a neighborhood- resident physician partnership to evaluate ... · community center, a range of...

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7ACCC8

A Neighborhood- Resident Physic ian Partnership

to Evaluate Health

Written by Katherine Diaz Vickery, MD with contributions by MaryBeth Grewe, BA and Lynda Anderson MA, MPH

Table of ContentsOverview ....................................................................... 2

Background .................................................................. 4

Process ........................................................................... 7

Demographics ............................................................. 9

Findings .......................................................................10

Key Priorities...............................................................12

Local Context .............................................................18

Conclusions ................................................................21

Next Steps ...................................................................22

Appendix .....................................................................23

Thank you!This project would not have been possible without contributions from many, varied partners. A heartfelt thanks to:

• AllparticipantswhorepresenteddiversesegmentsoftheWest7thneighborhood

• Cooperationanddonatedtimeandspacefrommanycommunityorganizations

• MinnesotaAcademyofFamilyPractice,FoundationResidentResearchGrant

• UnitedFamilyMedicine(withaspecialthankstotheBoard)

• UnitedFamilyMedicineResidency

• AllinaHealth–CenterforHealthcareInnovation

• Cooper’sSupermarkets

• deZinnia,Inc.

Adams School

Assumption Church

Church of St.Stanislaus

Czech & Slovak SOKOL Minnesota

Eagle’s Nest Shelter

Fort Road Federation

Mad Hatter’s Coffee Cafe and Teahouse

Jewish Community Center of the Greater St. Paul Area

Jewish Family Services

Listening House of St. Paul

Little Bohemia Neighborhood Association

Mississippi Market

Nova Classical Academy

Neighborhood House

Pax Conversation Salon

St. Francis - St. James Catholic Parish

St. Mark Evangelical Lutheran Church

St. Peter’s Lutheran Church

West 7th Business Association

West 7th Community Center

West 7th Community Reporter

Healthy West 7th Assessment Report 1

BackgroundTherichhistoryoftheWest7thneighborhoodofSt.PaulprovidesthebackdropfortheHealthyWest7thproject.UnitedFamilyMedicineanditsresidencytrainingprogramhaveadecades-longfoundationofpartnershipwiththisneighborhood.Sinceitbegan,theresidencyhasemphasizedCommunityOrientedPrimaryCare(COPC)underthedirectionofclinicfounder,Dr.TimRumseyandresidencydirectorDr.KallyMacken.Residentphysicians(in-trainingtobecomefamilydoctors)completecommunityprojectsasapartofthecurriculum.

TheHealthyWest7thprojectbeganasaCOPCprojectoftheresidencyclassof2008-2011withgoalsofidentifyingcommunityprioritiesforhealthimprovementandbuildingeffectivepartnershipsforfutureprojects.InformedbytheCOPCmodel,HealthyPeoplecampaigns,andthehistoricWest7thCommunityPartnership,theprojecthasgrownindepthandscopesinceitbegan.

ProcessToaccomplishtheabovegoals,residentphysiciansdecidedtouseaCommunity-BasedParticipatoryResearchmodelintheirassetmap/needsassessmentoftheneighborhood.Togetherwithcommunitymembers,individualinterviews(36total)andfocusgroups(14total)werecompletedtargetingdifferentsegmentsoftheneighborhood.(Surveyswerealsodonebutminimallyused).Allmethodsaskedthesamefourquestions:

• Whoareyouandwhoarethoseclosetoyou?

• Howdoyouandthoseclosetoyoustayhealthy?

• Whatdoyouandthoseclosetoyouneedtobehealthier?

• Wheredoyougowhenyouneedhelp?

Intotal,theprojectcollectedresponsesfrom183peoplewholived,worked,orsoughtoutservicesintheneighborhood.Resultswereanalyzedbytheresearchteam,whichincludedresidents/clinicstaffandcommunitymembers,usingqualitativeresearchmethods.

Overv iew

The rich history of the West 7th neighborhood of St. Paul provides the backdrop for the Healthy West 7th project. United Family Medicine and its residency training program have a decades-long foundation of partnership with this neighborhood.

2 Healthy West 7th Assessment Report

ResultsParticipantslistedfamily,friends,faithcommunities,pets,co-workers,neighbors,andmorewhendefiningtheircommunities.Inresponsetohowtheykeephealthy,participantsdescribedpersonalfactorssuchasmotivation,socialnetworks,andhavingasenseofpurposeinlife.Participantsalsostressedtheimportanceofahealthyenvironmentandavailabilityofsafespaceforactivity,avibrantbusinesscommunity,andaccesstohealthyfoods.

Throughinterviews,focusgroups,andsubsequentneighborhoodmeetings,thefollowingeightkeyprioritieswereidentifiedandprioritized(formoredetailsseefullreport):

1. Basic Needs (food, shelter, employment, insurance coverage)

2. Health Education

3. Resource Coordination

4. Nutrition

5. Fitness

6. Community-Building

7/8. Volunteerism

7/8. Activities for Youth

Next Steps ThelargergoaloftheHealthyWest7thprojecthasalwaysbeentosparkcommunityactionaroundneighborhoodhealthimprovement.Forthistobesuccessful,itisessentialthatthecommunityitselfdecidewhat,when,andhowthingsproceed.Thisisalreadyunderwaywithnumerousconversationsandcollaborationsalreadydeveloping:AllinaHealthisnewlypartneringwithseverallocalorganizationsinWest7th.Activecollaborationisunderwaywithdiversepartnersonacommunitygardening/nutritionprojectencouragingintergenerationalvegetablegrowingandhealthymealpreparation.

RepresentativesfromdiversesegmentsoftheneighborhoodareinformingtheongoingrevisionoftheCommunity-OrientedPrimaryCarecurriculumforresidentphysiciansatUnitedFamilyMedicine.Thisincludesacommunitycounciltogivefeedbackandoversighttoresidentprojects.

Ifyouwouldliketobeinvolved,pleaseemail:[email protected].

healthywest7th.wordpress.com


West7thnowwelcomesdiverseimmigrantsfromaroundtheworldbutremainspredominantlyCaucasian(73.6%),withsomeAfricanAmerican(10.8%),andHispanic(7.9%)presence.Itisamixedsocioeconomicareawith14.4%ofallresidentslivinginpoverty.1West7thhasastrongdistrictcouncil(theFortRoadFederation)2andmanyactiveblockclubsthatpromotealivelyrangeofactivitiesandconnectionsintheneighborhood.AdditionallyWest7thishometomanysmallbusinessesrepresentedinastrongbusinessassociation,severalschools,numerousplacesofworship,anactivecommunitycenter,arangeofmedicalservicesincludingseveralnursinghomes,UnitedHospitalandaffiliatedclinics,UnitedFamilyMedicine,adentalclinic,severalchiropracticoffices,aswellasanumberofformalandinformalresidencesforthoseindrug/alcoholrecovery.

