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5 Community Development Approaches: Overcoming Challenges, Striving for ChangeA lthough many communities have initiated programs designed to reduce health disparities, a single community will want to address problems and solutions that are unique to them. At the same time,however, there are common ideas and elements to these programs acrosscommunities. This chapter highlights three community-based approachesthat are making a difference at both the local and national levels, servingas examples of how individuals and communities can improve the healthand lives of children. Veda Johnson of Emory University spoke about theWhitefoord Community Program she helped to found, which empowersresidents of the Whitefoord Elementary School area to improve the healthand education of their children. Marshall Kreuter of Georgia State Univer-sity and two of his colleagues who are community health workers, RoddieLongino and Travie Leslie, described their Atlanta-based initiative entitled“Accountable Communities: Healthy Together.” Wayne Giles of the Divi-sion of Adult and Community Health at the Centers for Disease Controland Prevention (CDC) provided an update on the progress of the Racial andEthnic Approaches to Community Health (REACH) program. Whitefoord Community Program: Caring For Children In The Context Of Family, Home, And Community Health disparities are multifactorial, Johnson said, and she prefers toapproach children’s health in a very holistic manner, going into the commu-nity and caring for them in the context of everything that affects their lives. 35

36 FOCUSING ON CHILDREN’S HEALTHIn 1994, Johnson and the late George Grimley (also of Emory University)decided that to better care for children, the two had to go where the chil-dren were. Health disparities were not a focus at the time. Rather, accessto health care was the primary issue they were trying to address. They setup the Whitefoord Elementary School-Based Center, located in SoutheastAtlanta, as a typical practice with pediatric primary health services for thechildren who attended the school and their preschool siblings. Johnson andGrimley’s goal was to increase access to quality health care and therebyimprove the academic achievement of the students. Initially, students came to the clinic when they were sick, and theywere treated accordingly. But after 2 or 3 months Johnson discovered thatphysical health really was not the greatest issue facing the children, and thattheir health outcomes were not entirely contingent upon whether their earinfection was treated or their asthma was controlled. Instead, the outcomesfor children were centered on psychosocial, academic, and family issues.She then saw the clinic as an entry point for interactions with the families.Out of the clinic grew the Whitefoord Community Program, a community-based, community-driven organization designed to care for children in thecontext of everything that affects their lives, their family, their home, andtheir community. The program empowers residents to take charge of them-selves, their children, and their community. Community Needs The Whitefoord Community Program is based on the needs that wereidentified by the families in the community. Johnson noted that it is veryimportant to go into the community and ask questions. Sometimes there isa tendency to think we know what families, communities, and individualsneed, when in fact we really do not. You need to go out and live amongpeople to really begin to understand what their challenges are, and whythey do what they do, she said. Based on the discussions, it was clear that the mission of the programwould be greater than just direct medical intervention; in fact, the missionevolved to a focus on working with families in the community to ensurethat every child had the ability to succeed in school. The primary need iden-tified was increased access to quality health care to address chronic healthproblems such as asthma, diabetes, and obesity in the community, as wellas issues of youth violence, teen pregnancy, substance abuse, and mentalhealth disorders. The families also wanted more affordable, high-qualityearly childhood education and after-school programs. Some parents saidthey needed adult literacy and General Educational Development (GED)instruction so that they could better teach and mentor their own children.(Prior to initiation of the program, about 50 percent of the families did

COMMUNITY DEVELOPMENT APPROACHES 37not have a parent with a high school diploma.) Families also needed moredirect social services in the community, including parenting support, andmore importantly, counseling for the parents so they could better deal withthe stresses in their own lives and thereby be better able to manage the livesof their children. Planning and Implementation As discussed above, the first step in planning the program was work-ing with the community to identify and prioritize needs. The next step wasto collaborate with everyone in the community who had a role in caringfor children—schools, parents, community leaders, community agencies,and potential funders—to develop programs to address each of the needs.An advisory committee was established within the schools to monitor andevaluate the effectiveness of the programs. Finally, community memberswere recruited to be on the board of directors to participate in governanceof the organization. The Whitefoord Community Program is run out of a series of fivehomes across the street from the Whitefoord Elementary School, where thefirst school-based health center was established. There are three major com-ponents of the program: school-based clinics, of which there are now two; achild development program that currently cares for about 75 children; anda family learning and community development center that provides GEDinstruction for families, and after-school programs, summer programs, andmentoring programs for children. Services and Staffing The in-school clinics are comprehensive and holistic. Clinic servicesinclude management of acute and chronic illnesses and injuries; routine andsports physicals; immunizations; dental care; mental health assessments andcounseling, including services for adults; psychoeducational assessmentsand testing to identify children who are at risk for failing; and referrals tomedical specialists and social services. The clinics are staffed by medical providers, including physicians, nursepractitioners, physicians assistants, nursing assistants, a dentist and dentalassistant, social workers, and mental health providers. There is also a full-time health educator, as health promotion and disease prevention is the bestapproach to decreasing health disparities, and administrative staff.

