Pueblo Challenge - Urban Strategies

Transcripción

T HE H EALTHY P UEBLO
W ELLNESS I NITIATIVE :
THE P UEBLO C HALLENGE
A summary of findings from the Pueblo Challenge
Pilot Program, June to September 2012
Pueblo del Sol, Boyle Heights, Los Angeles, CA
"Plant the Seeds of a Healthy Community" - Visions of a Healthy Community
Photo Courtesy of groundswellmural.org
By Charlene Chang & Abel Valenzuela Jr.,
UCLA Center for Study of Urban Poverty
With Charles Kaplan & Suzanne Wenzel,
USC School of Social Work
Final Report - August 15, 2013
Pueblo Challenge, 2012
The Healthy Pueblo Wellness Initiative:
the Pueblo Challenge
This report summarizes the efforts of the short-term Pueblo Challenge Pilot
Project from June to September 2012 as part of the Healthy Pueblo Wellness
Initiative (Healthy Pueblo) within the Pueblo del Sol community in Boyle
Heights, Los Angeles, California. The pilot project aimed to assess the health
and well-being of Pueblo del Sol residents and the health impact of on-site
fitness amenities and health programming on the community. An initial
demographic survey, pre- and post-health screenings, and pre- and posthealth assessments were conducted to evaluate the effects of participation in
Pueblo Challenge and identify the needs of the Pueblo del Sol community.
“Mi familia me apoya mucho
porque gracias a los programas [de
Healthy Pueblo] que ha existido,
podemos tener mejor calidad de
vida.” -- Estela
"My family supports me a lot because
thanks to the [Healthy Pueblo] programs
that we have had, we can have a better
quality of life."
Photo Courtesy of kennedycommission.org
1
TABLE OF CONTENTS
Acknowledgements............................................................................................. 3
About the Authors...............................................................................................4
Executive Summary........................................................................................... 5
Study Methods.................................................................................................... 7
Health & Demographic Profile.......................................................................... 9
I. Health Knowledge.......................................................................................... 12
A. Access to health information.............................................................. 12
B. Health conditions & Medical history................................................. 13
C. Service utilization............................................................................... 15
II. Program Participation................................................................................... 16
III. Health and Wellness.................................................................................... 20
A. Behaviors............................................................................................. 20
B. Psychological Health........................................................................... 23
C. Physical Health................................................................................... 24
V. Social Networks..............................................................................................26
By Charles D. Kaplan & Suzanne Wenzel
VI. Recommendations.........................................................................................28
2
ACKNOWLEDGEMENTS
The Pueblo Challenge within the Healthy Pueblo Wellness Initiative would not
have been possible without the assistance of a dedicated team of collaborators,
advisers and funders. We thank Urban Strategies, Inc., McCormack Baron Salazar,
McCormack Baron Ragan, Related Companies of California, and Building Healthy
Communities – Boyle Heights for research support. We also thank the UCLA
Center for Study of Urban Poverty and the Ford Foundation for also providing
research support.
The Healthy Pueblo Advisory Committee provided feedback on the planning and
progress of the Pueblo Challenge. We thank Denise De La Rosa Salazar of Urban
Strategies, Inc. for logistical coordination and other matters in support of the
Pueblo Challenge. We also thank Rocio Gandara and Sophia Sanchez of Urban
Strategies, Inc.; Teresa Antelo of the Los Angeles Christian Health Centers; Tony
Salazar of McCormack Baron Salazar; Michael Martinez, Inkye Yu, and Mirssa
Tapia of McCormack Baron Ragan; and Victor Lopez of the Variety Boys and Girls
Club.
The implementation of the Pueblo Challenge Pilot Project on site was spearheaded
by Rocio Gandara of Urban Strategies, Inc. along with an amazing team of staff,
interns, and volunteers at the Pueblo del Sol Community Service Center. We thank
you for your efforts that made the Pueblo Challenge and our evaluation possible.
We also give thanks to Margaret Avila and the Aliva Health and Wellness Center
for providing staff and volunteers to assist with the health screening and patient
consultations.
Finally, we thank all of the participants of the 2012 Pueblo Challenge and the entire
Pueblo del Sol community for their participation and support of the Healthy Pueblo
Wellness Initiative.
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ABOUT THE AUTHORS
Charlene Chang is a graduate student in the MSPH program in Community Health
Sciences at the UCLA Fielding School of Public Health where she is completing her
coursework and training as a pre-doctoral student. Previously, she received her MA
degree in Latin American Studies at UCLA with concentrations in Anthropology and
Public Health. Her research interests include health policy, particularly in the areas of
aging and long-term care, health disparities, and chronic disease management among
minority older adults and Latinos in the U.S.
Abel Valenzuela Jr. is Professor and Chairman of the UCLA Cesar E. Chavez
Department of Chicana/o Studies at UCLA. He also holds a joint appointment in the
Department of Urban Planning and directs the UCLA Center for the Study of Urban
Poverty. He received his PhD in Urban and Regional Studies and his MCP from the
Massachusetts Institute of Technology. His research addresses inequality and poverty,
immigrant settlement, and low wage employment.
Charles Kaplan is an Associate Dean of Research at the School of Social Work at the
USC where he has been responsible for overseeing programmatic interdisciplinary
research development of social work and medicine. He received his PhD from UCLA in
Sociology and has had a long-standing interest and specialization is in the cultural and
environmental factors in health research focusing on culturally diverse populations in
the U.S., Europe and Africa. He has functioned as a Principal Investigator and CoInvestigator on NIDA, NIMH, CDC SAMHSA and European Commission funded
research projects.
Suzanne Wenzel is a professor in the USC School of Social Work and Department of
Psychology. She received a PhD in Community Psychology from the University of
Texas at Austin and was a postdoctoral fellow at the Rutgers/Princeton Institute for
Health, Health Care Policy and Aging Research. For more than 20 years, she has
conducted research sponsored by the National Institutes of Health to understand and
address health and behavioral health among underserved communities, primarily in
Los Angeles.