UnitedFamilyMedicinehasahistoricrelationshipwiththeWest7thneighborhoodofSt.Paul,MN.Itsrootsdatebacktothe1930’swhentheWilderDispensaryofferedfreeandlow-costcare(onthesiteoftheMinnesotaHistoryCenterandlatermovingtoMillerHospitaltobecometheMillerOutpatientDepartment(M.O.D.).In1971,Miller

andSt.Luke’sHospitalsmergedformingUnitedHospital.Twentyyearslater,theDispensarymoveddownthestreetandjoinedHelpingHandsHealthCenter.UnitedFamilyPracticeHealthCenteropenedin1992whentheM.O.D.,HelpingHandHealthCenter,andDr.TimRumsey’sprivatepracticecombinedandbeganoperatingwithintheAllinaHealthsystem.

★The West 7th neighborhood of Saint Paul is a unique and vibrant area situated along the bank of the Mississippi River stretching west from downtown. The oldest residential neighborhood in Saint Paul, West 7th historically welcomed European immigrant families and was home to a number of breweries.

Adapted from City of St. Paul District Council map, available: http://www.stpaul.gov/DocumentView.aspx?DID=18476

Background


In2003,UnitedFamilyPracticeHealthCenterincorporatedasaseparateorganizationfromAllina.Since2004,UnitedFamilyPracticeHealthCenterhasbeenafreestandingFederally-QualifiedHealthCenterlook-alike(FQHC-la)withapatient-ledindependentboardofdirectors.WiththemovetoanewsiteonRandolphandWest7thin2009,thenameUnitedFamilyMedicinewasadopted.ThisnamereflectsthecloserelationshipwiththeUnitedHospital’sFamilyMedicineResidencyprogram.Throughoutthis70+yearhistory,themissionoftheclinichasremainedclear:“ToServe&ToTeach”whileprovidinghealthcareforthediverse,underservedpopulationsinSt.Paulanditsneighboringcommunities.3

TheUnitedFamilyMedicineResidencywasfoundedin1993underthedirectionofDr.KallyMackenandhascontinuallyhostedsixresidentphysicians(newlygraduateddoctorswhohavechosentotraininfamilymedicine)peryearforathree-yeartrainingcyclesincethattime.TheresidencyhasaspecialemphasisonCommunity-OrientedPrimaryCare(COPC)underthedirectionofDr.Rumseywhoremainsacentralfigureofthefaculty.EachyearresidentscompletecommunityprojectsasapartoftheCOPCcurriculum.Variedintheirfociandapproach,projectshaveincludedpartnershipwiththelocalcommunitycenterforSaturdaymorningopengymtime,foundingaReach-Out-and-Readprogramtoprovidefreebookstochildrenatwellvisits,numerousqualityimprovementinitiativeswithintheclinic,andmore.Reflectingonthemissionoftheclinic,theCOPCmodel,andtheirdesiretotrulyservethedesiresandneedsoftheneighborhood,theresidencyclassof2008-2011decidedtoworktogethertoconductacollaborativeassetmap/needsassessmentoftheareainpartnershipwithneighborhoodleaders.Thegoalwastoidentifythecommunity’sprioritiesforhealthimprovementandtobuildeffectivepartnershipsforfutureresidentprojects.Andso“HealthyWest7th”wasborn!

Thiswasnotthefirstattemptatsuchaneffort.TheWest7thCommunityPartnership(W7CP)conductedasurveyintheearly1990’sasapartoftheHealthyPeople2000campaign,andtheclinicwasoneofthekeypartners.Facilitatedbya$100,000grantfromtheHealthSpanCommunityTrust(whichlaterbecametheAllinaFoundation)andUnitedHospitalFoundation,theW7CPheldaseriesofconversationswithserviceprovidersintheneighborhoodoverseveralyears.Thisculminatedinalarge,communitymeetinginDecember1994whenaprofessionalfacilitatorledhundredsofparticipantsinreflectiononthestrengthsandneedsoftheneighborhoodrelatedtohealth.UltimatelytheW7CPchosefourareasoffocusfortheirimprovementefforts:

• Information&AccesstoCommunityServices Adirectoryofserviceswascreatedastheyfound,“ManypeoplewerenotawareofthehealthandhumanservicesavailabletoWestSeventhresidentsorhowtoaccessthem.”

• YouthEnrichmentActivities Initiativesincludeda“YouthShepherd”project,

andmini-grantsavailabletoserviceprovidersintheneighborhood.

• JobTraining&Availability Aneconomicstudyoftheneighborhoodwasfunded

inpartnershipwiththeUrbanLeague.

• Fear&SafetyConcerns PartnershipsforViolencePreventionwascreated.4


TheW7CP’sworkandapproachinformedtheprocessundertakenwithHealthyWest7thandprovidedcomparativedatafrom14yearsprior.TheHealthyPeople2020goalsalsoservedasaresourceandproceduralguide.5

WhiletheHealthyWest7thprojectcouldhavebeendoneasanoutreachactivityalone,theresidentphysicians,alongwithacommunitycouncil,agreedthattheprojectwouldadoptprinciplesofcommunity-basedparticipatoryresearch(CBPR).

Arelativelynewadditiontothefieldofmedicalresearchwithrootsinthesocialsciences,CBPRfocusesonequalizingthepowerdynamicbetweenresearcherandsubject.Traditionalresearchoftenbeginswithanacademicexpertgatheringdataaboutresearchsubject,publishingconclusionsanddiscoveriesaboutthisdata,anddevelopinginterventionsforthecommunitybasedontheseconclusions.CBPRaimstoreversethispowerdynamicbymakingthecommunitythecentralfocusofallstagesofresearchfromsettingtheagendatocreatingprogramsandpoliciesbasedonthedata.

AsDr.AnnMacaulayofMcGillUniversityexplains,community-basedparticipatoryresearchisaprocessofcollective,community-basedinvestigation,education,andaction.

… [Participatory Research] can break down the rigid boundaries between those doing research and being researched and thus affords all participants access to the production of knowledge.6

Participatory Research can break down the rigid boundaries between those doing research and being researched and thus affords all participants access to the production of knowledge.


