Alameda County is in the heart of California's San Francisco Bay Area. We are east of San Francisco extending from Berkeley and Albany in the north to Fremont and Newark in the south. Alameda County includes 14 incorporated cities (Alameda, Albany, Berkeley, Dublin, Emeryville, Fremont, Hayward, Livermore, Newark, Oakland, Piedmont, Pleasanton, San Leandro, and Union City) as well as six unincorporated, census designated places, as defined by the Census Bureau (Ashland, Castro Valley, Cherrryland, Fairview, San Lorenzo, and Sunol). As of January 2016, Alameda County had 122,034 individuals enrolled in the Supplemental Nutrition Assistance Program (SNAP). The cities of Oakland, Hayward, and San Leandro account for 72% of Alameda County SNAP participants. As the largest city in Alameda County and one with consistently the highest unemployment, highest poverty, and greatest number of social inequities, the city of Oakland further subdivides into a couple of neighborhoods. The neighborhoods of East Oakland and West Oakland have the highest concentration of poverty and consequently the worst health outcomes, leading to the public health need to prioritize place based prevention focused interventions.
Alameda County fares far worse than the statewide average when it came to proportion of unhealthy food options, with 4.61 times as many fast-food restaurants and convenience stores as supermarkets and produce vendors. This ratio of retail food outlets is one of many indications that there is little availability of fruits, vegetables, and other healthy foods for those who need it the most. Additionally, there are some places in East and West Oakland where residents can travel for miles without finding a grocery store. This makes healthy eating a huge challenge.
The Alameda County Public Health Department's Nutrition Services Program (ACNS) envisions that all people live in safe, connected neighborhoods that offer fresh, affordable foods, are choosing active healthy lifestyles and are engaged in their communities. We exist to promote and support healthy eating and physical activity through committed partnership with communities to reduce chronic disease and improve long-term health.
As a place based prevention focused strategy, ACNS implemented two signature programs throughout the community: the Champions for Change (6 class nutrition education series) and the Cooking for Health Academy (6 class nutrition education, food safety education, culinary skills development, and hands on practice cooking a healthy recipe). This model practice highlights our best organizational practices towards continuous quality improvement in order to address health inequities.
As obesity rates and diabetes rates continued to rise over the past two decades, there was increasing news coverage and public awareness of an epidemic which really needed to be addressed. With increasing public awareness, our program experienced an increased demand for nutrition education workshops. Furthermore, our program noticed more requests for our class series. One shot nutrition education workshops resulted in community demand for a 6 class series to return to the site, and with that came the increased opportunity to use a validated evaluation tool to conduct pre and post surveys with class participants, to measure behavior change.
Using primarily USDA's SNAP-Ed funds, our program delivered multiple 6 class series throughout our County, prioritizing East and West Oakland, and we were able to gather valuable feedback from class series participants. Over time, quantitative results from the pre and post behavior change surveys have show statistically significant, positive behavior changes in participants' lives. Our program also tracked qualitative impacts on participants' lives.
2015 marked a major quality improvement shift in our program. While both of our 6 class series showed statistically significant positive results, community voices were so loud and clear that the need was for the Cooking for Health Academy series. Our community members struggled not only with gaining nutrition knowledge: learning about fats, proteins, whole grains, sugar, etc.. They struggled with very practical food preparation challenges, from culinary skills to practicing safe food handling. We responded to the community by phasing out the Champions for Change program in order to increase our offering of the Cooking for Health Academy program.
At the core, the Cooking for Health Academy is a series of 6 two-hour long classes, comprised of four distinct components in each class: nutrition education, food safety, culinary skill techniques, and hands on practice cooking of a healthy recipe. Each component lasts approximately 30 minutes, so that the classes are stimulating, highly relational, highly interactive, and incredibly practical.
The Cooking for Health Academy curriculum was first developed by Alameda County and piloted in 2012. The curriculum has undergone continuous quality improvement, and evolved from an emerging practice into an evidence based program that received United States Department of Agriculture's approval to be an approved curriculum to implement with the SNAP-Ed eligible populations in the nation. Also by community demand, we piloted a Spanish curriculum to ensure we can effectively reach that segment of our SNAP-Ed eligible population who are monolingual in Spanish.