38 FOCUSING ON CHILDREN’S HEALTH Funding Funding for the Whitefoord Community Program comes from a vari-ety of sources. Medicaid alone, Johnson noted, is not sufficient. Neitherare reimbursem*nts from private insurers. Currently, 35 to 50 percent ofthe funding for the center comes from a Health Resources and ServicesAdministration (HRSA) federal grant. Medicaid and private reimbursem*ntsupply about 25 percent of the funding, philanthropy about 20 percent, andin-kind donations (e.g., clinic space, utilities, malpractice insurance) makeup about 5 to 10 percent. Programwide Accomplishments and Individual Success Stories The Whitefoord Community Program has some impressive program-wide accomplishments. Overall, the program has increased communityaccess to quality medical and dental care. Over 5,000 children have receivedmedical care since the program began in 1995. The clinics are currently themedical home to about 1,000 children, but in reality, the clinics see about1,500 to 1,600 children and adults per year. There is very strong supportfrom the schools and community, with 95 percent clinic enrollment and uti-lization. Johnson believes that this speaks to the quality of their approach tocaring for children. The immunization rate for 2-year-olds is about 90–92percent. The immunization rate for adolescents in the same families is alsohigh, at 82 percent. School attendance has improved, especially among children who havechronic diseases such as asthma. Johnson believes that performance hasalso been positively affected, but improvement has not yet been measureddirectly. Every child in the school receives health education on drug andsubstance abuse, violence prevention, safety, general health, and nutrition.The program goes into the classrooms and provides about 8,000 studenthealth education encounters every year. Children with chronic illnesses, especially asthma, have shown improvedhealth outcomes. Eight percent of the asthma visits to the clinic are childrenwho are asymptomatic, a result of the very aggressive approach to manag-ing these children. The program also improved the health outcomes for thechildren who are overweight. Since an after-school fitness and nutritionprogram was implemented several years ago, about 50 percent of the chil-dren have had a reduction in their body mass index (BMI), and 40 to 50percent of the children have had a decrease in their cholesterol level andfasting insulin level. A very important accomplishment, Johnson said, is the increased paren-tal involvement. The program has been able to impart to them the impor-tance of having an active role in the lives of their children, and families are

COMMUNITY DEVELOPMENT APPROACHES 39engaged even when it is difficult or stressful for them. There has also beena reduced cost to the state’s Medicaid program and decreased emergencyroom use and hospitalization of students with asthma (Adams and Johnson,2000). As important as these program-based figures are, Johnson likes tomeasure success one child and one family at a time. Among the examplesshe cited were the ability to detect a brain tumor in a third-grader while itwas in the early stage and treatable, the early detection of a genitourinarydeformity in a 9-year-old child that was successfully corrected, and earlydetection and intervention of children with chronic illnesses such as asthmaand diabetes. In addition, through onsite counseling and support, the program hasfacilitated the recovery of many emotionally troubled children. This, John-son noted, is probably the most important aspect of the program as faras improving the outcomes for children. Unless you adjust the emotionalaspect of the health of people, she said, you will not be able to makeimprovements in their physical health. In meeting needs and bridging gaps, Johnson concluded, the programhas been able to increase access to health care, improve health outcomes forchildren and their families, decrease health care costs, and improve schoolattendance and academic performance. Accountable Communities: Healthy Together Atlanta, Georgia is divided into 25 neighborhood planning units(NPU). The NPU system was established by Mayor Jackson in 1974 toensure that citizens, particularly those who have been historically disen-franchised, would have a voice in the structure and development of theircommunity. Accountable Communities: Healthy Together (ACHT) is acommunity-based, participatory research effort that Kreuter and colleaguesare conducting in NPU-V (letter V). ACHT is funded by a grant from theNational Center on Minority Health and Health Disparities (NCMHD),which supports a collaboration between the NPU-V community leadershipand the Georgia State Institute of Public Health, the Centers for BlackWomen’s Wellness, the Atlanta Regional Health Forum, the Fulton CountyDepartment of Health and Wellness, and the Southside Medical Center. TheACHT program, Kreuter explained, engages the community in identifyingtheir health issues, providing them with the methods, activities, and data todo so, and then identifying pilot programs to take action on those healthproblems. The neighborhood data advisory group (NDAG), composed of localresidents, developed a profile of NPU-V in 2004. The NDAG identified anunambiguous pattern of health, social, and environmental disparities in