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EXECUTIVE SUMMARY
The Pueblo Challenge is a pilot project and a component of the Healthy Pueblo
Wellness Initiative (Healthy Pueblo) at Pueblo del Sol, a HOPE VI redeveloped
public housing site in the east Los Angeles community of Boyle Heights. During the
three-month long summer program, 33 participants were challenged to take an
active approach to their health and well-being by increasing their physical fitness
and health awareness, and adopting healthier behaviors. The Pueblo Challenge
contributes to the three main objectives of Healthy Pueblo: (1) Increase the
residents' awareness of health and wellness (including their own); (2) Help families
feel better (improve their health) where they reside through a variety of programs,
activities, and services; (3) Create and maintain a healthy residential environment
to improve families' health behaviors. Results from the pilot project show that after
three months, a few individuals were able to make improvements in their health
and overall well-being. We discuss those findings and offer our thoughts and
recommendations for future research in this area. We also caution that this was a
pilot study and that the number of participants was too small to make causal
inference.
Key findings from the pilot project include:
S Healthy Pueblo was frequently cited (52.9%) by slightly more than half of the
heads of households as one of the motivational factors in changing their
health behaviors.
S Heads of households in the post-health assessment expressed strong interest
in the preservation of Healthy Pueblo programming in the future, which
includes the Pueblo Challenge.
S Nine out of 12 of the most active participants1 in the Pueblo Challenge lost
weight in 3 months.
S Four out of 17 heads of households reduced their waist circumference at
the end of the Pueblo Challenge.
S There was a 29.5% increase in participants who definitely felt that they had
control over their physical well-being at the end of the Pueblo Challenge.
S The Pueblo Challenge increased health knowledge and improved health
behaviors among the most active heads of households.
Active participants are heads of households who were distinguished by attendance to at least two or more out
of the three monthly programming as part of the Pueblo Challenge.
1
5
S The Pueblo Challenge was effective in improving the health and well-being of
only the most active participants. Findings suggest that future recruitment
strategies should target the least active participants and other family
members (e.g. children, spouses, etc.), and for programming to be tailored to
those individuals.
S 70% of household family members and 65% of friends of the
participants expressed support of their participation in the Pueblo
Challenge.
S The most engaged and active families who participated in the Pueblo
Challenge may have a unique network of household family support and
healthy eating behaviors that aided in their success in the program.
S Among those who demonstrated improvements in their psychological wellbeing, the majority of head of households indicated feeling calm and relaxed
more often after the Pueblo Challenge.
The Pueblo Challenge contributed to: a) increased individual and family awareness
of health and wellness, b) increased health and fitness programming to create a
living environment conducive to a physically active and healthy lifestyle, and c) the
improvement of head of household members' sense of control over their physical
well-being. Although responses from the pilot project are not representative of the
entire community of Pueblo del Sol, the program was able to provide a snapshot of
the health practices and well-being of a subset of the Pueblo del Sol community.
The data collected from the 3-month period suggests that the program was most
directly influential to the head of household participants and indirectly impacted
those participants' families and friends.
In addition, the Pueblo Challenge was successful in recruiting individuals who
already demonstrated high levels of engagement in other Pueblo del Sol programs.
Participants of the Pueblo Challenge were also highly committed to the 3-month
program from start to finish. Ten of the total 27 individual participants who
completed the Pueblo Challenge were children of the head of households. The
participation of children highlights the potential for the program to increase multigenerational household participation. Future efforts should consider tailoring the
Pueblo Challenge programming to children and other members of the household,
including older adults. The inclusion of other household members in the health
assessment offers the potential to construct a more comprehensive perspective and
understanding of socially and culturally relevant strategies to improve the health
and well-being of multi-generational households. For more understanding of the
program's direct impact on the family unit and the community as a whole, future
6
assessments should include specific indicators and measures that account for these
related factors.
STUDY METHODS
The Pueblo Challenge involved assessment and community programming
components: pre- and post- comprehensive health assessments, biometric health
screenings, monthly group activities, and individual health activities recorded on
participants' activity logs. Data was collected at the beginning and end of the 3month duration of the Pueblo Challenge. An initial demographic survey of 49
individuals was conducted prior to the initiation of the Pueblo Challenge to provide
an illustration of the health profile of the community. Half (21) of the initial head of
households recruited began the challenge and 17 finished at the end of the summer.
The pilot project's assessment components took place in two phases: before and
after the Pueblo Challenge programming (pre- and post-health assessments and
screenings). The health assessment was a questionnaire that was administered to
the head of households to capture baseline data regarding: 1) health knowledge, 2)
program participation, 3) health and wellness indicators, and 4) engagement in the
community. The health screening was administered to head of households and
their family members to capture biometrics such as height, weight, systolic and
diastolic blood pressure, (non-fasting) glucose, and waist circumference.
Table 1. Pueblo Challenge Program Evaluation Timeline
Initial
Recruitment
Event
June 2012
Pre-Health
Screening &
Assessment
July 2012
49 Head of
Households
21 Head of
Households
33 Individuals &
Data Sou rce:
Initial
Demographic
Survey
Data Sou rce:
Screening 1 &
Assessment 1
PUEBLO
CHALLENGE
Post-Health
Screening &
Assessment
September
2012
17 Head of
Households
27 Individuals &
Data Sou rce:
Screening 2 &
Assessment 2
7
Pre-Pueblo Challenge Phase 1: A pre-health assessment and pre-health
screening were each conducted at the beginning of the community programming.
Prior to the initiation of programming, 21 heads of households were administered a
pre-health assessment and 33 individuals participated in the pre-health screenings.
Post-Pueblo Challenge Phase 2: A post-health assessment and post-health
screening were administered to head of households participants. At the end of the
3-month programming, a total of 17 heads of households were administered the
post-health assessment and 27 individuals participated in the post-health
screenings. The pilot project achieved high participant retention where 81.8% of
individual participants (children and head of households) and 80.9% (head of
households) completed the health screenings and health assessments, respectively.
8
HEALTH & DEMOGRAPHIC PROFILE
The Pueblo del Sol community is situated in
the historic neighborhood of Boyle Heights in
Los Angeles County located near the web of
freeways east of downtown Los Angeles.
