Funder Toolkit
Making the Case and Getting Underway: A Funder Toolkit To Support Healthy People in Healthy Places
By working together, funders can support activities that they may not have the expertise to tackle themselves, or that may be seen as too controversial to do alone. Download Making the Case and Getting Underway: A Funder Toolkit To Support Healthy People in Healthy Places (pdf). The HTML version of the toolkit is below. The anchor links in the Table of Contents will take you to a specific section in the toolkit.
TABLE OF CONTENTS Introduction: How this toolkit can help you
Section 1: Why Support Healthy People in Healthy Places? Why foundations are expanding their vision for healthy communities What foundations are doing Section 2: Making the Case: What Your Foundation Can Do Twelve steps to get started The work is not easy, but the rewards are tremendous Conclusion Seven roles for foundations Section 3: Challenges and How To Overcome Them Section 4: Case Studies Case Study 1: Missouri Foundation for Health Case Study 2: Kaiser Permanente Case Study 3: Robert Wood Johnson Foundation Section 5: Resources and Acknowledgements Resources (includes two powerpoint presentations: Environmental Change is Critical to Promoting Healthy Eating and Active Living; and Healthy People in Healthy Places: A Vision and Call to Action) Acknowledgements INTRODUCTION: HOW THIS TOOLKIT CAN HELP YOU
Interested in creating multi-field environmental change strategies to enhance healthy eating and active living but unsure where to begin? Wondering if your board will support expanding your current grantmaking portfolio to support healthy people in healthy places? Unclear about which sectors should be at the table? You are not alone. Many foundation staff, from small family foundations, to health conversion foundations, to large state and national funders have asked themselves these same questions. The great news is that many foundation staff have traversed this road, successfully made their case within their foundation, and created exciting new partnerships and grantmaking efforts resulting in improved health outcomes in communities.
The Convergence Partnership is committed to increasing the number of funders supporting place-based, comprehensive, multi-field initiatives that will lead to environmental and policy change and create healthy people in healthy places. In order to facilitate additional funder involvement in these efforts, the Convergence Partnership decided to create an online toolkit for funders. This document, Making the Case and Getting Underway, is the first toolkit product and is designed to assist foundation program and executive staff who seek to:
The areas of focus for 2008 include:
This document was created with funders who have already struggled with how to shift and expand their foundation's approach to supporting healthy communities. It includes steps you can take to make your case at your foundation, lessons learned by foundation colleagues, roles foundations can play, challenges your colleagues have encountered in this work and the solutions they used (or wished they had used), case studies of three foundations that successfully developed healthy eating active living initiatives, and resources used and produced by foundations, such as logic models, presentations, and conference proceedings, that will help you envision and implement the change you seek. Inside this toolkit you might find ideas to support your vision, inspiration to encourage your efforts, and strategies to tackle the challenges you will certainly encounter. You may also identify existing efforts to leverage or organizations to partner with. By working together, funders can support activities that they may not have the expertise to tackle themselves, or that may be seen as too controversial to do alone.
Additionally, funders involved in the Convergence Partnership are happy to talk with foundation staff about their experiences, answer your questions, provide feedback, help you identify ways to make your case; internally, and connect you to others working in this field. Submit your request and PolicyLink will contact you with suggestions of foundation colleagues you could talk to.
SECTION 1: WHY SUPPORT HEALTHY PEOPLE IN HEALTHY PLACES?
One number may determine how long people live and whether they are healthy, but it's not their weight or cholesterol count. It's their address. Where people live, work, and play affects health. People thrive when they live in safe communities with parks and playgrounds, living wages, grocery stores selling nutritious food, and neighbors who know one another. Without a healthy environment, people are less likely to lead active lives, eat healthy meals, and are more likely to suffer from one of several chronic diseases such as diabetes, asthma, heart disease, or high blood pressure.[i] Concerned about rising rates of obesity, diabetes and other nutrition-related diseases, public health advocates are working together with those concerned about agriculture and the food system, schools, parks and recreation departments, developers, city planners, and others who are starting to take health into consideration as they engage in planning for neighborhood development and revitalization, including greater access to supermarkets, transportation, and parks. Professionals from various fields are beginning to see how working together can influence and enhance progress in other fields, and improve health overall.[ii] For example, in the past advocates for neighborhood revitalization might have identified a supermarket as a potential source for economic revitalization, providing jobs, foot traffic, and vital neighborhood services. Now, these advocates could be joined by advocates concerned about health issues. Together, in a broader coalition, all of these advocates can point to the potential health benefits for whole communities. As their interests and actions converge, advocates and professionals are cultivating connections across all the environments that influence health. Change requires attention and action from individuals, and also from decision-makers—elected officials, agency officials, institutional leaders, and other policymakers—as well as their constituencies—including community residents and leaders. Policies and practices that give rise to healthy environments must be identified, advocated for, and enacted within organizations and throughout government.
