Experimenting with Collective Impact for Childhood Obesity: The 5 Conditions

In today’s 3rd post of our 4-blog series, we explore how the 5 conditions of collective impact—common agenda, shared measurement, mutually reinforcing activities, continuous communication, and backbone support— play out in childhood obesity efforts. Several obesity prevention initiatives are implementing elements of the collective impact model and are pushing the thinking on what the elements mean for public health more generally.

Common Agenda

Aligning partners around a common agenda is a critical first step in collective impact. With so many potential areas in which to intervene to address to childhood obesity, practitioners and partners may feel a desire to attempt to address all potential contributing factors; however, doing so may dilute overall impact by spreading resources too thin. Defining a clear vision and strategy will aid in keeping efforts focused around the primary objective.

One key question related to the common agenda is whether the initiative’s primary objective is to prevent obesity or is to promote healthy eating and physical activity, with a reduction in obesity occurring as a result. This will impact strategic choices made about where to focus the effort.

In crafting a common agenda, consider the areas of influence of the partners at the table. For example, if school administrators and food service personnel are not involved, improving school-based nutrition and physical activity would probably not be a key strategy. Another approach would be to identify strategies to which all partners can contribute in their own way. In pursuit of its common agenda to create healthy environments for all children and families through advocacy, education, policy development, and environmental change, the San Diego County Childhood Obesity Initiative recently adopted two overarching strategies that each sector will work toward implementing in some way: (1) reduction of access to and consumption of sugar-sweetened beverages and (2) safe routes to healthy places (active transport). This approach keeps activities aligned in pursuit of the common agenda while leveraging the influence and assets of the partners.

Shared Measurement

A key component of collective impact is the development of a common set of shared measures that allows a community to track progress and adjust and improve over time. Many childhood obesity practitioners identified shared measurement as the most challenging aspect of collective impact-inspired work. Thinking creatively about the types of measures collected and tapping into existing measurement systems can make the data collection process more manageable and impactful. 

Assessing impact related to nutrition and physical activity is not always straightforward and can leave practitioners wondering “is this really working?” While shared measurement is challenging in any discipline, several characteristics of obesity prevention make it especially difficult:

  • Lag time between the delivery of an intervention and its effect on BMI;

  • Dose of the intervention needed to have an effect on BMI; and

  • Challenges with measuring BMI among a large target population.

To address some of these difficulties, practitioners should consider including additional measures that focus on processes and outcomes that can eventually lead to lower BMI. Let’s Go! Maine, for example, has successfully engaged partners to collect data on measures such as:

  • Awareness of Let’s Go! And the initiative’s primary health-related message. (Assessed via a statewide survey.)

  • Policy and environmental change based on 10 key strategies for promoting behavior change. These measures are collected in different environments across all sectors.

  • Behavior change related to nutrition and physical activity. (Assessed through a statewide school-based survey.)

  • Obesity prevalence among youth. (Assessed using publically available data.)

Tapping into existing data collection systems, such as the Youth Risk Behavior Surveillance System, can also help mitigate the burden of data collection among a large target population. For example, many districts and states are now mandating BMI collection and reporting for school-aged children. Public data about physical infrastructure changes, such as the creation of sidewalks and bike lanes, can also serve as tangible measures of success.

Beyond identifying and collecting key measures, issues of credit, recognition, and attribution can also complicate shared measurement. Practitioners are well served when they anticipate these issues and work to ensure appropriate recognition to both the initiative as whole and all contributing partners.

Mutually-Reinforcing Activities

With numerous causes of obesity rooted in different sectors and environments, coordinated action by stakeholders from multiple sectors will be necessary to realize meaningful change. However, determining where to focus efforts in order to create the greatest impact can be challenging. In Northeast Iowa, all partners were engaged on a yearly basis in crafting a collaborative budget. Each put together a dream list of activities based on the action plan that they helped to create and then crafted a budget for executing those activities. All of the budgets were combined into a shared document and the partners then spent six weeks prioritizing the activities based on their potential for impact in pursuit of the shared vision, ultimately agreeing upon a plan for the year. This type of collaboration keeps the partners engaged and can help to ensure that all activities support the overall agenda and vision.

In a constantly changing environment, it can be challenging to find the “sweet spot” of mutually reinforcing activities. Engaging partners in an honest, trustful, and respectful conversation to determine how to best connect activities, and helping them to see connections that aren’t readily visible, can enhance the success of this element. For example, Let’s Go! Maine has found that when talking with school principals, the principals’ primary concern is academic performance, not general student health. Therefore, when the initiative approaches a school in an attempt to engage it with Let’s Go!, initiative staff do not make the case that schools should participate purely to improve children’s health. Rather, they approach the school with significant evidence indicating that healthier kids actually perform better in school. In doing so, they identify ways in which Let’s Go! can help the school and the school can help Let’s Go!. 

