Systems and Environmental Change

Maternal, Child, and Adolescent Health (MCAH) programs have a unique role in addressing environmental system changes, which help to make healthy choices practical and accessible to all members of a community. Their work with various local and governmental organizations and the vast population they serve allow for many collaborations and partnerships to be formed and expertise to be shared. Focusing on environmental changes addressing nutrition, physical activity, and breastfeeding can lead to sustainable and cost-effective methods of promoting the well-being of the MCAH population.

Environmental and Systems Interventions Backgrounder (PDF)

Nutrition 

 

There are four main types of nutrition environments: the community, consumer, organizational and information. The community nutrition environment includes the type, location, and accessibility of food outlets such as stores and restaurants. The consumer nutrition environment includes the availability of healthy options, price, promotion, placement and nutrition information. The organizational nutrition environment encompasses the home, school, work, and other affiliations. The information environment covers the media and advertising of food items.2 These environments are not mutually exclusive and often overlap one another. Conceptualizing these different environments and their variables is useful in establishing the type of food people are exposed and have access to, and allow for targeted interventions to address their specific needs.

Nutrition plays an important role in the prevention of chronic diseases, and changing the food people eat has been defined as “one of the major modifiable determinants of chronic diseases.” However, our current food system and environment do not encourage people to eat healthy. California Center for Public Health Advocacy’s 2007 study found that California has more than four times as many fast-food restaurants and convenience stores as grocery stores and produce vendors.  It has been demonstrated that access to high-calorie, low nutrition foods and convenience stores increases the risk of being overweight and obese.9 Obesity prevalence is highest for California adults who have high Retail Food Environment Indexes (RFEIs), which is the ratio of fast food-restaurants and convenience stores relative to grocery stores and produce vendors near their homes. Here are some ideas for interventions to change the food environments and make it easier for people to make healthier eating choices.

Farmer’s Markets and WIC 

The WIC Program supports the consumption of fresh, locally grown fruits and vegetables, and encourages shopping at farmers’ markets. Since May 2010, farmer’s markets in California have been able to apply for authorization to accept the Women Infants and Children (WIC) Fruit and Vegetable Check (FVC). Since 2010, over 450 farmer’s markets have been authorized to accept the WIC benefit. Learn more about participating farms and farmer’s markets. Maternal, Child and Adolescent programs can promote local use Farmers' Markets Research has shown that access to farmers' markets increases fruit and vegetable consumption among participants and that access to neighborhood supermarkets and farmers' markets reduces the risk of overweight and obesity. This is especially effective in low income communities where fresh produce is less accessible and more expensive. Farmers' markets can increase the availability of healthy foods and lower the overall food costs for the neighborhood. Since locally-grown produce is sold by local farmers, the cost of a middleman and transportation can be avoided making the sale prices competitive compared to grocery stores. Ultimately, farmers' markets can alter the community nutrition environment by making fresh fruits and vegetables more available and affordable, ensuring that more people have the opportunity to make healthier nutrition decisions.

Community Gardens 

Research supports the use of community gardens to improve a population's nutritional status. One study reported that adults with a household member that participated in a community garden consumed fruits and vegetables 1.4 times more per day and were 3.5 times more likely to consume fruits and vegetables five times a day than those who did not participate. Another study reported that community gardeners consumed fruits and vegetables 5.7 times per day compared with 4.6 times per day for home gardeners and 3.9 times per day for non-gardeners, suggesting that community gardens may benefit the health of its participants more so than private home gardens. Community gardens can also increase one's willingness to try the fruits and vegetables grown in a garden, which could prove useful for younger picky eaters. By improving the community nutrition environment with these gardens, participants may increase their consumption of fruits and vegetables and thus improve their health outcomes.

Farm-to-Institution 

Programs such as Farm-to-School change the food environment in a school setting and help to increase the intake of fruits and vegetables in children. It has been reported that, by changing the organizational nutrition environment through school lunches, children consume an increase of one serving of fruits a vegetables per day. In working with various stakeholders involved with farming, institutions such as schools can improve the nutrition, and therefore the health outcomes children as well as their families.

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Water Access 

Access to free and safe drinking water is essential to the health and well-being of communities. Work that supports creating access to free, safe drinking water (can includes working with partners to include water refilling stations, free water available in food service environments) and increasing the safety, taste, and appeal of water as a beverage choice. This work encourages consumption of water, especially in places of sugar-sweetened beverages (SSBs), and can help increase hydration and decrease risk for dental cavities, obesity and diabetes among community members.

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Physical Activity 

 

Encouraging daily physical activity as a means for improving overall health is one of the main branches of environmental change in MCAH programs. Strategies for increasing physical activity have included new curricula for school physical education, fitness and active lifestyle classes and programs at community recreation centers, and increasing the walkability of communities. Increasing walkability has been an especially important goal, as it has been shown that residents of walkable neighborhoods who have good access to recreation facilities are more likely to be physically active and less likely to be overweight or obese⁴, as described in the Environment and Systems Interventions Report. One study concluded that residents of easily walkable neighborhoods engage in an extra 70 minutes of physical activity each week and are 2.4 times more likely to meet physical activity recommendations than residents that live in less walkable neighborhoods. However, less than a third of adults in California reported participating in vigorous physical activity at least three times per week. Therefore, creating safe and inviting areas through which to walk and bike and pursuing joint-use agreements to ensure that recreational facilities are accessible to the community may increase physical activity levels and improve the well-being of the entire family.