Foundations are a part of this movement for change. They are realizing that they can have a more powerful and lasting impact when strategies involve a focus on organizational, practice, and policy changes and involve multiple constituencies engaged in efforts to create environments that foster health.
Why foundations are expanding their vision for healthy communities
Americans are already suffering from the impact of policies and environments (communities, neighborhoods, workplaces, schools) that do not support healthy eating and active living. Consider these statistics:
What foundations are doing
In the fall of 2005, Kaiser Permanente, the W.K. Kellogg Foundation, and the Robert Wood Johnson Foundation initiated the Healthy Eating/Active Living Convergence Project to better understand how to collaboratively strengthen the work in and among the various fields that are focused on improving the health of people and places across the country. [vii] Believing that by working together they could better leverage their resources to produce outcomes that none could achieve alone, and that creating a national partnership would raise visibility and more effectively influence practice and policy changes, these funders joined together.
Research and discussion with the field in June 2006 led to the creation of the Healthy Eating Active Living Convergence Partnership, whose members also now include: The California Endowment, Nemours, and the Centers for Disease Control and Prevention.[viii] The Convergence Partnership has an expansive and ambitious vision of stimulating actions that will lead to healthy people in healthy places. This vision will be realized when:
These funders seek to accomplish this vision through four key strategies:
The funders will invest in these strategies by focusing on equity and specific geographic locations. Equally important will be encouraging leadership and engaging community members, and seeking to address disparities in health status. Multiple sectors will always be engaged as strategies are implemented across different projects and activities.
SECTION 2: MAKING THE CASE: WHAT YOUR FOUNDATION CAN DO
Below are steps you can take to make your case within your foundation, and roles that your foundation can play in support of healthy people in healthy places. The steps do not need to be completed in order, but all will be important for the success and sustainability of your efforts.
Twelve steps to get started Regardless of foundation size, type, or geographic location, funders interviewed for this toolkit recommended a similar set of steps that they took or wished they had taken; to initiate or expand their foundation's efforts to support multi-sectoral, place-based policy and environmental changes to support healthy people in healthy places. Included in the descriptions of these steps are the lessons these foundations learned as they journeyed forward in their work, and questions you can ask yourself as you get started.
Step 1: Building your case: Target the most promising issue area for your foundation. When deciding what issue to target, you can try focusing on where foundation efforts are already underway, where current funding is most closely linked to multi-sectoral policy and environmental change goals, and/or where partnerships already exist. Often times, tackling the low-hanging fruit; opportunities will produce both early wins and learning opportunities. Developing a strategic plan, logic model or theory of change will be important down the road, but you do not need to have all your detailed strategies and outcomes mapped out at the onset. Consider starting with pilot grants to test new strategies, partnerships, and grantmaking approaches. Ask yourself: What are we already doing in support of healthy people in healthy places that could be further developed, leveraged and expanded to produce greater impact? What efforts would produce early wins and learning opportunities? What new approaches could we turn into pilot grants? Which partners would be easiest to start with? Which current grantees are already working in this arena and how can we expand their efforts?
Step 2: Build support among staff and board leadership. Ensure program executives, the CEO, and board members understand the role of policy and environmental change in advancing healthy communities, and that the standard of practice is now moving toward more comprehensive, cross-disciplinary, and community-based preventive approaches. Be certain to address the costs of inaction, how absent environmental and policy changes, problems will persist, as well as all the costs associated with them. Link the proposed multi-field effort to the foundation's mission and goals. Show how this new approach will build momentum for the foundation's mission and develop important new strategic relationships. Surface board members; questions and opinions. Identify and cultivate professional and board champions to help make the case and increase support for the new grantmaking direction. Without strong support from the top, efforts to shift the funding paradigm will not be sustainable. To assist your efforts, The Healthy Eating Active Living Convergence Partnership is developing a PowerPoint presentation, Making the Case: Why Support Healthy People in Healthy Places that you can use in making your case to foundation staff and boards. Ask yourself: Who can best encourage the foundation to take this new approach? How can we maintain our leadership's on-going engagement and learning? Who among the Board can become change agents?