Residentphysiciansfromthegraduatingclassof2011utilizedexistingtiesbetweenclinicandcommunityleaderstofirstbuildacommunityadvisorycouncil.ThecouncilandresidentphysiciansthendecidedtogetheronaresearchplantolearnmoreaboutthehealthoftheneighborhoodadaptingamodelusedinasimilarprojecthostedbyAllinainMinneapolis,theBackyardInitiative.Theydecidedtoaskthefollowingfourquestions:

• Whoareyouandwhoarethoseclosetoyou?

• Howdoyouandthoseclosetoyoustayhealthy?

• Whatdoyouandthoseclosetoyouneed tobehealthier?

• Wheredoyougowhenyouneedhelp?

Thegroupdecidedonintentionallybroadparticipantcriteriaincludinganyonewholived,worked,orsoughtservicesintheWest7thneighborhoodofSt.Paul(definedbySt.PaulCityDistrictPlanningCouncilboundariesofDistrict9inWard2,seemap,page4).Tomaximizeparticipationandfitthelimitedtimeframe,thegroupdecidedtoasktheirquestionsininterviews(withkeyinformantleaders),focusgroups(withspecificsectorsof

theneighborhood),andsurveys(widelydistributedinthearea),allconductedatthesametime.Inaddition,allparticipantswereaskedtocompleteabasicdemographicsformthataskedabouttheirage,race,primarylanguage,countryofbirth,connectiontotheWest7thneighborhood,andeducationlevel(seeDemographicForm,page8).

Participantswererecruitedusingflyersdistributedthroughouttheneighborhood,advertisementsinthelocalpaper,andpersonalinvitationsbyphysiciansandstaffatUnitedFamilyMedicineaswellascommunityleaders.Communityleaderswithlong-standingtiestotheneighborhoodwereidentifiedbyclinicstaffandinvitedtoparticipate.Allparticipantswereaskedtoinviteotherstoparticipate(Snowballrecruitment).Unfortunately,timeandresourceslimitedtheprojectwithmorepeopleexpressinginterestthancouldbeincluded.

Asummerinterncompletedkeyinformantinterviews(36total).Shespokewithformalandinformalleadersintheneighborhoodincludinggovernmentandpublicserviceofficialsaswellasleadersofsocialserviceorganizations.

Process

The Backyard Initiative Beginning in May, 2008 Allina partnered with the Cultural Wellness Center and the Wilder Foundation to conduct a series

of conversations in the Powederhorn-Phillips neighborhood (home to Allina’s corporate headquarters) to “create a picture

of health and well-being in the backyard.” They conducted “Listening Circles,” or focus group conversations, with people

in the neighborhood asking: (i) How do you keep yourself and your family healthy? (ii) How do you maintain balance and

harmony in life? And (iii) Who do you turn to for help? True to the spirit of community partnership, local residents were

hired and trained to conduct most of the focus groups. The Listening Circles were followed by “Walk-Around Interviews,”

door-to-door surveys of a statistically representative sample of 700 families in the neighborhood. After analysis was

completed, Allina supported the creation of a commission which now oversees the work of Citizen Health Action Teams

(CHAT’s) to address the community’s identified needs.vi


Focusgroups(14groupswith96participants)weredoneusingacollaborativemodelpairingresidentphysicianswithcommunityleaders.Thefocusgroupteamsattendedatrainingsessiontogetherandusedadetailedfacilitator’sguidetoattemptstandardizationbetweengroups.Thecommunityleadersrecruitedtheirfriends,neighbors,andotherinterestedpeopletoparticipateandhelpedguidetheconversations.Residentphysiciansarrangednecessarypaperwork,space/foodrequirements,andaudiorecordingofthegroups.(Thepartnershipmodelwasthegoal;however,only5ofthe14groupswereconductedinthiswaywiththeother9groupsfacilitatedwithpartnershipofaresidentphysicianandanuntrainedcommunitymemberorbyonlyresidentphysician(s)/clinicstaff.)Surveys(51completed)werelargelyunsuccessfulduetoshortorone-wordresponsestoouropen-endedquestionsandcontributedlittletofinalresults.

Allfocusgroups(exceptoneduringwhichmanyparticipantstalkedoveroneanother)andkeyinformantinterviews(excepttwoduringwhichparticipantsrequestednorecording)weretranscribedverbatim.Detailednoteswerealsotakenforallkeyinformantinterviewsandmostfocusgroups.(Noteswereusedtoanalyzedatainsessionsthatweren’ttranscribed.)

Inanefforttoclarifyandprioritizetheoften-disparateresponsestothebroadquestions,participantswereaskedtovoteontheirtoppriorityattheendoftheinterviewsandfocusgroups.Thiswasusedtogenerate8topthemes.Thesethemeswerepresentedattwocommunitymeetingsheldtoshareresults,andthoseattendingcommunitymeetingsalsovotedontheir“toppriorities.”Thesevoteswerethencombinedwithparticipants’votestogeneratefinalrankings(seeKeyPriorities,page12).

AnalysisAteamincludingtheproject’ssummerintern,aneighborhoodresident/

communityleaderontheadvisorycouncilwithrelevantprofessionalandeducationalexperience,residentphysicians,andtheirfacultyadvisorcompletedtheanalysis.Theteamreviewedandcodedthetranscriptsfromtheinterviewsandfocusgroupstoidentifycommonthemesfollowingprinciplesofimmersion/crystallization.Theyusedbothformalcodingsoftware(NVivo9.0)aswellasinformal,paper-basedmethods.Communicationbetweentheteamsaboutemergingthemeswasencouragedhowevertimeandgeographicalconstraintslimitedgroupcoding.AnalysisofdemographicinformationwascompletedusingSurveyMonkey(anonlinesurveyprogram).

Age: _______ Sex: Male

Female

My first language was: English

Other: ____________

I was born in: the U.S.

Other: ____________

Race/Ethnicity: White

Black Asian Latino American Indian

Other: ____________

Where do you live? I own a house/apartment/condo..

I rent a house/apartment/condo.. I stay with a friend/family member. I stay at a shelter./ I am homeless.

What connection do you have to the W. 7th neighborhood of St. Paul? I live here.

I work here. I shop here. I get my health care here. I come here for religious worship

Other: _____________________

What is your main form Car

of transportation? Bus Other: _______________

How many people live with you?

