Supporting Community-based Healthy Eating and Active Living Efforts in Sustaining Beyond the Funding Cycle

Supporting Community-based Healthy Eating and Active Living Efforts in Sustaining Beyond the Funding Cycle

RESEARCH ARTICLE Supporting Community-based Healthy Eating and Active Living Efforts in Sustaining Beyond the Funding Cycle Rebecca D. Ochtera, PhD,1...

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Supporting Community-based Healthy Eating and Active Living Efforts in Sustaining Beyond the Funding Cycle Rebecca D. Ochtera, PhD,1 Claire J. Siemer, MPA,2 Leslie T. Levine, MPH2 Introduction: Considerable research has been done to define, conceptualize, and study sustainability for public health initiatives. New research suggests evaluating sustainability through additional characteristics, like type of intervention or focus of change, may help uncover differences in approaches and resources needed for sustainability. Additionally, available research often misses perspectives from those involved on what is necessary to sustain strategies long term.

Methods: Data collected through community reports and interviews with eight Colorado communities implementing large-scale community-based healthy eating and active living initiatives were used to document strategy characteristics, barriers to sustainability, and community-based perspectives on supports needed for long-term sustainability. Characteristics of implementation were also assessed based on intervention type (program, environment, policy) and to identify similarities and differences in implementation.

Results: Policy and environment interventions were sustained more often compared with program interventions. Coalitions or formal committees, community-level coordination, and diverse partnerships were associated with sustainable strategies regardless of intervention type, though primary transition partners varied by intervention type. Loss of a sole champion and shifts in institutional priorities were common barriers for sustainability. Communities requested supports for creative funding and formal coordination, public and political will-building, inclusivity, and advanced evaluation methods to support long-term sustainability.

Conclusions: Findings suggest that community intervention strategies can be highly sustainable, particularly for environment and policy change, and suggest strategies may require similar, yet tailored, partnerships based on intervention type. Additionally, supports requested highlight sophisticated community needs, offering important insights for how providers and funders can best support communities in long-term sustainability efforts.

Supplement information: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health. Am J Prev Med 2018;54(5S2):S133–S138. & 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (



urrent public health efforts place significant emphasis on sustainability, particularly for stakeholders investing in long-term community-based initiatives to improve community health. Much research has been done to define sustainability, conceptualize and

From the 1Spark Policy Institute, Denver, Colorado; and 2LiveWell Colorado, Denver, Colorado Address correspondence to: Rebecca D. Ochtera, PhD, 2717 Welton Street, Denver CO 80205. E-mail: [email protected] 0749-3797/$36.00

& 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. This is Am J Prev Med 2018;54(5S2):S133–S138 S133 an open access article under the CC BY-NC-ND license (


Ochtera et al / Am J Prev Med 2018;54(5S2):S133–S138

Table 1. Definition of Intervention Types Intervention type Program Environment Policy



Coordinated activities that promote Healthy Eating Active Living (HEAL) behaviors for voluntary participants Infrastructure improvements that intend to increase access and availability to HEAL opportunities Formally recommended or required actions that promote systemic HEAL behaviors in organizations, institutions, and/or communities

Education classes, physical activity programs and clubs Playground equipment, bike paths, recreation center improvements Vending machine requirements, school wellness policies, adopted physical activity curriculum

frame its components, and document the implementation characteristics, like coalition involvement or institutional features, associated with sustainability.1–11 More recent research suggests the field may be better served by also researching sustainability based on variables beyond implementation characteristics.12,13 This expansion is important to support the field in a greater, and more nuanced, understanding of what drives sustainable change. As an example, public health research has often focused on sustainability specifically for public health programs that influence individual behavior change. However, sustaining strategies for other types of intervention (such as environment and policy intervention that support systems change) are also fundamental within public health frameworks.14,15 Greater understanding of factors, like the type of intervention pursued, may help to inform potentially important variations in the approaches, influences, and resources needed for sustainability. The available research also includes a wide variety of perspectives on what is needed to sustain interventions long term. However, it often misses the perspectives of those within the community regarding what they believe is necessary to ensure sustainability. Those involved at the community level have been identified as key to strategy design and implementation, community action, and sustainability.16 Capturing their perspectives brings firsthand knowledge and experience to research, helping to generate key insights and bring greater understanding of the capabilities and needs a community faces when working toward long-term change. This paper seeks to address these issues utilizing evaluation data from the LiveWell Colorado Community Health Initiative (LiveWell, CHI), a multi-year, multi-community intervention implementing healthy eating and active living (HEAL) strategies to improve population health. The evaluation, undertaken at the end of the Initiative’s funding cycle, was intended to help support LiveWell in understanding community progress towards sustainability as well as to explore ways to provide meaningful services and supports for communities beyond direct funding.