Research shows significant correlations
between an individual's built environment
and their health status and outcomes.2 This
area of research and public health is of great
relevance to residents of Boyle Heights, and
particularly the community of Pueblo del Sol.
The greater Boyle Heights community is
predominantly Latino (98%), 15% of whom
are unemployed, and 62% of whom are lowincome households and have limited English
proficiency.3
In B oyle H eights …
•
•
•
•
•
15% are unemployed
32% are uninsured
12% delayed getting medicine or
medical care in the last year
36% are overweight
35% are obese
In t he Pueb lo Ch allenge…
•
•
•
•
•
35% are unemployed
41% are uninsured
24% delayed getting medicine or
medical care in the last year
47% are overweight
47% are obese
Source: Chang & Valenzuela, 2013, Initial
Demographic Survey, Screening 1
Data from a health profile compiled by the UCLA Center for Health Policy Research
(2011) provide a snapshot of several health indicators of individuals in Boyle
Heights. Typical of poor communities, 32% of adults in Pueblo del Sol are
uninsured, which is much higher than the county and state at 26% and 22%,
respectively. In addition, 22% of adults in Boyle Heights reported no doctor visit in
the last year; 17% visited the emergency department; and 12% delayed getting
prescription drugs or medical care in the last year. Among children living in Boyle
Heights, 27% visited an emergency department in the last year. Half (50%) of all
teens in Boyle Heights are overweight and obese compared to 34% in the county and
29% in the state. Interestingly though, children
Figure 1: BMI Status of Head of
in Boyle Heights (68%) walked, biked, or skateHousehold participants prePueblo Challenge
boarded home from school at least once in the
last week; a higher percentage than the county
5.9%
47.1%
(49%) or state (42%).
Overweight
Obese
Normal
47.1%
These data suggest that the growing burden of
chronic disease and the effects of the built
environment are particularly relevant to this
community. As such, preventive health efforts
Source: Chang & Valenzuela, 2013, Screening 1
2 Frumkin, H., Frank, L., & Jackson, R. (2004) Urban Sprawl and Public Health: Designing, planning, and
building for healthy communities. Island Press: Washington, DC, Pg. 101
3 Building Healthy Communities: Boyle Heights Health Profile. UCLA Center for Health Policy Research,
November 2011 Fact Sheet. Retrieved from:
http://www.calendow.org/uploadedFiles/Health_Happends_Here/Communities/Our_Places/BHC%20Fact_Sheet_
Boyle%20Heights.pdf
9
2
1
will require a multidimensional strategy to address the health and well-being of the
community. Among Pueblo Challenge head of household participants (N=17) before
the program, 6% had a normal weight status (BMI=18.5-24.9), 47% were overweight
(BMI=25-29.9), and 47% were obese (BMI=30.0 and above) (See Figure 1). In
addition, 41% had elevated blood glucose (above 125 mg/dL4) after a non-fasting
diabetes screening pre-Pueblo Challenge. After a one-time blood pressure screening,
4 individuals were preliminarily identified (24%) as pre-hypertensive (systolic blood
pressure between 120-139, or diastolic blood pressure between 80-895). Details of
the demographic distribution of the sample is shown in Table 2. Although this
group of participants is neither representative of the Pueblo del Sol Community, nor
Boyle Heights due to our small sample size, they demonstrate higher proportions of
no insurance, obese and overweight persons compared to Boyle Heights and the
state. Some improvements were made in these areas post-Pueblo Challenge.
In 3 months, program participants lost a total of 33 lbs. and 6.75 inches of waist
circumference collectively. A total of 12 individuals (70.5%) had lost some weight by
the end of the Pueblo Challenge and 4 individuals (23.5%) reduced their waist
circumference. Only one individual was able to make some reduction in their Body
Mass Index (BMI), a reliable indicator of body fat used to screen for weight
categories that may lead to health problems6. While BMI is a stronger indicator of
weight-related health problems, 3 months was a considerably short amount of time
to observe significant improvements in BMI. Five individuals were observed to
have elevated blood glucose at the time of pre-screening, a reduction from results
observed in screening pre-Pueblo Challenge. The improvements made over a 3month period among the program participants suggest that a sustained duration of
increased physical activity and improved nutrition can make a positive impact.
3-Month Pueblo Challenge Results
By the
nu mbers...
32 lbs.
6.75 in.
