mph 609 Week 8 assignment

We Can Cook!

A Community Based Participatory Research Project Proposal for Cleveland’s Central Neighborhood

Steven C. Banjoff

8/9/2015

Aim, Target Population, and Significance

It is widely accepted that Americans in general do not eat enough healthy, fresh, fruits,

and vegetables (United States Department of Agriculture, 2009). The tide does seem to be

turning, and public health efforts over the past decade may have contributed to a behavioral shift

in diet seen amongst U.S. consumers (Ng, Slining, & Popkin, 2014). Unfortunately, research also

indicates correlations between access to food retailers and quality of diet, and many studies show

limited food access associated with greater consumption of non-nutritious foods. Research also

reveals a relationship with quality of diet, chronic disease, and obesity (USDA, 2009). The

United States Department of Agriculture has identified farmers markets as excellent avenues to

increase healthy food access and help stimulate local economies (Cleveland-Cuyahoga County

Food Policy Coalition, 2011). This program seeks to examine barriers, consumption,

motivations, policies, and access of healthy foods in marginalized community of the Central

neighborhood in the city of Cleveland, Ohio, especially those currently receiving SNAP

subsidies.

The Central neighborhood is considered a food desert community using the USDA one

mile from a grocery store (USDA, 2009). Central is surrounded by farmers markets, most of

which participate in SNAP, and the double value produce perks program, making it an excellent

location to investigate the viability of improving healthy food access to this community. It is

hoped the use of Community Based Participatory Research will identify community strengths,

facilitate collaboration, provide intimate insights behind the drivers of dietary behavior, and help

design the most appropriate educational cooking experience that will provide the best chance for

success in all aspects of the program.

The Central neighborhood is 95% Black, with 79% of the children residing in poverty,

64% of households receive SNAP benefits, high unemployment, low educational attainment, and

a median household income of $9,418 (Cleveland City Planning, 2014). Community health

assessments that have been currently conducted in Cleveland show that chronic disease impact

the black community of Cleveland and Cuyahoga County far more significantly than the white

community (Health Improvement Partnership-Cuyahoga Initiative, 2013). These devastating

numbers have led to heavy grant investment and program investment over the past decade,

giving Central many assets and existing organizations that can be utilized in our We Can Cook!

research and intervention project.

Central, has a high volume of public housing throughout the neighborhood, and was one

of the first areas in the nation to have such housing constructed (Sisters of Charity Foundation of

Cleveland, 2014). In person interviews, revealed information is spread by word of mouth,

additional communication strategies and methods need exploration, and social media is used

sparingly within the Central neighborhood. Food and nutrition literacy is quite low, and many of

the residents practice a diet that is familiar, convenient, and of low cost. Shopping at the corner

store or other fast food options to fulfill their dietary needs is the dominate practice in the

neighborhood, making a high-energy, low nutritional value diet commonplace. Central lies in a

corridor with the highest obesity rates in the city, with 40.4% of the area residents considered

obese, and overall 42.4% of the black community of Cleveland is considered obese (Bruckman,

Jewett-Tennant, & Borawski, 2012). A community advisory board will be critical in providing

insight, recruitment, intervention formation, and selection of housing development(s) to target

our program.

According to the Center for Disease Control and Prevention, improved access to

healthier food retailers has been adopted as a promising strategy to improve dietary quality

(Grimm, Moore, & Scanlon, 2013). With non-traditional farmer market points of access

surrounding the Central neighborhood, it is crucial to uncover methods and motivations that

consider socioeconomic, cultural, transportation, and awareness factors related to their use that

exist within the community to improve consumption of healthy foods. Doing so may contribute

substantially to improving the health of the residents while providing avenues of empowerment

to a historically marginalized community. It is the aim of this project to give community

members the lead role throughout the process and increase the self-determination of the

community.