40 FOCUSING ON CHILDREN’S HEALTHNPU-V. Examples include physical or mental disability at twice the citywiderate; high school graduation at half the citywide rate; infant mortality attwo and a half times that of white infants; owner-occupied housing at halfthe citywide rate; overweight among women at 64.5 percent versus 44percent among women citywide; male cancer mortality 50 percent higherthan for white men in the state; diabetes prevalence 48 percent higher thana decade prior; 68 percent of households with incomes less than $25,000;and 25.4 percent of reported major crimes classified as violent versus 16.8percent citywide. As described in the IOM report From Neurons to Neighborhoods: It is important to emphasize that early biological risk and insults, such as iron deficiency, often do not occur in isolation. In fact, they typically are increased among infants who also grew up in a disadvantaged environ- ment. . . . It can be exceedingly difficult to disentangle poor development and behavioral outcomes that are due to the biological exposure from those due to the problematic environment. (IOM, 2000, p. 206) And in fact, Kreuter said, in NPU-V it is the environment that is theculprit. Health Data Collection and Community Listening Sessions NPU-V has about 16,000 residents, 94 percent of whom are AfricanAmerican, said Longino. As described above, the community is burdenedby a disproportionate number of health, social, and economic disparities.After receiving the NCMHD grant for the community-based, participatoryresearch program, community health workers were recruited and trained,and collection of health information for NPU-V began. One primary source of health information was medical records fromSouthside Medical Center. Records were reviewed to determine the mostfrequent diagnoses for NPU-V residents who presented at the hospital. Thedata showed that the neighborhood mirrors the national pattern for disad-vantaged populations, with hypertension, diabetes, asthma, and disordersof the skin, eyes, and teeth being the predominant complaints. To help assess disparities, health indicators in NPU-V were comparedwith those in another Atlanta neighborhood, NPU-F. Demographic datafrom the year 2000 show that NPU-V was 90 percent black with 68 per-cent of homes having an income of less that $25,000, while NPU-F was 85percent white with 40 percent of households earning more than $75,000.Despite the marked differences in race and income, the differences in vacanthousing were less dramatic, with 88 percent of houses in NPU-V occupied,