Safe Routes to School 

Initiatives such as Safe Routes to School provide a safe way for children to exercise regularly by walking or biking to school. According to the Environment and Systems Intervention Report, the percentage of children 5-14 years of age walking or biking to school dropped from 48% to just 13% from 1969 to 200927. Environmental factors, such as distance to school, traffic-related danger, and crime danger or perceived safety, are likely to have played a major role in this decrease. Safe Routes to School addresses these issues through infrastructural and non-infrastructural interventions. Infrastructural interventions include grants for better crosswalks and signage, while non-infrastructural interventions may include Walk to School Day or organizing Walking School Buses so that groups of children have adult chaperones when walking to school. A California study referenced in the Environment and Systems Intervention Report showed that schools that implemented infrastructure interventions through Safe Routes to School had walking and bicycling increases in the range of 20 to 200%29. In Marin County’s second year of enacting the Safe Routes to School Program, participating schools reported an increase of 64% in school trips made by walking and 114% by biking. They reported a 39% decrease in trips by private vehicles carrying only one student. Moreover, a safety analysis estimated that the safety benefit of the program was an approximate 49% decrease in childhood bicycle and pedestrian collision rates.

• Active Transportation Safety Program

• Prevention First 

• Safe Routes to School 

• Safe Routes to School Success Stories 
  

Joint Use Agreements 

Increasing levels of physical activity in a community does not always require long-term development projects, but can also be achieved by increasing access to existing recreational facilities. Establishing joint-use agreements, such as opening school yards to the community after school hours, is one way to reduce barriers to safe places and provide opportunities for engaging in physical activity. Joint-use agreements can be formal or informal partnerships between two entities – usually a school and a city – to share use of indoor and outdoor spaces such as gymnasiums and athletic fields. For example, a school could share their pool with a swim team or a school employee could unlock the school gate after hours so people in the community have access to the basketball courts. This agreement is ideal for rural or low-income populations that may otherwise lack access to physical activity facilities.

• California Project Lean’s Current Projects and Highlights: Joint Use of School Facilities for Physical Activity  Information on CA Project Lean’s use of “Communities Putting Prevention to Work” grant to work towards adoption and implementation of a state joint use policy to reduce at least one major barrier to community after-hours use of indoor and outdoor school physical activity facilities. A power point presentation and joint use fact sheet can be found on this website. Links to additional joint use resources also available.
  

Pedestrian Safety and Walkability 

Environments that encourage physical activities such as walking and biking are ideal for improving a community's health and preventing chronic illnesses. It is therefore important to ensure that the environment is conducive to this sort of daily physical activity. First, it is important to note that mixed land use, connectivity, safety, and aesthetic qualities all contribute to the "walkability" of a place7, as described in the Environment and Systems Intervention Report. "Walkability" refers to how safe, convenient, and usable facilities are for pedestrians and bikers to get to their destinations. Safe and attractive sidewalks that are destination-oriented, especially with required mixed-land use zoning so that people live near where they work, shop, and play, may encourage more members of communities to walk or bike as their primary mode of transportation.

• The Active Transportation Safety Program (ATSP)  assists local communities with creating, evaluating, and sustaining active transportation education and encouragement (non-infrastructure) programs, including Safe Routes to School (SRTS) programs, through targeted trainings, technical assistance, and resources.
• California Walks  is a state-wide voice that partners with state agencies, organizations and communities to establish and strengthen policies and practices that support pedestrian safety and healthy, walkable communities. Links to network affiliates and further resources available on website.
• Pedestrian Safety Training : Power Point presentation sponsored by California Office of Traffic Safety and presented by CDPH describing “It’s All Up to Us” campaign.
• Walkability Checklist (PDF) : A tool to help evaluate your community’s walkability and provides solutions for improvement. Developed in partnership by A Walkable America, Pedestrian and Bicycle Information Center, the US Department of Transportation, and the US Environmental Protection Agency (EPA).
  
• Walk Friendly Communities : Applications for designating your community as Walk Friendly. The website also includes an assessment tool for determining how walkable your community is.
• Walking 101: The Role of Maternal, Child, and Adolescent Health Programs :
  This webinar highlights the opportunities to promote walking for those working in Maternal, Child, and Adolescent Health.

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Parks 

Increasing access and physical activity in parks can help launch a culture of active communities and increase awareness and appreciation for parks and nature. Work with local parks can include specific programs like Parks Rx, Parks After Dark, and others, and includes partnership activities with parks departments and other partners to increase access to services, and safe recreation areas.

Resources:

• Transportation and Health | APHA 
• Improving Health and Wellness through Access to Nature 
• Park Prescription Program Toolkit 
• Complete parks overview: Creating an equitable parks system . ChangeLabs Solutions (2018).
• A playground for everyone, no matter your age or ability (YouTube)