METHODS LiveWell has provided funding, oversight, and technical assistance to 25 Colorado-based CHI communities since 2007.17,18 At its initiation, the organization worked with selected communities to develop or strengthen existing HEAL efforts, including support for developing or strengthening community coalitions and funding for the community to hire a coordinator who could provide formal support and organization across identified HEAL strategies. Eight communities with 8- to 9-year funding cycles, whose funding either ended or was significantly reduced by the end of 2016, were selected to be the focus of an evaluation to inform LiveWell’s continuing efforts to support communities beyond funding. These communities implemented, and regularly reported on the progress of, a variety of HEAL strategies to address community health through coordinator-written reports and check-ins. Communities were also asked to submit documentation, such as data or reports, to demonstrate strategy progress and impacts. Available progress data collected from community reports were used to identify and code strategies implemented as sustained (continued in part or in whole by entities and funding other than LiveWell); possibly sustainable (operating on reduced support and funding by LiveWell); and not sustained (strategies no longer supported by LiveWell and not continued by another community entity). Strategies were also coded by primary intervention type (policy, environment, program; defined in Table 1)a and by intervention setting (school, community) as well as by implementation characteristics available in the data including coalition or formal committee involvement (yes/no); partners involved (community member, nonprofit/service provider, government agency, business, school district, university); and institution providing oversight in 2016 (community organization, government, business, school district). To initiate the coding process, a sample of strategies across communities were individually reviewed and coded by four staff and research team members. Coded data were then reviewed by the team to refine coding definitions. Final coding was completed by two team members; any discrepancies were reviewed and a final code was jointly determined. Brief phone calls were then conducted with the majority of community coordinators in July 2017 to verify a The definition of “intervention type” used for this evaluation differs from the definition in Scheirer (2013). Where Scheirer presents intervention type as who or what is needed for continued delivery of an intervention, this evaluation uses intervention type to describe the primary focus of intervention for a strategy.

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Table 2. Sustainability of Primary Strategies Implemented Over the Funding Cycle School setting (n¼60, 69%) Type of intervention Program (n¼42) Environment (n¼30) Policy (n¼15) Sustainability by setting

Sustained, n (%)

Possibly sustainable, n (%)

Not sustained, n (%)

Sustained, n (%)

Possibly sustainable, n (%)

Not sustained, n (%)

19 (45) 15 (50)

3 (7) 1 (3)

5 (12) 2 (7)

9 (21) 11 (37)

1 (2) –

5 (12) 1 (3)

15 (100) 49 (81)

– 4 (7)

– 7 (12)

– 20 (74)

– 1 (4)

– 6 (22)

codes and finalize ratings. For sustained strategies, implementation characteristics were then assessed by intervention type and intervention setting to explore strategy similarities and differences. Data from two phone interviews, completed in July and November/December of 2016 to support LiveWell’s overall evaluation of the initiative, provided additional insights to more deeply explore community progress related to coded report data. These calls used semi-structured interview guides derived from components of LiveWell’s proposed model of community readiness to implement HEAL in order to explore community progress as well as identify continuing perceived resource and support needs (Appendix A). Communities were provided the interview guides in advance to support preparation for the calls. Interviews were conducted for each community by one to two LiveWell staff and a member of their external evaluation team. Interviewees included a mix of community-based CHI community coordinators, evaluators, and support staff. Interview notes were triangulated to create a comprehensive transcript that was reviewed and coded by a member of the research team using deductive codes initiated from the interview guide (Appendix A). For each community, a twopage summary document was developed from the coded data and sent to interviewees for review and feedback. Research team data dialogues were then used to develop, refine, and synthesize themes across communities related to community progress, including facilitators and barriers to sustainability, and perceived needs for long-term sustainability. As a final step, interviewees were sent a copy of the drafted manuscript for review and asked to provide feedback to ensure accurate representation of information and interviewee perspectives.

RESULTS Information was collected and analyzed for 87 strategies implemented across the eight communities (Table 2). Of these 87 strategies, 69 (79%) have been sustained; 5 (6%) are in position to be sustained; and 13 (15%) were not sustained. Almost half of the 87 strategies (48%) were program interventions; 34% sought to create environment change; and 17% focused on policy change (which occurred only in school settings). The majority of these strategies (n¼42) took place in school settings (69%), though sustainability rates were relatively similar across May 2018

