Increasing Opportunities for Health in a Southeast Michigan Community Through Local Policy Change

Abstract

Disparities in health outcomes are closely linked with social, economic, and environmental conditions. The burden of these disparities are most often experienced by racial and ethnic individuals of color, those with low income, and those who live in vulnerable communities. Local policy and systems change efforts provide a means to address health inequities and create sustainable change at the community level. The Inkster Partnership for a Healthier Community was formed in 2010 to create sustainable opportunities for health, with a special focus on diabetes prevention and management. Policy and infrastructure change efforts were documented and tracked over time and qualitative data were collected to create deeper understanding of the change efforts. Eleven policy outcomes have created sustainable change around access to health resources and services, access to healthy foods, opportunities for physical activity, diabetes prevention and management education, and increased capacity for ongoing community change.

Keywords

diabetes environmental and systems change health disparities health promotion qualitative research health research physical activity/exercise program planning and evaluation social determinants of health community organization chronic disease

Introduction

The prevalence of diabetes and prediabetes has increased dramatically over the past several decades, with the largest burden experienced among racial and ethnic individuals of color, those with low-income, and those who live in vulnerable neighborhoods with concentrated poverty, which translates into lower resources for health (Bishaw, 2011; Braveman et al., 2011; Braveman & Gottlieb, 2014; Graham, 2004; Harris et al., 1995; Jargowsky 2013; PolicyLink, 2017; Singh, Siahpush, & Kogan, 2010). The presence of health inequities is well established and closely linked with social, economic, and environmental conditions, which makes these priority populations an important focus of collaborative efforts that aim to change conditions in communities (Adler & Stewart, 2010; Cullen, Cummins, & Fuchs, 2012; Galea, Tracy, Hoggatt, DiMaggio, & Karpati, 2011; Roux & Mair, 2010). Local policy and systems changes are needed to create opportunities for health in those communities experiencing the greatest burden of diabetes (Amaro, 2014; Centers for Disease Control and Prevention [CDC], 2015; National Partnership for Action to End Health Disparities, U.S. Department of Health and Human Services, & Office of Minority Health, 2016). Policy and systems changes provide ways to sustain critical programs and practices that positively affect the lives of residents at the community level (Bell & Standish, 2005; Freudenberg & Tsui, 2014; Friedman & Wicklund, 2006; Shediac-Rizkallah & Bone, 1998).

Inkster, a city in Wayne County, Michigan, approximately 20 miles southwest of Detroit, with a declining population of 24,786, faces pronounced health inequalities and decreasing economic resources (U.S. Census Bureau, 2014). Wayne County (where Inkster is located) ranks last among Michigan counties in health outcomes and social determinants of health, including lack of access to health care, healthy food, safe places for physical activity, as well as high unemployment and poverty (Lombard, Burke, Waddell, & Franke, 2015; University of Wisconsin Population Health Institute, 2016). The prevalence of those diagnosed with diabetes in Wayne County is above both the state and national average and continues to rise (CDC, 2016).

In 2010, the Inkster Partnership for a Healthier Community (IPHC) formed, with leadership from the National Kidney Foundation of Michigan (NKFM), to address factors that influence diabetes-related disparities. The IPHC comprises diverse stakeholders from Inkster, including community leaders and residents, as well as representatives from health systems, health and human service agencies, faith-based organizations, businesses, and other community-based organizations.

The aim of this collaboration between the IPHC, the NKFM, and the University of Michigan Center for Managing Chronic Disease was to develop policy change strategies at the local level to increase opportunities for healthy eating and physical activity, build capacity in individuals and organizations, connect the community with health care, improve health care navigation, and develop strategies to sustain the work of the partnership. The theoretical framework for this community partnership approach to health promotion in disenfranchised or marginalized populations is socioecologic model, which links the social environment to individual health (McLeroy, Bibeau, Steckler, & Glanz, 1988). The socioecologic model provides a useful framework for thinking about the multiple levels of influence that affect health behavior and ultimately health outcomes, including intra- and interpersonal factors, community and organizational factors, and public policies (Richards, Potvin, Kishchuk, Prlic, & Green, 1996; Stokols, 1996). Local policy change addresses a key component of the broad socioecological perspective through environmental changes in schools, neighborhoods, and churches; community networks; and other power structures that can positively or negatively affect health behavior (Minkler, 1999).