Step 3: Map who in the local community may be concerned with working in the targeted issue area(s). Determine all the sectors and systems that have an impact on your issue. This may include transportation, city planning, the food and beverage industry, public health, schools, parks and recreation, agriculture, policy advocates, youth, and community residents. Identify key professionals and providers from across these sectors. Identify community members most impacted by the problem, to ensure that they have a voice in the development and implementation of environmental and policy change solutions. For example, you can tap into the experience of grantees, local residents, parents, youth, and community-based organizations. Identify where the necessary level of existing community infrastructure exists and where productive relationships can be readily developed. Ask yourself: What patterns and trends exist in the community? What systems and fields are involved? Who is doing what? Step 4: Develop a logic model or theory of change to guide your efforts, track progress, and make mid-course corrections. Once you have gained a better understanding of the issues, the sectors that should be at the table, the types of partners you need to work with, and the outcomes you seek, it is important to create a plan, logic model, or theory of change to guide your efforts. Logic models and theories of change are planning tools that allow stakeholders to collectively identify the long-term goals of social change initiatives, define all the building blocks required to bring this change about, and clarify the steps to get there. Developing the models and the plan itself, ideally linked to the foundation's mission, was critical in some funders; efforts to convince their foundation leadership and boards to shift and embrace a new direction.
It is important to ensure that all stakeholders, including foundation board leadership, are involved to ensure that goals, benchmarks, processes, timelines, roles, and accountability measures are clearly delineated and adhered to. Be sure to regularly evaluate your progress against these benchmarks, and make changes to your plan as needed. View the logic models used by The California Endowment (pdf of logic model), the Centers for Disease Control and Prevention, and Kaiser to see how they used this tool to improve community outcomes. Mapping Change: Using a Theory of Change to Guide Planning and Evaluation (produced by Grant Craft) provides additional information for foundations about how to create a theory of change. Ask yourself: What process should we use to develop our vision and road map? Which stakeholders should be involved? Who should lead this effort? What resources do we need? What are our vision, short- and long-term outcomes, and strategies? What are our assumptions and are they logical? Is this doable? How will successful efforts be rolled-out and sustained? How will we measure progress and make necessary mid-course corrections? Do our existing foundation structures support or inhibit this theory of change? Step 5: Recognize that place matters and limit your geographic scope. Healthy eating and active living will only be realized when neighborhoods, schools, workplaces, child care centers, and cities have the ingredients for healthy living. Specific communities and environments should be targeted, with a clearly defined set of criteria guiding this process. It is important to limit the geographic scope of your efforts. Even if your foundation funds broadly, focus on place-based strategies in certain communities. For example, Kaiser found that counties were often too large, and sought to work with smaller communities within counties. The BlueCross BlueShield Foundation of Minnesota through its Foundation and Center for Prevention funds state-wide, but supports local collaborations. Ask yourself: Where should we focus our place-placed work? What communities are most impacted? What geographic boundaries make sense given the outcomes we seek?