_Adults:__________Children:______________ (who live with you 50% of the time or more)

How do you pay for healthcare? No insurance (self-pay).

Private insurance Public insurance (Medicaid (MA), Medicare, MN Care)

Where do you go for regular healthcare? Clinic: United Family Medicine

Other: ______________ Emergency Room Urgent Care I donʼt get regular healthcare.

Do you work or go to school? Unemployed

Work: Student. Retired Other: _______________

Does your household use: Foodstamps

WIC Public Assistance SSI/Disability None of the above

Did you finish? Jr. high school or less

High school/ G.E.D. Community college/technical school College Graduate school

Please help us learn more about you! We want this to be anonymous. No names please! Check ALL boxes that apply!

Demographic Form


Theprojectincludedinsightsfrom183peoplewhometthebroaddefinitionofliving,working,orseekingservicesintheDistrict9ofSaintPaul.Thegroupincluded124womenwhomadeup77.5%ofparticipantsand36men(22.5%)(remainingparticipantsdidnotindicategender),andhadaweightedmeanageof51.6years.Therewasanover-representationofBlacksandHispanicscomparedtothe2010censusdata,likelyduetointentionalrecruitmentofminorityandtraditionallyunder-representedgroups(specificallypeoplewhohadexperienceddomesticviolence,homelessness,andwhowereinrecoveryfromdrug/alcoholaddiction).InclusionofrefugeeandimmigrantfamilieswhodidnotspeakEnglish(orspokeitasasecondlanguage)wasattempted,andmostsuccessfulwithHispanicfamilies,with2focusgroupsconductedinSpanish.Overall,15.3%ofparticipantsdidnotspeakEnglishasafirstlanguageinsteadspeakingSpanish,Vietnamese,Tigrinya,Amharic,German,andSioux.And14.7%ofrespondentsreportedbirthoutsideoftheU.S.inplacesasvariedasCanada,Mexico,Columbia,Laos,Vietnam,andRomania.Justover55%ofparticipantslivedinWest7thwhileotherssharedvariedconnectionsincludingworking,shopping,andseekingouthealthcareintheneighborhood.Ofparticipants,16%lackedanyinsuranceandtheremainderwassplitnearlyevenlybetweenpublicandprivateinsurance(46.3%vs.47.5%).

Demographics

Overall, 15.3% of participants did not speak English as a first language instead speaking Spanish, Vietnamese, Tigrinya, Amharic, German, and Sioux. And 14.7% of respondents reported birth outside of the U.S.

Participant’s Race

Connection to W. 7th Neighborhood

White 73.3%

Black 10.8%

Asian 1.8%

I live here. 55.3%

31.8%

24.1%

27.1%

16.5%

14.1%

I work here.

I shop here.

I get my health care here.

I come here for religious worship.

Other (please specify).

Latino 13.8%

American Indian 6%

Other 4.2%

People could respond to more than one option (non-exclusive choice).


Defining Community Todefinetheircommunities,focusgroupparticipantswereasked,“Whoareyouandwhoarethoseclosetoyou?”Toclarifythequestionandpromoteconversation,aworksheetwasdevelopedaskingparticipantstofillinwords/picturesdepictingwhobelongedtotheircoreandextendedcommunities.Corecommunityoftenincludedfamily,afewspecialfriends,faithcommunities,andpetswhileparticipants’extendedcommunitymostofteninvolvedco-workers,neighbors,serviceproviders,theirchildren’sschools,workoutfacilities,andcoffeeshopstheyfrequented(manyintheneighborhood).

Findings

Focus Group Introduction Worksheet

Extended Community

YOU

Core Community

Inresponsetothisandotherquestions,focusgroupandkeyinformantparticipants(whoweren’taskeddirectlytodefinetheircommunity)mentionednumerousformalandinformalcommunityorganizationsthatsupportedhealthintheneighborhood.Theseinclude:

• 511Club

• TheAAcommunity

• Allina–UnitedHospital

• Cooper’sSupermarket

• Czech&SlovakSOKOLMinnesota

• DorothyDayCenter

• Eagle’sNestWomen’sShelter

• FortRoadFederation

• HealthEast–SaintJoseph’sHospital

• HealthySt.Paulrecreationprogram

• TheIndianCenter

• Informalnetworksamongnewimmigrants

• JewishCommunityCenteroftheGreaterSt.PaulArea

• MississippiMarketCo-op

• NaturallyOccurringRetirementCommunities(NORC)

• NeighborhoodHouse

• Numerouschurches/synagogues

• PalaceRecreationCenter

• SalvationArmy

• SholomHome

• SmithAvenueNeighborhoodAssociation(nowLittleBohemiaNeighborhoodAssociation)andotherblockclubs

• St.PaulPublicLibrary’sBookClub

• UnitedFamilyMedicine

• West7thBusinessAssociation

• West7thCommunityCenter

• West7thPharmacy

• WestEndArts

• WestEndGardeners


Personal Factors Participantsfrequentlyemphasizedhealthycommunitiesbeginwithhealthyindividuals.Severalpeoplediscussedthatpersonalmotivationhastocomefirstinanyhealthtransformation.Participantstalkedabouttheimportanceofexerciseandeatingnutritiouslyandtheireffortstoputthisintopracticeintheirdailylives.Whilediscussingpersonalhealth,abroaddefinitionofhealthemergedfrombothfocusgroupandinterviewparticipantsalike.Oneparticipantshared,

I think a community is healthy when it nurtures the best of each individual, whether that’s their emotional health, their physical health, or their spiritual health…health and well-being.

Practicesthatsupportedemotional,mental,andspiritualhealthwerefrequentlymentionedsuchasyoga,meditation,andsimplywatchingthesunrise.Faithcommunitiesservedasanimportantsocial,spiritual,andemotionalsupportforpeopleintheWest7thcommunity.

Spiritual health comes through the family connections, through Mt Zion temple for me, through JCC that I belong, the Masonic lodge that I belong.

Onefocusgroupparticipantexplained,

To me, spiritual health is the connections we have close to us and widely around us but keeps me in a kind of life—life the way it should be.

Inaddition,manyfaithcommunitiesalsoofferedprogramsfortheircongregantsthatpromotedphysicalwell-being(healthfairs,informationsessions,etc.).KeyInformantsalsohighlightedtheconnectionbetweenphysical,emotional,andspiritualhealthincreatingahealthycommunity.Animportantthemethatcameupinseveralfocusgroupswasthenecessityofhavingapurposeormeaningtolife.Itwasimportanttoparticipantstogivebacktothecommunity,to“haveareasontogetoutofbed.”

