Factors such as employment, transportation, and the built environment influence the health of individuals and communities. One environmental indicator of community health is the accessibility of healthy food. Areas with low access to healthy food have been termed “food deserts” by the United States Department of Agriculture. Currently in Manatee and Sarasota counties, there exist 20 food deserts, resulting in healthy food insecurity in one out of every four children throughout both counties.
Food systems in the United States are not restricted by county lines. In recognition of this trend, health departments in Sarasota and Manatee counties embarked on a cross-county food assessment and food access plan. This project utilized a community-based participatory methodology to collect residents’ perspective on assets, barriers, and preferred interventions for healthy food access and education points. A robust combination of focus groups, key informant interviews, randomized door-to-door surveys, recorded oral histories, and photo-voice was used to gather input, allowing for a meaningful evaluation of community needs. Collection tools were consistent throughout all food deserts; however, results were analyzed to determine which food access interventions (i.e. increased transportation routes, healthy corner stores) were most appropriate for each food desert community.
Following assessment, a cross-county action council was convened, comprised of community residents, farmers, decision makers, and representatives from food assistance agencies. Results from the cross-county assessment were used to drive policy, systems, and environmental change-based food access intervention planning.
Manatee County Health Department
A Regional Approach to Community Engagement and Healthy Food Access in Underserved Communities
This practice was a collaboration between the Florida Department of Health in Manatee and Sarasota Counties (DOH-Manatee and Sarasota).
Located on the southwest Florida coast, Manatee County has a total area of 743 square miles. Manatee County has a population of 342,106, a median age of 47.6 years, a median household income of $46,956, and a diverse population (9 % Black, 16% Hispanic, 87% White.) Sarasota County sits just below Manatee County, totaling 555 square miles. Sarasota County has a population of 396, 962, a median age of 53.1, a median income of $49,052 and similar demographics to Manatee County (5% Black, 9% Hispanic, 84% White).
Childhood and adult obesity rates are steadily increasing in both counties. According to the Florida Department of Health's 2013 Healthiest Weight Profile, 61.9% of Manatee County adults and 57.5% of Sarasota adults are overweight or obese and 18.1% of Manatee County middle and high school students and 13.2% of Sarasota students are overweight.
To create a community that supports healthy weight, multiple barriers to healthy choices must be addressed. Across the country, public health workers are collaborating to develop solutions to address gaps in access to healthy food. For these initiatives to be successful, they must meet the distinctive needs of the community.
The first goal of this practice was to identify the perceived barriers, assets and desired solutions of food desert residents. This was achieved by engaging food desert residents using a variety of qualitative and quantitative methods.
The second goal was to collaborate across county-lines to maximize resources, share best practices, and plan regional solutions. This was done by engaging stakeholders from both counties in the assessment process and convening a cross-county action council to address assessment findings and plan solutions.
This practice utilized a robust combination of focus groups, key informant interviews, randomized door-to-door surveys, photo-voice and recorded oral histories to gather input for meaningful evaluation of community needs. Methodology and tools were consistent across both counties.
The USDA food access research atlas was utilized to identify local food desert census tracts. DOH-staff discovered 19 food deserts in the bi-county area, at the USDA 1 and 10 mile food desert definition. To focus efforts, staff worked with County Neighborhood Services staff to identify cohesive neighborhoods within food desert census tracts which are more likely to support community wide health interventions.
Once target food desert neighborhoods were selected, recorded personal narratives and focus groups identified residents’ perceived barriers, assets, and solutions around increasing access to and consumption of fruits and vegetables for their communities. This feedback was analyzed for themes and used to develop a survey questionnaire.
Randomized door-to-door surveys collected details necessary for action planning. DOH-staff utilized a survey tool called Community Assessment for Public Health Emergency Response (CASPER) developed by the CDC for emergency response. The tool was repurposed to engage food desert residents in planning interventions for their neighborhoods. CASPER is normally applied to census tracts impacted by a disaster. In our case, only food desert census tracts were included. Then 30 census blocks were selected using a randomization tool. Finally seven homes in each block were selected at random, using GIS mapping. A 100% response rate would mean seven homes in each of the thirty blocks completed the survey. An 80% response rate is enough to be a representative sample. This methodology only requires 168-210 surveys to obtain a representative sample.
The aim of the assessment was to gather as much resident feedback as possible and involve residents in the planning neighborhood interventions.
DOH-staff completed twelve focus groups and six recorded interviews in seven food desert neighborhoods. Both counties completed CASPER. Following assessment, an ongoing council was convened, comprised of over 35 residents and stakeholders. Results from the assessment were used to plan food access interventions including community gardens, a mobile market resident-led and planned educational programming.