Step 6: Ensure that you have adequate staff and organizational capacity. Allocate and align resources; human, financial, infrastructure, information tracking, and evaluation systems; to lead, manage and support efforts. Ensure that staff overseeing this work have the time and skills necessary to develop relationships internally across program areas and externally across sectors. This may involve grooming existing staff or hiring qualified staff or consultants to fulfill these roles. It also involves structuring workloads so staff to have time to build relationships. Program officers, whose time is already filled reviewing proposals, conducting site visits, and preparing dockets, will not have the time to support multi-sector collaboration. Additionally, consider the capacity you may need for non-grantmaking activities, such as planning, convening, knowledge creation and dissemination, communication, and technical assistance. Ask yourself: Do we currently have the capacity to accomplish our goals? What additional resources and expertise are needed? Is this available in-house or do we need to hire qualified staff or consultants to fulfill necessary roles? What non-grantmaking activities will we use? How will we allocate sufficient financial resources to succeed? Step 7: Develop internal knowledge and understanding across program areas. Invite perspectives of others who are already engaged in this multi-sectoral work to share their experiences, frameworks, and strategies. Identify and connect with a wide range of peers who bring a prevention and advocacy orientation, ranging from public health professionals to nutrition, food system, transportation, school, and urban development specialists. Bring scientific and clinical experts together with foundation board and staff to discuss the science and theory of change that supports healthy people in healthy places. Learn from local and national colleagues who are already doing this work. Consider ways your foundation's program areas can better coordinate and collaborate. Ask yourself: What can we learn from existing knowledge, research, and practices? What are others doing to effect positive change? What might we do? Step 8: Convene and collaborate with allies, key influencers and members of the local, state, and national communities from multiple sectors and systems. Recognize that most funders do not have all the expertise needed in-house. For example, knowledge about transportation, land use, school reform, and food production rarely exists within one foundation. Gaps in knowledge can be filled through collaboration with other foundations, consultants, researchers, organizations, and community members. Collaboration can also allow foundations to jointly tackle a project that might be perceived as too risky to address alone. Be sure to build in time to share your resources and knowledge. Others have as much to learn from you as you do from them. Begin by convening potential partners to:
Ask yourself: Who are our funding and operational partners at the national, state and local levels? What does success look like for us? What policy and environmental changes do we seek to make? How can we leverage our respective talents and resources?
Step 9: Turn to foundation colleagues for help and guidance. There is much to be learned from local and national foundation colleagues who are engaged in similar efforts. Not only can you benefit from their experience, reduce your isolation, learn from their mistakes, and replicate their models, but there is also potential to leverage efforts already underway. Resources used and produced by foundations, such as logic models, presentations, and conference proceedings, are available in Section 5 of this toolkit. Ask yourself: Where are we stuck and what kind of advice, information, or support do we need to move forward? Which are the models, strategies, and activities of other funders that we might want to borrow or replicate? Would further conversation with other foundations be helpful? Step 10: Be willing to take risks and stay over the long haul: Though still considered to be cutting edge; by some, comprehensive, equity-focused, prevention approaches that engage multiple sectors to create environmental change are starting to become the standard of practice for improving health outcomes. However, that does not mean that there is a clear-cut path or set of evaluated best-practices to follow. This work inherently involves risk, is ambitious and takes a long time to achieve impact. Complex initiatives seeking significant environmental changes take years of work, and indicators of success are newly emerging. Short term funding and immediate outcomes will not yield success. Funders must be aware of what it takes at the outset. Collaborating across disciplines with new partners, and working in support of environmental and policy change, may require foundations to change their approach, both internally and externally. Work with your colleagues and stakeholders to identify potential risks you might encounter as you move outside of your foundation's comfort zone. For example, there may be perceived risks working with new sectors and partners. Strategies that might work: you can explore how to create a win-win; outcome by reaching out to the business community, seeking their support to create grocery stores or find creative ways to engage policymakers on issues they care about and also serves your needs. Consider, for example, making a case to city planners to get involved in your grantee initiatives to build parks and more open spaces for physical activity. Success may be gained through piloting new grantmaking strategies, or shifting internal organizational structures. Continually identify ways to mitigate risks, and update the list as new risks arise. Ensure that your foundation's leadership is aware of the risks, and that foundation policies and procedures do not penalize staff if a grant or strategy does not succeed as planned. Ask yourself: What are the risks of moving forward with this plan? What speed bumps are we likely to encounter? Which individuals, organizations, and systems are likely to be resistant? Are there steps we can take now to reduce these risks? What are ways you can prepare your foundation for the