CX 3 : Evolution & Accomplishments Presented by: Valerie Quinn, MEd, Health Program Specialist &...

CX3: Evolution & Accomplishments

Presented by:

Valerie Quinn, MEd, Health Program Specialist &

Alyssa Ghirardelli, RD, MPH, Research Associate

YOU are part of the CX3 evolution…

CX3 Evolution: Grounding

Quick trip back in time

circa 2004-5

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

How do you assess it?

How do you

change it?

CX3 Evolution

• Real world information/data a must for planning nutrition education programs

• Local, Local, Local

• Relevant to surroundings, tailored to issues, persuasive, empowering!

CX3 Evolution: Norm Change

CX3 -- 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

CX3 Evolution: 2005

Indicators organized in6 Community

Environments:– Neighborhood– Preschool– School– After-school– Worksite– Government

• Nutrition and Activity

Assets organized into:

– Health department infrastructure

– Political will

– Community infrastructure

CX3 Evolution: 2005

Neighborhood Focus

Neighborhoods MatterResearch: Clear connection between neighborhood factors and health outcomes

Neighborhoods Matter

= Pilot Sites (2006)

= Group 3 (2008)

Local Health Departments

= Group 2 (2007)

CX3 sites

CX3 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

Tier 1

Tier 2

Community Assets

CX3 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


Pilots Oodles of data! How

make data easier to understand? Toward what end?

Mapping to mobilization!

Group 2Scoring system

Communications templates

Health dept survey– Tier 1

CX3 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!

CX3 Evolution: Communications pieces


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?

Accomplishments

70+ low-income neighborhoods in CA Pilots: 22 neighborhoods

Group 2: 18 neighborhoods

Group 3: 30+ neighborhoods

310 food stores surveyedPilots: 180 food stores

Group 2: 138 food stores

Group 3: TBD, field work wrapping up

Accomplishments (Cont.)

• Show some charts & graphs from pooled data

• Identify patterns, issues

• Limitations: – Not representative sample for CA– Data for local use

CX3 Sample: Food Store Types

SupermarketChain

Small Chain

Grocery Other

Convenience

Other

Other: Warehouse, Health Food, WIC Only,

Specialty, Fruit and Vegetable Market

SupermarketChainLarge Grocery

Small Market

Convenience

Other

Other: Discount, Drug Stores, Health Food,

Ethnic

Pilots Sites Group 2

WIC Vendor/Not FS n = 9

WIC/FS Vendor n = 28

CX3 Pilot Findings: Food Assistance Programs Available

23% of Store Sample are WIC

Vendors

Store Size Among Food Assistance Programs

0

57

127

100

43

8893

0

10

20

30

40

50

60

70

80

90

100

WIC VendorNot FS

WIC/FS FS Only Not WIC orFS

Pe

rce

nt

of

Sto

res

Large stores ≥ 4 Registers

Small Stores < 4 Registers

FS Only n= 78

Not WIC or FS Vendor n=44

CX3 Group 2 Findings: Food Assistance Programs Available

18% of Store Sample are WIC

Vendors

Store Size Among WIC and FS Vendors

50

60

50

9097

04 3

0

10

20

30

40

50

60

70

80

90

100

WIC/FS Vendor Food Stamp OnlyVendor

No WIC or FS

Perc

ent of S

tore

s

Large stores≥ 4 Registers

Small Stores< 4 Registers

Other

WIC/FS Vendor n=24, Food Stamp Only n=79, No WIC or FS n=29

CX3 Pilot Findings: Fruit Availability

Overall Availability of Fruits by Store Size

0%

16%

0%

55%

8% 6%

92%

23%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Large Stores Fruit(≥ 4 Registers)

Small Stores Fruit (< 4 Registers)

None Limited (1-3 types)Moderate Variety (4-6 types) Wide Variety (≥ 7 types)

Large Stores

n=25

Small Stores

n=83

CX3 G2 Findings: Fruit Availability

Overall Availability of Fruits by Store Size

0%8%

0%

38%

0%

18%

100%

36%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



Per

cen

t o

f S

tore

s

None Limited (1-3 types)Moderate Variety (4-6 types) Wide Variety (≥ 7 types)