Methods

When asked to describe the health priorities of Central, Dawn Glasco a Cleveland Central

Promise Neighborhood Engagement Coordinator, stated, the top priority issues as “the lack of

money, education, and knowledge to live a decent quality of life.” This indicates it is crucial to

develop a program that can empower the community, improve economic conditions, and build

on marketable skills as well as the benefits in terms of chronic disease and obesity prevention.

Community Based Participatory Research principles acknowledge the community’s identity,

builds on strengths, facilitates collaboration equitably, uses an ecological perspective, while

reporting results to all parties involved, and achieve sustainability (Israel, Eng, Schulz, & Parker,

2013).

The use of these CBPR principles provides the best method to ensure the program

addresses these priorities in a manner that is sensitive to the community’s wants and needs,

empowers the community to take control of their situation with solutions and methods they help

create. Provides research and learning opportunities that improve marketable skills, builds

partnerships, provides ownership, empowerment, and ensures existing assets within the

community are utilized, identified, and hopefully improved upon. Trust will be fostered

throughout the process from recruitment process which will entail individual and small group

work, establishing mechanisms to ensure follow through of commitments and confidentiality,

mechanisms to ensure continual engagement and on-going relationship building, shared

leadership guidelines, and ensuring there is a balance of power and influence (Israel, Eng,

Schulz, & Parker, 2013).

CBPR goes beyond the traditional research and intervention project, by striving to be a

social change process, with goals of learning and knowledge relevant to the task, building

relationships and solidarity, and engaging in action that wins victories and builds self-sufficiency

(Stoecker, 2008). With these goals in mind, a central tenet of CBPR is to address community-

identified concerns, and a formation of a community advisory board (CAB) similar to the board

formed in the Transgender Community Health Project (TCHP) (Clements-Nolle & Bachrach,

2008). The community advisory board of the TCHP was integral in design and implementation

of quantitative protocols, designing the interview process, simplified data collection,

empowerment of the community, inspiring further research, new initiatives, and opening new

career opportunities (Clements-Nolle & Bachrach, 2008). The use of a CAB will also facilitate

easing of tensions, misconceptions, and distrust that may be a result of white privilege of

academic researchers (Chavez, B, Baker, Avila, & Wallerstein, 2008), historic miscarriages of

justice during research, such as the Tuskegee experiment, and other notorious human research

projects. Building alliances across differences may increase the demand for justice, and provide

greater examination of systemic and personal barriers (Chavez, B, Baker, Avila, & Wallerstein,

2008), and failing to address racism in a community that is over 95% black would be a fatal

mistake.

The, We Can Cook! research and intervention project strives to be led by community

members during all phases. This necessitates training of investigative staff, and community

advisory board members, in team building skills, organization skills, data collection, and

analysis, which fosters leadership and empowers (Cheathem-Rojas & Shen, 2008). Incentives

will be offered for participation in the training sessions. The incentives will include a stipend of

pay, refreshments, and transportation, and will provide an opportunity to strengthen dialogue

concerning the research, how it pertains to the community, and builds marketable skills. Due to

the high level of activism, community projects, and established community engagement

organization may not need to be intensive or have a long duration, and may serve as a refresher

course.

Supplementing existing food behavior surveys that have been adapted and added to

fitting the community through a team effort of academic researchers and the CAB investigating

quantitative and qualitative data, will be photovoice. Photovoice was first developed by Wang,

Burris and colleagues in the Ford Foundation, and is an innovative method to use visual image as

an aid to critical think about the root causes related to historical and social patterns. It “builds on

commitment to social and intellectual change through community members’ critical production

and analysis of visual image (Wang & Pies, 2008). Photovoice will be used twice during the

project. The first use will be between academic researchers, investigators, and the CAB before

finalization of the written survey to be given. It will be used again with the program participants

before they answer the written survey, and begin the educational and skill-building portion of the

project.

Staffing and Implementation

Staffing for the project will begin streamlined, and will include; project manager whose

duties include smooth functioning between investigators, participants, partners, and community

advisory board members to ensure project remains on agenda and community focused. The

manager will also team with community ambassadors to handle delicate matters of performance,

attendance, etc… with community team members. The project manager will take the lead in

organizing, evaluation efforts, data analysis collaboration, and presenting results.