This practice was successful due to collaboration and high levels of community engagement. Partnering cross-county allowed for health departments to maximize resources. Collaboration and resident engagement didn’t end after the assessment; it was vital to planning regional solutions. Multiple engagement methods eliminated guessing and allowed food desert residents to speak for themselves.
This practice provides a model for successful collaboration between health departments, a partnership which is not often created. Additionally, the practice provides a framework for multi-tiered, grassroots community engagement. Meaningful community engagement allows for more successful planning and implementation.
Food deserts are defined by the USDA as areas with low access to healthy foods. Food deserts have a negative impact on the health of a community, leading to increased obesity levels because prepared and processed foods high in calories, sugar, and salt are more readily available for residents to buy than nutritious foods such as fresh fruits and vegetables. When fast and convenient, nutrient-poor foods are easier and cheaper to access than fresh, nutrient-dense foods, our population’s weight increases and health worsens.
In Manatee and Sarasota counties of Florida, there are over 19 census tracts designated by the USDA as food deserts.
Manatee and Sarasota Counties are geographically close and demographically similar. Obesity trends are rising in both counties. The Florida Department of Health in Manatee and Sarasota Counties partnered to address the issue impacting both counties. The aim was to identify the unique barriers, assets and solutions to accessing and consuming healthy foods, and then to leverage regional resources and partnerships to address neighborhood-specific needs. Each county has unique resources that may be maximized by cross-county collaboration, which would allow for more cost-effective solutions. Cross-county partnership also allows us to share best practices, shining a light on regional bright spots.
In Manatee and Sarasota Counties, over 80,000 residents live in food deserts. Both Manatee and Sarasota County have diverse populations and according to a USDA study on food desert characteristics, it is likely that these food desert census tracts have a greater concentration of minorities. This study also demonstrated a higher rate of poverty in food desert tracts vs. non-food desert tracts.
In Manatee County, 41,229 people are designated by the USDA as having low access to healthy food, of which 16,573 people are low income. In Sarasota, 38,432 residents live in USDA designated food deserts. Of that number, 33,419 are low income.
This practice utilized a comprehensive engagement plan to overcome the challenge of having such a large target population. By engaging residents using a variety of methods, staff gained insights and identified the unique differences among the various cultural groups and food desert neighborhoods. Furthermore, randomization of the door-to-door survey allowed staff to obtain a sample of responses which can provide a reasonable representation of the larger population.
Prior to this assessment, DOH-Manatee received funding through a NACCHO Action Communities for Health, Innovation, and EnVironmental change (ACHIEVE) grant to open a farm stand outside of the local WIC office, but it failed, despite following CDC recommended best practices. Staff engaged community members in planning, but they didn’t engage the right community members. For example, church leaders were engaged, rather than the parishioners themselves. The farm-stand failed because residents were not adequately engaged in the planning.
Additionally, in 2010 a food policy council was developed in Manatee County but, lacking direction, it never gained traction and is no longer active.
The current practice incorporated these lessons learned to improve upon engagement strategies.
This practice was highly participatory and engaged food desert residents using an assortment of methods such as focus groups, recorded interviews and randomized door-to-door surveys. DOH-staff relied on high level community leaders to connect us with residents, but recognized that those key leaders could not speak for the residents. This practice sought to involve residents as much as possible throughout the assessment and planning processes.
After the assessment was completed, a cross-county council was convened to plan solutions. To maintain stakeholder interest, the current practice engaged stakeholders heavily throughout the entire assessment process. Furthermore, the assessment done helped direct and streamline existing efforts based on resident feedback. Stakeholders were committed to the planning process, as assessment feedback and DOH facilitation helped connect the dots throughout the community, increasing regional communication. Resident engagement remained vital throughout planning. For example, when educational programming was planned, residents provided details on where and when classes should be held.
Cross-county health department collaboration, multi-level community engagement, and creative use of an existing assessment tool make this practice highly innovative.
Health departments rarely partner to tackle issues on a regional level. Cross-county partnership, while not without its challenges, offers extensive benefits such as maximizing staff time, which is critical as many health departments function with limited staff. Additional benefits include sharing best practices across counties; this allows key leaders of best practices or “bright spots” in one county to mentor their counterparts in another county.
