Recent research estimates that as many as 50% of cancer cases could be prevented by more consistently applying current knowledge to the population [1]. Experts have routinely provided cancer prevention recommendations [2] and defined evidence-based interventions for effective cancer prevention at the community level [3, 4]. Yet, a tremendous gap continues to exist between this knowledge and the implementation of effective prevention strategies. A critical step in reducing cancer incidence is to effectively deploy evidence-based interventions for primary prevention at the population level, with a focus on communities experiencing health inequities. NCI-designated cancer centers are uniquely positioned to engage the communities they both serve and seek to serve through population health initiatives that can reduce the cancer burden and increase equitable access to the highest quality cancer prevention and control programs.
For more than 40 years, cancer prevention has been a cornerstone of The University of Texas MD Anderson Cancer Center’s mission to eliminate cancer. Established in 2016, Be Well Communities™ is MD Anderson’s place-based approach for comprehensive cancer prevention and control, by working with communities to promote wellness and address modifiable risk factors for cancer. The approach has been implemented in three Texas communities - Baytown, Pasadena and Acres Homes. Built on nearly 100 years of healthy community initiative best practices, literature, and experience, Be Well Communities is a signature program of MD Anderson’s Cancer Prevention & Control Platform, a community impact accelerator which implements evidence-based interventions (EBIs) involving community services, public education and policy interventions, targeting measurable reductions in cancer incidence and mortality. Be Well Communities unites individuals, schools, workplaces, government agencies, health care providers, and policymakers to plan and carry out sustainable, community-led solutions to make positive, long-lasting changes in people’s lives. Specifically working in those areas that can have a direct impact on cancer risk reduction: healthy eating, active living, sun safety, tobacco-free living, and preventive care (i.e., cancer screening and vaccines). Central to this place-based approach is creating systemic change by serving as a catalyst coordinating and supporting the implementation of EBIs through community-based organizations who will sustain the work long into the future, all with a specific focus on reducing health inequities and access issues.
Be Well Communities Model
Be Well Communities was founded on effective strategies for community-based, cross-sector, multi-component approaches to promote health equity. Multi-component approaches can reduce risk factors such as obesity and excessive sun exposure across the lifespan [4, 5]. Successful examples of these types of approaches, such as Shape Up Somerville [6], include implementation of EBIs coupled with a community-driven coalition. Community-driven coalitions help to ensure that interventions are relevant to and executed in alignment with the needs of the community. Key components of effective community-based approaches include at a minimum three key elements: 1) making health equity a shared vision and value, 2) fostering multi-sector collaboration; and 3) increasing community capacity to shape health outcomes [7]. Through delivery of EBIs placed effectively in the context of individuals and families, community-driven coalitions can reduce disparities and improve health.
Leveraging these lessons, the Be Well Communities model (Fig. 1) focuses on the specific needs and context of the community through phases of community assessment, planning, and implementation, supported by evaluation and sustainability planning. An evaluation plan, developed in partnership with RTI International, guides this work to ensure adequate data collection, align organizational objectives with outcomes, and assess progress and impact.
Following the principles outlined in the Centers for Disease Control and Prevention’s (CDC) Sustainability Planning Guide for Healthy Communities (2012), sustainability is foundational and integrated into practice by creating, executing, and evaluating a Community Action Plan [8]. The model relies on three groups working collaboratively: the backbone team, a steering committee, and collaborating organizations [9]. The backbone team is responsible for overall coordination, convening, fund stewardship, management and evaluation of the initiative. The Steering Committee, which includes community residents, is the active community advisory board or health coalition that establishes shared goals, reviews available interventions, develops the Community Action Plan, and guides and champions the initiative. Collaborating organizations are funded Steering Committee organizations carrying out EBIs tailored to the community’s culture that make up the Community Action Plan.
Additionally, since many cancer risks (e.g., tobacco exposure, obesity, sun/UVR exposure) appear to accumulate across the lifespan, it is increasingly clear that cancer prevention needs to begin in childhood [10]. As such, youth-serving institutions (e.g., elementary schools, daycares, sports programs) are critical collaborators across Be Well Communities initiatives. This includes interventions focused on vaping prevention and HPV vaccination as well as healthy eating and physical activity programming. Addressing risk factors from early childhood through adolescence, can increase healthy behaviors and reduce unhealthy behaviors, ultimately reducing the risk for cancer later in life.
Together with strong, cross-sector community partners, Be Well Communities made a tangible difference in its inaugural community, Be Well™ Baytown [11] and has since expanded that initiative and expanded work in additional communities across the Greater Houston area. More than 195,000 have received direct support through Be Well Communities initiatives to date. See Table 1 for additional information about Be Well Communities key indicators of impact.
