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HKHC Case Examples: Communities Putting Prevention to Work

July, 2012 CPPWlogoGears.ashx_

Communities: Chicago, IL, Hamilton County, OH, Jefferson County, AL, King County/Seattle, WA, Louisville, KY, Omaha, NE, Philadelphia, PA, Multnomah County/Portland, OR, and San Antonio, TX

The leading causes of premature death in the United States are directly associated with obesity and tobacco use. Because obesity and tobacco use are preventable, the U.S. Department of Health and Human Service created Communities Putting Prevention to Work (CPPW) grants to address these two issues through funding environmental interventions in 50 communities around the country. The grant is administered by the Centers for Disease Control and Prevention (CDC). Starting in March 2010, nine HKHC communities (three HKHC Leading Sites and six Round Two sites) were awarded CPPW funding. In many ways, these HKHC communities were primed for this type of work as it has similar characteristics of the HKHC initiative: policy and environmental change, coalitions and partnerships and collaborative approaches to create sustainable change. Unlike the HKHC grant, the CPPW communities were given more funding and less time (two years) to implement the strategies. The following vignettes tell the stories of six sites and how the HKHC and CPPW initiatives complemented one another, created synergy and sometimes worked through barriers.

Case Examples

Chicago, IL: Moving the Needle towards a Healthier Chicago
Chicago has a history of policy and environmental change that promotes healthy living. The Logan Square Neighborhood Association was part of RWJF’s five-year Active Living by Design grant in 2003 and was designated as an HKHC Leading Site in December 2008. A close partner to the HKHC initiative, the Consortium to Lower Obesity in Chicago Children (CLOCC), submitted the CPPW application on behalf of the city a little over a year after HKHC started. The CPPW funding in Chicago focused on four issues in ten Chicago communities: food access, breastfeeding support, safe walking and biking and the school environment. While all four of these issues complement the HKHC Chicago partnership’s goal of lowering childhood obesity in Chicago, the area most aligned to build on the HKHC work was the safe walking and biking component. The CPPW-funded work is impacting the HKHC initiative, and visa versa. Lucy Gomez, the HKHC project director, said, “HKHC can only move the needle so far,” and having both efforts allows for the city to invest more resources into creating safe parks, which includes lowering speed limits around parks. The HKHC initiative, and a piece of the CPPW effort, is to put parks on the radar and create a culture where people think about park zones the same way they think about school zones. As Lucy puts it, “it is changing the way people think about where children are.”

Jefferson County, AL: A Strong Foundation Starts with Strong Blueprints
Three and a half months after Jefferson County was awarded the HKHC grant, they also received the CPPW grant. Amanda Storey, the HKHC project director said, “HKHC was a blueprint for the CPPW application and thinking through it […] a game plan was already in place.” The HKHC partnership took what was written for the HKHC proposal, enriched some of the elements, added partners and intentionally overlapped some areas of the initiatives to enhance support. Storey says, “CPPW was a way to add to what was already being done,” and in some cases, the partnership purposefully overlapped the initiatives to enhance support. But not without some challenges. Early on, Jefferson County partners recognized the need for a joint task force, as some of the focus areas, including the school system and child care centers, were feeling inundated with requests from partners associated with HKHC, CPPW and other grants. Forming a joint task force was also helpful for many of the partners who realized they were attending different meetings with similar agendas.

Over time, the joint task force, including those associated with the two different funding sources, aligned their efforts to streamline communications and more effectively create changes in the community. The HKHC and CPPW partners, along with the school wellness coordinators, Children’s Policy Council of Jefferson County and Jones Valley Urban Farms, have worked together to create new wellness policies in six of the county’s 12 school systems. Many of these policies reengaged school-based wellness committees, which began implementing Safe Routes to School programs and other pieces of the wellness policies that work best for the individual schools. The child care setting is also an area where the groups joined forces for enhanced support. The HKHC workplan included advocating for nutrition and physical activity standards in child care centers. Where the HKHC partnership could only put together a stakeholder group to focus on this piece of the workplan, CPPW provided additional support that included a dedicated staff person in this role. This provided more structure, and 100 Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) could be done. This type of assessment within 100 child care centers could not have been done with just HKHC.

HKHC allowed the time to cultivate relationships with the community while the CPPW initiative, which had a shorter timeline, intentionally focused on engaging elected officials. Between the two funding sources, the task force could simultaneously focus on top-down and bottom-up strategies to effect change. When speaking about both grant awards, Storey simply said, “The intention is good and policy-based, and now we have the additional dollars that can move it forward faster.”

