By Wilma Wooten, M.D., M.P.H., Public Health Officer, County of San Diego, Health and Human Services Agency; CTG staff, Dean Sidelinger, M.D., M.S.Ed., Child Health Medical Officer, County of San Diego, Health and Human Services Agency, & Lindsey McDermid, M.S., Community Transformation Grant Program Director, County of San Diego, Health and Human Services Agency
While, nationally, San Diego County has a reputation of a healthy population, more than 21 percent of the area’s population is obese and another 37 percent are overweight.
Since 2001, the Health and Human Services Agency (HHSA) has looked for innovative ways to make the healthy choice the easy choice for everyone, and prevent obesity. In 2008, HHSA began planning for the first component of its Live Well San Diego 10-year initiative to create healthy, safe and thriving communities.
To transform a community for the greatest impact, emphasis was placed on addressing the 3-4-50 principle: three behaviors (no physical activity, poor nutrition and tobacco use) contribute to four costly chronic diseases (cancer, heart disease and stroke, diabetes, and respiratory conditions such as asthma), which account for over 50 percent of deaths. Efforts also focused on building strategic and innovative partnerships aimed at making health an integral part of decisions made about transportation, education and other public policy areas that we know can benefit the health of a community. This “health in all policies” approach underpinned the partnerships we formed with other County government departments.
At the same time as we formed these partnerships, we also looked internally at HHSA chronic disease activities and developed an integrated plan to address chronic diseases – no longer did HHSA have siloed activities in different divisions and programs addressing different aspects of chronic diseases. There was now a coordinated approach, utilizing evidence-based interventions, to focus on a single outcome: creating healthy environments through upstream prevention. In total, public health resources were aligned to optimize impact and bring to bear resources from other government agencies to ensure policy was created and implemented with health in mind.
Of course, none of this work could have lasted or been as successful without consistent and sustained funding. HHSA competed for and received two grants from the Centers for Disease Control and Prevention (CDC) to promote healthy living. Initially, we focused on evidence-based interventions to promote nutrition and physical activity strategies that create healthy places, healthy foods and healthy schools.
Then, with a Community Transformation Grant (CTG), funded through the Prevention and Public Health Fund, we continued to further chronic disease prevention by addressing the leading causes of chronic disease. The grants contributed to the very foundation of the Live Well San Diego health component – behavior risks – and grant interventions continue to combat the three behaviors that significantly contribute to chronic disease and death, by reducing tobacco use, increasing physical activity, and improving nutrition.
In addition, the CTG supports work with the San Diego Association of Governments (SANDAG), the regional Metropolitan Planning Organization, which was started to create opportunities for active transportation. Our work with SANDAG enables us to improve how we monitor active transportation – what gets measured gets counted – spreading complete streets to more neighborhoods, and supporting more Safe Routes to School.
Recently, SANDAG made creating healthy communities one of the overarching goals of the Regional Plan – a 40-year guiding policy document for the region. This step represents a huge change in how the county approaches transportation decision-making and would not have been possible without the foundation laid through strategic partnerships and the resources initially provided by the grants.
In addition, federal grants have supported us in working with the county’s largest school district, San Diego Unified, to promote farm-to-school practices to increase access to local farms and agriculture. Through this initial partnership, San Diego Unified School District refined its food procurement processes to support purchasing local food. While typical procurement policies prioritize the cheapest food possible, now, the District’s purchasing procedures prioritize the selection of local, healthier food. In addition, the District’s school gardens are part of a garden-to-cafeteria program and a culinary garden agreement, established in partnership with our Department of Environmental Health, which enables produce from school gardens to be served in cafeterias.
Within other county school districts, we have worked to increase the amount of physical activity students engage in during the school day. San Diego schools not only increased the percent of time students are physically active during physical education classes, but they also increased the length of physical education classes. Now, through our CTG, we are working with the Chula Vista Elementary School District to increase physical activity throughout the entire school day. By creating strong relationships with school administrators and training physical educators, the schools in this District are making systems and environmental changes to increase opportunities for physical activity.
Beyond schools, a mini-grant program administered through SANDAG provided support to the City of San Diego staff to ease the permitting process for community gardens, and improve opportunities for urban agriculture. Furthered by the CTG, this work will be expanded to six additional jurisdictions.
Because San Diego has the largest number of small farms in the country, it is important to leverage those resources by establishing a better local food system. Federal grants have helped create the Fresh Fund project at five Farmers Markets in high-need areas, which provided CalFresh (Supplemental Nutrition Assistance Program), WIC, and SSI recipients with monthly matching funds to increase their ability to purchase fresh produce, with the profits going to local farmers. We also helped establish community gardens and education centers to educate San Diego residents about how to start their own community gardens. In addition, for those on food stamps, we provide education on the importance of nutrition, through support from the Nutrition Education and Obesity Prevention Grant Program, created through the Healthy, Hunger Free Kids Act of 2010 and funded by the United States Department of Agriculture.
At HHSA, we’re always looking to do more with less. One area we’re hoping the CTG will help us address is strengthening the connection between primary care and public health. We recently developed a partnership through the CTG with the University of California, San Diego Right Care Initiative: Be There San Diego, where we’re working to educate physicians on best practices for treatment of patients who have high blood pressure and cholesterol. We are also working to educate people about risks for heart disease and stroke, and increasing awareness about the need for timely and appropriate care. Long term, this partnership will connect patients with resources in the community that make healthy living easier.
The CTG has also strengthened bonds with the rather large military presence in the county. We’ve added a military representative to the CTG leadership team and have begun looking at that nexus of linking upstream prevention with military personnel and their families.
For years, HHSA has focused on building a better health service delivery system, supporting and increasing healthy choices, pursuing policy and environment changes with health in mind, and improving the culture within government. Every county department and sector – public health, healthcare, schools, transportation, community- and faith-based organizations, business, education, military, city and tribal governments, and others – are involved to support a culture of health in all policies that create healthy, safe, and thriving communities. Without federal support, we likely would not be able to continue or expand these efforts to ensure everyone who wants to be healthy can be in San Diego.