Our current implementation team is comprised of a program manager, a program evaluator, a registered dietitian, and four nutrition educators. This team meets regularly to discuss program progress, problem solve, as well as share successes at monthly staff meetings. The Nutrition Services Director oversees the program. This team-approach and regular check in ensures opportunities for responsiveness to community voices and community needs.
The creativity and innovation comes from our commitment to continuous quality improvement. We wanted this model practice of the Cooking for Health Academy series to serve multiple purposes: 1) direct education; 2) new knowledge and self efficacy that results in advocacy for policies, systems, and environmental change within the participants' own communities, 3) workforce development opportunities and community capacity building, and 4) partnership.
When the number of requests for the Cooking for Health Academy series were so high that our staff could not meet the demand fast enough, we thought, why not invite former graduates of this program to come co-teach with us? This doubled our number of class offerings because we had been pairing staff to teach these series together, and now our staff are paired with a community member. We carved out the most ideal section for these former graduates to begin to co-teach, and that was the food safety component of each class. This was incredibly exciting to implement because it meant that our community members, most of whom are low-income and SNAP-Ed eligible, now have the opportunity to make some money and build their resume for potential future employment.
Another innovation that resulted from quality improvement thinking was around offering to pay for the California Safe Food Handlers Exam for the former graduates to take in order to co-teach with our staff. If our community residents were going to have the credentials” and the privilege to co-teach that component of the class, they needed to pass the exam, and we were willing to pay.
Our participants who had the opportunity to take the exam were completely grateful and proud of their accomplishments, and very soon, we encouraged ALL of our Cooking for Health Academy series graduates to take the exam because we knew the practical and positive impact it would have on their lives. The results of that was astonishing in that many participants were able to use what they learned and the certification to be the best candidate when applying for a job in the food industry. It really made them stand out above other candidates! We are proud to have had 107 graduates take and pass the California Safe Food Handlers exam which further increases self esteem, confidence, and employability.
The Cooking for Health Academy (C4HA) has worked in partnership with community members and community based organizations since 2012, to provide nutrition knowledge, food safety awareness, and cooking techniques. One of our primary goals is for the participants to increase their fruit and vegetable intake and decrease sugar-sweetened beverage consumption. This is what we measure quantitatively through the pre and post behavior change survey. The C4HA series is designed to assist community members, many of whom have limited time and funds, to learn and practice ways to provide healthful meals for themselves and their families. Another goal is to improve and impact participants lives so powerfully that they want to spread the same health message to others in their circles of influence. In that sense, they are our community champions.
The Alameda County Nutrition Services (ACNS) plays a key role in the development of the Cooking for Health Academy, and we consider ourselves as the lead agency. However, to truly be effective we recognize the need to partner with other agencies in the community. It is altogether very different to try to invite participants to a class at the Public Health Department, and much more safe and community friendly to be able to host and offer these classes in low-income housing units, in public schools, public libraries, in senior centers, in parks and recreation centers, in places of faith and worship, in cultural centers. To that extent, we have equally invested in developing relationships with these partner agencies, who have also seen the value in bringing this model public health practice into their places and spaces.
The Alameda County Nutrition Services program is approximately 20 years old. Community engagement and partnerships has always been a core value and written into our mission statement. We meet the community where they are, literally. Nutrition assistants are on the ground with all of our programs talking to residents, store owners, church leaders, families which is why staff often receive requests to offer the series again. Many of our staff are also from the communities in which they serve, and ALL of our community resident co-educators are from the very communities where we need to be serving. Our longest program manager grew up in east Oakland and resides in the unincorporated area of the county. One of our nutrition educators is an alumnus of a local high school that we service. Another nutrition educator partners with her church congregation. Yet another nutrition educator had worked in the city parks and recreation department prior to coming to work with the public health department. It is these types of personal relationships that serve the community well. The relationships are reciprocal as well. We have testimonials on our website (www.healthylivingforlife.org) sharing how our interventions have changed people's lives and views. We also recently honored five community members at a Community Health Services Division meeting in Alameda County. This practice of being with, listening to feedback, honoring and acknowledging shows community support of our work.