King County/Seattle, WA: Lifting up Residents’ Health-Related Needs
The King County Housing Authority, along with the Seattle Housing Authority, received an HKHC Leading Site grant from RWJF in December 2008. Over the next year and a half, the partnership realized they would fall short on some aspects of their community-developed workplan due to their limited resources. The CPPW grant allowed the King County Housing Authority (KCHA) to garner additional resources, ensuring the goals of the community would be met. Elizabeth Westburg, the HKHC project coordinator with KCHA said, “KCHA was poised to successfully apply for CPPW funds because of the prior work we had done with our HKHC project. Through our HKHC initiative, we conducted focused resident outreach to identify HEAL related priorities of our residents and other stakeholders.”

The leg-work done through HKHC to identify community priorities made the CPPW application process easy. One of the CPPW priorities focused on healthy food in child care and after school youth programs, which was also a priority of the KCHA residents. Elements of the CPPW grant included developing and implementing Nutrition and Physical Activity standards in on-site child care and youth programs with the county housing authority. This fit perfectly with the HKHC work already taking place: the partnership could quickly develop these nutrition standards and policies after they received the CPPW funding.

With additional money brought additional partners to support this work. The partnership – at this point, some working on HKHC and some focused on CPPW – were able to broaden their reach, leverage additional support and accomplish more of the community’s goals. Westburg said, “CSHEL [the Coalition for Safety and Health in Early Learning] was able to develop best practice standards and train us on them, Seattle King County Public Health Department was able to provide additional technical assistance, Child Care Resources has been able to provide one-on-one technical assistance, resources and support to our child care providers, and we were able to pilot a CSA-style Healthy Kid box through Puget Sound Food Network.” Because of the HKHC funding, Westburg doubts that the housing authority would have even explored the CPPW opportunity. Now with both funding streams working in complementary ways, KCHA has the resources to develop and implement new health standards, create longer term partnerships and support the community in more comprehensive ways.

Multnomah County/Portland, OR: Working with Non-Traditional Partners for Sustained Change
The HKHC grant lasts for four years and the CPPW grant lasts for only two, but the work related to these initiatives in Portland, OR will last long after the funding is gone. The two initiatives are not duplicating efforts but finding complementary ways to impact long-term plans and policies. The comprehensive plan, called the Portland Plan, includes technical advisory groups that have representatives from the HKHC and CPPW initiatives at the table. Amy Gilroy, the HKHC project director and a part of the CPPW team, said, “HKHC has helped us to become more knowledgeable where some policy gaps are.” HKHC deliberately included an assessment period and many of those gaps were identified during that time. Having a few staff from Oregon Public Health Institute (OPHI) involved in both initiatives created an efficiency that prevented redundancies and overlapping efforts. This allowed CPPW funds to be used for purposes that were not already being addressed through HKHC. Gilroy said, “There was overlap with the Portland Plan and Healthy Housing, but otherwise, not too much.” Overlap occurred when the partnership realized a stronger, joint effort was needed.

It was important to move the work beyond the health sector and to include nontraditional partners. CPPW funds helped the City’s Bureau of Planning and Sustainability, which worked with OPHI, to look at zoning codes through a health lens. Gilroy is working to integrate healthy foods into updated zoning codes, which includes looking at soil quality, water quality and food safety. The HKHC and CPPW initiatives both worked on urban food zoning. Through HKHC, the partnership was interested in encouraging community gardens, which led to a zoning scan analysis. They found that the zoning codes included some barriers and some incentives for urban growers. This inconsistency encouraged the partnership to focus on eliminating barriers and enhancing the incentives. Another goal within the CPPW initiative for Portland includes creating nutrition standards and guidelines in public spaces. The new standards would include all recreation centers and ballparks in Portland. Partnering with the health department also has allowed them to expand their reach. The health department has a Healthy Homes initiative that looks at the quality of the housing, but now they are also looking at housing and design as an obesity prevention strategy.

Portland is working with 30 contractors within CPPW and many other partners within HKHC. These partners are from government agencies, non-profit organizations and advocacy groups developing multi-sector public health strategies to reduce obesity and increase quality of life. This diverse group – working on policy change – is sure to have sustained success in creating a healthier Portland long after these two grant programs are gone.