The work of the IPHC builds on existing research demonstrating that community-driven policy and environmental changes can improve opportunities for health and wellness (Brownson, Haire-Joshu, & Luke, 2006; Clark et al., 2010; Clark et al., 2013; Israel et al., 2010; Minkler, Garcia, Rubin, & Wallerstein, 2012; Themba, Minkler, & Freudenberg, 2008; Wallerstein & Duran, 2010). This article examines the IPHC as a case study of local policy and environmental change to provide real-world examples and share lessons that can be applied to similar practice-oriented work.

Methodology

Several processes were used to guide and evaluate the work of the IPHC that are important to elucidate for this case study: (1) community needs assessments to help the partnership identify where to focus their efforts and which local assets could be leveraged, (2) key informant interviews with partnership members to understand the collaborative processes behind the policy and environmental change efforts, and (3) policy tracking forms to assess progress of specific efforts as well as barriers and facilitators.

Needs Assessments

The IPHC conducted community needs assessments in 2010 and 2011 to better understand local socioeconomic conditions, health trends, and the built environment. Data were compiled from publicly available data sources (on socioeconomic and demographic characteristics) in addition to surveys, interviews, and focus groups from the Toolkit for Health & Resilience in Vulnerable Environments (Prevention Institute, 2010) and the Community Health Assessment aNd Group Evaluation Tool (CDC, 2010). Based on the ranking of self-reported community needs and assets identified through this assessment process, the partnership established priorities and developed a strategic action plan (Lombard et al., 2015).

Interviews on Collaborative Process for Policy Change

Key members of the IPHC were interviewed to gain a deep understanding of the collaborative process surrounding policy change and community contextual information. Twelve members of the partnership were interviewed (four in leadership positions, four representatives of community organizations, and four community residents). Partnership leadership selected interview respondents for these three categories based on familiarity with the partnership’s structure, processes, and policy change efforts as well as their level of engagement in the IPHC. Interview questions focused on partnership activities, successes and challenges, and lessons learned. Interviews were conducted at two time points between 2013 and 2015, with approximately 24 months between baseline and follow-up. Due to evolving membership and levels of involvement, half of the interviews in 2015 were with new informants. These new informants were selected to represent the same category (partnership leader, representative of community organization, and community resident) of the baseline informant they replaced. Digital audio-recordings were used to transcribe the interviews verbatim. All information from the interviews was de-identified. NVivo 10 (QSR International, 2012) was used to organize and manage the interview data. The Center for Managing Chronic Disease team used inductive qualitative thematic analysis to identify the key themes in the data (Patton, 2002). Two independent coders participated in meetings to come to consensus over themes and coding structure.

Policy Change Tracking

Local policy and infrastructure change efforts were measured and tracked over time throughout the period of study (2013-2015). Policy and infrastructure changes were defined as documented agreements and changes that would be sustained after grant funding has ended. Examples of local policy change were generated and distributed within the partnership to provide clarity and focus the work. Examples included funds allocated in institutional or public budgets, job positions created and written into hiring procedures, administrative rulings, documented changes to city plans, school improvement plans and budgets, enforcement of existing policies, and improved physical conditions in the community.

Policy and infrastructure tracking forms were developed and used to document change efforts and collect regular reports on outcomes. The tracking forms were completed by leaders of the partnership with input from other partnership members (and periodically reviewed to inform decisions about ongoing work). Each effort was updated on an ongoing basis and included a description of the effort, phase of change achieved, the partnership’s role in the change effort, strategies used to create the change, as well as facilitators and barriers to the change efforts. Phase of change was described over time using the following categories adapted from policy change process and evaluation literature: (1) Development, (2) Adoption, (3) Implementation, and (4) Maintenance/Enforcement (descriptions of each phase can be found in the note at the bottom of Table 1; CDC, 2012; Connecticut State Department of Education, 2010; North Carolina Department of Health and Human Services, 2001; Reisman, Gienapp, & Stachowiak, 2007). Additional documentation, such as written agreements and job postings, accompanied reporting forms when applicable to provide verification of policy and infrastructure changes. Mixed methods were used in both data collection and analysis to integrate quantitative and qualitative data.

