Jessica Kelley-Moore (left) is partnering with Gladys Wolcott and other community gardeners to promote healthy eating in urban neighborhoods. Photo by Mike Sands.
If only more Americans would eat right, as doctors and public health officials continually urge them to do, rates of chronic disease in the United States would be much lower than they are today. Deficient and unbalanced diets are implicated in a long list of illnesses, including diabetes, hypertension, heart disease and cancer. But in a society overrun with convenience foods and junk foods, unhealthy eating habits are hard to break.
This is especially true for people living in poverty. Residents of disadvantaged neighborhoods are at high risk of developing chronic diseases, and experts agree that unhealthy food choices are largely to blame. Yet until recently, says sociologist Jessica Kelley-Moore, the reasons for those choices haven’t received the attention they deserve.
For instance, it is impossible to find a full-service supermarket in many urban neighborhoods. The primary food outlets are corner stores that rarely sell fresh produce, lean meats, lowfat milk or whole-grain breads. While some residents can travel to other parts of town to buy groceries, this isn’t an option for everyone. From Cleveland’s Central neighborhood, for example, no city bus runs to any major supermarket. And since more than two thirds of the residents lack private transportation, they can’t drive out to Giant Eagle to stock up on foods that aren’t available close to home.
Sociologists call neighborhoods like Central “food deserts.” But as Kelley-Moore points out, the scarcity of healthy foods isn’t the only issue. A mother who wants to prepare nutritious meals for her family may not know where to begin. Her children may prefer burgers or buffalo wings. Besides, buying fast food may be the only way she can keep within her budget.
The lesson here, says Kelley-Moore, is that you can’t understand people’s food choices without knowing the social context in which they live. And from the history of failed efforts to promote healthy eating in poor communities, she draws a further conclusion: If you want to develop a successful intervention, you can’t come in with some generic program and treat the residents as mere clients. Instead, you must involve them in the process. A community-based, participatory approach offers the best hope of creating sustainable programs that will bring about lasting behavioral changes.
With these principles in mind, Kelley-Moore, an associate professor of sociology, is leading a five-year study that aims to expand healthy food access in four local communities. The study is the core project of the new Prevention Research Center for Healthy Neighborhoods, created last year by the CWRU School of Medicine with a grant from the Centers for Disease Control and Prevention (CDC). The CDC funds 37 prevention research centers around the country, all seeking ways to close economic, racial and ethnic disparities in health outcomes.
Elaine Borawski (GRS ’92), associate professor of epidemiology and biostatistics, is the center’s co-director as well as a co-investigator on the core project. Although she is now a faculty member in the School of Medicine, Borawski has a doctorate in sociology from the College of Arts and Sciences. Both she and Kelley-Moore came to the project with experience studying food access in urban neighborhoods, and their shared recognition of how social factors shape dietary choices has made them natural collaborators.
“It’s pretty hard for people in urban neighborhoods to be healthy when they just don’t have the options that the rest of us in the suburbs have,” Borawski says. “And when you look at the food environments, you really do see the disparity. You realize this is just wrong—and it’s wrong that it’s been overlooked as long as it’s been.”
When the core project was launched last spring, researchers began collecting baseline data on food availability in the Central neighborhood and in East Cleveland. They conducted audits of grocery stores, corner stores, convenience stores and gas station markets. They visited restaurants and produced an inventory of social services such as food pantries and Cleveland Foodbank drop-off sites. They also walked the neighborhoods in search of less obvious food sources, documenting what Kelley-Moore calls “the informal food economy.” (In Central, their most surprising find was a mobile phone store that sells corned beef sandwiches on the side.) All of these findings have contributed to the team’s understanding of each neighborhood’s “total food environment.”
Although she has studied food deserts before, Kelley-Moore admits that she was dismayed by some of the audit results. In all of East Cleveland, only two stores sell fresh chicken breasts. In Central, only three out of 16 stores carry lowfat milk or at least two varieties of fresh fruits. “We’ve got the data to that level of specificity,” says Kelley-Moore, “and it will break your heart. We actually found that for shelf-staple healthy foods, such as canned green beans, it was better to go to a chain drugstore than to any corner store in either of the neighborhoods. We never would have suspected that.”
In its next phase, the core project will create working groups in Central, East Cleveland and two other neighborhoods. Consisting of researchers, residents and representatives of community organizations, the working groups will select an area within each neighborhood as an intervention zone, making sure to include a K-8 school, at least one community garden, a corner store and a community center. Once the zones are established, each group will develop plans to increase the availability of healthy foods, educate residents about nutrition and raise community awareness through social marketing campaigns.
Kelley-Moore notes that many of the resources needed for the intervention plans—people, expertise, facilities—are already in place. “Our organizational partners, which include the Cleveland and Cuyahoga County Boards of Health, often have effective programs around healthy food access and nutrition education,” she explains. “But until now, they haven’t had the flexibility to customize these programs for a specific neighborhood.”
The core project is distinctive in another way as well. Most healthy foods initiatives have been conducted at a single venue, such as schools or community centers, to serve a specific population, such as children, young mothers or senior citizens. In contrast, says Kelley-Moore, the core project aims to reach all the residents of the intervention zones by coordinating programs at multiple sites. For example, while corner store owners receive advice and assistance to expand their produce sections, community gardens may boost demand for fresh fruits and vegetables by offering classes in food preservation. A logo identifying healthy foods in the school cafeteria may reappear beside nutritious snacks in a community center. The mix of programs in the intervention zones will vary according to the resources, needs and priorities of each neighborhood.