long-term nature of this work? Step 11: Walk the talk: Change organizational practices. Demonstrate internally what's being professed externally by instituting healthy food practices and opportunities for physical activity among foundation employees. Efforts being implemented by foundations across the country include providing healthier foods in cafeterias and vending machines, removing trans fats from cafeterias, scheduling walk breaks; during long meetings, adopting local food purchasing policies, encouraging employees to take the stairs instead of elevators, incorporating walking and biking onto facility sites, and structuring opportunities for learning and coordination across program areas. The Centers for Disease Control and Prevention offers information, ideas, and toolkits to help workplaces become healthier and safer through its Healthier Worksite Initiative. Ask yourself: What practices do we need to change or institute to reflect our commitment to healthy people in healthy places? How can we make our foundation a healthier environment for our employees and visitors? Who are change agents already working internally and how can they be supported? Step 12: Communicate and share accomplishments and lessons learned. Share what successes have been realized and how you accomplished them. Similarly, exchange information about efforts that didn't produce satisfactory results, potential risks, and what you recommend doing differently. Share your success stories, useful resources, and the lessons you have learned with the Convergence Partnership for possible dissemination to the field. Ask yourself: What are we learning? What would be beneficial to share with others? Who is the audience? The work is not easy, but the rewards are tremendous There are unique challenges associated with philanthropic efforts seeking to support healthy people in healthy places. Some of these challenges are related to working across disciplines. For example, within a foundation, there may not be structures and systems in place for foundation staff to collaborate effectively across program areas. You might have limited experience working with community-based sectors that need to be at the table, or you might have concerns about working with them. For example, as an environmental funder you may be unsure how to work with city and transportation planners to create more walkable communities. Or perhaps your foundation supports diabetes treatment programs, but never considered how the lack of public transportation, unsafe neighborhoods, and the lack of grocery stores selling healthy foods impacts the ability of community members to eat healthy food. You might not even know who you need to work with, and where to start.
Similarly, there are challenges associated with supporting policy and environmental changes, since they require different approaches than traditional grantmaking. Internally, for example, your foundation's board may associate policy advocacy with lobbying and be unclear about the foundation's legal boundaries. Or as a grantmaker, you might not fully understand which policy targets should be identified, how to develop or support an advocacy or communications campaign. This new territory often comes with a sharp learning curve.
Working across disciplines with new and unusual partners, and working in support of environmental and policy changes, may mean that foundations will need to change how they do business, both internally and externally. There is a need to foster a climate of entrepreneurialism and risk-taking, since new alliances and approaches may move the foundation into unchartered territory. There is also a need to develop new allies and alliances - both inside and outside the foundation.
Foundations across the country are quickly overcoming these challenges. For example, the WK Kellogg Foundation determined that working across disciplines externally meant that two program areas (Health and Food Systems & Rural Development) needed to join forces internally. As a result, they created a new cross-cutting Food and Fitness Initiative, co-led by program directors from each program area. These two program directors now work hand in hand in a more coordinated approach to healthy eating and active living than either program area was achieving alone. According to one of the program directors, Gail Imig, they realized that millions of children don't have access to fresh foods that are good for them. Their neighborhoods and communities aren't conducive to exercise and play. Instead, they live in places where a convenience store—if there is one—is the only grocery store, and where facilities like safe playgrounds and bike paths are equally scarce.[ix] Bringing the two program areas together in this initiative allowed the foundation to promote long-term, sustainable change by improving the systems that determine how communities are built and how food arrives on the table. This cross-cutting initiative and the close working relationship among the two program directors is now seen as a model within the foundation about how to collaborate across program silos.
Conclusion
Most foundations value opportunities to assume leadership in new trends or to become familiar with ways of leveraging resources to achieve maximum impact. Foundations involved with the Convergence Partnership have spent years researching what it takes to create healthy people in healthy places and are eager to share that knowledge and experience with you.
What have we learned? The overwhelming message is that where children and families live, learn, work and play affects their health. Communities must change in order for the health of its residents to change. Not all communities benefit equally from America's opportunities. So solutions must be tailored to meet the needs of those most affected. An even more critical message is that not one single entity can make the needed changes alone.
Boundaries are being crossed between and among sectors. And there is promise on the horizon. This toolkit will support you in making the case for your foundation to join with your colleagues in addressing the need for place-based, equity-focused, healthy eating active living initiatives. Outlined are steps, rationale, challenges and case studies that will guide you.