Table 1

Status of Policy and Infrastructure Change Efforts Over Time

Effort	Description of Effort With Quotes From Key Stakeholders	Phase of Change by Year (2013-2015)^a
Institutionalization of community health workers (CHWs)
Creation of a permanent CHW position	Created comprehensive care for patients by connecting patients to resources offered in the community, facilitating evidence-based disease self-management programs, and leading diabetes support groups. NKFM-IPHC created the position and Western Wayne Family Health Center authorized and housed the position. [The CHW is] benefitting our community and making [residents] feel like they can go and advocate for their own selves because they’ve learned.
Policy changes at local businesses
IPHC corner store initiative	The IPHC has garnered commitments from businesses and other local entities to participate in providing healthy food options for the community. I think the store owners in the community . . . instead of having . . . kids come through the gas station on their way to school and . . . get a soda pop and some potato chips . . . if there was some fresh fruit there, then they would have an option, maybe they would pick up a (a healthy snack) on the way to school.
Local restaurant diabetes-friendly menu changes	IPHC partnered with a local restaurant to provide healthier food options at community meetings and events using a diabetes-specific cookbook. A registered dietician was used for menu planning support and to provide ongoing assistance as needed. Since the restaurant closed in 2014, the owner has continued using the diabetes-friendly modified recipes in her catering business serving organizations throughout Inkster and surrounding communities. (Local business) caters healthy food now . . . with the fresh veggies, baked, broiled or no meat, and that’s a huge thing out here. If you were in California it would be a common thing to see . . . (local business) is our only thing like that, and it changed as a result of our requests to provide for our luncheons . . . and the (local business) just decided to do it all the way.
Changes to city infrastructure
Establishment of community gardens in Inkster	IPHC partners including schools, churches, and resident housing developed and maintained community gardens that have yielded over 25,000 pounds of fresh vegetables since 2011. In addition to improving access to healthy foods, the effort aimed to create opportunities for community residents to adopt a healthier lifestyle and feel empowered to take control of their health. We don’t have a major supermarket. We don’t have that for this city of 23,000 people or more. So the majority of our people have to go outside of Inkster in order to feed their families. (The community gardens) are important because they give fresh, locally grown vegetables to people who otherwise would not have it, and that’s the poor who can’t afford it as well as senior citizens . . .
The development of a new walking path	The Greenway project Phase I was completed in the City of Inkster in October 2013. The IPHC provided needs assessment results to the local government and informed city council and the mayor about how the walking path could prevent and reduce the effects of chronic conditions, such as diabetes, and promote safe and active living spaces within the community. Next steps include securing further funding to extend the walking path further to connect adjacent city paths. We don’t have a safe place to walk, and we can’t get out and get exercise if you are dodging bullets; a lot of drug traffic, there are so many things, the recreation center was closed most of the year (due to a flood) . . .
Joint use agreements
Agreement with Inkster school board to use school property to serve as a space for meetings, community gardens, and trainings for community residents	The IPHC developed relationships with public housing, schools, and faith-based and community organizations in order to secure space to support evidence-based programs, meetings, trainings, events, and gardens. Several formal subcontracts were signed with the leadership of the aforementioned organizations in the past 6 years. There’s a lot of cooperation. People are going two and three times a week to fitness classes, I think they are a great success and they’re a good doorway to the other classes. If a person commits to coming to the fitness class then they’re already open to the conversation about their diet and other things that have to do with health . . . the churches have opened their doors for that to happen.
Agreement with Inkster Resident Housing Council to use Housing property to conduct evidence-based programs for chronic disease self- management, diabetes self- management, free or low-cost physical activity opportunities, and other trainings
Permanent sites established for evidence-based programming
Agreement with Gethsemane Missionary Baptist Church to use space for conducting evidence-based programs and offering healthy food options at church events
Capacity building
Community members trained to conduct healthy eating, physical activity, health literacy, as well as evidence-based diabetes prevention and management, programs.	Over 200 community members—lay health educators and CHWs—have been trained and certified by the NKFM to conduct one or more evidence-based programs in the community. Many of these programs are now institutionalized into partnering organizations’ service offerings. Most of the residents like myself, we are not employees, but we have been trained (to lead programs). We have teachers that can teach others. The IPHC has people that are volunteers and leaders that are not a part of the National Kidney Foundation. We are pretty much ready to continue . . .
Sustainability of the partnership
Assimilation of IPHC into the Inkster Task Force^b as the Health Engagement Group	The IPHC has been designated by charter as the Health Prevention and Community Engagement arm focused on addressing health disparities and social determinants of health within Inkster. The Task Force was “defunct” when the IPHC began. Since that time, it has been reformed and revamped by community residents. The change benefits the IPHC partnership because it is a catalyst for IPHC sustainability and maintaining a focus on health and wellness within the task force and throughout the community. . . . We are working in tandem . . . they hold their meetings together, do things together, bring their resources and use them. I mean it’s an alliance.