0.5
125
1,265
Total weight lost
Total waist circumference lost
Total BMI lost
Healthy Pueblo events attended
Hours of physical & educational
Source: Chang &activities
Valenzuela, Screening
logged 1 &2
4 American Diabetes Association (2013). Diagnosing Diabetes and Prediabetes. Retrieved from:
http://www.diabetes.org/diabetes-basics/diagnosis/
5 American Heart Association (2013). Understanding Blood Pressure Readings. Retrieved from:
http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/UnderstandingBlood-Pressure-Readings_UCM_301764_Article.jsp
6 Centers for Disease Control (2013). Body Mass Index. Retrieved from:
http://www.cdc.gov/healthyweight/assessing/bmi/index.html
10
TABLE 2. SUMMARY OF SAMPLE DEMOGRAPHICS P ROFILE O F P UEBLO D EL S OL I NITIAL D EMOGRAPHIC S URVEY ( N=49) P ROFILE O F P UEBLO C HALLENGE P ARTICIPANTS (N=17) 88% ( 43) 10% ( 5) 2% ( 1) 49% ( 24) 22% ( 11) 8% ( 4) 14% ( 7) 46.2 45 37 86% ( 42) 14% ( 7) 18% ( 9) 14% ( 7) 45% ( 22) 8% ( 4) 8% ( 4) 4% ( 2) 8% ( 4) 49% ( 24) 24% ( 12) 4% ( 2) 2% ( 1) 10% ( 5) 2% ( 1) 2% ( 1) 10% ( 5) 33% ( 16) 43% ( 21) 100% ( 17) -‐-‐ -‐-‐ 47% ( 8) 41% ( 7) 12% ( 2) -‐-‐ 44.4 44 37 94% ( 16) 6% ( 1) 17% ( 3) 12% ( 2) 4 7% ( 8) 12% ( 2) 12% ( 2) -‐-‐ 6% ( 1) 59% ( 10) 17% ( 3) 6% ( 1) -‐-‐ 6% ( 1) 6% ( 1) -‐-‐ 6% ( 1) 35% ( 6) 53% ( 9) 2% ( 1) -‐-‐ 2% ( 1) 8% ( 4) 6% ( 3) 16% ( 8) 6% ( 3) 33% ( 16) 2% ( 1) 2% ( 1) 8% ( 4) 24% ( 12) $1,047 $1,129 39% ( 19) 49% ( 24) 4% ( 2) 8% ( 4) -‐-‐ 6% ( 1) 6% ( 1) 12% ( 2) 6% ( 1) 29% ( 5) 6% ( 1) 6% ( 1) -‐-‐ 35% ( 6) $1,000 $1,197 41% ( 7) 5 3% ( 9) 6% ( 1) -‐-‐ GENDER Female Male A GE 19-‐30 31-‐45 46-‐55 56-‐65 65+ M EAN M EDIAN M ODE R ACE Hispanic Asian/Pacific I slander M ARITAL S TATUS Single, n ever m arried Common-‐law m arriage/co-‐habitation Married Divorced Separated Widowed E DUCATION L EVEL None Elementary S chool High S chool GED Technical D egree/Certificate Degree/Professional Other H OUSEHOLD C OMPOSITION Lives a lone Lives w ith S pouse/Partner Lives w ith C hildren Lives w ith S pouse/Partner & C hildren Lives w ith S pouse/Partner & O ther Family Lives w ith C hildren & P arents Lives w ith C hildren & O ther F amily E MPLOYMENT S TATUS Working f ull-‐time Working h alf-‐time Temporarily U nemployed Unemployed, l ooking f or w ork Unemployed, d ue t o d isability Disabled, u nable t o w ork Retired Housewife S ELF -‐R EPORTED M ONTHLY H OUSEHOLD I NCOME Median Mean H EALTH I NSURANCE Uninsured MediCal MediCare MediCal & M ediCare ( dual e ligibles) Source: Chang & Valenzuela, 2013, Initial Demographic Survey
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I. HEALTH KNOWLEDGE
An important component in understanding the potential impact of a wellness
initiative in this community is through a social assessment of health topics.
Questions related to awareness of health issues, nutrition, access to health
information, and utilization of health services were asked in the pre- and posthealth assessments. Results from the assessments are addressed in three
subsections: access to health information, health conditions and medical history,
and service utilization.
A. Access to Health Information
Among the heads of households (N=17) in the pre-health assessment, respondents of
an open-ended question most frequently cited going to a clinic (29.4%) and Pueblo
del Sol7 (29.4%) to learn more about a health condition, nutrition, or an illness (See
Figure 2). Other responses included Women, Infants, and Children (WIC) food and
nutrition services, the doctor. Some reported going nowhere. The post-health
assessment showed a greater range of responses to the open-ended question.
Figure 2: Where do you go to learn more about a health condition, nutrition,
or an illness? (N=17) (Responses by Percentage, %)
Pre-Pueblo Challenge*
Post-Pueblo Challenge
41.2
29.4
29.4 29.4 29.4
29.4
17.6
11.8
29.4
17.6
11.8
5.9
5.9
5.9
5.9
* 17.6% of data was missing due to no response or decline to response
Source: Chang & Valenzuela, 2013, Assessment 1 & 2
For example, books and the Internet were most frequently cited (41.2%) as places to
go to learn more about health related topics. The second most frequently cited place
(29.4%) included the health fair, Healthy Pueblo workshops, Pueblo del Sol, and
7 Pueblo del Sol here refers to the Pueblo del Sol Community Service Center
12
places outside of Pueblo del Sol (e.g. library, health fairs at local parks). In
addition, children and family members were just as frequently mentioned as doctors
for sources of medical information (17.6%). Among respondents in the post-health
assessment to the same open-ended question, Pueblo del Sol and its specific
programming such as workshops and health fairs were cited more frequently
compared to the pre-health assessment (See Figure 2). Responses demonstrate
that the Pueblo del Sol Community Service Center is one of the places that is
identified by the participants as a primary source of health information.
B. Health Conditions & Medical History
Information collected on health conditions and medical history is limited to only a
brief snapshot of the health status of participants. In the pre-health screening, 14
of the total 33 individuals reported having a health condition, and 6 of the 14
reported having more than 1 health condition. According to recommendations by
the Centers for Disease Control (CDC), Body Mass Index (BMI) is used here to
measure overweight and obesity because it requires only a simple and inexpensive
calculation of the height and weight8. Using standards described by the CDC,
having a BMI of 18.5 and below indicated underweight status, a BMI of 18.5-24.9 is
normal; a BMI of 25-29.9 is of overweight status; and a BMI of 30 and above is
obese status6.
Among the 33 respondents pre-Pueblo Challenge, 9 were obese, 16 were overweight,
and 8 had normal weight status (See Figure 3). In comparison to the estimates for
Figure 3: Distribution of BMI among Pueblo Challenge
Individual Participants (Responses by percentage)
60.00%
48.50%
50.00%
44%
40.00%
24.20%
30.00%
20.00%
10.00%
27.30%
33%
19%
4%
0.00%
Underweight
Normal
Pre-Pueblo Challenge (N=33)
Overweight
Obese
Post-Pueblo Challenge (N=27)
Source: Chang & Valenzuela, 2013, Screening 1 & 2
CDC (2013). Healthy Weight: About BMI. Retrieved from:
http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/#Why
8
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adults in Boyle Heights9, participants demonstrated better BMI statuses at baseline
(pre-Pueblo Challenge), with 27% who are obese compared to 35% in the city, and
48% who are overweight compared to 36%. Following the Pueblo Challenge, among
the 27 total respondents, 1 was underweight; 5 had normal BMI; 12 had a BMI
status of overweight; and 9 were in the obese BMI range (See Figure 3).