Seven roles for foundations
Foundations have many tools available. To succeed in preventing obesity and reducing health disparities, the Convergence Partnership has outlined the following roles foundations can play.[x] These roles are based on the Spectrum of Prevention, which offers a systematic framework for developing effective and sustainable primary prevention strategies and approaches.[xi]
SECTION 3: CHALLENGES AND HOW TO OVERCOME THEM Along with steps for getting started and lessons learned, funders describe eight major challenges they experienced and share either what they did to overcome them, or what they wish they would have done differently. These are presented in the table below.
SECTION 4: CASE STUDIES Case Study 1: Missouri Foundation for Health
Why this foundation sought to develop a healthy people in healthy places; initiative
The Missouri Foundation for Health's (MFH) mission is to empower the people of the communities we serve to achieve equal access to quality health services that promote prevention and encourage healthy behaviors. In 2006, MFH program officers attended a national convening of the Healthy Eating Active Living Convergence Partnership and shared the view that foundations need to utilize a socio-ecological model to enhance the health and activity of local communities, reach populations at increased risk of developing obesity, and maximize impact. Rather than joining a national effort, MFH decided to replicate on a state level what the Convergence Partnership was developing nationally and commenced the creation of a new initiative: Healthy & Active Communities (H&AC).
What they did to make the case internally
Leveraged existing models To inform their work, MFH's program officers sought to take full advantage of what others were learning and examined approaches used by other funders and organizations, such as the American Obesity Association. Robert Wood Johnson Foundation's Active Living by Design served as a primary model.
Developed guiding assumptions MFH applied three assumptions to guide the development of its initiative: a multi-level approach was required to address the complexity of obesity and its multi-faceted causes; a socio-ecological model of change was needed in recognition that individuals are affected by family, schools, and the broader community; and sustained, community level change required continued resources to maintain any benefits.[xii] Encouraged partnerships MFH understood that there really wasn't a silver bullet; and that no one program would have the impact MFH sought.[xiii] MFH strongly encouraged its grantees to identify and work with stakeholders outside the realm of healthcare. In addition, MFH has sought to be active partners in coalitions such as the Missouri Council for Activity and Nutrition, the Missouri Coordinated Health Coalition, the School Health Coalition and the Healthy Youth Partnership.
Listened and responded to board concerns The foundation's board was concerned about shifting the percentage of expenditures allocated to direct support to improve health outcomes. Some members wondered if funding projects such as taking soft drinks out of schools and checking kids; Body Mass Indices might be a better way to proceed. Staff discussed with the board that to really be effective in the enormous battle against obesity, it would take a much broader approach; that if MFH only focuses on children it was going to lose several generations to this epidemic.[xiv] Piloted its approach while continuing longer-term planning. Another challenge was the considerable time it took to develop the specific goals and implementation strategies required for its multi-sectoral approach. As a result, staff developed a two-pronged approach: piloting grants while continuing to plan. Staff recommended to the board an initial plan to conduct two rounds of two-year funding while they simultaneously developed the Healthy & Active Communities Strategic Plan. This allowed staff to begin piloting their new approach while continuing to plan.
The result
New initiative: Healthy & Active Communities MHF' $9 million initiative' vision is: Through the convening of traditional and non-traditional partners, we will serve as a catalyst to empower communities to increase access to physical activity and nutrition and influence individual and societal attitudes towards maintaining healthy lifestyles.[xv] The initiative addresses obesity prevention and targets community-based organizations to reach populations at increased risk of developing obesity. H&AC supports program implementation, community education, improved community access, and local public policy development. Technical assistance is also provided to grantees on topics such as funding sustainability and social marketing, and convened grantees in smaller, regional peer learning exchanges. A total of 33 grantees were funded to:
Case Study 2: Kaiser Permanente
Why this foundation sought to develop a healthy people in healthy places initiative
In 2002, the leadership of Kaiser Permanente, whose mission is to provide affordable, high-quality health care services to improve the health of our members and the communities we serve; determined that the organization could increase it's impact on community health by marrying Kaiser's expertise in clinical prevention and evidence-based medicine with a focus on community conditions and the social determinants of health.[xvi] According to Loel Solomon, National Director of Community Health Initiatives and Evaluation, We felt in light of the existing evidence that the Centers for Disease Control and Prevention, the Institute of Medicine, and others were generating, we felt we had to go beyond the doctor's office to have the kind of scale and impact we desired on population-level health outcomes.
