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Researchers have identified as effective and worthy of broader dissemination a variety of intervention strategies to promote physical activity among older adults. This paper reports results of a community-organizing approach to disseminating evidence-based interventions in a sustainable way: The Southeast Seattle Senior Physical Activity Network (SESPAN). SESPAN was implemented in Southeast Seattle, a group of multicultural neighborhoods extending 8 miles southeast of downtown Seattle, with a population of 56,469 in 2000, with 12% (7,041) aged 65 and older. The SESPAN organizing strategy involved networking to: (1) make connections between two or more community organizations to create new senior physical activity programs; and (2) build coalitions of community groups and organizations to assist in making larger scale environmental and policy changes to increase senior physical activity. The SESPAN evaluation used an uncontrolled prospective design focusing on sustainable community changes, including new or modified programs, policies, and practices. Networking among organizations led to the creation of 16 ongoing exercise classes and walking groups, serving approximately 200 older adults in previously underserved Southeast Seattle communities. In addition, the project's health coalition is sustaining current activities and generating new programs and environmental changes. The success of the SESPAN organizing model depended on identifying and involving champions in partner organizations who provided support and resources for implementing programs.
Researchers have identified as effective and worthy of broader dissemination a variety of intervention strategies to promote physical activity among older adults. These strategies include individual home-based, group-based, and educational interventions (see van der Bij1 or King2,3 for reviews) as well as lifestyle modification,4 and environmental and policy change.5 Examples of evidence-based interventions include instructor-led aerobic and strength classes, telephone counseling that encourages exercise, and building and promoting walking trails. The challenge now is to implement these evidence-based interventions on a scale sufficient to promote population-level improvements in older adult physical activity levels.6 This challenge is even greater when adapting programs for low-income, multicultural, and underserved populations.7,8
Successful implementation of evidence-based intervention approaches requires strategies that result in sustainable organization- and community-level changes and take into account limited resources on the part of initiating organizations (e.g., foundations, health departments, and state and local government agencies). Sustainable changes are those that can be supported by organizational or other community resources in an ongoing way, after initial grant or other start-up funding ends. Examples of implementation strategies include partnerships between public health departments or universities and community-based organizations.9–11 Descriptions of program implementation in the published literature do not cite costs, but all apparently involved a substantial initial investment from either a grant or a health department budget.
The Southeast Senior Physical Activity Network (SESPAN) in Southeast Seattle is an example of a relatively low-cost, partnership-driven approach to promoting sustainable programmatic and environmental changes to support increased physical activity among low-income, multicultural older adults in a defined geographic region. SESPAN was developed by the University of Washington Health Promotion Research Center (HPRC), a Prevention Research Center funded by the Centers for Disease Control and Prevention This paper reports final SESPAN evaluation findings and lessons learned during implementation.
SESPAN operated in Southeast Seattle, a collection of culturally diverse neighborhoods extending 8 miles southeast of downtown Seattle. Based on US Census figures, the population was 56,469 in 2000, with 12% (7,041) aged 65 and older. With a large immigrant population, more than 50 languages are spoken in the area. The largest racial/ethnic group of residents 50 years and older is Asian Pacific (42%); 31% of the residents are white, 22% are African or African-American, 2% are Hispanic, and 1% are American Indian/Alaska Native. Residents of the area have a lower average income than Seattle as a whole—with per capita income of $18,871 versus $30,306—and the area has a high concentration of subsidized housing and social service organizations. In 2005 in Southeast Seattle, only 35% of adults 65 years and older met Centers for Disease Control and Prevention standards for moderate or vigorous physical activity (based on a telephone survey of 200 residents conducted by HPRC), compared with 46% for King County as a whole (based on 2005 Behavioral Risk Factor Surveillance System12 data).
SESPAN used a community-organizing strategy to increase physical activity opportunities and reduce barriers to being physically active. (In a previous paper, we described the project implementation in more detail13). The strategy involved hiring a half-time community organizer to develop partnerships and network among a variety of community-based organizations (CBOs), groups, and institutions. The organizations included those directly connected to older adult physical activity programs (e.g., Seattle Department of Parks and Recreation, senior centers, and senior housing), as well as organizations with indirect connections to physical activity programming, such as community-based organizations that serve specific racial/ethnic communities, businesses, community coalitions, schools, and health-care providers.
