By Colleen Gross Ebinger and Sarah Morris

 

“We had achieved more momentum and more success with other projects than we had expected. It gave the group a feeling of “What’s next? Be bold!” There was a rallying cry and that helped us get public health management partners on board for the first conversation.”

—Kelly Corbin, SHIP grant coordinator, Olmsted County Public Health Services, Olmsted County, Minnesota

 

For many years, public health efforts focused on changing individual behavior. The belief was that if people only knew what was healthy, they would make better lifestyle choices. But experience shows that healthy living is not principally about personal choices. Rather, it is impacted significantly through the policies and laws by which we organize our society, the systems in place where we live and work, and the physical environment that surrounds us.

A two-year funding effort by the U.S. Department of Health and Human Services launched the largest policy, systems, and environmental (PSE) change effort to date, providing $373 million to 50 communities nationwide as part of its Communities Putting Prevention to Work (CPPW) program. As technical assistance providers working with 15 communities across the nation on behalf of the Minnesota Department of Health, the two organizations of Grassroots Solutions and Fourth Sector Consulting worked with local community leaders who wanted to ensure that the changes enacted with the grant money could be sustained once the funding ended.

As the CPPW program wrapped up—officially ending in December 2012—we wondered: What could the world learn from communities whose work will live on past the grant cycle? What did they do to prepare for sustainability? Through 11 interviews across six communities, we learned that each had devoted significant time and resources to strengthening community relationships and building local capacity.

 

 

Strengthening Community Relationships

These communities worked intentionally to build and maintain community relationships. They cultivated new partnerships and leveraged existing ones, drawing on both their personal and professional networks while actively supporting the leadership of those within their organization and outside of it. We found them doing this in four important ways:

 

1.            Demonstrating authenticity and commitment to the project and to its partners. Leaders believed that building and maintaining relationships with partners in the CPPW project was essential. They spent significant time identifying and breaking down silos, and building connections between the communities’ public agencies. Open, authentic, and trusting personal relationships between individuals—whether preexisting or conscientiously cultivated during the grant period—enhanced the communities’ formal CPPW partnerships.

In Clark County, Nevada, Outside Las Vegas Foundation Executive Director Mauricia Baca believes the success of her community’s CPPW work can be attributed to the relationships formed in 2008 when a working group came together to promote area trail usage. “That’s a really special element of the whole process—the fact that these are professionals who have gotten used to really working well with one another. Even when their jurisdictions might not always work well together, these people work well together.”

 

2.            Embracing community engagement. From media campaigns to attendance at popular communitywide events, these CPPW teams engaged the public in multiple ways both before and throughout the project. While resource and time constraints limited their ability to formally solicit input from the community in the way that some teams had hoped to do, they were skilled at recognizing and responding to informal feedback received from community members.

Bev Brody, coordinator of Get Fit Kauai in Hawaii, supported the mayor’s unofficial policy to “deal with the emotional side first” by hosting community meetings and two-way discussions before implementing policies. She also co-hosts a local broadcast radio show to engage listeners in public health initiatives and to provide a platform for community voices.

 

3.            Encouraging and supporting staff in exercising leadership. Project leaders encouraged team members at all levels to make meaningful changes and build relationships. They also supported their team members professionally and emotionally.

Kelly Corbin, SHIP Grant Coordinator for Olmsted County Public Health Services in Minnesota, said, “I think our leadership is really great at saying, ‘We hired you. We understand that you know how to get things done.’ So, when you say ‘I’m dressing up as a carrot and going to the Farmers Market for Kids’ Day,’ they kind of take a minute and hold their laughter and say, ‘Ok, I understand you are sustaining that partnership, and that you have to do a give-and-take with relationships.’”

Alisa Haushalter, bureau director at the Metro Public Health Department in Nashville, Tennessee, emphasized the need to support staff and keep things in perspective. “Trying to sustain staff through something this intense, you have to have a sense of humor at times, and a willingness to accept things not going exactly like you want them to go on a given day.”

 

4.            Holding partners accountable. Several communities had to navigate relationships with project partners that were slow to get on board, didn’t meet deadlines, or otherwise created challenges; leaders went to lengthy efforts to bring along crucial partners rather than allowing them to slow down the work.

Work-arounds, as one person put it, were “time-intensive solutions” that included making “behind the scenes” telephone calls, sending persistent e-mails, and making face-to-face visits to exert peer pressure. The challenges varied by community—from slowdowns due to cumbersome bureaucracy to individual interpersonal and interagency conflict.