NOTE: NKFM-IPHC= National Kidney Foundation of Michigan–Inkster Partnership for a Healthier Community.

Phase of change (1-4): 1. Development (e.g., identified and agreed on goals, strategies developed, strategic partnerships formed, idea for change is growing in momentum, base of support beyond the partnership is growing, formalized plan has been introduced); 2. Adoption (e.g., the change has been adopted by the decision-making body and is documented in memos, guidelines, regulations, laws; funding application has been approved); 3. Implementation (e.g., funding for the change is appropriated by an organization, institution, system, or legislature; state or local entities are beginning to implement the change); 4. Maintenance/Enforcement (e.g., efforts are underway to ensure that the change and funding for the change is sustained; efforts are underway to enforce the change by responsible authority, i.e., a system for monitoring has been established). ^bThe Inkster Task Force, a 501(c)(3) organization, is a community action group that encourages participation by individuals and community-based organizations in its efforts to promote a strong, healthy, and safe community of opportunity where multiple generations live, learn, and work.

Data from the interviews and the policy-tracking forms are interwoven to provide a narrative for the policy change efforts of the IPHC in the Results section.

Results

Community Context

At the onset of this initiative, individuals from Inkster faced a number of barriers to health and wellness. Inkster residents viewed diabetes as a condition that could not be prevented. IPHC stakeholders reported that Inkster residents were very closed off when it came to discussing their health and chronic conditions, such as diabetes. Community members viewed diabetes with a mixture of stigma and fatalism. One community member described the community perception of diabetes,

Do you have brown eyes or green eyes? Do you have sugar in your family or not?

In addition, with Inkster being a disadvantaged community composed of many residents of low socioeconomic status, individuals often had many competing priorities that were often placed before their own health, such as finding employment, caregiving, and earning money to pay for basic necessities. As one member of the partnership described,

They’re trying to fulfill their basic needs—shelter, food, clothing . . . if those are not met, they’re not even concerned about anything else.

Instability in the community, including poor infrastructure, city-wide financial problems, along with neighborhood safety issues were key challenges that the initiative faced. In addition, community organizations lacked a history of collaboration until the IPHC convened its various partners. One member of the partnership explained,

Prior to all of this, people were working out of silos and one didn’t know what their neighbor was doing. And that’s changing. We’re all getting to know each other, what each other has to offer, what we’re doing within the community and how we can all work together for the same common goal.