At least four graduate students to act as data collection support and training, initial draft

of additional grant proposals that may be relevant, moderate photovoice and focus group

discussions. Training in moderating skills may be necessary, as graduate students may have little

experience in moderating skills.

Four community investigators, this may change once interest and participation numbers

are revealed. Responsibilities will include data collection on research and program evaluation.

At least two community ambassadors, which will aid in the recruitment of the CAB and study

participants, help to develop a communication program, and aid in conflict resolution and

performance issues. There is also a need for six intervention assistants whose duties will include

aid in organizing cooking sessions, make necessary travel arrangements, distribute incentives,

and aid in logistics of educational experience of the program.

Necessary partnerships include but not limited to, Burton Bell Carr a community

development company, Friendly Inn Settlement House, Outhwaite Community Center, and

Sisters of Charity Foundation of Cleveland. These partners have needed resources, meeting

space, and deep community connections that are vital to the success of the program. Graduate

students will be compensated in accordance of University policy and will receive state minimum

wage currently at $8.10 an hour (National Conference of State Legislatures, 2015). To show

respect for their hard work, contribution, and dedication community members who fill the

investigator, ambassador, and intervention roles will be paid $15 an hour, with their subordinates

receiving $12.50 an hour. This higher hourly rate will not only help convey respect and gives

comparatively fair compensation, but will also help in the retention of staff, saving on training

costs as well as maintaining established relationships.

The project will be split in two phases, with an initial period of eighteen months per

phase. Phase 1 will start with small group discussions facilitated by Dawn Glasco, a Cleveland

Central Promise Neighborhood Engagement Coordinator, DeEtta Brown a Cleveland Central

Promise Neighborhood Ambassador, to determine who to recruit for CAB members and

community filled positions of the project. These group sessions can also aid in discovering of

hidden assets, institutions, and organizations that would be useful to approach for included

partnership. The development of these partnerships, filling of positions, and formation of the

CAB is given a year timetable to be accomplished, though provisions are in place in case this

happens faster or slower than expected.

After all positions have been established, all team members will participate in a

photovoice session. This will provide an opportunity to strengthen relationships, reveal differing

points of view, aid in the discussion and confrontation issues of race and privilege that may be

felt among team members. It fosters critical thinking and social examination (Wang & Pies,

2008), and offers an opportunity for two-way learning between the community and academia.

First on the agenda after this team building experience is completed is deciding whom we are

going to specifically target within the community. Stakeholder interviews have revealed child

mortality rates, teen pregnancy, and child abuse issues are some of the most prominent in the

neighborhood. Central also has the youngest demographic in Cleveland with 0-20 year olds far

above the city average (Statistics Atlas, 2015) so it may be determined to target a young age

group or partner with an existing program.

Once the determination of target audience is completed, the work on devising a relevant

survey that assesses healthy food access and consumption barriers and motivations begins. It

will first be determined if adaptation of previously, evidence based surveys, or a completely

designed by scratch survey using accepted appropriate theory will be used. Discussions will be

had on the added time, and difficulties in publishing, comparative use a “from scratch” survey

may entail. Work will also begin on tailoring the educational and cooking experience to the

target audience. Much like the survey, the program will be adapted from other successful

community cooking CBPR projects such as Cook It Up!, a community cooking program for at

risk youth (Thomas & Irwin, 2011), Jamie’s Ministry of Food Australia, a community based

cooking skills program primarily aimed at improving skills and confidence (Herbert, et al.,

2014). Discussions will also be held on optimal duration of the program, with original designs

seeing it lasting eighteen months happening once a month with two educational experiences

within that month. This may be too long of a commitment, and it may be determined that

shortening to six months with more frequent cooking sessions may be deemed most appropriate.