Helpingotherswasnecessarytogoodhealthanditmadethemfeelhappy.Thisthemewasoftenparticularlystrongwitholdercitizens,withonesuchparticipantsharing

I call it participating in life: I think if you participate in things it makes you healthier and also the people around you healthier.

Environmental FactorsKeyinformantsandfocusgroupparticipantsallidentifiedenvironmentalfactorsthatsupportorhinderhealthylifestyles.Theseincludedbasicneeds(food,jobs,shelter),accesstovitalservicessuchashealthcare(especiallyformarginalizedgroups),nutrition,andphysicalfitness,eachofwhicharediscussedinseparatesubsequentsections.Peoplealsosharedthatneighborhoodsafety,lowlevelsofcrime,andanaestheticallypleasing,cleanenvironmentallhaveimportantimpactonhealth.

Afeelingofsafetyinaneighborhoodallowspeopletobeoutandbeactive.Peoplewhodidn’tfeelsafewalkingorbeingoutdoorsnotedthismadeitdifficulttostayphysicallyactive.Whilemanyparticipantsidentifiedsafetyasaconcern,othersnotedimprovementinthelastfewyearsinthisarea.

Leadersfromthebusinesssectorpointedoutthatwithasafeenvironmentcomestheopportunityfortheneighborhoodtohaveahealthyeconomicandsocialenvironment,otherkeyelementsofahealthycommunity.

Oneshared,

Strong businesses make a healthy community. I think [it is important to have] good businesses, strong businesses, businesses where you can walk in and people know who you are and you know who they are and you can develop relationships.

SeveralkeyinformantsfeelthereisprogressunderwaytoimprovetheeconomichealthoftheWest7tharea.

This community is resurging back to the luster of the old days when it was thriving.


The main conclusions for health improvement offered by focus group and key informant interview participants were summarized in eight key themes. Voting (as described previously) prioritized the themes in this order:

Key Pr i or it ies 1. Basic Needs

2. Health Education

3. Resource Coordination

4. Nutrition

5. Fitness

6. Community-Building

7/8. Volunteerism

7/8. Activities for Youth


1. Basic Needs Critical basic needs, as influenced by larger systems, must be in place for a community to be healthy.

Whenaskedwhatmakesacommunityhealthy,thefirstthingmanyparticipantsmentionedwasaccesstoandknowledgeofthebasicresourcesnecessaryforhealthincludingfood,shelter,transportation,adequateemployment,nutrition,physicalfitness,andhealthcare.Theseissueswereofcriticalconcerntocommunitymembersandserviceprovidersalike.Theneighborhood’ssocialserviceagenciesarearecognizedresource,butaccesstoandawarenessoftheseagenciesisoftenwhereparticipantssawabreakdown(SeeResourceCoordination).

Problemswiththehealthcaresystemwereafrequenttopicincludinglackofinsurancecoverage,poorcoverage,highcostsofhealthcare,andmedications.Someparticipantssawsystemreformastheirtopprioritytoaddresshealthconcernsintheneighborhood.HomelessparticipantsexpressedtheircriticismoftheCriticalCareDeliverySystem(CCDS)(astate-widereformofthesafetynetpublicinsurancesystem)asconfusinganddisorganized.Oneparticipantshared,

It seems like they’re just making it up as they go along!

Othersmentionedtheneedforcareredesigntooptimizecostandincreasetimespentwithproviders.

Accessibilitytoservicesandremovalofbarriersformarginalizedgroupswasofconcerntokeyinformantswhowereoftenserviceproviders.Theyemphasizedtheparticularimportanceofmakingservicesaccessibletomarginalizedgroupsincludingimmigrants,thehomeless,seniorcitizens,andpeoplewithdisabilities.Mentalhealthaccessibilityforthesegroupswasofspecialconcern.Onehomelessparticipantshared,

if you’re messed up up here [points to head], you’re not going to be okay down here [points to body].

Anotherparticipantstated

[In a healthy community] people [have] access to programs and services that can help them help themselves.

Barrierstoaccessingservicesmentionedincludedlackofmoney,time,trust,acceptableformsofidentification,transportation,childcare,andEnglishlanguagecapabilities.

“In a healthy community people have access to programs and services that can help them help themselves.”


2. Health Education Access to information about health/wellbeing is crucial.

FindingreliablehealthinformationonavarietyoftopicswasawidelyrecognizedneedintheWest7thneighborhood.Intoday’sdigitalera,manyparticipantsfeltoverwhelmedwithinformationwithoutawaytosortthroughwhatismostimportant/relevanttothem:Howdoyousortoutalloftheinformationyouget?What’sgood?What’snotgood?Wheredoyoufindgoodinformation?

Topicsofdesirededucationforparticipantsrangedfromhealthmaintenance/wellness,tospecificknowledgeforchronicdiseasemanagement(diabetes,depression),topreventionstrategies,tonutrition(seeseparatesectionbelow),andalsoincludedcomplementarymedicine,anddesireformoreknowledgeaboutvitaminsandsupplements.

TwofocusgroupsofHispanicparticipants,predominantlywomen,fromtheneighborhoodvotedfor“charlas,”orinformalchats,abouthealthtopicswithprovidersastheirmostdesiredintervention.

Anothergroupemphasizedschool-based,interactivesessionstoteachchildrenabouthealthylifestyles,referencinganinitiativedonepreviouslyattheirchildren’sschoolthathassinceended.

Womeninrecoveryandhomelessfocusgroupparticipantsfeltpassionatelyabouttheneedtoimprovetheirexperiencesinthehealthcaresystem.Theycalledfortheeducationofhealthprovidersandothersinthehealthcaresystemabouttheirspecificneedsasmarginalizedcommunitiesandwereeagertobeinvolvedasteachers.

3. Resource Coordination Resource coordination must improve to connect those in need with available services.

Participantsfromallsectorsoftheneighborhoodrecognizedaknowledgegapcontinuallyuncoveredininterviewsandfocusgroups:Peopleareoftenunawareoftheservicesofferedinthearea.Oneparticipantshared,

I think it’s about coordination of information and resources and making sure that people know about what already exists.

Thispresentsastruggleforbothindividualcitizens,whodonotknowaboutservices/programsthatareavailabletohelpthemmeettheirneeds,aswellasforserviceprovidersandprogramcoordinatorswhostruggletokeeptheirorganizationsafloat.