Community setting (n¼27, 31%)

settings (school, 81%; community, 74%). Strategies focused almost equally on active living (54%) and healthy eating (46%). Policy and environment strategies were sustained more often compared with program strategies despite being implemented less often over the funding cycle. This was true in both community and school settings (Table 2). Coalitions or formal committees were highly involved in sustained strategies regardless of intervention type. Engagement ranged from 73% involvement in school policy strategies to 91% involvement in community environment strategies. These groups most often played strategic roles early in design, implementation, and oversight. Many of these coalitions and committees drove the work through coalition action teams that included a mix of community leadership and local residents or grassroots champions. Similarly, funded community coordinators were involved champions for all tracked strategies. The role of a formal coordinator was described as a key capacitybuilding partner. These individuals were unique in that they built relationships and sustained HEAL momentum by being a stable and dedicated support across the community’s portfolio of HEAL work. They used historic knowledge of HEAL strategies and partners to build consistency for the initiative, promote connections, and ensure resources were available to respond to changing community priorities and influences. All sustained strategies included diverse community partnerships, with the majority (70%) of sustained strategies involving three or more types of partners. Community members, service providers, and government entities engaged in the majority of strategies implemented in both community and school settings, with the exception of less government involvement (26%) in school programs and less community member involvement (22%) in community programs (the latter because of a variety of program strategies run by institutions without specific need for community member support). Businesses and universities were present partners but less involved; approximately 20% of program and just 430% of environment strategies


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included business partners, and o15% of all strategies involved university partners across community and school settings. How these partners were typically involved is described below. In community settings, community residents and leaders were most often included in strategy planning and decision-making processes to help ensure strategies met the priorities and needs of the community. Parents volunteered significant time and resources to HEAL program activities, for youth in school as well as community settings. Municipal government divisions, including community development, parks and recreation, and public works largely provided funding and supports for environment strategies. County departments of public health and environment were additional collaborative partners, providing technical assistance, funding, and programming support primarily for sustained healthy food strategies. When involved, businesses primarily participated in planning, decision making, and resource allocation for sustained strategies whereas university staff and students supported program implementation and evaluation services. The diverse partnerships involved played important roles in transitioning strategies to community ownership. Of strategies based in the school system, school districts now oversee close to 75% of school program and environment strategies and 100% of school policy strategies. School districts are utilizing wellness committees, school-funded wellness coordinators, community coalitions, and contracts with district-based food suppliers and nonprofits to continue the work initiated through LiveWell CHI. Community nonprofits and government entities have been the transition partners for the remaining school strategies. Within the community setting, government entities now support the majority (64%) of sustained environment strategies and 33% of program strategies. Service organizations, and to a small extent community businesses, are also involved in community strategy ownership, supporting 27% of environment strategies and 44% of program strategies with a primary focus on healthy eating. School districts make up the rest, supporting 10% of environment and 22% of program strategies in the community. Two predominant themes emerged in both school- and community-based settings for strategies that were not sustained. These strategies were mostly program-based interventions that lost a primary champion or succumbed to priority shifts at the institutional level. School-based barriers occurred primarily when a strategy depended upon one primary champion or champion group who was lost through staffing transitions or through school systems shifting priorities to focus on more academic activities or both. Within community settings, the loss of a prominent champion or group through retirement, work transitions, and changing organizational priorities were

described. Additionally, several strategies were not sustained specifically because of the loss of a local government champion or changes in government leadership negatively influencing funding and support. Input from interviews on ways to overcome barriers and more generally promote longer-term sustainability fell into five main categories:

Help to Develop Capacities for Creative and Diverse Funding Communities recognized finding and acquiring funds will be a continual need. A few communities expressed the desire to explore new or different funding options. Public/private sector partnerships,19 blending/braiding funding strategies,20 and help advocating for funding collaboration versus competition, such as collective impact models, were all mentioned.19–21 Supports to Help Shape Political Will Several communities expressed a desire for additional supports to help communities better understand and influence political agendas through engaging in the political process. Suggestions included policy advocacy training to support building relationships with decision makers, and community education on local political context to increase understanding of political impacts on the community and to build will to advocate. Help to Sustain Partners Through Capacity Building, Inclusion, and Communications Some communities noted maintaining involvement from community volunteers could be difficult, particularly for those most affected by HEAL issues, thereby reducing opportunities for equitable community voice. Continued supports to grow community engagement would be helpful, including capacity building for individuals, coalitions, and agencies to help them transition effectively into leadership roles. A few communities also noted additional marketing and communication support could be a significant benefit by helping tell success stories and share impacts of the work in a way that motivates community involvement and funder support. Several communities requested supports to build community skills for conducting evaluations that map to the strengths and voice of the community, including training in participatory evaluation methods to help communities better understand, buy into, and improve strategy efforts. Additionally, a few communities reported working to develop or identify measures related to community impact, resident engagement, and collective impact to more effectively assess and validate their work. Exposure to and use of methods and metrics that provide community- and systems-level

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tion results, like community resilience and return on investment, could help promote a more realistic and comprehensive understanding of strategy impact. These results could also be used to build public and political will, as well as help support funding efforts.