COMMUNITY DEVELOPMENT APPROACHES 41compared to 95 percent in NPU-F. However, by 2007, only 58 percent ofthe housing in NPU-V was occupied, with 42 percent of houses vacant. Geographic information system (GIS) maps provided by the GeorgiaDepartment of Human Resources enabled the team to compare similarhealth problems in the two neighborhoods. Figures 5-1, 5-2, and 5-3compare NPU-V and NPU-F with regard to the rates of all cancer deathsfor males, type II diabetes prevalence for males, and type II diabetes preva-lence for females, respectively. In all three examples, the rates are higher inNPU-V. But notice the pattern, Longino said, when the incidence of breastcancer in females is compared between the neighborhoods (Figure 5-4). Theincidence of breast cancer in NPU-V appears lower. The different patternwas puzzling at first, Longino said, until it was determined that in this case,incidence reflects how many women were screened for breast cancer. Thebreast cancer mortality rate in females in NPU-V is 50 per 100,000, nearlytwice that of NPU-F at 26 per 100,000. Clearly, low rates of screening cor-respond to higher rates of mortality. The question to be answered next is ifthis low rate of screening is due to lack of knowledge about the importanceor availability of screening, lack of access or transportation to screening,lack of insurance, or a combination of all of these things. Another phase of data collection was small group community listeningsessions (about 15 to 20 people per group) employing “perception ana-lyzer” technology. This approach is an effective alternative to focus groups.Each participant received a handheld device that he or she used to instantlyand anonymously register his or her responses to questions. Everyone hasan opportunity to respond, participants remain engaged throughout thepresentation, and the tallied responses can be displayed in real time, spur-ring further discussion. Participants in the listening sessions, for example,were shown the GIS maps on breast cancer incidence and the data on mor-tality, described above, and were asked to provide instant feedback usingthe perception analyzer. Eighty percent of the participants indicated thatthey were not aware of the disparity. As another example, residents were asked how many days during theprevious month they would say their mental health had not been good.Twenty-six percent said that their mental health was not good for 14 daysor more, which is considered to be “frequent mental distress.” This is con-sistent with the national pattern of mental health findings in disadvantagedcommunities. By comparison, only 12 percent of residents in a statewidesurvey indicated mental distress 14 days or more within a month. Social Determinants of Health In addition to collecting health data, the team sought to understandthe social and environmental determinants of health, starting with the loss

42 Death Rate per 100,000 males* 0 – 43.4 Death Rate per 43.5 – 78.8 100,000 males* 78.9 – 122.2 1.6 – 43.4 122.3 – 185.2 43.5 – 78.8 185.3 – 1,005.1 78.9 – 122.2 122.3 – 185.2 185.3 – 1,005.1 1,005.2 – 3,031 Created: February 2006 Created: February 2006 Georgia Department of Human Resources Source: Division of Public Health Georgia Department of Human Resources Source: Division of Public Health Division of Public Health Projection: Georgia Statewide Division of Public Health Projection: Georgia Statewide Office of Health Information & Policy Lambert Conformal Conic Office of Health Information & Policy Lambert Conformal Conic * Manual Classification * Quantile ClassificationFIGURE 5-1  All cancer deaths among males in Atlanta, Georgia, neighborhood planning units V and F, 1998–2002.SOURCE: Georgia Department of Human Resources Behavioral Risk Factor Surveillance System. Figure 5-1.eps bitmap images landscape

Prevalence Rate per 100,000 males per year* 0 0.1 – 21.4 21.5 – 53.6 53.7 – 160.8 Prevalence Rate per 160.9 – 2,733.2 100,000 males per year* 3.0 – 21.4 21.5 – 53.6 53.7 – 160.8 160.9 – 2,808.0 Created: February 2006 Created: February 2006 Georgia Department of Human Resources Source: Division of Public Health Georgia Department of Human Resources Source: Division of Public Health Division of Public Health Projection: Georgia Statewide Division of Public Health Projection: Georgia Statewide Office of Health Information & Policy Lambert Conformal Conic Office of Health Information & Policy Lambert Conformal Conic * Manual Classification * Quantile ClassificationFIGURE 5-2  Type II diabetes prevalence among males in Atlanta, Georgia, neighborhood planning units V and F, 2002–2004. Figure 5-2.epsSOURCE: Georgia Department of Human Resources Behavioral Risk Factor Surveillance System. 43 bitmap images landscape

44 Prevalence Rate per 100,000 females per year* 0 0.1 – 14.4 Prevalence Rate per 100,000 females 14.5 – 44.2 per year* 44.3 – 88.4 0 88.5 – 245.2 0.1 – 14.4 14.5 – 44.2 44.3 – 88.4 88.5 – 245.2 245.3 – 1,089.0 Created: February 2006 Created: February 2006 Georgia Department of Human Resources Source: Division of Public Health Georgia Department of Human Resources Source: Division of Public Health Division of Public Health Projection: Georgia Statewide Division of Public Health Projection: Georgia Statewide Office of Health Information & Policy Lambert Conformal Conic Office of Health Information & Policy Lambert Conformal Conic * Manual Classification * Quantile ClassificationFIGURE 5-3  Type II diabetes prevalence among females in Atlanta, Georgia, neighborhood planning units V and F, 2002–2004. Figure 5-3.epsSOURCE: Georgia Department of Human Resources Behavioral Risk Factor Surveillance System. bitmap images landscape