Representation of the data to the greater Pueblo del Sol
community, however, is difficult to predict given the
The vast majority (65%) of
nature of the recruitment strategies and the sample
participants strongly
agreed that they were
size. Successes from the three-month program included
more knowledgeable after
weight loss and reduction in waist circumference. Nine
the Pueblo Challenge.
of 12 of the most active participants in the Pueblo
Challenge monthly programming lost weight over just
three months. In addition, four of the total 17 heads of households reduced their
waist circumference in three months.
In only the post-health assessment, participants were asked about their awareness
of their own and their family's health conditions. About 9 (53%) respondents
indicated they strongly agreed with the statement (See Table 3), while 8 (47%)
respondents felt they agreed with the statement. In addition, 12 (71%) strongly
agreed that they have more knowledge to manage good health and good nutrition
for themselves and their family since the Pueblo Challenge (See Table 3). The vast
majority (65%) of participants strongly agreed that the change (whether increase or
Table 3: Post-Health
Assessment Questions
(N=17)
Strongly
Agree
Agree
Neither
agree nor
disagree
Disagree
Strongly
Disagree
Would you agree that you are aware of your and your family's health conditions? 53% 47% 0 0 0 Would you agree that you have more knowledge to manage good health and good nutrition for you and your family since June 30? 71% 24% 6% 0 0 Would you agree that the change in your knowledge (increase or decrease) was due to your participation in the Pueblo Challenge? 65% 29% 6% 0 0 Source: Chang & Valenzuela, 2013, Assessment 2 9 Building Healthy Communities: Boyle Heights Health Profile. UCLA Center for Health Policy Research,
Boyle%20Heights.pdf
14
decreased) was due to their participation in the Pueblo Challenge (See Table 3).
The individuals who were less confident about having knowledge to manage good
health and good nutrition were also less likely to participate in the Pueblo
Challenge monthly programming. Overall, the vast majority of participants (71%)
at the end of the Pueblo Challenge strongly agreed that they were more
knowledgeable in regards to their health since the Pueblo Challenge. One of the
study objectives was to assess participant's awareness of their own and their
family's health conditions. Knowledge of one's health status is critical to
intervention efficacy10.
C. Service Utilization
Among responses in the pre-health assessment, cost and lacking health insurance
were most frequently cited as reasons for delaying medical care when it was needed.
In the post-health assessment, 4 of 17 heads of households (24%) indicated delaying
care due to: few options for medical care; did not know where to go; did not have
time; no health insurance; do not have extra money to pay for what the emergency
room does not cover; could not afford medical care (cost too much); and long waits at
the ER. In the Initial Demographic Survey, 39% of respondents indicated that they
were uninsured, a much higher proportion compared to the 32% reported in Boyle
Heights11. Respondents in the Post-Health Assessment reported a higher likelihood
of delaying care (24%) compared to the city proportion of 12% (See Table 4).
Delayed care has been attributed to health-care related financial burden and
discordant insurance between parents and children, leading to delays in preventive
services and negative impacts on health outcomes12. Although the vast majority of
individuals in the Post-Health Assessment did not report delaying care, data from
the demographic survey indicates that just under half of the respondents indicated
they were uninsured while others reported
Table 4: Service
Pueblo
Boyle
they were covered under MediCal and/or
Utilization
del Sol
Heights
MediCare. Lack of health insurance has
Uninsurance rate 39% 32% been significantly linked to increased
Delayed Care 24% 12% mortality and premature death13,
Source: Chang & Valenzuela, 2013, Assessment 2; UCLA CHPR suggesting that nearly half of the
2011, Boyle Heights Health Profile
10 Pignone, M., DeWalt, D.A., Seridan, S., Berkman, N., et al. (2005) Interventions to improve health outcomes
for patients with low literacy: A systematic review. Journal of General Internal Medicine, 20(2): 185-192.
11 Building Healthy Communities: Boyle Heights Health Profile. UCLA Center for Health Policy Research,
Boyle%20Heights.pdf
12 Wisk, L.E. & Witt, W.P. (2012) Predictors of Delayed or Forgone Needed Health Care for Families with
Children. Pediatrics, 130:1-11.
13 Marwick, C. (2002) For the uninsured, health problems are more serious. Journal of the National Cancer
Institute, 94(13): 967-968.
15
participants of the Pueblo Challenge are more likely than insured participants to
experience poorer health outcomes. Additional information about the insurance
status of children and other members of the household may provide further insight
into potential barriers to health services and services utilization.
II. PROGRAM PARTICIPATION
Behavior change is one of the greatest challenges in many public health
interventions. It is well documented, however, that making improvements in an
individual's built environment can make positive contributions to their lives and
their health. In one such study, individuals who perceived having access to places
to be physically active were more likely to be physically active in their leisure time
and to get the recommended levels of physical activity14. Access to areas for
physical activity such as parks, trails, or sidewalks is a design feature that
promotes physical activity15. In addition, access to sidewalks and footpaths is
associated with more walking.
Figure 4: Factors preventing participation in wellness/health/nutritional program
at Pueblo del Sol (Pre-Health Assessment) and during the Pueblo Challenge
(Post-Health Assessment)?
61.5%
52.9%
41.2%
23.1%
15.4%
5.9%
Financial Cost
Lack of Energy
Lack of Time
Pre-Pueblo Challenge (N=13)
Not applicable, I
participated in all
Pueblo Challenge
activities
Other
Post-Pueblo Challenge (N=17)
Responses from the Pre- and Post-Health Assessment show that participants
indicated lack of time as the largest factor that prevented their participation in the
Healthy Pueblo programming and in the Pueblo Challenge (See Figure 4). The
Walking Trail is highly utilized by both the heads of households and their family
members. Nutrition programs were also highly utilized by the heads of households.
Among family members, the pool, the walking trail, the park, and Variety Boys &
building for healthy communities. Island Press: Washington, DC, Pg. 101.
building for healthy communities. Island Press: Washington, DC, Pg. 101.