Table 1
Be Well Communities key milestones to date across three communities in the greater Houston area (2017–2022)
Community Capacity Building | • Engagement with stakeholders across the community o 50 local, regional and state organizations are actively engaged on Be Well Communities Steering Committees, guiding the implementation of an action plan in partnership with residents in each community o 3000 + hours of capacity building, technical assistance, project management and program evaluation provided by the Be Well Communities team |
Infrastructure Investments | • Investments in the built environment and integrated active living o 33 sunshades have been installed at city parks, schools and college campuses o 6 walking trails built |
Cancer Prevention Programs | • Prioritized actions to prevent cancer and other chronic diseases: o Over seven million pounds of healthy food have been distributed to families o 83,000 + students have participated in school-based health and physical activity programs o 10,000 + students and staff have access to tobacco prevention resources through high school and colleges campuses o 24 vaccination clinics have been hosted to provide all recommended free shots to adolescents, including the HPV vaccine o 195,000 + have received direct support through Be Well Communities initiatives to date |
Community Assessment Phase and Site Selection: Acres Homes
In 2020, to further test and refine the effectiveness of our model, a rigorous community assessment was completed of communities in the Greater Houston Area, to prioritize potential implementation sites. The community assessment included understanding both community need and capacity. Community need included understanding demographic characteristics, health behaviors and related outcomes, (e.g., rates of obesity, tobacco use, screening) as well as social, economic and physical factors (e.g., median income, access to public transportation, available green space). Community capacity included understanding community assets, existing resources, ongoing initiatives, active coalitions, and key community partner organizations.
The assessment was also used to identify neighborhoods that refer in high numbers to Harris Health’s Lyndon B. Johnson (LBJ) Hospital, the safety net hospital where the MD Anderson Oncology Program provides cancer care for low-income and medically underserved residents. Selecting a site that is already directly connected to MD Anderson clinical services ensured that research, evidence-based community actions, and the delivery of clinical cancer care could more easily be integrated to overcome key challenges facing one of our local medically underserved communities. As a socio-culturally diverse community with both significant need and strong community resources, Acres Homes was selected as the next community to partner with to further test and refine the Be Well Communities model.
Acres Homes is a City of Houston-designated Super Neighborhood in northwest Houston with more than 57,000 residents [12]. This historic neighborhood was established during World War I and was once considered to be the American South’s largest unincorporated African-American community [13]. While the changing demographics show increasing numbers of residents of Hispanic descent (43% of the population), Acres Homes still experiences effects of a legacy of Blacks experiencing poverty. Table 2 includes further demographics for Acres Homes, including its status as a medically underserved area with relatively high rates of unhealthy behaviors, as compared to Healthy People 2030 goals. Specifically, 45% of residents are dealing with obesity, 18% are diabetic, and 36% self-described as sedentary outside of work [14]. An additional, ongoing challenge is that more than half of the population of Acres Homes resides in census tracts that are considered areas of persistent poverty [15]. Almost 40% of residents live under the federal poverty line, and 37% of adults are uninsured.
Table 2
Acres Homes demographics and key indicators related to cancer risk reduction compared with Healthy People 2030 goals
Total Population (57,947)a | % | | | | |
Race | | | | | |
White | 14.1 | | | | |
Black | 44.9 | | | | |
Hispanic | 41.0 | | | | |
Socioeconomic Indicator (age range)b | Acres Homes (%) | | | | |
Without Health Insurance (18 + years) | 35.7 | | | | |
Living below poverty level (all ages) | 23.6 | | | | |
Median household income | $41,358 | | | | |
Health Indicator (age range) | Acres Homes (%)b | Harris County (%)b | Texas (%)c | U.S. (%)c | Healthy People 2030 Goal (%)d |
Mammography use among women (50–74 years) | 78.2 | 72.4 | 74.9 | 78.3 | 77.1 |
Papanicolaou smear use among women (21–65 years) | 81.2 | 81.8 | 77.1 | 80.1 | 84.3 |
Up-to-date on colorectal cancer screening among adults (50–75 years) | 51.4 | 55.4 | 59.8 | 69.9 | 74.4 |
Obesity among adults (18 + years) | 45.1 | 33.0 | 34.8 | 30.9 | 36.0 |
No leisure-time physical activity among adults (18 + years) | 36.5 | 28.0 | 25.6 | 23.8 | 21.2 |
Diabetes among adults (18 + years) | 17.6 | 13.7 | 12.6 | 11.0 | NA |
Current smoking among adults (18 + years) | 21.2 | 15.8 | 14.4 | 16.1 | 5.0 |
aUS Census Bureau: American Community Survey, 2014–2018 |
bHealth of Houston Survey, 2019 |
cCenters for Disease Control and Prevention, Behavior Risk Factor Surveillance System, 2018 |
dU.S. Department of Health and Human Services Healthy People 2030 |
NA – not available |
While Acres Homes is a high-need community, it is also rich in assets, including actively engaged community members, organizations, and small businesses. In 2017, Acres Homes was selected as a part of the Mayor of Houston’s Complete Communities initiative [13]. Communities were selected by the city of Houston based on being underresourced, having diverse demographic and physical characteristics, and maintaining a consistent level of community activism.
