1. CX 3 : Evolution & Accomplishments Presented by: Valerie Quinn, MEd, Health Program Specialist & Alyssa Ghirardelli, RD, MPH, Research Associate

2. YOU are part of the CX 3 evolution…

3. CX 3 Evolution: Grounding Quick trip back in time circa 2004-5

4. Metro Atlanta has Removed 58 acres of forest per day for the last 25 years Georgia Department of Natural Resources Bog box store TOXIC ENVIRONMENT

6. How do you assess it? How do you change it?

7. CX 3 Evolution Real world information/data a must for planning nutrition education programs Local, Local, Local Relevant to surroundings, tailored to issues, persuasive, empowering!

8. CX 3 Evolution: Norm Change CX 3 -- a planning framework that evaluates communities in relation to a variety of benchmarks knows as community indicators and assets. – Standardized indicators –Community strengths, assets, gaps and weaknesses –Develop local action plans for promoting policy, systems and environmental change –Strengthen evaluation of local efforts Goal: Change Norms

9. CX 3 Evolution: 2005 Indicators organized in 6 Community Environments: –Neighborhood –Preschool –School –After-school –Worksite –Government Nutrition and Activity Assets organized into: –Health department infrastructure –Political will –Community infrastructure

10. CX 3 Evolution: 2005

12. Neighborhood Focus

13. Neighborhoods Matter Research: Clear connection between neighborhood factors and health outcomes

14. Neighborhoods Matter

15. = Pilot Sites (2006) = Group 3 (2008) Local Health Departments = Group 2 (2007) CX 3 sites

16. CX 3 Cohorts 2006 -- Pilot sites: Berkeley, Santa Clara, San Bernardino, Riverside, Alameda, Kern 2007 -- Group 2 (G2): Marin, Contra Costa, Solano, Sacramento, Ventura, San Diego* 2008 -- Group 3 (G3): San Mateo, Monterey, Sonoma, Stanislaus, Shasta, Yolo, Santa Barbara, Orange, Pasadena, Butte/CSU Chico + CCROP*: Fresno, Kern, Kings, Madera, Merced and Tulare 2009 – Group 4: Tulare, Long Beach * Not Network funded

17. Tier 1 Tier 2 Community Assets

18. CX 3 Evolution: Tools, etc. Pilots Food store survey - lengthy –In your face scale; quality on all f/v; store cleanliness, etc. Walkability –Wording refined Fast Food –Signs; outside only Outdoor Alternative Healthy Foods –Assess quality, etc. Food banks –Lengthy survey, assessed quality, etc. Group 2 Food store survey- streamlined –Overall quality; reduced items; –Added: PoP; pricing comparison data Walkability Fast Food –Nutrition information!; menu items Outdoor Alternative Healthy Foods –Chart only, no assessment Food banks and emergency food outlets -- focused

19. CX 3 Evolution: Tools, etc. Pilots Oodles of data! How make data easier to understand? Toward what end? Mapping to mobilization! Group 2 Scoring system Communications templates Health dept survey– Tier 1

20. CX 3 Evolution: Scoring system TOTAL NEIGHBORHOOD FOOD STORE QUALITY (based on access and marketing) Access and Availability of Healthy Foods: Are local stores offering healthy, affordable foods? Are those stores easily and safely accessible to neighborhood residents? Sample of stores surveyed in neighborhood (If less than 15 stores, all were surveyed) n= Percent of stores meeting WIC and food stamp vendor acceptance and signage standards Percent of stores selling a range of quality fruits Percent of stores selling a range of quality vegetables Percent of stores selling a range of quality other healthy foods Percent of stores with reasonable prices for fruits and vegetables *** Percent of stores meeting standards for safe, walkable streets Store Marketing: Are stores actively promoting nutrition information and healthier choices? Percent of stores participating in in state sponsored retail nutrition programs Percent of stores offering nutrition information Percent of stores with exteriors that provide healthy marketing practices Percent of stores with interiors that provide healthy marketing practices Total Neigborhood Food Store Quality (% meeting standards) *** Reasonable Prices=no greater than 10% of the county average price for fresh fruits and vegetables in survey FAST FOOD: What type of marketing and presence do fast food outlets have near local schools, parks and playgrounds? Sample of fast food outlets within 1/2 mile of school, park, playground (if less than 15, all were surveyed) Percent of outlets with school visible Percent of outlets with park/playground visible Percent of outlets with exterior healthy marketing practices & limited unhealthy marketing practices Percent of outlets with limited child- oriented marketing practices Percent of outlets with Interior healthy food marketing and healthy food options. Fast Food (% meeting standards) Food stores 100 pts, 75 pts for “quality” standard Fast food 50 pts; 35 pts for “quality” standard Formulas auto- calculate scores!

21. CX 3 Evolution: Communications pieces

22. CX 3 Evolution: Tools, etc. Group 3 Tools refined –Food store survey New WIC food items covered Changed exterior marketing approach –Fast Food Nutrition info refined –Outdoor E-boards Scoring refined! –School score created Group 4 -- ?? Neighborhood score? Survey mobile vendors?