Support Funded Community-level HEAL Coordination Efforts to sustain HEAL strategies across the community required dedicated time and coordination perceived to be beyond what could typically be supported through nonpaid community volunteer investment. Ensuring some type of formal commitment to a community-level coordinating role across strategies was viewed as a necessity for sustaining strategies as well as the connections and knowledge needed for long-term success.

DISCUSSION For Colorado-based LiveWell CHI communities, policy and environment strategies were pursued less often during the funding period, yet these strategies sustained more often than program strategies when reviewed at the end of the funding cycle. This reinforces research findings that suggest these strategies are more difficult to pursue but may be more likely to sustain given they require less resources over time.14 This is also important as these types of strategies can more effectively promote inclusivity and equity, issues these communities felt were important to address.12 Community members, service providers, and government entities were linked to sustainability across community and school settings, regardless of intervention type, with the caveat that the partner most important for transitioning to community oversight may look different depending on intervention type. For example, municipal government tended to support environment, particularly active living, whereas community organizations were more likely to support programs and healthy eating within the community setting. This suggests diverse partnerships are important throughout the life cycle of the strategy, but successful transition to a community partner may be more successful when tailored by intervention type. Additionally, the concept of diverse partnerships was further supported by findings that point to the fragility of relying on a single individual or group for sustainability and suggests a network of partner champions, including those in formal institutions, may be an attribute that provides resilience for sustainability. In addition to a breadth of community partners, formal community coordinators’ connections were supportive across strategies, providing cohesion and stability to the work implemented within the community. This role of cross-strategy connector is not typically discussed May 2018


in the literature but may be important to explore further and may help to explain the relatively high rate of sustainability for LiveWell CHI community strategies.11 Specific community requests for support suggest technical assistance needs over long-term funding cycles may involve more sophisticated capacities and resources to implement and sustain population-level change. These capacities include support for innovation, large-scale community mobilization, and building community efficacy to assess efforts as well as impact in both traditional and nontraditional ways. These requests provide unique insights for funders and technical assistance providers on supports that can be implemented proactively, well before the funding cycles near their end.

Limitations This study provided evidence that policy and environment strategies were more likely to sustain compared with program strategies. The effectiveness of these sustained strategies, however, was not evaluated. Demonstrating the value of sustained strategies for the health of the community should be researched to provide greater context to the importance of these results.6 Additionally, the data available for not-sustained strategies provided additional support to findings related to the importance of diverse partnerships; however, the limited number of not-sustained strategies reduced the ability to speak to group differences and further validate findings overall. Finally, formal coordinators were a primary source of information for this evaluation. This is an important perspective, as coordinators provided support across the spectrum of strategies implemented within the community. Nevertheless, including additional community perspectives in future studies would enhance insights and provide additional context to the current findings.

CONCLUSIONS Findings suggest the type of strategy pursued for a community-based HEAL initiative may impact sustainability, with environment and policy strategies potentially more likely to sustain compared with programs. These different types of intervention demonstrated similar implementation characteristics related to types of partnerships, but differences in primary transition partners. This suggests that similar, yet tailored, approaches to partners may be important depending on intervention type. Additionally, supports identified and requested highlight sophisticated community-based technical assistance needs for sustainability after longterm funding cycles. These requests offer important insights for how providers and funders can best support communities in long-term sustainability efforts.


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ACKNOWLEDGMENTS The following institutions and grants contributed to the work included in the evaluation and the publication of this article: Kaiser Permanente, DA-2014-53119; The Colorado Health Foundation, Grant 2578; The Colorado Health Foundation, Grant 4837; The Colorado Health Foundation, Grant 5910; The Colorado Health Foundation, Grant 6459. The authors acknowledge and thank Kaiser Permanente as well as the other funders for financial support. The authors would like to thank the participating LiveWell Community Health Initiative communities for their valuable insights and investments in community health. We would also like to thank Loan Nguyen and Terri Livermore for their significant roles that helped to support data collection, data management, data analysis, and reporting. Spark Policy Institute received funding from LiveWell Colorado to implement evaluation activities described in this manuscript and to support the writing and review of this manuscript. Dr. Rebecca Ochtera, an employee of Spark Policy Institute, was the primary developer of this manuscript, including design, data collection and analysis, report and manuscript writing and review, and the decision to submit this manuscript for publication. Claire Siemer and Leslie Levine, as employees of LiveWell Colorado, participated in evaluation activities that led to the development of this manuscript, including data collection, data analysis, report and manuscript review, and the decision to submit this manuscript for publication. No financial disclosures were reported by the authors of this paper.

SUPPLEMENTAL MATERIAL Supplemental materials associated with this article can be found in the online version at amepre.2017.12.019.

SUPPLEMENT NOTE This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives: Evaluations from 10 Years of Kaiser Permanente's Community Health Initiative to Promote Healthy Eating and Active Living, which is sponsored by Kaiser Permanente, Community Health.

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