As plans are implemented in the Central neighborhood and East Cleveland, two other communities will initially serve as control groups. In the next phase of the study, however, these communities will establish intervention zones as well. Researchers will evaluate the core project’s impact in all four neighborhoods by assessing changes in healthy food availability, people’s shopping habits and their knowledge about healthy eating.
Molodian Price (left) and Charissa Murphy inspect their harvest at the East Cleveland Grows community garden. Photo by Mike Sands.
During the first months of the project, Kelley-Moore and her team were in the field, talking with residents and learning the social dynamics of each neighborhood. “Why would you work with that corner store?” residents in one community asked them. “Nobody shops there.” In Central, they learned that E. 55th Street functions as a social boundary, and that residents on each side rarely cross the street to shop. Such local knowledge will be invaluable as the working groups decide where to locate the intervention zones.
Introducing the project to each neighborhood is a gradual process, Kelley-Moore says. It requires building relationships with a community’s “gatekeepers”—formal and informal leaders who can help the researchers connect with local residents. This past summer, for instance, a local nonprofit invited Kelley-Moore’s team to a meeting of residents and officials from the Cuyahoga Metropolitan Housing Authority (CMHA). The topic of the meeting was an innovative community gardening program in one of Central’s housing complexes.
At events like this, Kelley-Moore doesn’t try to sell her project: “We actually spend most of the time listening,” she explains. In the course of the meeting, some older women said that their children, and now their grandchildren, rely on convenience foods because they never learned to cook. These women volunteered to do cooking demonstrations as part of the core project.
Kelley-Moore took their proposal to another organizational partner, the Ohio State University-Extension (OSUE), whose Cuyahoga County office supports community gardens and nutrition education programs. OSUE has offered cooking classes before, but always with its own teachers. Now, it is trying a different approach. The women from Central will receive whatever training they need in healthy food preparation, and then offer demonstrations in CMHA’s certified kitchens.
The core project has also joined forces with the Cleveland-Cuyahoga County Food Policy Coalition. The coalition has been calling on the Regional Transit Authority to reinstate several bus routes that were dropped earlier this year to cut costs. Using data from the project’s food audits and conversations with residents, the coalition demonstrated that the elimination of these routes has reduced healthy food access for people living in neighborhoods like Central.
Sociology graduate student Melinda Laroco Boehm (right) confers with Kelley-Moore, her dissertation advisor. Laroco Boehm has been awarded a two-year fellowship to pursue her research with the healthy foods project. Photo by Mike Sands.
Because of the flexibility of the research design, Kelley-Moore can respond whenever new opportunities for collaboration present themselves. When she learned, for instance, that local foundations would consider funding community gardens, she started talking with the gardeners about how to apply for grants. One of her partners in this effort, Gladys Wolcott, is the leader of the East Cleveland Grows garden, where residents produce a rich variety of vegetables. Whatever portion of the harvest they cannot use themselves, they give away to family and friends, schools and churches.
Community gardeners like these are a civic asset, says Kelley-Moore. “They become great advocates for other people’s gardening, for gardening on school property, for bringing more fresh fruits and vegetables into the neighborhoods. And when other residents walk by and see the gardeners at work, they may well stop and think to themselves, ‘People around me are doing things.’” By their example, community gardeners convey the message that residents can act collectively to improve their lives.
Through their participation in the core project, Kelley-Moore hopes that increasing numbers of community members will develop habits of cooperation and mutual trust, expand their social networks and become effective advocates for their own interests. These are all forms of “social capital,” she explains, and their significance extends beyond the project’s immediate goals. In addition to making healthy foods more widely available, a neighborhood with a large stock of social capital will have the capacity to address other longstanding community problems.
For Melinda Laroco Boehm, an advanced doctoral student in sociology, the core project marks the formal beginning of her research career. Early this spring, she received a Minority Health Fellowship from the Association of Schools of Public Health (ASPH) and the CDC’s Prevention Research Center program. Only four such fellowships were awarded nationally in 2010.
During the next two years, Laroco Boehm will conduct focus groups and qualitative interviews in the intervention zones. Her goal is to supplement the quantitative data from the audits by learning how residents perceive their local food environments. What do they think about the availability of healthy foods in their communities? From their perspective, what are their neighborhoods’ food assets and unmet needs? Laroco Boehm is also interested in knowing where residents buy healthy foods and how they get to those places.
Laroco Boehm’s focus groups will help the research team assess the core project’s interventions. “We’ll actually hear from the residents which programs are working the best, and what factors make some interventions more successful than others,” she explains. “And that will help improve interventions in the neighborhood after that one.”
Laroco Boehm developed her fellowship proposal after studying interviews from the project’s pilot phase. As she read the transcripts, she realized how much she could learn by hearing residents describe their food environments in their own words. “I get off work at 10, and I like to get something to eat,” one resident said. “Everything except the McDonald’s is closed. So if I want to get something, that’s all I’ve got near my house.” This resident also noted that “better neighborhoods” have grocery stores that stay open longer.
For her dissertation, Laroco Boehm is examining how people living in food deserts can prevent and manage type 2 diabetes. She formulated her research question by talking with health professionals in her family—her mother is a physician, and one of her sisters is a clinical pharmacist.
“It is so disheartening to see older people come in with a chronic illness that could have been prevented if they’d had the proper education, nutrition and food-buying behaviors,” she says. “What people don’t understand, sometimes, is that prevention of disease is so much cheaper than treating a disease.”
Laroco Boehm continues, “Just because you live in a certain neighborhood, and are of a certain ethnicity or race, doesn’t mean you have to get diabetes when you’re older.” She could have said the same of any chronic illness. Everyone involved in the core project is determined to prove her point.