Thereweremanysuggestedmarketingstrategiestoaddressthisneedincludingthecreationofaresourceguide/list,informationalmeetingsinareaapartmentbuildings,flyersorposters(availableinmultiplelanguages),bulletinboards,storewindowadvertisements,andaWest7thFacebookgroup.Inseveralfocusgroupssuchcoordinationandsharingofknownresourceshappenedspontaneouslyamonggroupmembers(e.g.aboutlocalavailabilityoffreshvegetablesattheSt.PaulFarmer’sMarket).

Alongwiththis,manyparticipantsidentifiedaneedforgreaternetworking,communication,andcollaborationamongexistingorganizations.Onekeyinformantsaid,

I think the name of the game is more and more people have to collaborate and do some of this together so that we become arms…[for example,] a health clinic uses the already existing successful agencies to support that outreach and that linkage back with physicians.

“I think it’s about coordination of information and resources and making sure that people know about what already exists.”


4. Nutrition Nutrition and healthy eating is an area of concern. People want access to good food, good information, and good ideas about how to make real change.

Almostunanimously,participantsnotedaccesstolowcost,healthyfoodsasahealthpriority.ThenearbySt.PaulFarmer’sMarket,Cooper’s(afamily-rungrocerystorewithtwolocalbranches),MississippiMarket(anorganicfoodco-op),aswellasthe“FareforAll”emergencyfoodprogram,andavailablemealsforkidsduringthesummerwereidentifiedasstrengthsintheneighborhood.However,manypeopleidentifiedaffordabilityasabarriertoeatingwell,andobservedthatdespiteexistinggroceryoptionssomepeoplemuststilltraveloutoftheneighborhoodtoaccessfarmersmarketsandlargergrocerystoresthatoffercheaper,healthyfoods.

Topromotehealthyeatinginformantssuggestedhostinggardeningdemonstrations,teachingkidstogardenatschool,andencouragingneighborstoshareyardspaceforgrowingfood.

If we just go to every door and knock, and garden West 7th out, imagine the quantity of food we have around here…that’s what it’s going to take to have a healthy West 7th—let’s just start growing!

ManyofthekeyinformantsandafewfocusgroupparticipantswereexcitedabouttheexistinggardeninginitiativesinWest7thandwouldliketoseetheseincreasefurther.Asoneinformantshared,

The gardening, from my perspective, is one of the most crucial things the neighborhood can do to enhance the health of people outside their own personal health…I think it’s the key, I really do. And I’m seeing it. I’d like to see more of that done.

Manyparticipantssharedthattheystrugglewithtimeandknowledgebarrierstohealthyeating.Onefocusgroupmemberstatedfrankly,

We don’t know how to cook. We eat fast food.

Otherstalkedaboutjugglingworkandlifeschedules,somementionedburdensfromtheirchildren’sbusyextracurricularschedule,allofwhichleftlittletimeforhome-cookedmeals.

Aunified,multi-facetedapproachwascalledfor:Improvedaccesstofreshfoodsalongwithteachingaboutcookinghealthymealsandpracticalsupporttoabandonfastfood,ready-madeoptions.

Severalhomelessparticipantsandkeyinformantsexpressedthattheywouldliketoseehealthier,fresherfoodsgivenoutatfoodbanksandinshelters.AType1diabeticparticipantnoted,“everythingisfullofsugar!”Andtherewasconcernbyseveralgroupmembersaboutpreservativesandadditivesinfoodaswellasexposuretohormonesandtheeffectongeneralhealthandfasteragingofcurrentpopulations.Onefocusgroupparticipantwhoishomelessemphasizedtheneedto,“feeddownherehealthy!”

“The gardening, from my perspective, is one of the most crucial things the neighborhood can do to enhance the health of people outside their own personal health.”


5. Fitness Getting motivated and having affordable options is an area of concern for many different people in the neighborhood.

Participantsoftendiscussedphysicalfitness.Motivationtobeactiveandstayphysicallyfitwasoftencloselytiedwithone’sfriend/familyandothersocialnetwork(seeCommunityBuildingsection).KeystrengthsenjoyedintheWest7thcommunitynotedbyparticipants(mostlykeyinformant,neighborhoodleaders)includetheexistingbikingandwalkingpathsaswellasthephysicalfitnessopportunitiesattheJewishCommunityCenter,theSalvationArmy,PalaceRecreationCenter,theWest7thCommunityCenter,andSholomHome.

Participantsfrequentlynotedtheneedformorespaceandresourcesforphysicalactivity(althoughsomewereunawareofabove-listed,existingresources).Oneofthechallengespeopleidentifiedwasthatalthoughsitesexistinthearea,thereremainsalackofaffordableplacesforchildrenandyouthtobeactiveandparticipateinexerciseprograms.Manyparticipantsofferedsuggestionsthatincluded:

• low-cost/freefitnessclasses

• creatingabikelaneonWest7thStreet

• improvedworkplacefitness

• betterpromotionofexistingrecreationsites(mentionedabove)

• establishmentofacommunitypool.

Othersthoughtoflow-cost,community-drivensolutionssuchas:

• walkingclubs

• exercisegroupsatchurchesandotherplacesofworship

6. Community Building Healthy communities have a strong community identity and vibrant social networks which combat isolation and loneliness.

Strongsocialnetworkswereanimportantthemethatemergedfromfocusgroupsandinterviews.Peoplesharedthatastrongsenseofsocialcohesionpromotedhealthbothonanindividualaswellasacommunitylevel.EventssuchasNationalNightOutgatheringsandorganizationssuchastheSalvationArmy,theWest7thCommunityCenter,andtheJewishCommunityCenter(JCC)aswellastheexistenceofstrongcommunityleaderswereidentifiedascommunitystrengthsinthisarea.ManyofourkeyinformantspointedoutthestronghistoryintheWest7thneighborhoodofcommunityprideandusinglocalsolutionstoaddressrisingchallenges.

Keyinformantsshared:There are people who live here and have lived here for a long time who are deeply committed the community and seeing it survive and thrive, neighbors who care for each other.

Because West 7th is its own little, personal, private area in St. Paul, I [see] more unity here…and there’s this ownership, and there is a sense of pride.

Healthy communities have residents who care about each other and are invested in their community.

Infocusgroups,wherediscussionsincludedmorereflectionaboutindividualhealth,peopleoverwhelminglyidentifiedsupportfromfamilyandfriendsaskeyfactorscontributingtotheiroverallwell-being.Thisincludednotonlyemotionalsupport,butsupporttomakehealthylifestylechoicesandtakecareofthemselves.