16
Girls Club activities were most highly utilized. About 80% of participants indicated
that Healthy Pueblo/ the Pueblo Challenge were effective in increase their own and
their family's awareness and knowledge of overall health and wellness. The same
proportion reported that Healthy Pueblo/ the Pueblo Challenge programming were
effective in helping heads of households and their family to improve their health. In
an open-ended question, respondents indicated ways the programming improved
their health:
S “To do more exercise, [at least] 60 minutes of exercise, eat
healthier for my family” (hacer mas ejercicio, 60 minutos de
ejercicio, comer mas sano para mi familia)
S “To exercise and eat more healthy” (hacer mas ejercicio y comer
mas saludable)
S “The nutrition classes were fundamental for me and my
family.” (las clases de nutrición fueron fundamental para mi y mi
familia)
S “To be more [physically] active, to cook healthier foods like
vegetables, whole grain bread, and not to give my family fast foods
like hamburgers, etc.” (estar más activo, cocinar comidas
saludables como mas verduras, pan con grano integral y no darles
a mi familia comida rápida como hamburger, etc.)
Source: Chang & Valenzuela, 2013, Assessment 2
Nearly 88% of participants in the Post-Health Assessment indicated that their
participation in the Pueblo Challenge helped them to get more physical activity, buy
healthier food at the grocery store, improve their eating habits, cook healthier foods
at home, talk to friends and family about health related topics and about living
healthier lives, and get friends and family to be more active in general.
17
Figure 5: Motivations to change health bheaviors
Frequency of Responses by % (N=17)
52.9
35.3
23.5
17.6
11.8
Group Activities Communication
11.8
Pueblo
Programming
(workshops)
To be more
educated
To live a
Avoid illness/
healthier life health conditions
11.8
Lose Weight
In responses about how their family members' participation in the Pueblo Challenge
has affected their health behaviors to buy healthier food, to get more physical
activity and to improve eating habits, most head of households indicate that they
have had positive influences in those areas, or they do not know.
Motivations to change health behaviors derive from the Pueblo Challenge and
Healthy Pueblo programming. Participants in the Post-Health Assessment
reported most frequently (52.9%) in an open-ended question that the presence of
workshops motivated them to be more active (See Figure 5). In addition, other
areas of motivation came from the individuals themselves (35.3%). Losing weight,
avoiding illness, and the group activities were least frequently cited as direct
motivations to change their health behavior.
These findings indicate that further qualitative methods may be beneficial and
helpful in understanding these areas more. Respondents provided other areas of
motivation for behavior change including:
18
S “To have good health knowledge and to live a healthier life” (para
tener una buena educación de la salud y vivir más sano)
S “To have a healthier life for my children and for myself” (para
tener una vida mas saludable para mis hijos y para mi)
S “To take care of our health, to prevent illness, and the information
from the community center about health programming.” (por cuidar
nuestra salud a tiempo, para evitar enfermedades, información del centro
comunitario sobre programas de salud)
S “Yes, because I learned that snacks don't always have to be
chips; they can be fruit or yogurt, or wheat bread with peanut butter.” (si
porque aprendi que los snacks no son siempre chips puede ser fruta o yogour,
pan integral con cacahuate.)
S
“With the help of these programs, we are motivated to keep
improving a lot of areas of [our] health.” (porque con la ayuda de estos
programas somos motivadas a seguir mejorando en muchas areas de la salud)
19
III. HEALTH AND WELLNESS
The concept of wellness in public health is gaining more ground than ever before as
a perspective that provides a holistic approach to health and well-being. Wellness
is also viewed as a multidimensional state involving multiple components related to
physical, social, psychological and social well-being. The World Health
Organization's definition of wellness involves both the absence of illness and a state
of physical, social and mental well-being16. The concept of wellness includes the
presence of positive elements (physical health and happiness) and not merely the
absence of negative elements (illness and disease)17. The terms wellness and wellbeing have been used interchangeably, but here, wellness is defined holistically to
include a state of physical, psychological and social well-being. Wellness has been
widely used in the alleviation and prevention of obesity within exercise programs9.
The Pueblo Challenge was developed to improve both physical and emotional wellbeing.
A. Health Behaviors
Self-reported information including food consumption, quality of life, emotional
health, mental health, quality of sleep and overall health were collected in order to
develop a more holistic overview of the health behaviors of individuals in the Pueblo
del Sol community. Although these responses are not representative of the entire
community of Pueblo del Sol, they provide a snapshot of the well-being and health
practices of individuals there. In the responses to self-reported overall health, there
was nearly a 20% increase in the post-Pueblo
Challenge responses (N=17) for those reporting
Pueblo Challenge offers
excellent overall health. Nearly the same
increase was also observed for individuals
potential to improve
reporting excellent quality of life after the Pueblo
both physical and
Challenge. Self-reported sense of overall wellemotional well-being
being improved from pre-Pueblo Challenge
suggesting that the Pueblo Challenge may have
influenced this overall improvement in well-being
among the program participants. Statistical significance and correlations for these
variables require larger sample sizes. An increase in responses was also observed
for individuals reporting the status of their physical health. There was a 12% and
17% increase in responses for those reporting excellent and very good physical
health, respectively. A 24% increase in responses was observed in individuals
reporting excellent emotional health. In addition, there was a 7% increase from prePueblo Challenge among individuals reporting very good emotional health and 12%
World Health Organization (2003), WHO definition of Health. Retrieved from:
http://www.who.int/about/definition/en/print.html
17 Miller, G. & Foster, L.T. (2010) Critical Synthesis of Wellness Literature. University of Victoria.
16
20
decrease in individuals reporting good and fair emotional health. These
observations suggest that after the Pueblo Challenge, there was an improvement in
physical and emotional health. This improvement highlights the potential for the
Pueblo Challenge to offer both physical and emotional benefits to the participants
who completed the Pueblo Challenge from start to finish. Other measures for sense
of well-being included mental health and quality of sleep. Previous research has
indicated the positive influences of physical activity on mental well-being and in the
management of stress and improvement in self-esteem18. An increase of 12% and
11% was observed by individuals indicating excellent and very good mental health,
respectively (See Figure 6). In line with this improvement was a 17% decrease in
individuals reporting fair mental health and none reporting poor mental health.