Several leaders said that, in the future, they would be more discerning about which partners to collaborate with and the level of responsibility that such partners would hold. In the meantime, project leaders’ emphasis on maintaining productive relationships allowed them to ensure that the work was carried out in a timely manner and that reputations remained intact.

 

 

Building Local Capacity

Sustainable initiatives focused intently during the grant period on building local capacity so that the PSE work would continue after the grant cycle ended. Communities often brought in outside experts for technical expertise—technical assistance providers or temporary project staff—but they intentionally used these opportunities to build up their own capacity so that they could continue to drive the PSE work locally once they no longer had access to that outside expertise. These three specific tactics emerged:

 

1. Leveraging volunteers. Project teams trained local volunteers to help sustain the work of current staff. While volunteers require management and some organizational resources, they can play a big role in mitigating the loss of paid project staff and they also help to maintain institutional memory. Importantly, creating volunteer opportunities is also an excellent way to increase public knowledge of the project and create champions for the work.

In Ohio, Hamilton County Public Health started an Ambassadors Program as part of its WeTHRIVE! initiative. The goal was to support volunteers—who are already working locally to build healthy schools, places of worship, businesses, or neighborhoods—in taking on leadership positions. Ambassadors serve as liaisons, recruit like-minded people or organizations to join the movement, and develop and implement action plans focused on specific, small changes that can improve the health of their community. The hope is that the community will be better equipped to improve health outcomes and share knowledge, experiences, skills, and leadership with others in their community.

 

2. Building technical knowledge within communities. Project teams used CPPW-funded technical assistance to expand capacity in local government and community groups. Outside technical assistance providers helped Get Fit Kauai and its partners understand concepts like engineering issues for Complete Streets projects.

Jodi Drisko, chair of the steering committee for Get Fit Kauai, explained, “We had numerous people out here around Complete Streets, and that would not have been possible without CPPW. They really helped public works and planning understand the concepts around Complete Streets. [They] had to hear specific things from other engineers, so it was really nuts-and-bolts, concrete stuff.”

 

3. Cultivating ongoing funding and human resource capacity. While volunteers can help institutionalize the work, their capacity will generally be limited and there is nearly always a vital role for paid staff. To ensure the public health work would continue, project leaders involved other government departments and university partners from the very beginning. Keeping in mind the two-year CPPW commitment, they focused efforts on securing more grant funding or institutionalizing new tax revenue streams that could sustain the work.

Maggie Thompson, health program manager, San Antonio Metropolitan Health District, said of their work, “I actually see it being sustained by some of our partners. Our model was to find a partner to do the project with us, and then hand it over to them.” Her team, for example, created a Fitness in the Park program with the parks department. “We’re closing shop pretty soon. [Partners] were aware that they were going to need funding ahead of time when they agreed to do it with us.”

 

 

Lessons for All

Policy, systems, and environmental (PSE) change is a relatively new approach to public health and harder to implement than traditional strategies focused on individual behavior change alone. As the biggest PSE funding attempt to date, CPPW grants provided communities with large injections of resources in an effort to catalyze large-scale systems change within a short period of time.

Challenges and unanticipated delays were inevitable, but they also offer important learning opportunities that can inform other large-scale change efforts. Similarly, the project successes—both anticipated and unanticipated—serve as important case studies from which we all can learn.

Read the full report upon which this article is based: “Be Bold! Findings from Six CPPW Communities’ Efforts to Improve Health Outcomes.” Both the report and article were made possible with funding from the Centers for Disease Control and Prevention and sponsored by the Minnesota Department of Health.

 

 

 

Colleen Ebinger is founder and CEO and Sarah Morris is project consultant and business manager, Impact Strategies Group, Minneapolis, Minnesota (www.isgImpact.com). They wrote this article in collaboration with Grassroots Solutions (www.grassrootssolutions.com) and Fourth Sector Consulting (www.fourthsectorconsulting.com) as part of a CPPW technical assistance contract with the Minnesota Department of Health.

Katie Eukel, president and chief executive officer, Fourth Sector Consulting; Paula Fynboh, project manager, Grassroots Solutions; Dana Montgomery, senior project manager, Grassroots Solutions; and Tuesday Ryan-Hart, owner of Confluence Unlimited, also contributed to the research project.