Participantssharedtheimportanceofextendingthissocialsupporttomarginalizedsegmentsofthecommunityincludingtheincreasingnumberofdiverse,newresidents.Theyexpresseddesireformoreprogramsandactivitiestobuildneighborhoodcohesivenessandtostrengthenthecommunity.Suggestionsincludeddiscussiongroups,moreneighborhoodgatherings,potlucks,outreachtoisolatedseniors,andactivitiestomeettheneedsofpeoplewithdifferentculturalbackgrounds.

“Healthy communities have residents who care about each other and are invested in their community.”


7/8. Volunteerism Healthy communities have civic engagement, help each other, and support those in need.

Citizenshipandengagementwereidentifiedasakeyareatosupportahealthycommunity.Asdescribedintheprevioussection(CommunityBuilding),participantsfeltavibrant,healthycommunitymusthaveinvestedparticipants.Thisinvolvesalevelofciviccommitmentonthepartofeachindividualaswellasthecommunityasawhole.Informantspointedtotheimportanceofcivicengagementandcommunityactivism,wherecitizensidentifyandreacttoissuestogether.

If you’re going to have a healthy community I think you have to have some group of people that are invested in making it a healthy community. I don’t think it just happens.

Otherspointedoutthatculturaleventsandactivitiesandpublicgatheringspacesareimportantaspectsofcreatingthissenseofidentity.

SeveralparticipantshadideasabouthowtoenhancecivicengagementintheWest7thneighborhoodincludingavolunteertimebankthatofferedhelpforprojectsbigandsmall(especiallybetweenyoungfamiliesandelders)andincreasedpartnershipwithareahospitals.

7/8. Activities for Youth Activities for youth is an area of needed improvement.

Someparticipantsdesiremoreprogrammingandspacesforyouth,particularlyteens.Inparticular,oneinformantshared,

I think they need really good positive role models that are a little older than them.

Focusgroupmembersdiscussedchallengestheyfacefindingaffordableprogramsforchildren/teensincludingeverythingfromchildcare,tosports/physicalactivities,andextracurricularclasses.Oneparticipantwouldliketoseeayouththeatergroupdevelopintheneighborhood.Othersaskedforsafespacesforteenstohangout“withoutbeinghassled”oraplacewherepeopleofallagescouldcomeforsupport,tohavesocialinteraction,andtolearnnewthings.

Whileafewparticipantsaskedformoreservicesforseniors(suchasacheck-in/visitprogram),manyexistingresourcesforseniorswerementionedduringourfocusgroupsandinterviews.


TheseresultscanbecomparedtonumeroussimilarandoverlappingeffortsintheWest7thneighborhoodandotherareasoftheTwinCities.Inaddition,effortstoimproveneighborhoodhealthusingCBPRhaveprecedentindiverseareasthroughouttheU.S.andtheworld.Understandingthesefindingsinthecontextofthisworkisimportant.

TheWest7thCommunityCenter,akeycommunitypartnerintheproject,conductedaneedsassessmentoftheirservicesinJuly2008.Despitethedifferenceinscope,theirfinalreportcitesseveralconclusionsthatreinforcefindingsfromHealthWest7th.Thisincludestheneedforacentralplaceforresourcecoordinationintheneighborhoodandrecognitionofcontinuedunmetneedsdespitemanyexistingprogramsandservices.7

FromSeptembertoNovember2010,AllinaconductedCommunityEngagementDialoguesineachofitsnineregionsacrossthestatefocusedon(1)healthyeating(2)activeliving(3)stressreduction/lifebalance.ThedialoguesnotedtheeconomicdownturnandneedforworkandotherbasicneedsasafundamentalpriorityasitwasinWest7th.TheWest7thneighborhoodexistsinAllina’sEastMetroregionandsharesnumerousspecificconcernswithdialoguesdoneinthisarea.ParticipantsintheEastMetronamedsomeofthesameassetsidentifiedWest7thincludingwalking/biketrailsandparkswithregardtoactivelivingbutalsoagreedthatroomforimprovementstillexists.

HealthyWest7thandEastMetroparticipantsagreedabouttheneedforincreasedaccesstohealthyfoods,particularlyexpandedFarmer’sMarketsandCommunity-SharedAgriculture(C.S.A.)programs.Participantsinbothgroupsdiscussedcompetingdemandsonbusyfamiliesjugglingwork,school,andpersonalcommitmentsthatoftendetractfromthetimeneededforhealthyeatingandproperfitness.Bothgroupsalsomentionedconcernoverneighborhoodsafetyasabarriertofitnessandotheraspectsofhealth.

TheEastMetrodialogueechoedthecallsofthepeopleofWest7thforbettercoordinationofresourcesandcitedasabarrierthelackofcommunityawarenessofavailableservices.Theymentionednewsletters,awarenesscampaigns,partnershipsbetweenlocalorganizations,aswellasa“clearinghouse”ofavailablecommunityresourcescloselyparallelingsolutionsproposedintheHealthyWest7thproject.8

Local Context

Participatory Research can break down the rigid boundaries between those doing research and being researched and thus affords all participants access to the production of knowledge.


HealthyWest7thprojectquestionsweredesignedtoparallelthoseusedintheListeningCirclesofAllina’sBackyardInitiative.TheBYIfolloweduptheirdiscussionswithamorecomprehensivedoor-to-door“walk-around”surveyofnearly700communitymembers.Despiteobviousdifferencesinscale,severalparallelscanbedrawnbetweenthedatagatheredinthetwoprojects.WhenBYIListeningCircleparticipantswereaskedhowtheykeepthemselvesandtheirfamilieshealthymanypeoplediscussedpersonalfactorsalsosharedbyWest7thparticipantsincludingeatinghealthyandgettingproperexercise. BYIrespondentsdiscussedaccesstocareandmaintaininghealthcarecoverageechoedbyparticipantsinWest7th.

IntheBackyardasinWest7th,therewasmuchdiscussionofbalanceandharmony,andtheimpactofstrongsocialnetworksandrelationshipsonhealth.Spiritualityandparticipationinfaithlifewasalsoemphasizedbyparticipantsinbothgroups.AndsimilartothethemeofCommunityEngagement/CitizenshipthatemergedintheHealthyWest7thproject,participantsintheBYIrecognizedparticipationinthecommunity,providingandreceivingsupport,andfeelingacceptancebyothersisakeypartofimprovinghealth.


