framework for environmental change and shifts in cultural and social norms that can be locally tailored but also broad reaching. The proposed model needs further operationalization and research. Specific measures at multiple levels need to monitor peer-to-peer effects and community trends such as social media network analysis and policy changes within community institutions. The CRM also provides a useful measure of social change. SaludableOmaha will use a 2-year post repeated CRM assessment to gauge the impact of our effort on social change locally.

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Acknowledgments

This project was partially supported with funding from the Robert Wood Johnson Foundation, Active Living Research (Grant # 68502).

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Author Information

*tthuang@unmc.edu.

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References

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Table

Table 1. Average Community Readiness Scores to Address Childhood Obesity from Community Leader and Parent Interviews in South Omaha, NE

Evaluation

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Post-Test Questions

Study Title: Routine Check-Ups and Other Factors Affecting Discussions With a Health Care Provider About Subjective Memory Complaints, Behavioral Risk Factor Surveillance System, 21 States, 2011

CME Questions

1. Your patient is a 62-year-old man with subjective memory complaints (SMCs). According to the surveillance study by Adams, which of the following statements about the percentage of older adults with SMCs who discussed memory problems with their clinician is correct?

   1. Among all respondents at least 45 years old who reported SMCs, more than half reported discussing them with a health care professional

   2. Among all respondents at least 45 years old who reported SMCs and had a recent routine check-up, more than two-thirds reported discussing them with a health care professional

   3. Among respondents 65 years or older reporting SMCs, 17.9% of those who had a recent check-up, vs 11.9% of those who did not, reported talking to a health care professional about their SMCs

   4. The results differed considerably from those of previous studies

2. According to the surveillance study by Adams regarding older adults with SMCs, which of the following variables is mostlikely associated with these patients discussing their memory problems with their clinician?

   1. Reporting that SMCs never caused them to give up household chores

   2. Reporting that SMCs never interfered with work

   3. Increasing age

   4. Being a college graduate

3. According to the surveillance study by Adams, which of the following statements about the clinical implications regarding older adults with SMCs discussing their memory problems with their clinician is correct?

   1. Among respondents who discussed SMCs, one-quarter received treatment

   2. Routine check-ups may be a missed opportunity for discussions of SMCs that might lead to diagnosis or treatment

   3. The Affordable Care Act requires a cognitive assessment for Medicare recipients every 5 years

   4. Among study respondents with SMCs who received treatment, three-quarters reported a diagnosis of dementia

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