Incidence Rate per 100,000 females* 0 – 41.4 41.5 – 88.7 Incidence Rate per 88.8 – 139.0 100,000 females* 139.1 – 201.1 0 – 41.4 201.2 – 754.0 41.5 – 88.7 88.8 – 139.0 139.1 – 201.1 201.2 – 318.0 Created: February 2006 Created: February 2006 Georgia Department of Human Resources Source: Division of Public Health Georgia Department of Human Resources Source: Division of Public Health Division of Public Health Projection: Georgia Statewide Division of Public Health Projection: Georgia Statewide Office of Health Information & Policy Lambert Conformal Conic Office of Health Information & Policy Lambert Conformal Conic * Manual Classification * Quantile ClassificationFIGURE 5-4  Breast cancer incidence among females in Atlanta, Georgia, neighborhood planning units V and F, 1999–2002.SOURCE: Georgia Department of Human Resources Behavioral Risk Factor Surveillance System. Figure 5-4.eps 45 bitmap images landscape

46 FOCUSING ON CHILDREN’S HEALTHof businesses in the community. The first half of the 1900s saw a steadyincrease in businesses in the community, peaking at 178 businesses inNPU-V by the early 1960s. But between 1964 and 2006, the communitysaw an 86 percent decline in the number of local businesses, with only26 remaining in 2006. You don’t have to be an economist, Leslie said, tounderstand that losing 80 percent of local businesses, and therefore alsolocal jobs, is not good for community health. To study the social environment, the team used “photovoice,” a quali-tative method that combines photography and grassroots social actions tobetter understand how residents see the conditions they live in, and to bringthese graphic realities to the attention of policy makers. Leslie cited onephotovoice submission from a 7th grader in NPU-V. Describing the pictureshe took of a boarded-up home, the girl said “This is an abandoned housewith lots of trash. Anybody from criminals to rapists could just walk in andmake themselves at home. I’ve been in the Pittsburgh community for a longtime, and this house is one of the issues in our community. When I walkby this house on the way to school with my friends, it makes us worried,especially the little kids.” Another photovoice picture of a house in disrepair was used as part of acampaign entitled “The Dirty Truth.” The campaign was designed to spreadthe message about the high number of vacant properties in NPU-V, and theassociated concerns including increased crime, rodents and pests, pollution,strained community services, and poor physical and mental health. Thiscampaign also enabled the documentation and update in the percentages ofvacant properties from 12 percent vacant to 42 percent vacant. Establishing Priorities and Pilot Interventions In August 2006 a community meeting was held to set priorities forNPU-V based on the health and social environment information collected.Participants marked ballots with what they perceived to be the two mostimportant local health issues and social determinants of health (Figure 5-5).Residents then voted a second time on a subset of items that received themost votes. The residents’ first priority health issue was mental health anddepression, and they saw this as a root cause of other problems. Interest-ingly, the data from the Southside Medical Center presented by Longinoearlier did not list mental health as one of the top 10 diagnoses stemmingfrom hospital visits. The reason, Leslie said, is because the hospital does notscreen for it. But based on their experience, the residents identified depres-sion and mental health as a top concern for NPU-V. After establishing the priorities, the NCMHD grant required severalpilot interventions be undertaken. The first intervention was improvingaccess to mental health services through a clinic-based strategy designed