Local Policy Change

By fostering policy change at the local level through community collaboration, the partnership sought to have a positive effect on the lives of residents for years to come and build capacity among residents to support future endeavors. Table 1 summarizes policy changes made by the partnership since reporting began in 2013. In all 12 policy change efforts related to diabetes, prevention and management were accomplished as of final reporting, 11 of which reached the implementation or enforcement stage. Of those 11 policy change efforts, 6 major categories emerged (1) institutionalization of community health workers, (2) policy changes at local businesses to support healthier choices, (3) changes to city infrastructure, (4) joint use agreements, (5) increased capacity for community change, and (6) sustainability of the partnership. These efforts are briefly described in Table 1 with particular attention to the purpose of the effort, the decision-making bodies, as well as barriers and facilitators. All of these changes created shifts in infrastructure and support for those with diabetes in the community and help individuals make more diabetes-friendly choices in their daily lives. Relevant quotes from members of the IPHC partnership have been included to further elaborate on each effort. The phases of change for each effort (depicted as line graphs on the right-hand side of the table) illustrate the process of local policy change from 2013 to 2015.

Three distinct patterns of change over time emerged from the IPHC local policy change efforts: continued progress after initial success (progression over time; ), decreased momentum for the effort (derailment; ), interruption after initial success followed by renewed progress (rebuilding after derailment; ). The following examples illustrate the three patterns of policy change reported in this work.

Progression Over Time

The IPHC and NKFM, in partnership with Western Wayne Family Health Center, a federally qualified health center, created a permanent CHW position. The position supports comprehensive care for patients by promoting community–clinic linkages, connecting patients to evidence-based resources offered in the community, facilitating evidence-based disease self-management programs, and leading a diabetes support group. The NKFM-IPHC created the position, and Western Wayne Family Health Center authorized and housed the position. This position originated as a CHW role funded by grants received by NKFM and was transitioned to a permanent paid position with the health center after demonstrated value to staff and clients.

The steady progression of this policy change was marked by the stability of the two major entities driving the effort and the relationship with key stakeholders within the health center that could allocate funding to ensure the permanency of the CHW position. One stakeholder, speaking about successful collaboration, stated,

You can do anything you want with the right people.

This viewpoint is particularly relevant when looking at this example of an effort steadily progressing over time. Many partnership members agreed that identifying the “right” type of stakeholder was especially important to the long-term success of the partnership. The informants emphasized commitment, sustainability, diversity, and community-oriented focus when considering what characteristics comprised the “right” partner. The “right” partners also often had the ability to make key decisions and leverage resources within organizations.

Derailment

An effort to use school property for community gardens, programs, and meetings was solidified in 2013 through an agreement with Inkster Public Schools. However, due to the unexpected dissolution of the entire Inkster school system, the IPHC was forced to identify a new partner to take on this role. In 2014, an agreement was put into place with nearby Westwood Public Schools; however, in 2015 a leadership change resulted in the ending of the agreement. As a result, the IPHC has had to explore new partnerships to fulfill the duties previously held by the schools (e.g., reaching a younger population). Speaking about this topic, one member of the IPHC stated,

The Inkster Public Schools were dissolved quickly and that was a big challenge for us as a community as a whole because our children were displaced to different communities to get their education and some of the programs were disrupted within the schools. Inkster is a really close-knit community; many generations live here so it made a big impact in our community when those schools were quickly shut down that summer.

The overall instability vulnerable communities, such as Inkster, face can lead to a breakdown of policy change progress, particularly when a key partner or essential resources dissolve. In these instances, efforts can be modified to best suit the new situation (the course of action pursued by the IPHC, in this case), or if no viable alternative exists the policy effort can be put on hold until a more feasible scenario arises.

Rebuilding After Derailment

A joint use agreement was implemented in 2013 with the Inkster Resident Housing Council to secure space for programing and partnership activities. A leadership change at the housing council led to the suspension of activities in 2014. However, in this instance, after developing a relationship with the new housing leadership, the partnership was able to reestablish their agreement and resume activities in 2015. The importance of trust among partners was concisely intimated by one stakeholder, who said,

You have to build trust among different leaders . . . get to know what the needs of the organization are, the needs of the people, the challenges that we face . . . the IPHC has done that. . . . I did not know a lot of the people, the key players in the community until this partnership came about.

