Community-based health promotion programs impact the attitudes and behaviors of individuals while programming is taking place, but their influence does not end there. The experiences that participants have affect their health and well-being for years after the conclusion of the program. However, the literature often lacks long-term follow-up with communities, making it difficult to understand programs’ lasting impacts on communities. In this project, we returned to the community to explore the aspects of the FIT4YES PA and nutrition program that continued to influence participants three years later, and discussed possible mechanisms that allowed for the continuation of these behaviors.
Based on our analysis of the interviews, we found that cultural exposure, relationships, and self-growth were necessary ingredients for long-lasting change within this community. The literature also acknowledges the importance of addressing “deep-structure” cultural characteristics such as the values, traditions, acculturation levels, and psychological influences within a community when developing culturally appropriate programs, rather than focusing on only superficial cultural characteristics such as language [18, 19, 20, 21]. The importance of relationships is also commonly described in the literature. Family dynamics have previously been shown to strongly influence individual nutritional choices. Specifically, within the Hispanic community, social support has been identified as the strongest predictor of PA [4, 22, 23]. Safe and trusting relationships between participants and program leaders increase the likelihood of community members engaging in new behaviors [24, 25]. Similarly, exposure to challenging experiences within the safe environment of a community program allows students to develop new skills within that curriculum but also enhances student self-efficacy to engage in novel, challenging activities outside of the context of the program [26, 27].
From our team’s initial qualitative analysis of family interviews immediately after the FIT4YES program, themes reflected the dynamic nature of the program characteristics, and a model emerged based on an adaptation of the SEM. We initially reflected on the static nature of the widely accepted SEM and discussed how this model cannot accurately illustrate how aspects within a program synergize through dynamic interactions at all levels. Our model integrated the derived themes of FIT4YES with the levels of the SEM, linking program “ingredients” into a funnel, which ultimately results in the empowerment of youth to engage in new and healthy activities. This iteration of our program-specific model was intended to be dynamic and evolve over time with new knowledge and experiences. The first model, with revisions after community partner feedback, is provided in Additional File 4.
The absence of comments that fit within the organization level became increasingly obvious with each focus group. Some parents commented on the difficulty of engaging their children in activities without the formality of a structured commitment with mentors and facilitators outside the family unit, reinforcing a common experience. Existing literature supports the beneficial effect on weight management of culturally tailored programs that program leaders directly supervise for the duration of the program [28, 29]. Even though the group consensus favored the reimplementation of the FIT4YES program, multiple ideals instilled by the program remained intact, inspiring the continuation of healthy substitutions into meal-time recipes, activities around the neighborhood, and choosing to become more health-aware throughout daily life. Particularly, our “self-reflection” theme under the self-growth category incorporates each participant’s individual choices. The new skills and knowledge that were gained throughout the program act as an additional tool for families to support health. Not every aspect of the program continued for each family, but the ability for families to reflect and decide for themselves what matters most, we believe, has helped with sustained behavior changes over time.
Our previous model utilized the community and organization to build a safe environment and provide opportunities to gain new skills and experiences. Without the program intentionally creating this top-down “flow,” the community becomes the anchor for sustained change. The individual level is now at the top, supported by each of the levels below. The program ultimately created a strong foundation to continue through the three themes: cultural exposure, relationships, and self-growth. It left behind a legacy with strong memories that continue to influence participants’ decisions. The effect is similar to casting a shadow throughout the community because it occurred within a common community center, the UCC, leading to a constant reminder of the shared experiences with each passing. The ease of remembrance and longing for a new program demonstrates the deep-rooted seeds planted within each individual family. The model progression is shown in Fig. 2.
While it is worthwhile to note that the conclusion of the FIT4YES program led to the loss of structure at an organizational standpoint, it is equally important to emphasize that even without its continued presence, many of the healthy behaviors and life lessons taken away from the program still stuck with the families over time. The children who participated in the program as middle schoolers are now graduating high school, and their parents are moving on to different phases of their lives. Additionally, the discontinuation of the program was compounded by additional life stressors because of the COVID-19 pandemic. Despite this change, our recent discussions with program participants have shown that, while they have evolved as families, their healthy behaviors have evolved with them, even without the accountability provided by a structured program.
Our previous study discussed the interplay of the various components that made this program successful, such as the interpersonal relationships that created a safe, culturally appropriate environment for participants to try new healthy behaviors. This study validates these findings and demonstrates the complexity of creating a sustainable program within this Hispanic community. Perhaps it is not the strength of the program which determines its success. Still, rather it is the strength of its individual components that will ensure the longstanding impact of a community-facing health education program. Like building blocks when a tower is created with intention and a solid foundation, the structure remains intact even if one piece is removed. A successful community-engaged program depends on the strength of its parts, and the strength in what remains, despite the conclusion of formal programming, can help drive the evolution of a community towards a healthier future. These results may be specific to this Hispanic community, which shared a strong bond already due to its geographical location with a longstanding community center at its core; however, the value of the individual components of this ecosystem that make up the whole cannot be understated in implementation of future programs and should be explored in other communities.
The impact of the FIT4YES program was largely catalyzed by its integration within the UCC, a long-standing institution dedicated to the Hispanic community in Milwaukee. The UCC and MU created the FIT4YES program to embody the mission of the UCC: “to transform the lives of Hispanics, families and individuals of all ages by providing the highest quality comprehensive services in education, human services, health, community development and cultural arts” [30]. The harmony between the UCC’s standing commitment to its community and FIT4YES allowed for seamless integration of the program into the fabric of the community. It must be acknowledged that this foundational anchor may be difficult to replicate. The UCC has remained a constant for over 40 years in the Milwaukee community, allowing it to develop into the integral role it now plays. An organization so devoted to and beloved by the community it serves is difficult to recreate but is essential to the success of implementing a program such as FIT4YES in which longevity is a key outcome.
“Because of this [FIT], we had the exposure to those activities, like how to do it, how to access it, and then also helping us financially... We were never going to take him skiing or snowboarding or rock climbing or mountain biking or camping. You know it after Fit that finally, we went camping for the first time like as a family, but if it wasn't for FIT none of that would have ever happened.” – Parent 2, Group 1