Throughout the years, the variety of sites in which we offer the C4HA sites has grown. The 2012 pilot was conducted with representatives of schools. Sites exanded to include WIC and housing sites. Additionally, we have formal partnerships established via a grant relationship. For example, a local housing developer Resources for Community Development has prioritized a health zone” in an unincorporated locale of Alameda County. ACNS is partnering with them for their first bi-lingual offering of the Cooking for Health Academy in 2019. We have already collaborated with them in April 2018 for Public Health Week and have been collaborating with them on healthy, livable streets initiatives such as safe routes to school programs. We also have collaborative partnerships with faith-based organizations
Initial assessments of the pilot included review of logistics of the location/site, the reality of all program participants experiencing hands-on recipe demonstrations which yielded additional needs such as additional supplies needed for the demonstration, procedural feedbac insuring making sure residents receive adequate follow up (writing questions down, laminating recipes for ease of cleaning, more detailed descriptions in regards to cooking skills). Additionally, an overview hand-out for peer-based curriculum was developed.
The criteria for the service delivery sites for the C4HA is prescribed according to the USDA Food and Nutrition Service, federal guidelines to states' SNAP-Ed Guidance Principles 2015 document. Therefore, ACNS provides the Cooking for Health Academy in partnership with sites such as senior centers, recreation centers, housing sites, community based organizations/non-profit entities that serve low-income populations eligible to receive SNAP benefits or other federal assistance programs that are means-tested.
Nutrition Services has a multi-pronged, multi-need evaluation utilizing both process and outcome evaluation. The process evaluation utilizes a results-based accountability framework documenting number of activities, number of people services, number of locations in which the Cooking for Health Academy is offered. Staff internally use process evaluation to reflect on the delivery and anecdotally report on efficacy of the 6-week series to make course corrections during program delivery. Outcome evaluation details statistical significance whether the curriculum is creating behavior change towards healthy eating habits and safe food handling. Evaluation data comes from 1) residents, 2) service delivery staff and is reviewed by the LHD evaluation staff and the California Department of Public Health (CDPH).
We utilize CDPH developed tools, the Food Behavior Checklist (FBC) and the Cooking Attitudes and Self Efficacy surveys for data collection. The C4HA staff provide pre-test surveys to participants during the first session attended and provide the survey instruction guide to follow. Participants who entered after the second session were not provided with a FBC to reduce the possibility of data being included in the analysis. Post-test surveys were collected at the final session. Participants were instructed to complete the surveys and individual guidance was given as needed.
In our most recent data collection, thirteen (13) series of the Cooking for Health Academy were conducted at 10 eligible sites between July 1, 2017 and June 30, 2018. A total of 218 participants attended the series, with 106 completing the minimum five classes required for graduation.
Food Behavior Checklist data from 109 matched participants of the Cooking for Health Academy program showed improvement over last year's results. More findings were statistically significant (statistical significance is measured with a p-value <0.05) in a positive manner in several of the indicators measuring healthier eating behaviors. As shown below, participants overall reported (all statistically significant changes are noted in bold font):
--an increase in eating fruit and vegetables as snacks (mean=2.78 pre test vs. mean=3.02 post test; p-value=0.004)
--a decrease in consumption of sports drinks or punch (mean=2.13 pre test vs. mean=1.81 post test; p-value=0.000)
-- an increase in eating fruits each day (mean=1.21 pre test vs. mean=1.44 post test; p-value=0.001);
--an increase in eating vegetables each day (mean=2.70 pre test vs. mean=2.80 post test; pvalue=0.001)
--an increase in eating different kinds of fruit each day (mean=2.42 pre test vs. mean=2.71 post test; p-value=0.001)
--an increase in removing the skin off chicken prior to consumption (mean=2.37 pre test vs. mean=2.63 post test; p-value=0.004)
--an increase in reading nutrition facts when shopping (mean=2.32 pre test vs. mean=2.61 post test; p-value=0.002)
--An increase in self-rating of eating habits (mean=5.83 pre test vs. mean=6.36 post test; pvalue=0.004)
While not statistically significant, there was strong results demonstrating a decrease in consumption of regular soda (p-value 0.07), and an increase in eating two or more vegetables at the main meal (p-value 0.052).