COMMUNITY DEVELOPMENT APPROACHES 47 NPU-V Resident Ballot – Select 2 from each column Health Problems Social Determinants of Health___Hypertension ___ Crime/safety___Diabetes ___Lack of grocery stores___Asthma ___Neighborhood cleanliness___Depression/mental health ___ Decline in businesses___Heart disease ___ Parks and green space___Early detection of cancer ___ Unaffordable housing/ vacant housing___Upper respiratory infections ___ Lack of employment___Sanitation ___Youth support and development___HIV/AIDS ___Racism___Drug/alcohol abuse ___Access to health services___Childhood diseases/vaccination ___Lack of health knowledge___Pregnancy (prenatal/postnatal care) Criteria to consider in making your judgment: •Do you perceive it to be of highest importance? Is this problem or issue changeable? • Can you point to evidence to support this as a priority?FIGURE 5-5  NPU-V resident ballot to establish community priorities.SOURCE: Kreuter, Longino, and Leslie, 2008. Figure 5-5.epsto improve the rates of follow-up support services. The second was theDirty Truth campaign, mentioned above. Using the photovoice method asan advocacy and community empowerment strategy, the campaign wasdesigned to improve the environment and housing problems (factors thatare known to influence depression and hopelessness) through changes inlocal policies and enforcement practices. “Everyone Deserves to Work,”the third pilot intervention, is an innovative strategy to reduce crime byproviding social support and connection to services for reentry candidates(ex-offenders). It pairs previously incarcerated individuals, male and female,with a resident sponsor who is willing to help them navigate through thesystem of job placement, job training, and so on. Finally, during the listening session there were repeated references toresidents using the 911 system for health care. Analysis of emergency medi-cal services (EMS) data at Grady Memorial Hospital led to a 2-year pilotgrant funded by the Healthcare Georgia Foundation to determine whethera strategy to make primary care services more available to NPU-V residentswould result in a decline of EMS and 911 services for nonemergency healthneeds.

48 FOCUSING ON CHILDREN’S HEALTH Accomplishments and Challenges Examples of accomplishments of the ACHT pilot interventions to dateinclude demolition of several hazardous structures, increased access tomental health services at the Center for Black Women and Wellness, and asnoted above, support from the Healthcare Georgia Foundation to addressthe nonemergency use of 911 and emergency services. Challenges fall into two basic categories: community challenges andinstitutional (university) challenges. For the community, a key challenge hasbeen developing trust. Other challenges include balancing differences in per-spective, priorities, assumptions, values, beliefs, and language, determiningwho “speaks” for the community, and documenting intervention success.A significant challenge at the institutional level is institutional review board(IRB) approval of interventions. Recall that this is community-based par-ticipatory research. Other institutional challenges include time-consumingprocesses, budget issues, benefits for community health workers, docu-menting intervention success, and the inability to fully specify all aspectsof research up front. Leslie concluded with advice for those who undertake the community-based participatory approach, from her perspective as a community healthworker and NPU-V resident. Remember that we are people, not subjects orexperiments, she said. Also be aware that there is a “research disparity” inthat the university gets all the indirect costs, which is not a “partnership”in the eyes of the community. Collaboration and trust are not one-timeevents—they are fragile and need constant care. The roles of social, racial,and economic determinants of health have been known for decades. Dis-parities cannot be resolved in 2, 5, or 10 years time, and funding supportmust reflect this reality. Racial And Ethnic Approaches To Community Health (Reach) “We must endeavor to eliminate, so far as possible, the problem ele-ments that make a difference in health among people,” Giles began, offeringa quotation that could have easily been current, but in fact was written byW.E.B. Dubois over 100 years ago, in 1899, in the first systematic review ofthe health status of a non-Caucasian population in the United States. Weare still talking about those same disparities, Giles said, and while we doneed to continue to document disparities, what we need now is action. Wecan’t still be documenting these disparities 100 years from now. The disparities are well known. Heart disease death rates are 30 percent   W.E.B. Dubois, The Philadelphia Negro, 1899, p. 148.