When developing relationships with organizations, the SESPAN organizer had two broad objectives, which we will refer to as program and coalition objectives. The program objective was to make connections between two or more community-based organizations or institutions to create new programs. For example, the SESPAN organizer connected a low-income senior housing building that did not have a physical activity program with the Seattle Department of Parks and Recreation, which had a walking program for older adults and wanted to increase the number of program participants. The community organizer brought the organizations together and helped them to overcome start-up barriers.
The coalition objective was to build a coalition of Southeast Seattle groups and organizations interested in health promotion. The intention was that this group could assist in making larger-scale environmental and policy changes and also help sustain SESPAN activities after the 5-year research funding period ends. To develop this network, the SESPAN organizer attended meetings of existing coalitions, collaborated with other organizations to sponsor community events, and convened meetings of potential coalition partners.
The SESPAN community organizer, employed half-time by HPRC, was a former senior center director with extensive experience working with older adults and developing senior programs. Other program resources included staff for evaluation and limited funding for start-up costs for the individual community projects. The SESPAN annual budget was approximately $75,000, of which $30,000 covered the salary and benefits of the community organizer.
The SESPAN evaluation used an uncontrolled prospective design that emphasized process and intermediate outcomes. The primary process outcome was the number of contacts made by the SESPAN community organizer with community-based organizations and other key community stakeholders. The primary intermediate outcomes were sustainable "community changes," using the definition of the term developed by Fawcett and colleagues at the University of Kansas: "new or modified programs, policies, and practices facilitated by the effort and related to its aims."14 For SESPAN, these community changes included sustainable programs, policy and environmental changes, and increased networking and connections among relevant organizations.
We used several data sources in evaluating SESPAN, including program logs maintained by the community organizer, key informant interviews with community partners, and counts of program participation from community-based organizations working with SESPAN. The program logs were a key source of process data. Each significant contact made by the organizer was recorded in a database with fields for date, contact, organization(s), category of organizations (e.g., faith groups and CBOs), purpose of contact, result, and next steps. The database allowed us to track contacts with people and organizations to assess the eventual results of those contacts.
We conducted key informant interviews with community stakeholders in November 2006 and June 2008 (mid-point and end of the project). The semi-structured telephone interviews were conducted with two groups: (1) current and potential coalition partners involved with overall SESPAN design and implementation, and (2) program partners who worked on specific projects. Interview questions focused on the benefits of the community changes for the respondent's organization, their clients, and the community as a whole, and the role of SESPAN in bringing about the changes. In addition to the structured interviews, we conducted regular debriefing sessions with the SESPAN organizer during and after the project to gather lessons learned and suggestions for program improvement.
Finally, we gathered approximate counts of program participation from organizations that worked with the SESPAN organizer to set-up new programs. It was not feasible, given our limited evaluation resources, to maintain detailed record-keeping (e.g., sign-in sheets), but program leaders provided counts of regular participants which were independently verified by the SESPAN organizer when she visited the programs. These counts provide an approximate indication of the reach of the program-related community changes.
A threshold SESPAN process evaluation question was whether the community-organizing model was actually implemented as planned. That is, were contacts made with a range of key organizations, was there adequate follow-through on potentially useful relationships, and was the community organizer perceived by the community partners as effective in her role? Based on the evaluation results, the answer to this threshold question is "yes". The organizer log provided a summary of the contacts made as she worked to build relationships with various community groups and organizations. As reported in the previous paper,13 in the first year and a half of the program, more than 320 significant contacts were made with 75 organizations across nine organizational sectors (e.g., senior organizations and faith groups). The next year and a half involved repeat contacts and follow-through with organizations already contacted. Over the life of SESPAN, the community organizer made 630 contacts with 110 different organizations.
In addition to the large number of contacts, comments from interviews with key partners suggested that the organizer was perceived as effective in carrying out her work; for example:
[The organizer] has a lot of energy and momentum, she was passionate about the work that she did.
[The organizer] does a lot of community building and has a good sense of what the needs are for our community. She connects very well, has a lot of energy, and she does what she says she will do as well as she can.