Whenaskedaboutwheretheyseekhelp,BYIparticipantsmentionedthesamecirclesoffamilyandfriendsandsocialservicesthatvarydependingonone’scircumstanceorspecificneed.Participantsalsorecognizedthatclosefriends,especiallyingroupssuchasAlcoholicsAnonymous,canbecomepartofone’sfamilynetwork.IntheBYIthecommunityandresearchpartnersdidnotaskspecificallyaboutbarrierstohealth.Nevertheless,theyheardmanyofthesamebarriersintheirstudyaswedidincluding:

• Accesstoinsuranceandaffordablehealthcareisaproblemformany.

• Challengewiththecurrenthealthcaresystem’slimitsonthedevelopmentofrelationshipswithproviders

• Needformoreproviderswhoaresensitiveandattentivetopeople’sculturalandpersonalexperiences

• Improvedeaseinnavigatingthehealthcareandinsurancesystems9

InOctober2010theBlueCrossBlueShieldandWilderFoundationspublishedareportentitled,“TheUnequalDistributionofHealthintheTwinCities.”TheysystematicallydocumentedthatnationalandinternationaltrendsinsocioeconomicdisparitiesinhealthalsoexistintheTwinCities.Inthisarea,asinmanyothers,“aperson’shealthisstronglyinfluenced—asmuchas50percentormore—bysocialdeterminants,includingincome,education,andneighborhoodconditions.”ThedataspecificallyhighlighttheWest7thareaasoneofpoorestsectorsofSt.Paulwithsomeoftheshortestlifeexpectanciesofanyareainthestate.PeopleintheWest7thneighborhoodliveonaveragetoanageof70to74.9years.Thisiscontrastedby83+yearsinsomeofthebestperformingsectorsoftheTwinCitiesincludingthenearbysuburbofMendotaHeights,lessthanfivemilesfromtheWest7thneighborhood.10

“National research suggests that a person’s health is strongly influenced—as much as 50 percent or more—by social determinants, including income, education, and neighborhood conditions.”


Thefindingsofthisreporthighlightcommonthemesfoundacrossdiversesegmentsofpeoplewholive,work,andseekservicesintheWest7thneighborhood.Thefindingshavebeencorroboratedbyseveral,separateinitiativesbothlocallyandregionallyandrepresentaboldcallforimprovementofhealthacrossavarietyofareas.

Whilediverseintopicandscope,manyofthesolutionscalledforbyparticipantsinvolvemorere-structuringandorganizationalchangesthanlarge,complex,expensiveprograms.Participantsuniversallyrecognizedtheirownuntappedpotentialasneighbors,leaders,andorganizationsalreadypresentintheWest7tharea!

RatherthanacceptthefindingsoftheBlueCrossBlueShield/Wilderreportasinevitable,numerouscitizensofallages,fromneighborstoprofessionals,havetakenthesefindingsasachallenge.

Theyareasking:

What might we accomplish if we work together to improve the health of our neighborhood?

Conclus i ons

What might we accomplish if we work together to improve the health of our ne ighborhood?


Next Steps ThelargergoaloftheHealthyWest7thprojecthasalwaysbeentosparkcommunityactionaroundneighborhoodhealthimprovement.Forthistobesuccessful,itisessentialthatthecommunityitselfdecidewhat,when,andhowthingsproceed.Numerousconversationsandcollaborationsareunderwayrelatedtothisproject:

• AllinaHealthisexploringpartnershipswithlocalorganizationsandneighborhoodeffortsinWest7th.

• Activecollaborationisunderwaywithdiversepartnersonacommunitygardening/nutritionprojectencouragingintergenerationalvegetablegrowingandhealthymealpreparation(see:www.healthywest7th.wordpress.com).

• RepresentativesfromdiversesegmentsoftheneighborhoodareinformingtheongoingrevisionoftheCommunity-OrientedPrimaryCarecurriculumforresidentphysiciansatUnitedFamilyMedicine.ThisincludedpresentationsofproposedprojectsbyresidentphysicianstoacommunitycouncilinDecember2011.

• Acouncilmadeupofbroadrepresentativesfromthecommunitymeetsregularlytoworkontheprioritiesidentifiedinthisreport.Recently,thegroupapprovedamissionstatementforHealthyWest7th:“ToimprovethehealthandwellnessofSt.Paul’sWestEndinmeasurablewaysbybuildingrelationshipsthroughoutourcommunityfoundedontheuniquestrengthsofourneighborhood.”

If you would like to be involved, please email: [email protected] or call 651-241-1010.



1Census2010dataassummarizedbyMNCompass,http://www.mncompass.org/_pdfs/neighborhood-profiles/StPaul-West7thFortRoad-102011.pdf

2http://www.fortroadfederation.org/

3www.unitedfamilymedicine.org/index.php/about-us/our-history/,August5,2011.

4WestSeventhCommunityPartnership“ReporttotheCommunity,”October1996.OrganizationalPublicationbyWestSeventhCommunityPartnership.

InformationalInterviewwithConnieWalsh,WestSeventhCommunityPartnershipSteeringCommitteeMember,byMaryBethGrewe,June,2010.Unpublished.

5http://www.healthypeople.gov/2020/default.aspx,March26,2012.

6NAPCRG(NorthAmericanPrimaryCareResearchGroup),Macaulay,AC,etal..“ResponsibleResearchwithCommunities:ParticipatoryResearchinPrimaryCare.”Internet.20Jan.2009.Available:http://www.napcrg.org/responsibleresearch.pdf

7Mitchell,Joeetal.,“West7thCommunityCenterNeedsAssessment,”doneasaprojectattheCarlsonSchoolofManagement,UniversityofMinnesota,July29,2008.Unpublished.

8Johnson,Kirsten.“AllinaHospitals&Clinics:CommunityHealthAssessment,”Nov.,2010:http://www.allina.com/ahs/aboutallina.nsf/page/community_health_improvement

9AllinaHosptialsandClinicsandthePowderhornPhillipsCulturalWellnessCenter,“CommunityattheCore:BackyardInitiativeAssessmentReport,”April,2011.

10Helmstetter,Craigetal.,“TheunequaldistributionofhealthintheTwinCities,”BlueCrossBlueShieldFoundationandWilderFoundation:October,2010.Availableat:http://www.wilder.org/reportsummary.0.html?tx_ttnews[tt_news]=2337

Appendix


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If you would like to be involved, please email: [email protected]

or call 651-241-1010.


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