Basic community-based participatory research (CBPR) is utilized frequently by health departments. It is not uncommon for health department staff to host focus groups or send mail-out surveys to residents. This practice, however, goes above traditional community engagement and incorporated multiple engagement methods, rigorously applied over the period of one year. Staff started with key community leaders, interviewing them to learn about cultural groups, neighborhood cohesion, and community contacts. Next, staff held focus groups, hosting as many as necessary to ensure all relevant cultural groups were represented in feedback. After analyzing focus group transcripts for themes, a survey questionnaire was developed to gather planning data, critical for successful implementation. Finally, staff partnered with New College of Florida students to film recorded interviews with food desert residents. These interviews highlighted residents’ challenges, as well as how they overcome them and their ideas for sustainable solutions.
For the survey portion of this project, DOH employed an existing tool developed by the Centers for Disease Control (CDC) called Community Assessment for Public Health Emergency Response (CASPER). CASPER was developed as a tool which allowed for rapid randomization and deployment of a survey post-disaster. This unique methodology allowed staff to only deploy the survey in target food desert neighborhoods, while maintaining randomization.
Nutrition, Physical Activity, and Obesity
Health department staff in Manatee and Sarasota Counties collaborated to develop and implement this practice, with broad and ongoing participation from community partners.
The Florida Department of Health in Manatee and Sarasota Counties utilized a multi-tiered, community-based participatory methodology to collect residents’ perspective on assets, barriers, and preferred interventions for healthy food access and education points. A robust combination of focus groups, key informant interviews, randomized door-to-door surveys, and recorded oral histories, was used to gather input, allowing for a meaningful evaluation of community needs. The purpose of the interviews and focus groups was to identify residents’ eating and purchasing habits, perceived barriers to healthy eating, perceived assets that support healthy eating, and perceived solutions for what would improve healthy eating in their communities. Feedback gathered through interviews and focus groups was analyzed for themes and used to develop a survey questionnaire.
Qualitative data allowed staff to understand the personal stories behind the issue. Unique themes emerged from each focus group, in addition to common themes developing across all focus group discussions. Staff was able to extract these themes and utilize them to create a survey questionnaire. The goal of the survey was to dig deeper into the focus group themes, and gather quantitative, planning data around each theme.
The randomized CASPER door-to-door surveys collected specific details used to guide action planning. For example, focus groups revealed an overwhelming interest in classes among residents. Many agencies already offer these classes completely free, but have few participants. The survey aimed to gather information on where classes should be held and what would make it easier for residents to attend classes.
The assessment is to engaged residents in identifying community assets and barriers, and opportunities for interventions. Asking residents about their experiences eliminated guessing from planners, and that was vital.
To begin, DOH-staff reviewed USDA GIS data to locate local food desert census tracts and then worked with community partners to identify cohesive neighborhoods within food desert tracts which could support programs. DOH-staff then met with 2-3 key community leaders in each target food desert to develop an engagement plan specific to the neighborhood. A combination of focus groups, key informant interviews, randomized door-to-door surveys, and recorded personal narratives was used to gather input, allowing for a meaningful evaluation of community needs. Collection tools were consistent throughout all food deserts; however, results were analyzed to determine which food access interventions (i.e. increased transportation routes, healthy corner stores) were most appropriate for each food desert community.
It took approximately one year to complete this practice and any individual living and/or working in a target food desert neighborhood was eligible to participate. Depending on the number of staff dedicated to the project, this process could be fast-tracked. DOH-staff devoted two months to secondary data review and key informant interviews, three months to planning and hosting focus groups, two months to analyzing focus group transcripts for themes and developing/piloting a survey questionnaire. Due to limited staff, the door-to-door surveying took approximately three months to complete and about one month to enter and analyze. Personal narratives were done concurrently with focus groups and took about three months for students to complete.
This practice relied heavily on collaboration within each health department, between both health departments, and with a number of community stakeholders. DOH-staff engaged stakeholders from the beginning of the assessment process and continued throughout. The assessment began with interviewing stakeholders. Stakeholders helped us choose focus group locations, recruit focus group participants, recruit personal narrative participants, and even served as volunteer surveyors. Their guidance was critical.
Stakeholders were heavily involved in the process. Their unique resources and skills were vital to the success of this project. For example, Manatee County Neighborhood Services staff assisted by connecting DOH-staff to community leaders and also assisted with completing door-to-door surveys in the field. Manatee County Housing Authority (MCHA) staff helped recruit residents of public housing to participate in the assessment. DOH was unable to offer incentives for participants so MCHA offered their residents volunteer hours (a requirement for unemployed housing residents) for participation. The New College of Florida’s (NCF) anthropology department created a class on food desert personal narratives. Students in this class created the interview scripts and completed the actual interviews with guidance from NCF and DOH staff.