The use of focus groups and opinions of the CAB, along with weekly or bi-weekly meetings

between team members to discuss these elements will be the driving force of the final program

design, all relevant issues will be hammered out during this period, including appropriate

incentives that will be needed for success.

Phase 2 will commence by first obtaining informed consent of all participants, literacy

and language concerns will be accommodated. A general overview of the program will be

presented, and obligations, incentives, and research relevance will be explained. Photovoice will

be used prior to the survey being given to allow for a more critical thought approach to the initial

survey, as well as revealing qualitative information not appropriate for a written survey. The

participants will then embark on a predetermined educational and cooking experience. The

initial survey will also be given upon completion of the program. Because surveys can become

tiresome, in person interviews will be conducted on a regular basis throughout the duration of the

program. These interviews will not only be designed to gather data on food access and

consumption to track progress, but also as a program evaluation tool. This will allow us to tweak

the intervention as the process unfolds and unforeseen problems reveal themselves.

Analysis and Evaluation

Involving the community in the analysis portion of the program will be of high

importance. As the Minkler text shows community involvement lends expert knowledge

concerning the community not possessed by the researcher, add nuance to drawing conclusions,

help to adjust methods in the most efficient way, and provides greater quality of data (Minkler &

Wallerstein, 2008). It also enables the data to be interpreted from a lens of a very different life

experience angle and richness and a sense of social justice perspective that would be absent

without their inclusion. The statistics will be generated by the appropriate entity, but the

codification of the elements, data questions, and format were all provided by community

members so their exclusion from analysis and interpretation would be unethical. It will also be

important to give credit to all team members, and discussions will be held to determine primary

authors, while also crediting those who contributed to the project.

Guidelines for mechanisms that are agreed upon by the partnership must be developed,

and a good starting point would be examining and adapting appendix M of the Israel textbook to

ensure the research and collaborative process remains on task (Israel, Eng, Schulz, & Parker,

2013). It will also be important to provide investigators, ambassadors, and other relevant team

members the materials and training to take relevant and uniform field notes. Evaluation methods

that seek to understand the environmental, structural, and group dynamics of the partnership

need development that also examine interventions, intermediate success, and overall partnership

effectiveness (Israel, Eng, Schulz, & Parker, 2013). Data analysis and interpretation will begin

with scheduled meetings with all team members, then results will be presented to the community

in a town hall fashion with the audience able to question team members about the project and

what the data means, and where do we go from here discussion. This will all take place before

the final results and report are submitted for publication.

Continued Engagement

It is the hoped the community-centered nature of this program will give it sustainability,

and inspire a continuation of the intervention program even after the research is concluded. The

community may decide to make this a longitudinal study, and we should be prepared to assist

them in this endeavor. We may not be directly financing this endeavor (i.e. pay for

investigators), but we will aid in grant writing, data analysis, and publishing. It will also be

documented and reminded that the community is a trusted partner of the University, and a culture

of openness and friendship will be fostered amongst the staff and students.

The project uses elements that inspire thinking on a social and institutional level, which

could inspire partnerships with lead organizers of the Black Lives Matter movement sweeping

across Cleveland and the nation due to the rash of recent police shootings. This collaboration

can lift food access issues in a prominent social justice light changing the dominate view in the

neighborhood of “that’s just the way things are”, and provide motivation to change behavior

born from barriers, environment, habit, and convenience.

On a smaller scale, the cooking sessions can provide an avenue for recipe exchanges,

cookbook creations, organization of block parties, or awaken a new interest. The skills learned

from participation can lead to further educational attainment, greater community activism, and

feelings of greater self-determination, and inspire policy change. The success or failure of the

program can lead to the creation of more effective programs, and increase community capacity

and greater asset recognition. Because CBPR is such a dynamic and “hands on” process, the

possibilities are truly endless once the passion and empowerment have been experienced. That is

why it is paramount the University remains a trusted source of assistance, even if that role is

trusted advisor, to help ensure the flames of change are not extinguished even after our role in

the project is complete.

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