To measure cooking and self-efficacy of participants results of the Cooking Attitudes and Self Efficacy Survey showed promising results. 82 matched participants showed statistically significant (statistical significance is measured with a p-value <0.05) findings in several of the indicators measuring cooking self-efficacy and attitudes. As shown in the table below participants overall reported:
--an increase in cooking techniques and meal preparation self-efficacy (mean=3.87 pretest vs.mean=4.42 posttest; p-value=0.000)
--an increase in self-efficacy for food safety (mean=3.30 pretest vs. mean=4.37 posttest; p-value-0.000)
While not statistically significant to the 95th percentile, we did see a large improvement in cooking attitudes. More positive cooking attitudes were seen as a result of the cooking series (mean=3.58 pretest vs. mean=3.94 posttest; p-value-0.065)
Over the course of the five years Alameda County Public Health Nutrition Services has conducted the Cooking for Health Academy, the data has become more statistically significant over time. This demonstrates that differences in behaviors made could strongly be related to the program. One reason for this could be the expertise of the staff improving service delivery over time. We have a high staff retention rate with little turnover from the nutrition assistant and program manager team (some over 10 years). Staff continue to refine teaching the curriculum each time they conduct a series at various sites throughout the county. Individual behavior changes appear to be changing each year except for self-rating of eating habits, which has consistently shown improvement in a statistically significant manner each year, as well. Some foods are not focused on within the Cooking for Health Academy curriculum, such as juice, milk, and fish consumption, hence we would not expect a change in the results of these food items. This year we noticed that the consumption of fruit and vegetables has improved over previous years, as we noted a higher baseline for pre-test results.
When looking at overall fruit and vegetable consumption there has been an increase between the pre-post intervention for all four years. This year we saw a statistically significant increase, again, in all three consumption figures, fruit”, veggies”, and combined fruit & veggies” categories.
Regarding cooking attitudes and self-efficacy, there has been a statistically significant improvement noted each year. Self-efficacy for food safety has also increased each year, with the data showing statistical significance over the past three years. Negative attitudes” has been reduced in regard to cooking, though we cannot say it is a result of our program simply because changing one's attitude is a challenging task that can be attributed to many factors. We saw an improvement this year more than the prior two years, so we will continue to convey simple recipes that make it easier for participants to prepare.
In summary, all these findings indicate that the intervention has been successful, though some of the positive results are not necessarily attributed solely to our intervention. To enroll, participants were requested to commit to attending a minimum of five of the six classes. Having received five to six lessons, the participants had more knowledge to make healthy choices, more time for key messages to be reinforced, and on-going support by a consistent educator and community site champions who are passionate about helping their community make healthier choices.
We are continuing to offer the Cooking for Health Academy as a cornerstone program as over the past five to six years, the program continues to benefit the SNAP-Ed community by offering personal nutrition education and incorporating physical activity to eligible, priority neighborhoods and sites throughout the County as supported and evidenced by the data.
Year to year, one of our nutrition assistants has a waiting list of community based organizations, seeking the series. To address, the list, we have been able to continue and leverage our other preventative programming strategies such as our successful Rethink Your Drink campaign (formerly Soda Fee Summer, 2006), to complement the C4HA series.
Our analysis of cost is simply that if we had additional funding and staff to learn the curriculum, we would be able to offer the C4HA to additional county sites. As a practice and successfully strategy and because it is our value, we have continued to employ local residents (former participants) to co-teach the C4HA.