Developing strong, cross-county partnerships allowed for health departments to maximize limited resources and staff time. The counties worked together to work through any road blocks to the project. Collaboration didn’t end after the assessment. Following the assessment, a cross-county council was convened, comprised of over 35 community residents, farmers, decision makers, and representatives from food assistance agencies. The implementation phase of this project is active and ongoing. DOH is facilitating the council and is using results from the cross-county assessment to drive policy, systems, and environmental change-based food access intervention planning. The partnerships DOH staff has created and maintained are vital to developing regional solutions and sharing best practices between counties.
There are no costs associated with this practice, other than general overhead.
Through this practice, DOH-staff identified the perceived barriers, assets and desired solutions of food desert residents. Staff achieved this by engaging food desert residents by (1) hosting twelve focus groups in seven target food desert neighborhoods, (2) completing the CASPER survey methodology in each county, and (3) recording personal narrative stories from six food desert residents.
DOH-staff collaborated across county-lines in assessment and planning. Staff engaged stakeholders and residents from both counties in the assessment process and convened a cross-county action council to involved both stakeholders and residents in and planning interventions.
The food desert neighborhoods of Manatee County covered large swaths of the county. The neighborhoods targeted in Manatee County were Samoset, East Bradenton, Washington Gardens, Rubonia, and Pride Park. In Sarasota, most food desert tracts clustered around two neighborhoods: Newtown and North Port. Themes from the focus groups held in each neighborhood are summarized below.
Samoset- This community’s themes focused on lack of affordable produce, as well as lack of nearby, accessible produce vendors. The community is located 2.4 miles from a large farmers market that has very affordable prices according to focus group participants; however, the market’s distance is a barrier. The participants expressed interest in (1) a more centrally-located farm stand that accepts credit/debit and EBT. The participants also expressed interest in (2) nutrition and food preparation classes that would teach families how to incorporate healthy foods such as fresh fruits and vegetables into recipes traditional to African American, Hispanic, and Haitian customs.
East Bradenton – This community’s themes focused on the perceived high cost of fresh fruits and vegetables, as well as the perceived time it takes to prepare fresh fruits and vegetables. Focus group participants report a high density of fast food restaurants in their community and report buying meals from these fast food restaurants because of the convenience. Focus groups participants expressed interest in (1) more centrally-located produce options (farm stands or farmers markets) that accept EBT and debit/credit cards, as well as (2) nutrition and healthy food preparation education classes geared toward children.
Washington Gardens - The majority of participants expressed owning personal vehicles, but still feeling as though the grocery stores are too far away to feel convenient and to warrant the gas prices. Participants also reported concerns on perceived lack of affordability of fresh produce, as well as the amount of time (lack of convenience) involved in preparing healthy meals. Participants prioritize cooking traditional recipes, so they would like (1) education regarding easy ways to incorporate fresh fruits and vegetables into recipes customary in African American populations. Washington Gardens has one church, Eternity Temple, which has started a community garden. Focus group participants expressed interest in (2) having more small community gardens attached to churches.
Rubonia –Residents of Rubonia overwhelmingly express transportation disadvantages. According to GIS mapping, key informant interviews, and focus groups, the Rubonia neighborhood does not have a grocery store, and accessing the nearest grocery store requires crossing major highways. Rubonia is an isolated community in Manatee County, only served by public transportation three days a week. During focus groups, this community’s themes focused on lack of accessible and affordable options for fresh foods. Residents resoundingly expressed interest in (1) community gardens, interest and (2) more affordable and conveniently located produce (such as a farm stand that accepts EBT and/or has low prices.)
Pride Park –This community’s themes centered around the perceived high cost of produce, the difficulty of meal planning with healthy foods that are perishable, and the lack of fresh produce at local food pantries. Focus group participants expressed interest in (1) working in a community garden where they could grow their own vegetables, as well as (2) having a farm stand that accepts EBT. Focus group participants also expressed interest in (3) educational classes that would teach nutrition and healthy meal planning on a budget, as well as healthy meals for children.
Newtown- Residents of Newtown reported price as a major barrier to healthy eating and expressed quality as high importance. They are willing to “shop around” to get the best deal. Focus group participants expressed interest in (1) raised awareness of existing community assets such as gardens and farm stands as well as (2) education, particularly on the topic of meal planning.
North Port- This community’s themes focused on the perceived high cost of fresh fruits and vegetables, as well as the perceived time it takes to prepare fresh fruits and vegetables. Focus group participants expressed interest in (1) more centrally-located produce options (specifically farmers markets) that accept EBT and debit/credit cards, as well as (2) nutrition and healthy food preparation education classes.
Survey responses were analyzed using the CDC softare EpiInfo.
When asked what would make it easier to get more fruits and vegetables, the top three responses were (1) lower costs, (2) community fruit trees, and (3) community gardens.