These observations offer additional insight to the benefits of the Pueblo Challenge
on the mental well-being of participants. Associations between physical activity and
quality of sleep have been cited in literature to highlight the added benefit of
increased physical activity19. Decreases in self-reported good, fair and poor quality
of sleep were comparably observed with increases in self-reported excellent and very
good quality of sleep. In addition to improvements in other well-being indicators,
responses regarding quality of sleep post-Pueblo Challenge indicates that increased
physical activity played a role in this improvement.
Figure 6: Pre-and Post-Health Assessment responses to well-being
indicators (N=17)
60%
50%
40%
30%
20%
Overall Health
Quality of Life
Physical Health
Pre-Pueblo Challenge
Mental Health
Poor
Fair
Good
Excellent
Very Good
Poor
Fair
Good
Excellent
Emotional Health
Very Good
Poor
Fair
Good
Excellent
Very Good
Poor
Fair
Good
Excellent
Very Good
Poor
Fair
Good
Excellent
Very Good
Fair
Good
Excellent
Very Good
0%
Poor
10%
Quality of Sleep
Fox, K. R. (1999). The influence of physical activity on mental well-being. Public health nutrition, 2(3a), 411418.
19 Sherrill, D. L., Kotchou, K., & Quan, S. F. (1998). Association of physical activity and human sleep
disorders. Archives of Internal Medicine, 158(17), 1894.
18
21
Consumption of fruits, whole grains and fast food was also captured in the pre- and
post-health assessments to inform the potential influence of the Pueblo Challenge
on the shopping and nutritional practices of the head of households. Of note, there
was a significant increase in consumption of servings of fruit by the head of
households from 0-2 servings to 2-3 servings (See Figure 7). There was also a
13.2% increase in the self-reported consumption of 5 or more servings of fruits postPueblo Challenge (See Figure 7). Among the household, there was an increase
consumption of fruits of 3 to 5 or more servings. These increases of servings of fruit
post-Pueblo Challenge suggest that the nutritional workshops offered within the
Pueblo Challenge were influential. These increases also parallel open-ended
responses provided by participants regarding the value and interest in the
nutritional components of the Pueblo Challenge.
Servings of Fruit (HH)
Servings of Fruit (Household)
Whole Grains (HH)
More than once a week
Once a week
More than once a day
Once a day
Never
More than once a week
Once a week
More than once a day
Once a day
Never
5+ Servings
4 Servings
3 Servings
2 Servings
1 Serving
0 Servings
5+ Servings
4 Servings
3 Servings
2 Servings
1 Serving
45.0%
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
0 Servings
Figure 7: Pre- and Post-Health Assessment responses to questions
regarding consumption of Fruits, Whoe Grains, & Fast Food by Head of
Household (HH) and Household (N=17)
Whole Grains
(Household)
Changes in the consumption of whole grains among both the head of household and
the household were not as clear compared to the consumption of fruits. Findings
regarding consumption of fast foods were not reliable. These findings regarding food
consumption demonstrate the potential for the Pueblo Challenge to additionally
offer nutritional benefits to participants.
22
B. Psychological Health
Assessment of individual psychological health involved the use of the World Health
Organization (Five) Well-Being Index20. Raw scores for the WHO (5) Well-Being
Index range from 0 to 25, 0 representing the worst possible and 25 representing the
best possible quality of life.21 Among the 17 head of households who completed both
the pre- and post-health assessment, 13 provided complete responses. Following
the Pueblo Challenge in the post-health assessments, 38% (5/13) has scores that
indicated improvements in psychological well-being, 38% (5/13) had scores
suggesting slightly worse psychological well-being, and 23% (3/13) who maintained
the same level of psychological well-being (See Figure 8).
Figure 8: Change in WHO (5) Well-Being Index from
Pre- to Post-Pueblo Challenge (N=13)
40%
35%
30%
25%
20%
15%
10%
5%
0%
38%
38%
23%
Improvement No improvement
No Change
Percentage of Participants Exhibiting change in Well-Being Index
Among those who demonstrated improvements, all had indicated feeling calm and
relaxed more often. In addition, more than half of those respondents stated that
they have felt cheerful/ in good spirits, and active/ vigorous more often. Among
those who had lower scores, all of them indicated feeling fresh and rested less often.
It is possible that among those who demonstrated improvements in their well-being
scores, increased frequency of feeling calm and relaxed may be attributed to
increased individual physical activity. Among those who did not show
improvements in their well-being scores, external factors such as stress or work
may influence their sense of well-being. Developing statistically significant
conclusions and correlations require further investigation and a larger sample size.
Psychiatric Research Unit, WHO Collaborating Center for Mental health, WHO (Five) Well-Being Index,
1998. World Health Organization. (1998).
20
Scores were calculated by percentage by multiplying the raw score by 4. Scores of 0 represent the
worst possible, while scores of 100 represent the best possible quality of life.
21
23
Responses related to satisfaction with life resulted in a near 20% increase in
responses where head of households indicated they felt mostly satisfied, and a near
20% decrease in responses of feeling partly satisfied (See Figure 9). General
improvements in satisfaction with life was observed among the respondents, a
positive indication that the Pueblo Challenge may have contributed to this
improvement in sense of well-being.
Figure 9: In general, how satisfied are you with your life?
80%
70.6%
70%
60%
52.9%
50%
40%
30%
23.5%
23.5%
23.5%
20%
5.9%
10%
0.0%
0%
Completely
Satisfied
Mostly Satisfied
Partly Satisfied
0.0%
Not Satisfied
C. Physical Health
Greater control of physical well-being was observed more confidently by head of
households post-Pueblo Challenge compared to pre-Pueblo Challenge (See Figure
10). There is an observed improvement among those who initially felt somewhat in
control to definitely feeling in control of their physical well-being. The open-ended
responses by head of households regarding their feelings about the Pueblo
Challenge are an indication that the program has a positive impact on their lives.