She knows everyone in the area, who to contact, the connections, and how to develop friendships with most of the community. She always has great ideas about how to accomplish things.
I think [the organizer] is a strong advocate in the community and plays a big part. Participation is hard to come by, and she is good at following through.
Certainly she has incredible enthusiasm. She is very creative with activities and projects. Even when no one wants to move, she keeps people moving.
A number of significant community changes happened at least in part through the efforts of the SESPAN community organizer (Table 1 summarizes the changes). Related to the SESPAN program objective, we helped create 21 new older adult exercise programs, including walking groups, EnhanceFitness15 senior group-exercise classes, and tai chi and yoga classes. Twelve walking groups were started in a variety of community settings, including low-income senior housing buildings and senior congregate meal sites. The walking groups were part of the Sound Steps Senior Walking Program sponsored by the Seattle Department of Parks and Recreation (P&R). The SESPAN organizer worked with P&R staff to identify sites, conduct promotion and outreach, and in some cases, lead the walking groups. Six new EnhanceFitness classes were offered at senior housing buildings and nonprofit health clubs. To help start the classes, SESPAN provided hand weights and paid for some of the instructor time. A combined total of 200 primarily low-income, multiethnic older adults are regular participants in these new physical activity programs: 100 in the walking groups, 60 in the EnhanceFitness classes, and 40 in the other exercise programs (Table 1).
Related to the SESPAN coalition objective, a new community health coalition, the Healthy and Active Rainier Valley Coalition (HARVC), was formed with older adult physical activity as a major area of focus. According to its mission statement, HARVC is "a partnership aimed at building and strengthening the Rainier Valley by increasing the health of its residents through culturally relevant promotion of physical activity and nutrition". The coalition grew out of a community event, Columbia City Walks, a fitness-oriented health fair held in May 2006 in the Columbia City neighborhood of Southeast Seattle. The SESPAN organizer worked closely with P&R Sound Steps staff, a clinic health educator, and an organizer from King County Steps to Health (an employee of the Seattle/King County public health department) to organize the event and build the coalition. HARVC activities to date have included several ongoing annual community physical activity events: a "Walk Around the World" exercise program, a healthy restaurant initiative, and educational supermarket "shop-arounds". HARVC's work has also resulted in small-scale changes in the community's built environment, including a planned new crosswalk, changes in traffic light length, and signage near a senior center.
Determining how many of the community changes to attribute to SESPAN is difficult since other major partners were involved, for example, P&R's Sound Steps Senior Walking Program and King County Steps to Health, which both provided staff support and funding and helped co-found HARVC. The new EnhanceFitness classes can be more directly attributed to SESPAN, which provided funding for hand weights and instructors and worked with Senior Services, a local community-based organization serving older adults, to promote and implement the programs. Comments from the interviews with key partners suggested that the SESPAN organizer played a significant, if not crucial, role in the development of the physical activity programs and HARVC:
[The organizer has had a] huge impact. She co-founded HARVC. She is an instigator full of ideas and also the drive to accomplish them...very specifically, [the organizer] has helped enormously with outreach to new locations to set up walking groups, she has helped plan many special events and programs, she helped cast the vision for HARVC, and she has connected a huge number of programs/agencies.
She was one of the co-founders [of HARVC]. She (along with the other co-founder) defined what it should be. The guidance from her and the other founder is what keeps it going...
Sustaining the programmatic interventions (e.g., walking groups and EnhanceFitness classes) and the health coalition is essential for long-term, population-level behavior change. Seven of the 12 walking groups are still ongoing. Their continuation depends on the ability of the Seattle Department of Parks and Recreation (P&R) to maintain funding for the Sound Steps coordinator, which at the time of this writing seemed secure. The six EnhanceFitness classes have all developed independent funding sources, including subsidies from public senior housing buildings and sliding-scale fee schedules. Public Health—Seattle and King County, the local health department, has committed to funding ongoing staff support for HARVC, so the coalition will likely continue to plan and support programs and annual events. The SESPAN community organizer is now the director of the Southeast Seattle Senior Center and continues to play an active role in HARVC. Finally, the built environmental changes, including crosswalks and other pedestrian-friendly improvements, are inherently sustainable.