Philadelphia, PA: Impacting Philadelphia Children, In and Out of School
Health Promotion Council of Southeastern Pennsylvania had already begun the HKHC project when they were approached by the Philadelphia Department of Health to be part of the CPPW initiative. The Council was creating and implementing healthy eating and active living policies in after-school programs. They had been developing their relationship with Out-of-School Time (OST) partners, and in doing so, were able to use these partners to visualize how to expand their HKKHC goals with additional funding. The partnership used the CPPW dollars to support extra resources. Robin Rifkin, the HKHC project director said, “Having the city as partners and their regular feedback helped us learn how we needed to shape the Healthy Living Guidelines and eventually get them approved.” The HKHC partnership allowed for a more iterative and evolving process while the CPPW initiative was more “top down,” and the Philadelphia partnership found that there are advantages to both.

The CPPW funded work has impacted the HKHC work, and together both have already created long-term changes in Philadelphia. Rifkin said, “Our work was to create policy for Department of Human Services-funded OST Programs in Philadelphia.” The partnership created the Healthy Living Guidelines, which were standards implemented in nine pilot sites in 2011. The HKHC partnership also created a resource toolkit to support those pilot sites. The Healthy Living Guidelines were approved in March 2012 after successful implementation in the nine sites. The City has now accepted OST’s recommendations for afterschool standards for physical activity and healthy eating. These standards will be implemented in over 209 sites in Philadelphia and will reach 20,000 children.

The CPPW and HKHC partnership includes OST programs, city government, nutrition, food services, physical activity experts, evaluators and youth and their families. Together, it has positively shaped the environment in which youth attend after-school and summer programs in Philadelphia. Their approach focused on individual behavior change to understand the whole system, and in turn used the whole system to create positive strategies for change.

San Antonio, TX: Moving at Multiple Speeds to Achieve Change
San Antonio began mobilizing partners for the HKHC proposal in early 2009 before being funded in late 2009. These partners worked together without any promise of funding for nine months, and this showed their commitment to pursuing the objectives. David Clear, HKHC San Antonio project coordinator said, “We feel strongly that the success of our HKHC and CPPW programs are in large part due to the nine months of time that we spent building relationships with all of the new partners during the HKHC application process. The lengthy application process allowed our community the necessary time to build the solid partnerships that have now become the cornerstone of our obesity prevention programming in San Antonio.”

The partners and projects that were proposed in the HKHC application also became the starting point for San Antonio’s CPPW application proposal. CPPW helped expand the initiatives to cover a broader geographic area. However, a key challenge San Antonio faced was the slight difference in focus and timing between HKHC and CPPW. The major focus for San Antonio’s CPPW initiative was on job creation through health and wellness initiatives, while the HKHC initiative had a more direct focus on childhood obesity prevention and health disparities. The difference in timing was also substantial, and the two year CPPW effort was ambitious. Interestingly enough, it was challenging to spend down CPPW funds in the time allotted while meeting deadlines. Clear says, “Although HKHC has a smaller budget, the four year timeline of the grant enables incremental change, the ability to slowly build relationships with partners and community stakeholders, and I feel like we are slowly moving the ball forward in childhood obesity prevention.”

Having CPPW funding allowed the partnership to focus on quick wins, bringing health issues in the community to the forefront. This strategy will be an asset to the HKHC work in the last year and half of the grant. Although the San Antonio partners sometimes have different agendas, the initiatives that require collaboration, like HKHC and CPPW, have allowed agencies and organizations to learn about each partner, and complement each other’s needs and abilities, in order for the greater movement to be successful.

Lessons Learned
Funding partnerships, rather than individual organizations and agencies is an increasingly common approach, , seen by funders as using their funds most effectively. Collaboration and pooling resources among multiple agencies and across sectors creates a more impactful lever for change. CPPW and HKHC are initiatives that considered a community’s capacity, likelihood and readiness to create sustainable changes in communities before funding them. Having a partnership in place that already shows elements of success is a first step organizations should take before considering applying for grants of this nature. HKHC partnerships’ ability to quickly mobilize and collaborate on CPPW project proposals assisted in the application process and made these groups more attractive to funders.

Engaging the community and understanding the community’s needs is also vital to knowing what is both important and achievable within a project proposal. Prioritizing those needs was important for HKHC communities; however the capacity or resources were not always available to accomplish the goals in an efficient way. CPPW allowed these HKHC communities the opportunity to reconsider what was possible, given the amount of new resources made available.

Both initiatives required communities to focus on policy and environmental changes. For some communities, this shifted their public health improvement approaches away from awareness campaigns and individual education but to large-scale, environmental change. This brought on partners who had commonly been left out or of the public health conversation. Working with non-traditional partners for public health goals has helped those organizations and agencies to re-consider their strategies, which may not have been a top priority for them in the past.