Large stores n=11

Small stores n=73

CX3 Pilot Findings: Fruit Quality

Quality of Fruits by Store Size

0%

9%8%

29%32%

46%

60%

17%

0%

10%

20%

30%

40%

50%

60%

70%



Per

cent

of

Sto

res

All or most poor quality Mixed quality; more poor than goodMixed quality; more good than poor All or most of good quality

Large Stores n=25

Small Stores n=70

CX3 G2 Findings: Fruit QualityQuality of Fruits by Store Size

0%

8%

0%

26%27%

35%

73%

29%

0%

10%

20%

30%

40%

50%

60%

70%

80%



Pe

rce

nt

of

Sto

res

All or most poor quality Mixed quality; more poor than goodMixed quality; more good than poor All or most of good quality

Large stores n=11

Small stores n=72

Mean Price per Pound of Common Produce Items by CX3 Group

$0.00

$0.20

$0.40

$0.60

$0.80

$1.00

$1.20

$1.40

$1.60

Apple Banana Orange Tomatoes Cabbage

Pri

ce P

er P

ound

Pilot Jun-Aug2006

Group 2 May-Jul 2007

CX3 Pilot and G2 Findings: Store Prices

40% of G2 StoresMet the standard for reasonable prices

CX3 Findings: F&V Prices

12% of Pilots 16% of G2Stores that sell produce have

health promotions

around fruit and vegetable displays

CX3 Findings: F&V Promo

% of Stores that Have Unhealthy Marketing around Checkout by Store Size

63

92

0

20

40

60

80

100

Large Stores (≥ 4Registers)

Small Stores (<4Registers)

% o

f Sto

res

CX3 Findings: Checkout

Pilots:

CX3 Findings: Safety45% of Pilot 43% of G2 stores surveyed

have bars on windows

G2 Store Scoring

• Store score = 100 possible pts

• “quality standard” > 75 pts

• Total of 132 stores

not quality76%

close14%

made the "cut"10%

CX3 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)

CX3 Findings: Toys in Kid Meals

Fast Food Outlet with Toys in Kids Meals

2 1

54

74

0

10

20

30

40

50

60

70

80

Fast Food -Chain

Fast Food - AllOther

% o

f O

utl

ets Pilot

G2

Pilot Chains n =44

G2 Chains n= 27

Pilot Not Chain n= 83

G2 Not Chain n= 75

CX3 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)

CX3 Findings: Nutrition Info

Nutrition Information Available in Chain vs. Non-Chain Outlets

0

26 26

12

0

5

10

15

20

25

30

Menu

Boa

rd

Poste

r/Kio

sk

Broch

ure/

Pamph

let

Avail U

pon

Reques

t

Per

cen

t o

f O

utl

ets

Chain

Not Chain(all types)

Fast Food Chain

Outlets n=27

Non-Chain n=75

Group 2

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

You are Change Agents

• Add branding architecture– Change Agents

TV, Radio, Outdoor, Direct Mail

TV Spot

• Our Neighborhood, Our Rules

“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

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.com/

stories/001/?ID=8570

Bakersfield Californian (circ.: 71,000)

“Study: Kern No. 3 for fast-food, convenience

stores”

http://www.bakersfield.com/102/story/

429993.html

The Press Enterprise (circ.: 189,000)

“Neighborhood's food options affect obesity

rates, study finds”

http://www.pe.com/localnews/inland/stories/

PE_News_Local_D_obesestudy29.3cf0c48.html

San Bernardino Sun (circ.: 196,000)

“Food Choices Limited”

http://www.pe.com/localnews/inland/stories/

PE_News_Local_D_obesestudy29.3cf0c48.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/558500.html

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)

Challenges (cont.)

• Dynamic Marketplace

• Economic downturn• FSNE restrictions (where, what said, etc.)

– Partner with community organizations– Other funding sources

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.

YOU • Your dedication, passion, vision

• In-depth data/picture neighborhood nutrition

Thank you!

CX3 Team: Valerie Quinn, Alyssa Ghirardelli, Ellen Feighery & Lynn Moreno

CX 3 : Evolution & Accomplishments Presented by: Valerie Quinn, MEd, Health Program Specialist &...

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