To further understand the role and impact of the Pueblo Challenge on these
individuals and the family unit as a whole, additional insight may be obtained
through further qualitative investigations related to well-being.
24
Figure 10: Do you feel you have control over your physical wellbeing?
90%
82.4%
80%
70%
60%
52.9%
50%
41.2%
40%
30%
20%
11.8%
5.9%
10%
5.9%
0%
Definitely
Somewhat
Not Really
Among the individuals who indicated that they were motivated to do more to bring
regular exercise to their routine, individuals most frequently mentioned on an openended question that they plan to walk more (See Figure 11). Walking is
distinguished from walking path to indicate that more people were interested in
walking individually, while the walking path connotes the activity as a group-led
event. Future programming should consider media campaigns to encourage
walking and utilization of the walking path as individuals or with a walking buddy,
and not necessarily as a group-organized event.
Figure 11: Are you motivated to do more to bring regular exercise
to your routine? If yes, what exercises or activities do you plan to
participate in?
47.1
29.4
29.4
5.9
Walk
Gym
Zumba
Yoga
11.8
11.8
Cardio
Walking
Path
25
IV. SOCIAL NETWORKS
The pre- and post-health assessments included not only questions pertaining to an
individual’s behaviors, but also about the members of their social networks. Social
networks consist of family members in and outside of the household, friends, and
neighbors. These network members can play a role in shaping an individual’s health
behaviors. Social network members can support, model, and encourage healthy
behaviors, and be “buddies” in pursuit of a positive change in health behaviors.
Figure 12: How supportive have (family members in your
household) been of your participation in wellness & health
programs at Pueblo del Sol?
Percentage of Responses (N=17)
80
70
60
50
40
30
20
10
0
Definitely
Somewhat
A Little
Not At All
They Don't
Know About
My
Participation
The social network analysis revealed that 70% of the participants reported that
household family members were definitely supportive of the wellness and health
programs at Pueblo del Sol (See Figure 12). Only about 5% indicated that they
received only a little support from household family members. Less than half
(47% ) of the participants, however, reported that family members living outside of
the household were supportive.
An analysis was also conducted to compare the three families with the best22 results
from participation in the Pueblo Challenge with the other families who participated.
Two trends were found. First, most notable is the similarity between the top 3
families and other families. Two of the 3 top families (67%) and 70% of other
families definitely had support for participation from household family members.
22 The calculation for top performing families involved a range of data points that include: change in biometrics
(e.g. BMI, waist circumference), participation in the Pueblo Challenge monthly activities, and completion of
activity logs.
26
Figure 13: How supportive household family members of your
participation in wellness and health programs at Pueblo del Sol by top
family (N=3) and other family (N=14)
Frequency of responses by %
80
70
60
50
40
30
20
10
0
Definitely
Somewhat
A Little
Other Families
Top 3 Families
They Don't Know
About My
Participation
The main contrast is the split within the top three families (See Figure 13). One of
the top 3 families (33%) reported just a little support from household family
members, whereas 2 of these families (67%) "definitely" reported support. This
finding is not easily explained, but suggests that among top families, there are
probably two distinct types of household family dynamics that lead to positive
health outcomes. It could also be that those who received just a little support from
household family members were receiving support from others not measured in this
study. The second trend indicates that the majority of the top three families, and
the other families, had some friends that were eating healthy foods much of the
time (Figure not shown). However, one third (1 top family participant) reported
few friends have been eating healthy foods. This may indicate especially resilient
families that used the Pueblo Challenge to maintain healthy eating habits despite
friends who did not have these habits.
27
V. RECOMMENDATIONS
Findings from the Pilot study illustrate the potential for the Pueblo Challenge to
improve health behaviors and the overall health and wellness of its participants.
This pilot study provides a multi-dimensional perspective on the health and wellbeing of the individual participants and their families in the Pueblo del Sol
residential community. Participant responses to open-ended questions in
Assessment 2 allude to the personal and emotional impact of the Pueblo Challenge.
The Pueblo Challenge was effective in having a positive influence on the weight
status, health knowledge, health behaviors, and well-being factors of its
participants. The Pueblo Challenge provides foundational information about the
health status of the Pueblo del Sol community that future efforts can build upon.
Based on our findings, we offer the following recommendations with the caveat
already discussed, the limitations of our small sample size, short period of
assessment (3 months), and the sampling design:
S Informed by the PRECEDE-PROCEED model23,24, conducting formative
research, including focus groups and key informant interviews will likely
provide insight into the community's needs and ways to overcome lack of
time, which was most frequently cited as a barrier to participation.
S Qualitative methods including focus groups and key informant interviews
will provide additional information to help improve community engagement
in a future Pueblo Challenge.
S Future research will inform and potentially strengthen program
implementation and program evaluation efforts.
S Future research and assessments should include specific measures to identify
barriers to health care access and utilization of Healthy Pueblo programming
by other individuals within the Pueblo del Sol and Boyles Heights
community.
S Community participation in the development of programming or
brainstorming may provide enhanced community buy-in and interest.
S Future research should consider the development of more robust
measurements and sampling design, larger sample sizes, and a longer
evaluation period to assess for causality and statistically significant
correlations of multiple variables.
Green, L.W. (1974). Toward cost-benefit evaluations of health education: some concepts, methods, and
examples. Health Education Monographs 2 (Suppl. 2): 34-64.
24 Green, L., Kreuter, M. (2005). Health program planning: An educational and ecological approach. 4th edition.
New York, NY: McGraw-Hill
23
28
S Participant recruitment was the largest challenge for the Pueblo Challenge. A
re-evaluation of recruitment strategies and program incentives should be
undertaken.
S Future efforts should identify strategies to engage those who are least likely
to utilize services offered by the Community Service Center for a more
representative sample.
S Creative and hands-on (bilingual) workshops like cooking classes and
nutritional education were popular and praised. Additional novel and
thoughtful workshops should be offered including programs and classes over
the weekends, in the evenings and mornings. Increased attention to
programming for children is important for family support and participation.
S Future programming should involve key stakeholders within the community
to enable community buy-in.
29

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