Reaching a significant fraction of community residents is another essential prerequisite for population-level behavior change. The exercise programs listed in Table 1 are reaching only 3% (approximately 200 out of 7,000) of older adult residents of Southeast Seattle. However, this denominator of 7,000 does not reflect the actual size of the SESPAN target population, i.e., low-income (less than $20,000/year) residents from underserved ethnic-minority groups. This population is approximately 1,500, based on 2000 US Census data. Also, the numerator of 200 is likely to be somewhat understated because several of the HARVC programs, events, and environmental changes affect older adult physical activity beyond the ongoing walking groups, EnhanceFitness classes, and yoga and tai chi classes. Consequently, we estimate that we reached at least 13% of our target population; however, even the highest plausible penetration rates are still relatively low, underscoring the importance of continuing and expanding HARVC activities.
SESPAN networking among organizations led to the creation of a number of senior physical activity programs that continue to serve previously underserved, low-income, multicultural communities in Southeast Seattle. In addition, the health coalition established through the SESPAN project, HARVC, has the potential to continue to generate new, sustainable programs and environmental changes. Most of these physical activity programs have secure funding sources and organizational support that give them a good chance of being sustained.
Two lessons emerged from the SESPAN project, one related to building coalitions and another to implementing community-based programs in a sustainable way. The coalition lesson is simply a confirmation that resources matter, and in particular that even small amounts of funding can contribute significantly to a coalition-building effort. After HARVC had been meeting for several months, Steps to Health King County contributed $35,000 to support small community projects. Community-based organizations in Southeast Seattle were invited to apply, and the coalition selected 14 projects for funding, including purchasing blinds for a community fitness center to provide privacy for Muslim women to exercise, supporting a marketing campaign for P&R programs, and training senior center staff in the Matter of Balance16 Fall Prevention Program. Organizations receiving funding were invited to join the coalition, and a number began to come regularly to meetings. The core membership expanded from five to ten regular attendees to 15 to 20, and many of the new members are continuing to attend even though their mini-grant funding has ended.
The second lesson, related to implementing sustainable programs, is the importance of finding organizational champions at multiple levels within organizations that have the resources and ability to implement programs. The most significant programmatic accomplishment of SESPAN was the work with P&R to expand the Sound Steps walking groups from P&R recreation centers to a more diverse array of community-based settings. This came about because the Sound Steps staff coordinator became convinced of the value of moving the program into the community and because P&R leadership was supportive of the approach.
The importance of having internal champions to bring about dissemination of innovations in health and social-service organizations is well-established,17 as is the importance of leadership support for change at multiple levels in larger organizations.18 In a project such as SESPAN, which uses a community-organizer model, the challenge is identifying organizations with leadership support and internal champions for change. Before the proposed changes are suggested or implemented, it is often unclear how supportive an organization will be. For example, a senior center in Southeast Seattle appeared to be a promising SESPAN partner, and initially, the senior center director supported relocating some of the Center's programs to other community sites. However, as the project progressed, the Center proved unable to relocate the programs. The SESPAN community organizer, therefore, identified other partners who could bring the programs to different settings in the community.
There are several limitations to our study that should be noted. The participant counts reported in Table 1 are only approximate since we did not have sufficient resources to log participation in a more systematic way. Also, the highly positive comments from the qualitative interviews with key partners may have been due in part to the friendships the organizer formed with many of the partners over the course of the project.
The principal limitation of the SESPAN project was that it was a single-case study and generalizability to other communities may be limited. However, although other organizations and coalitions will differ in their goals and structure, opportunities for collaboration are likely to exist in all communities if enough contacts are pursued energetically. Organizations interested in implementing organizing strategies similar to SESPAN must address the question of whether the opportunities for collaboration are sufficiently productive in terms of reach and sustainability to justify the cost of the organizing effort required to bring them about. Many communities lack the resources to fund a community organizer with an open-ended, non service-related job description for an extended period of time.
This work was supported by the Centers for Disease Control and Prevention, Prevention Research Centers Program, through a cooperative agreement (U48/DP000050) with the University of Washington Health Promotion Research Center.