24. Accomplishments 70+ low-income neighborhoods in CA Pilots: 22 neighborhoods Group 2: 18 neighborhoods Group 3: 30+ neighborhoods 310 food stores surveyed Pilots: 180 food stores Group 2: 138 food stores Group 3: TBD, field work wrapping up

25. Accomplishments (Cont.) Show some charts & graphs from pooled data Identify patterns, issues Limitations: –Not representative sample for CA –Data for local use

26. CX 3 Sample: Food Store Types Other: Warehouse, Health Food, WIC Only, Specialty, Fruit and Vegetable Market Other: Discount, Drug Stores, Health Food, Ethnic Pilots Sites Group 2

27. WIC Vendor/Not FS n = 9 WIC/FS Vendor n = 28 CX 3 Pilot Findings: Food Assistance Programs Available 23% of Store Sample are WIC Vendors FS Only n= 78 Not WIC or FS Vendor n=44

28. CX 3 Group 2 Findings: Food Assistance Programs Available 18% of Store Sample are WIC Vendors WIC/FS Vendor n=24, Food Stamp Only n=79, No WIC or FS n=29

29. CX 3 Pilot Findings: Fruit Availability Large Stores n=25 Small Stores n=83

30. CX 3 G2 Findings: Fruit Availability Large stores n=11 Small stores n=73

31. CX 3 Pilot Findings : Fruit Quality Large Stores n=25 Small Stores n=70

32. CX 3 G2 Findings : Fruit Quality Large stores n=11 Small stores n=72

33. CX 3 Pilot and G2 Findings: Store Prices

34. 40% of G2 Stores Met the standard for reasonable prices CX 3 Findings: F&V Prices

35. 12% of Pilots 16% of G2 Stores that sell produce have health promotions around fruit and vegetable displays CX 3 Findings: F&V Promo

36. CX 3 Findings : Checkout Pilots:

37. CX 3 Findings: Safety 45% of Pilot 43% of G2 stores surveyed have bars on windows

38. G2 Store Scoring Store score = 100 possible pts “quality standard” > 75 pts Total of 132 stores not quality 76% close 14% made the "cut" 10%

39. CX 3 Findings: Fast Food Ratio Both Pilots and G2 Range for # of FF outlets to population –Low: 1:127 –High: 1:8185 Ratio of <1:1000 15 of 37 neighborhoods (45%) Most impacted: Solano (4 of 4), Berkeley (3 of 4); Santa Clara (2 of 3); Riverside (2 of 3)

40. CX 3 Findings: Toys in Kid Meals Pilot Chains n =44 G2 Chains n= 27 Pilot Not Chain n= 83 G2 Not Chain n= 75

41. CX 3 Findings: Fast Food Marketing Ads on roof/walls… 77% of Pilot Fast Food chains (n=44) 54% of Pilot Other Fast Food Outlets (n=41) 39% G2 Fast Food Chains (n=26) 12% of G2 Other Fast Food Outlets (n=74)

42. CX 3 Findings : Nutrition Info Fast Food Chain Outlets n=27 Non-Chain n=75 Group 2

43. Index of Unhealthy to Healthy Food Sources: G2 C-Stores + Fast Food____________ Supermarket/lg grocery + Farmers Market Index of 0 = Food desert 5 neighborhoods (28%) NO healthy food sources at all Index of 5 or higher = Poor/toxic? 10 neighborhoods (55%) Index range from 2.5 to 18 –Low score is better; 0 means can’t calculate-NO healthy food sources –CCPHA REFI index: CA average = 4.48, similar but not directly comparable

45. You are Change Agents Add branding architecture –Change Agents

47. TV Spot Our Neighborhood, Our Rules

48. “Now that is a real commercial! I like it! There is no suburban greenery in this one. It talks about my community…get involved…time’s are changing. That spoke to me as a low income African American woman in the ‘hood! It makes me take a second look. More importantly, it made me think deeper about the whole issue.” –Oakland African-American mother

49. Sacramento Bee (circulation: 279,000) “Study links ‘food environment’ to diabetes, obesity” http://www.sacbee.com/101/story/897193. html Los Angeles Times (circ.: 816,000) “UCLA study links poor health to fast-food neighbors” http://www.latimes.com/news/local/la-me- fastfood29apr29,0,6657131.story Central Valley Business Times (circ.: ~ 30,000) “Would You Like Fries with that Heart Attack?” http://www.centralvalleybusinesstimes.co m/stories/001/?ID=8570 Bakersfield Californian (circ.: 71,000) “Study: Kern No. 3 for fast-food, convenience stores” http://www.bakersfield.com/102/story/4299 93.html The Press Enterprise (circ.: 189,000) “Neighborhood's food options affect obesity rates, study finds” http://www.pe.com/localnews/inland/storie s/PE_News_Local_D_obesestudy29.3cf0c 48.html San Bernardino Sun (circ.: 196,000) “Food Choices Limited” http://www.pe.com/localnews/inland/storie s/PE_News_Local_D_obesestudy29.3cf0c 48.html Inland Valley Daily Bulletin (circ.: 185,000) “In SB County, too much bad food” http://www.dailybulletin.com/ci_9090193 Fresno Bee (circ.: 158,000) Fresno’s Fast-Food proximity harms health, study says http://www.fresnobee.com/263/story/5585 00.html

51. Challenges No comparison (high-income) neighborhoods 1 local health department for many cities & communities –Selective investment –Policy change is local; walk fine line Community work takes time. –When evaluate? 2 years, 3 years, 4 years? –Familiar vs. new/risk Flexibility a must (bureaucracy, rules)

52. Challenges (cont.) Dynamic Marketplace Economic downturn FSNE restrictions (where, what said, etc.) –Partner with community organizations –Other funding sources

54. Positive shifts? FARM BILL 2008 – Shift in sight? –Renames the Food Stamp Act and Program Supplemental Nutrition Assistance Program (SNAP); Food & Nutrition Act of 2008 –Findings of Congress: Directs USDA Secretary… –“to support the most effective interventions for nutrition education under the FSA, including public health approaches and traditional education, to increase the likelihood that recipients and potential recipients of benefits under the SSNAP program choose diets and physical activity practices that are consistent with the Dietary Guidelines for Americans.

55. YOU Your dedication, passion, vision In-depth data/picture neighborhood nutrition

56. Thank you! CX 3 Team: Valerie Quinn, Alyssa Ghirardelli, Ellen Feighery & Lynn Moreno