Primary themes from focus groups included education, growing food and affordable, centrally located market options.
Education is broad and can include a number of topics. To gather more information, respondents were asked about specific topics. 41% of respondents were interested budgeting classes, 37% were interested in cooking classes and 35% were interested in nutrition classes. Percentages do not add to one hundred. Respondents could express interest in multiple classes. Furthermore, DOH-staff asked respondents what would help them attend these classes. In both counties, the top responses were (1) holding the class in respondent’s neighborhood and (2) teaching the class in under an hour.
Respondents were also interested in affordable, fresh-market options closer to their homes. When asked about farm stands and 57% of respondents said they would like to shop at a farm stand in their neighborhood. To assist with planning, staff asked what days the farm stand should be open. 40% of respondents preferred weekend hours.
Gardening emerged as a major theme throughout the assessment. Overall, 53% of respondents said growing food would make it easier to get fruits and vegetables. In focus groups, gardening conversations centered on community gardens. When staff asked survey respondents, however, 84% expressed that they would like to grow food in their own yard and only 32% expressed interest in growing in a community garden. Respondents could say “yes,” to growing in both locations.
The randomized door-to-door survey allowed DOH-staff to access residents who would not or could not attend a focus group as well as delve much deeper into assessment themes, gathering specific planning data.
Resident feedback from the assessment drove the planning process. Plans included development of community gardens and the policies to support community gardens.
Another widely desired solution in the community was affordable market options, like farm-stands, located right in food desert neighborhoods. To address this, plans were developed to create a mobile market which can serve food desert areas of both counties.
The primary data sources for this practice were focus group recordings and survey responses
Focus group recordings were transcribed and analyzed for themes using CDC best practices for manual focus group analysis. This method involved organizing and labeling data by hand. According to CDC guide on analyzing qualitative data, manual analysis is typically the best method for analyzing your data if you have a manageable amount of data.
Focus group themes were used to develop a survey questionnaire specifically designed to delve deeper into themes, and gather relevant planning data around themes. The questionnaire was piloted, edited and re-piloted extensively to ensure appropriate language was used.
Secondary data sources for this practice include the USDA Food Atlas and Florida Community Health Assessment Resource Tool Set (FL CHARTS).
Performance measures include the number of focus groups held, number of recorded interviews completed, number of surveys completed and the number of attendees at each action council meeting. Overall, DOH-staff held eight focus groups in five food desert neighborhoods of Manatee County and four focus groups in two food desert neighborhoods of Sarasota County.
New College of Florida students completed six recorded interviews. Students created a five minute video for each interview and final ten minute compilation video to showcase the highlights for decision-makers.
Other than the cost of staff hours this practice has no costs associated.
One lesson learned was the importance of asking the right people, those who are directly impacted by the issue. Insight from community leaders was a helpful starting point, but differed in small yet significant ways from the insight gathered from actual food desert residents. One powerful example is found in the conversation around growing food. Leaders in the community felt strongly about community gardens as a solution, and while they were desired by small clusters of residents, the majority of individuals actually preferred the idea of growing food right in their own yards. This example provides evidence that engagement must be thoughtfully applied in order for the assessment data to lead to successful interventions. The outlined practice can be adapted to future assessment processes to ensure they are resident-focused.
Additionally, utilization of the CASPER survey tool allowed DOH-staff to randomize within select census tracts, in this case food desert census tracts. This allowed enough flexibility to focus on our target areas, without compromising structure or randomization. However, CASPER was not without its challenges. Randomization sometimes led staff to gated or deed-restricted neighborhoods, where participation was very low. Future efforts may consider controlling for these factors. Door-to-door surveying was critical to achieving high response rates from hard to access populations, but was labor intensive and time consuming, especially with limited staff dedicated to the project.
This practice relied heavily on collaboration: within between health departments, and with a number of community stakeholders. Partners were heavily involved in the process. Their unique resources and skills were vital to this project. Involving partners frequently and honoring their expertise increased the success of this practice in immeasurably.
Sharing results with partners and stakeholders increased community-wide awareness of the issue. When stakeholders’ understanding of the issue increased, so did their commitment to planning solutions.
Furthermore by building relationships with partners, DOH-staff was able to learn what their goals were and how they aligned with resident feedback. Assessment results helped stakeholders streamline their current efforts. DOH-facilitated, regional collaboration helped connect the dots between counties, allowing partners to create shared goals. By creating shared goals, sustainability of the planning process was increased, as partners and residents were invested in and accountable for the outcomes. Finally, high levels of resident participation informed planning efforts and increased sustainability and likelihood of success.
Colleague from another public health agency