COMMUNITY DEVELOPMENT APPROACHES 49higher for African Americans than whites, and stroke death rates are 41percent higher. Diabetes is more prevalent among American Indians andAlaska Natives (2.3 times), African Americans (1.6 times), and Hispanics(1.5 times). Vietnamese American women have a higher cervical cancerrate than any other ethnic group (5 times non-Hispanic white women).African American infants are 2.5 times more likely to die before their firstbirthday. Racial and Ethnic Approaches to Community Health (REACH) is anational program instituted by the CDC to eliminate racial and ethnicdisparities in health by providing grants to support community-based inter-ventions. Partners supporting the REACH program include the Office ofMinority Health, the Office of the Assistant Secretary for Program Plan-ning and Evaluation, the Administration on Aging at the Department ofHealth and Human Services, the Office of Minority Health and Healthdisparities at the National Institutes of Health (NIH), and the CaliforniaEndowment. REACH is about empowering community members to seek betterhealth, Giles said. REACH communities are working toward bridging gapsbetween the health care system and the community; changing their socialand physical environments to overcome barriers to good health; implement-ing strategies that fit their unique social, political, economic, and culturalcirc*mstances; and moving beyond individuals to community- and systems-level change. Health Disparities Can Be Overcome The number one lesson learned, Giles said, is that disparities in healthare not insurmountable and they can be overcome. In South Carolina,for example, there are REACH communities that are focused on diabetesamong African American men and women. They have been able to reducelow-extremity amputations among African American men with diabetes by36 percent and 44 percent in Charleston and Georgetown counties, respec-tively, over the last 8 years. These are people who otherwise would havebeen severely disabled from their diabetes. A second example, in Lawrence,Massachusetts, focused on Latinos with diabetes and has demonstrated anearly 9 percent improvement in blood sugar levels, 18 percent improve-ment in systolic blood pressure, and 14 percent improvement in diastolicblood pressure. A REACH community in Fulton County, Georgia, and others acrossthe country, are conducting blood pressure and cholesterol screenings atthe barber shop as young men are sitting down to get a haircut. The bar-ber is trained to talk with them about physical activity and healthy eating.In Charlotte, North Carolina, a local farmer’s market was established to

50 FOCUSING ON CHILDREN’S HEALTHprovide access to affordable fresh fruits and vegetables, and as an addedbenefit, it also helps local farmers. Survey data indicate an increase in freshfruit and vegetable consumption among African Americans in Charlotte. Although these examples of community-specific results are encourag-ing, it is important to assess the program’s impact nationwide. The REACHRisk Factor Survey compares data from all REACH communities with thelarger U.S. population, and larger racial/ethnic subpopulations. A surveycovering 2002–2006 shows that cholesterol screening for Hispanics livingin REACH communities is increasing, even while nationwide fewer Hispan-ics are being screened. And within the REACH communities, cholesterolscreening of African Americans is actually greater than the national averagefor all races. Today, only one out of every three people with hypertension has theirblood pressure adequately treated and controlled. Nationwide, althoughthere has been an increase in the percentage of people with hyperten-sion who are on medication, among American Indians nationwide therehas been minimal change. However, among the REACH communities thenumber of American Indians with hypertension who are taking medicationhas increased. Finally, cigarette smoking among Asian men has historically been veryhigh compared to the rest of the nation. But in REACH communities, thepercent of Asian men who smoke is now lower than the percentage ofAmericans of all races who smoke. Disparities are not insurmountable,Giles reiterated, and said we need to teach other communities how to dowhat these communities have done so well. Why REACH Works Echoing the comments of other speakers, Giles said there have beena number of challenges around community-based participatory research,including time; coordinating federal and community priorities; forming suc-cessful community, academic, and governmental partnerships; ownership;power; and division of resources. First, community-driven programs and policy development are key, saidGiles. During a planning year, the community developed an action plan,which was extremely important in terms of the success of the REACHprogram. This participatory activity led to the empowerment of individualswithin the community to take charge of their own health. It also empowersthe community as a whole. In the Bronx in New York City, for example,most people in the community were not aware that there were disparities indiabetes and cardiovascular disease. When they found out, they mobilizedand traveled to Albany, New York, and talked with state policy makersabout creating safe places for physical activity. In Los Angeles, Califor-