For each community selected, city of Houston leaders worked with residents and community organizations to develop an action plan focusing on a vision and specific goals to be carried out in a variety of areas, including health. For Acres Homes, the community prioritized four areas related to health: 1) increase access to fresh and healthy food, 2) nurture healthy and active living, 3) improve parks, trails, and community centers, and 4) improve well-being by expanding healthcare services and programs across the neighborhood. Through interviews and discussions with the Steering Committee formed during the community assessment phase, it was clear there was a strong desire to move forward with the health components of this plan, particularly as there had been little action since its creation in 2018. Specifically, there was an interest in doing work related to healthy eating and active living.
Planning Phase: Be Well™ Acres Homes
The planning phase of the project meant moving from the Community Assessment phase of the Be Well Communities model (Fig. 1) to launching Be Well™ Acres Homes and creating a new, health-focused Community Action Plan with organizations funded and activated to carry out EBIs. The following aims guided the planning phase:
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Aim 1: Convene community stakeholders (i.e. stakeholders as defined through an inclusive lens and leveled power structure lens as everyone with equal voice and agency in community decisions and community governance for health, including by not limited to residents, schools, nonprofit organizations, faith-based institutions, public and private entities, etc.) to share results of the Acres Homes Community Assessment, develop a common agenda, and facilitate strong community partnerships.
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Aim 2: Provide support and capacity building to community-based organizations in Acres Homes.
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Aim 3: Develop a Community Action Plan with the Be Well Acres Homes Steering Committee.
These aims were executed through convening monthly Be Well Acres Homes Steering committee meetings, hosting trainings, and facilitating discussions with key stakeholders. Critical to the success of Be Well Acres Homes is fostering multi-sector collaboration through the steering committee and other meetings. See Table 3 for a summary of related meetings and topics covered.
Table 3
Be Well Acres Homes Meeting Timeline
Month | Topics | Attendees |
September 2020 | • Introduced the project and the Be Well Communities model including topics such as the collaborative approach, shared goals, target areas for interventions, utilization of evidence-based interventions, and focus on sustainability • Reviewed Steering Committee structure • Fostered trust and dialogue among all participants | 32 |
October 2020 | • Reviewed Community Assessment findings and validated results with attendees • Heard from a long-time resident about the history and opportunities for Acres Homes | 45 |
November 2020 | • Hosted presentations on current community programming related to healthy eating, healthcare open enrollment and COVID-19 testing and information | 46 |
December 2020 | • Hosted presentations on current community programming related to active living, gardening & community resources • Reviewed the Be Well Communities process for becoming a funded collaborating organization | 53 |
January 2021 | • Reviewed evidence-based interventions for implementation including the specific options available for consideration and prioritization • Hosted presentations on current community programming related to health outdoor initiatives and community health • Hosted collaborating organization training on selecting evidence-based interventions, developing objectives and evaluation measures, program planning, and timeline development | 52 |
February 2021 | • Hosted presentations on current community programming related to Safe Routes to School & community resources | 63 |
March 2021 | • Hosted presentations on current community programming related safety and physical activity | 57 |
April 2021 | • Reviewed Be Well Acres Homes proposals • Voted on proposals and Community Action Plan overall | 69 |
May 2021 | • Provided recap as well as additional information on Be Well Acres Homes proposals | 56 |
June 2021 | • Finalized Community Action Plan, based on voting and feedback • Reviewed Stakeholder Survey Pre-assessment results • Hosted presentation on current community programming related to gardening and public transportation • Sent out follow-up Stakeholder Survey in follow-up to meeting | 57 |
July 2021 | • Confirmed final Community Action Plan • Hosted community presentations and planned for the following year | 50 |
All meetings were hosted over the Zoom meeting platform due to the on-going COVID-19 pandemic |