Continuous Communication

All of the obesity efforts profiled realized the importance of communication as a critical condition for collective impact. While critical through all phases of implementation, practitioners noted that their approach to communication was adapted to reflect different needs at different times. When the Northeast Iowa Food and Fitness Initiative was getting underway, communication focused on maintaining a commitment to complete transparency by sharing how funds were being used, meeting minutes, other forms of documentation, and evaluation plans and results. Over time, communication has come to play an important role in engaging the partners when changes need to be made to the initiative’s plan. Investing in the development of a robust communication structure during the early stages of an initiative can ensure that the infrastructure exists to nimbly adapt to meet changing communication needs.

Efforts also point to challenges in the demands of continuous communication, particularly in understanding who should receive what information and how to make it timely. As one practitioner put it: “Have we ever had so much information and had such a challenge in communicating?” Surveying key audiences about communication-related preferences can help to ensure that communications are effective and appropriate. For example, the Northeast Iowa Food and Fitness Initiative conducted a survey of external constituents to obtain feedback about how those stakeholders wanted to receive information. As a result of this work, the primary communication mechanism was shifted from longer monthly updates to a weekly newsbit that is more distilled and includes links that provide readers with the option to explore a particular section in more depth.

Initiatives are therefore using a variety of tools to communicate with key stakeholders, including newsletters, newsbits, social media, coalition-wide meetings, workgroup meetings, and annual reports. In selecting communications mechanisms, practitioners benefit from being thoughtful about the ability of different partners to interact with different modes of communication; for example, not everyone has access to a computer during the day, and not everyone can access social media sites at work. Let’s Go! Maine identified its annual report as a key communications medium and therefore invested time and resources into making it highly effective. Whenever possible, community partners and individuals were called out in the report with quotes and pictures to emphasize the community-based nature of the initiative’s work.

According to one practitioner, continuous communication is “never over, accomplished, or completed,” but rather is a living process that evolves over time to meet changing objectives.

Backbone Support

Backbone support is critically important for ensuring collaboration among partners and their respective activities. In childhood obesity efforts, backbone support can help to coordinate order among numerous organizations working in a crowded space. For example, public health officials, school staff and administrators, community-based organizations, colleges and universities, local media, and restaurants are but a few of the cross-sectoral players that participate in childhood obesity efforts. Taking a high-level view, the backbone can identify opportunities for collaboration across the partners and effectively “connect the dots.” In doing so, the backbone does not dictate a course of action for the partners but rather guides them in being effective contributors. LiveWell Colorado, for example, provides overall direction and guidance, resources, technical assistance, networking, and peer learning opportunities to its partners but allows partner communities throughout the state to take the lead in determining what will have the greatest impact in that community.

Backbone organizations serve six key functions:

  • Guide vision and strategy

  • Support aligned activities

  • Establish shared measurement practices

  • Build public will

  • Advance policy

  • Mobilize funding

While effective backbones must fill all of these roles, in a childhood obesity context, building public will and advancing policy are particularly important given increased potential for sustainability when policies, systems, and norms are changed. Perceived neutrality of a backbone is also critical as it enhances the ability to convene diverse stakeholders that lack a history of collaboration and come to the table with different agendas and priorities. Industry partners, who are often critical partners in childhood obesity collective impact efforts, may be particularly skeptical about engaging as they are sometimes viewed as “causing” the obesity epidemic. The presence of a neutral backbone that aims to convene rather than push a specific agenda can help in engaging these critical stakeholders. 

The backbone can sit in any number of organizational types—for example, the Shape Up Somerville backbone is in city government, whereas in San Diego an existing non-profit organization was selected to serve as the backbone. The essential functions of the backbone also do not need to be filled by one organization, but instead can sometimes be shared among multiple organizations. For example, in Northeast Iowa, the approach to the backbone has, to date, been collaborative. When a funding opportunity presents itself, the partners decide together whether or not to apply and who would be the strongest applicant. One advantage to this approach is that it has helped to keep all of the partners on level footing and has created a feeling that they are “all in this together.” However, lack of a designated 501(c)(3) backbone has led to challenges in applying for funding and can result in diffuse accountability among the partners. While it is possible to implement this shared backbone structure, this arrangement must be very carefully thought through and is not the ideal setup in many cases.

Coming up next: Lessons learned for others interested in taking a collective impact approach to address childhood obesity and other public health concerns.

How are you seeing the 5 conditions of collective impact “play out” in a public health issue? We’d love to hear from you!

Vanessa Lynskey is a Master of Public Health Candidate in the Public Health and Professional Degree Program at the Tufts University School of Medicine.

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