COMMUNITY DEVELOPMENT APPROACHES 51nia, members of a REACH community worked with the city council toestablish a moratorium on new fast-food restaurants in south central LosAngeles. When you mobilize communities, Giles said, they are empoweredto approach policy makers about these issues. A second key component for success is having community, academic,and governmental partnerships. All of the REACH community coalitionswere required to include a state or local health department, an academic orresearch institution, and a community-based organization. This has not nec-essarily been easy, Giles said, and many of the communities struggled withthis. For example, when the academic institution wants to conduct a surveyand publish the results, the community members also want to see the resultsand be part of the analysis and interpretation. During the planning phaseof the study, residents had the opportunity to have this type of importantdialogue, and it helped to move the process forward and helped the com-munities be more comfortable with the partnerships they engaged in. Community expertise is very valuable. Given time and guidance, thecommunity members are really best suited to determine the types of inter-ventions that should occur in their community. In Charleston, South Caro-lina, community members developed a program called “Praisercize” whereolder residents do chair aerobics to gospel music. They have become localcelebrities, and now they travel around the state to county fairs demonstrat-ing Praisercize. Finally, relying on the communities is an important aspect. This isa very different approach for CDC, and it has been challenging for theCDC staff conducting the community-based participatory approaches. ButREACH has proven to be a successful partnership, and it has been excitingto watch how the communities have grown. REACH has been able to givecommunities a sense of hope. They have the tools and the sense that thereis something that they can do to eliminate disparities. An example of this isthe Golden Girls in Charleston, who go out walking in their neighborhoodevery day. The idea of creating safe places for physical activity is important,as is giving communities the tools to actually make changes. REACH-ing Further Communities need to be aware of and understand health disparities intheir daily lives, Giles continued. They need to establish interventions, andthen they need to teach other communities about what worked for them.To facilitate this, REACH funds 16 Centers of Excellence in the Eliminationof Health Disparities (CEED). At the centers, regional and national expertsserve as mentors for other communities. These experts offer informationabout how to address disparities, and the centers provide small seed grantsto communities to begin the discussion around disparities elimination.

52 FOCUSING ON CHILDREN’S HEALTH Action Communities CEED Communities African-American/ Blacks American Indian/ Alaska Native Asian Native Hawaiian/ Guam Other Pacific Islanders Hispanic/Latinos Multi-EthnicFIGURE 5-6  REACH communities in the United States.SOURCE: CDC, 2007. Figure 5-6.epsIn addition to the centers of excellence, there are 22 action communitiesinvolved in the implementation and evaluation of established and innova-tive interventions (Figure 5-6). Giles concluded by emphasizing that over the last 9 years, REACHcommunities have been able to show that disparities can be addressed andcan be eliminated. Open Discussion Much of the discussion that followed the presentations focused onbudget issues and sustainability. We need to find creative ways to documentthe effectiveness of interventions, and we need to be much more politicallyactive in terms of communicating effectively with legislatures, Kreuter said.Even programs such as SCHIP, which has demonstrated efficacy, was dif-ficult to obtain funding for early on. Leslie noted that as a community health worker, she has seen thedisparities in her neighborhood, and said they are caused by the lack ofessential services, the lack of interest from political leaders, and the lackof government identifying and providing what is needed in order to closethe health gaps. Funding is badly needed, and she emphasized that the

COMMUNITY DEVELOPMENT APPROACHES 53communities are not asking for a handout, but a hand up. Giles concurredwith the funding issues. Kansas City, Missouri, he said, was one of thecommunities that REACH did not have the resources to continue to fund.Instead of discontinuing the interventions, the community mobilized andraised $400,000 to continue the work of the community. This is a realexample of community empowerment and shows what can happen whenthe communities realize the value of what they can accomplish. But, Gilessaid, there does need to be more federal dollars for this type of work. Therewere over 200 communities applying for REACH, and CDC was only ableto fund 40. Johnson noted that there are two very important issues around sus-tainability. First, initial funders have unrealistic expectations that therewill be results in 2 or 3 years. They need to be made to realize that thisis a long-term generational approach to changing the health climate forfamilies. Second, everyone is conducting similar work in different silos. Weneed to integrate and collaborate so we can use the paucity of funds moreeffectively, she said. In response to a question about the costs of clinic services providedby the Whitefoord program, Johnson said that the clinics are federallyqualified health centers (FQHCs), and there is a sliding fee scale, with somepatients charged a zero fee. She noted that because hers is a school-basedclinic, a large number of the children are seen without the parents beingpresent. While the clinic does not follow up with the parents regardingthe fee, it does make an attempt, when families come in together, to makethem aware that the clinic is an FQHC, and that they are responsible forpaying something. ReferencesAdams, E. K., and V. Johnson. 2000. An elementary school-based health clinic: Can it reduce Medicaid costs? Pediatrics 105(4 Pt 1):780-788.CDC (Centers for Disease Control and Prevention). 2007. REACH-U.S. Grantee partners. http://www.cdc.gov/reach_us.htm (accessed July 8, 2009).IOM (Institute of Medicine). 2000. From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press. P. 206.