This example shows that progress can be stalled when established relationships and trust are removed and may not resume until new connections are formed. IPHC members reported that the grassroots community involvement, which characterizes the work of their partnership, makes it distinctive from previous health promotion efforts in their community. This approach requires participatory processes, regular engagement, as well as the development and maintenance of trust with community members. Respondents indicated that trust takes time and demonstrated commitment to the mission of the partnership. If trust is eroded or, as in this case, a relationship is altered because of an organizational change, policy change efforts can fall apart or stall unless the relationship is rebuilt.

Key Reflections on Collaborative Process for Policy Change

Table 2 displays a summary of the key themes that emerged from the supplemental interviews related to the overall work of the partnership and the processes behind the policy change efforts. The themes have been organized into three major categories: successes, challenges, and lessons learned. Themes are listed in descending order, based on the number of stakeholders who spoke about the topic.

Table 2

Major Themes From Interviews With Key IPHC Stakeholders

Topic	Themes
1. Successes	A. Collaboration B. Engaging the right partners and stakeholders 1. Commitment 2. Sustainable C. Programs, classes, and events D. Policy and infrastructure changes E. Community-driven approach F. Identifying community needs G. Regular meetings H. Role of NKFM lifestyle changes I. Continued presence of partnership J. Increased awareness of community resources and services
2. Challenges	A. Community instability 1. Underlying social issues 2. Financial instability 3. Closing of Inkster schools 4. Vacant homes B. Other priorities for individuals C. Distrust D. Other priorities for community E. Poor physical environment and neighborhood safety F. Community buy-in and participation G. Funding H. Staff I. Engaging with partners J. Marketing K. Transportation L. Access to healthy foods
3. Lessons learned	A. Importance of collaboration B. Understand community and their needs C. Community ownership 1. Giving members opportunity to contribute and voice opinions 2. Consistent engagement of community members D. Building trust E. Engage the right partners 1. Diverse stakeholders F. Patience G. Importance of funding and resources H. Awareness of community resources I. Importance of connecting services J. Long-term planning K. Tailoring to low literacy L. Effectiveness of programming M. Importance of transparency N. Perseverance O. Importance of outreach and marketing P. Role of NKFM

NOTE: IPHC = Inkster Partnership for a Healthier Community; NKFM = National Kidney Foundation of Michigan.

Overall, stakeholders indicated that working as a partnership has encouraged teamwork, resulting in more information sharing, broadening amount of expertise, efficient use of resources, availability of more resources, and less competition. IPHC members frequently reported that the support of community organizations and the work of other community initiatives have helped the work of the partnership in their efforts to support individuals living with diabetes and diabetes risk. Several stakeholders indicated that relationships with political representatives and the presence of the NKFM were key factors helping their work. The capacity-building and grassroots organizing nature of this work was described by a partnership member, who stated,

[IPHC and NKFM] get the people in the community not only involved, they show them how they can sustain this on their own and they give them the tools to do it. They encourage them to do it.

The most frequent achievement referenced by IPHC stakeholders was the collaboration between individuals and organizations that resulted from the aforementioned efforts. One stakeholder, expanding on this idea, stated,

I do believe that there is a buy-in to the concept of cooperation, shared resources, and mutual support and partnership. And I consider that major. If you look around the world there’s not a lot of that going on.

Reflecting back on the work of the IPHC, one stakeholder considered the circumstances in Inkster prior to the initiative and described the need to address upstream factors influencing health through a community-based approach, saying,

The care that the diabetics were getting, it wasn’t comprehensive enough. And sometimes just what you do in the clinic isn’t enough. You need to look at the environment, look at the family. You have to look at the whole community because it does take a community to make a healthy person.

Discussion

These results show that community-based partnerships can bring about policy and infrastructure change with the potential to affect health and well-being of those living in vulnerable communities. The changes brought about by the IPHC have created opportunities for the prevention and management of diabetes and other chronic conditions in this community. The IPHC has increased access to health resources and services through the establishment of a permanent CHW position at a local clinic, training of community members to lead programs, and institutionalization of community programs. The CHW position encompasses a diverse set of roles and contributions to the health of the community. CHWs provide health education, serve as role models and community advocates, increase access to health care resources, and mentor volunteer program leaders (Lewin et al., 2005; Rhodes, Foley, Zometa, & Bloom, 2007). In Inkster, training of community members increased the capacity of residents to manage their health and created a path to sustainability for related activities.

The partnership has helped bring about greater overall collaboration between community residents and organizations, improved access to healthy foods, and increased opportunities for physical activity. Local policy changes aimed at creating diabetes-friendly menu options allowed Inkster residents to have increased access to healthy food options. Establishment of community gardens and walking paths allowed residents to find low-cost ways to make healthier meals and participate in physical activity. It is well established that these infrastructure changes are critical to health promotion, particularly in low-income neighborhoods, where opportunities for health are less prevalent (Gonzalez, 2012; Graham, 2004).

Many of these changes have endured even as resources have been lost, due in most part to the capacity that has been built within individuals and organizations to create change in their community. Capacity-building projects seek to develop and strengthen human and institutional resources (Robertson & Minkler, 1994). Capacity-building efforts in community health have been documented as a pathway to sustainability (Shediac-Rizkallah & Bone, 1998).

Many components of the IPHC have been sustained or will be sustained over time because they are institutionalized within community organizations and have demonstrated value to the citizens of Inkster. The IPHC’s responsiveness to the needs of the community has helped further long-term support for the partnership among residents and community organizations. The IPHC partners remain committed to working together to improve health equity in Inkster.

As the results show, policy change does not always occur in a linear fashion. Patterns of change included slow, steady change over time and sometimes rapid change. However, it was also the case that change efforts became derailed and the IPHC partners needed to stop and reassess their strategies. In some cases, although the partnership prioritized an effort, they found that they could not obtain alignment from needed decision makers or find the necessary resources to continue the effort. In most cases, policy change efforts in this work did regain momentum and advanced through the phases of change. Much of this success relates to the key partners that were already on board, capacity built within individuals and organizations to advocate for change, and perseverance.

The collaborative process documented here reflects 6 years of work from the IPHC, work that has taken a great deal of effort, patience, and persistence by the members of the partnership. The need to build trust was an important lesson learned by the IPHC, both within the partnership and with the Inkster community. Stakeholders also pointed to the need to find the right people and organizations to bring on board the partnership. Clark et al. (2010), suggests it is not the quantity of partners that helps a partnership bring about change but rather the level of commitment, the strategic placement, and regular engagement. Israel et al. (2010) assert that in order to have a broader and more sustained effect on health, models for influencing policy need to enhance the capacity of community residents and organizations to engage in the policy change process. The IPHC membership placed an emphasis on commitment, diversity, sustainability, and community focus.

A limitation of this work stems from lack of individual-level data related to the impact of these policies on health and wellness. Future research would benefit from monitoring of both individual-level and population-level health outcomes associated with policy change efforts.

Conclusion

Community partnerships represent a participatory approach to create local policy and infrastructure changes that increase opportunities for health. Community change does not always occur in a linear fashion. It is critical to continually monitor and evaluate strategies and the timing of change of efforts in order to ensure policy goals are progressing as planned. Local policy and infrastructure changes can create greater opportunities for healthy eating, physical activity, as well as diabetes prevention and management in vulnerable communities that often do not have adequate resources. The IPHC continues to build capacity for civic engagement in order to create local policy and infrastructure changes for health equity through collaboration.

Footnotes

Authors’ Note:

The authors would like to thank the community residents, partner organizations, and members of the Inkster Partnership for a Healthier Community for their devoted work to improve the health and wellness of the Inkster community. In addition, the authors would also like to acknowledge the work of several student research assistants for the important roles they played in the initiative. This work was supported by funding from the Centers for Disease Control and Prevention and the U.S. Department of Health and Human Services Office on Women’s Health.

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