What they did to make the case; internally
Started with supportive leadership Kaiser leadership believed that communities held the critical resources to address the rise in chronic illness, and that it could make a significant contribution to building the evidence base in this field.
Convened and engaged internal and external stakeholders in planning Kaiser's Community Benefit Program organized an interactive, two-day conference for Kaiser staff and leadership to create a shared vision of community health improvement that would bring scale and impact to existing efforts in order to measurably advance the health status of Kaiser Permanente communities. In addition, key community partners from public health departments, community clinics, nonprofit organizations, and advocacy coalitions participated in the conference. Having the realistic and practical viewpoints of these on-the-ground partners was critically important to developing Kaiser's new approach. Real dialogue and lots of space for interaction was key to the success of this important, formative meeting.
Developed a plan Kaiser began developing its new Community Health Initiative (CHI) on several fronts: within each of its regions across the country and among an inter-regional workgroup. Key internal partners in the delivery system and research units were enlisted. Kaiser also called upon and expanded its advisory group and committee structure. From November 2003 to September 2004 Kaiser worked to develop its CHI Framework.[xvii] Listened and responded to staff concerns Internal engagement and listening was needed to address staff and leadership concerns that the new initiative needed greater focus, felt overwhelming, and did not clearly connect with their daily work as health providers.[xviii] As a result, Kaiser focused the initiative on Healthy Eating, Active Living, or HEAL, as a thematic focus to address obesity. Targeting this significant and growing public health problem in the communities Kaiser serves resonated throughout organization, and increased the organization's support for an upstream, public health-oriented approach. Focusing on HEAL also allowed the Community benefit staff to more effectively partner with internal stakeholders involved on the clinical approaches to obesity, heart disease and other clinical conditions associated with inactivity and unhealthy eating.
Learned from and partnered with other foundations Board and senior staff appreciated that Kaiser would not be forging ahead alone, and pursued opportunities to collaborate with the W.K. Kellogg Foundation, Robert Wood Johnson Foundation, and The California Endowment (TCE). Kaiser recognized, for example, that it did not have expertise on transportation, land use, school reform, and food purchasing. Gearing up to design and launch a comprehensive community health initiative that involved multiple parties in multiple content areas required developing strong partnerships and a lot of learning. This was a win-win for all partners. For example, Kaiser recognized it had a lot to learn from TCE's considerable grantmaking expertise and its focus on place-based strategies. In turn, Kaiser benefited TCE because of its on-the-ground intelligence through its physicians and public affairs staff who had detailed knowledge of potential local partners and grantees, and by the ability of a healthcare organization to frame the obesity crisis as something requiring more than medical interventions.
The result
Community Health Initiatives A strategic framework outlines Kaiser's vision and the key elements of the initiatives include: long-term (7-10 year) partnerships across multiple-sectors in communities that were no larger than a county and no smaller than a few blocks; engaging and leveraging the strengths of local communities, conducting multi-level interventions (including environmental and policy change), focusing on racial and ethnic health disparities, utilizing evidence-informed public health practices, and evaluating their effectiveness.
Healthier organizational practices Demonstrating internally what it was professing externally, Kaiser helped create local farmers markets near Kaiser facilities, changed food purchasing practices to include greater local sourcing, changed what was available in its vending machines, removed trans fats from its cafeterias, encouraged employees to take the stairs, and incorporated biking and walking onto sites.
Case Study 3: Robert Wood Johnson Foundation
Why this foundation sought to develop a healthy people in healthy places initiative
The Robert Wood Johnson Foundation (RWJF) is the nation's largest philanthropic organization devoted to improving health and health care. The third of its four goal areas is promotion of healthy communities and lifestyles. Active Living by Design (ALbD) was launched in December of 2001 as part of a family of programs funded by the Robert Wood Johnson Foundation (RWJF) to increase physical activity among all Americans. RWJF created these programs in response to the growing national crisis of physical inactivity, obesity and chronic disease. Since then, the Foundation has enhanced and evolved its Active Living programming, which now has a major focus on preventing childhood obesity. RWJF remains committed to creating environments that support active living and healthy eating as part of its efforts to reverse the childhood obesity epidemic by 2015.
What they did to make the case; internally and externally
Built upon an existing approach Pursuing multi-sectoral, policy and environmental change approaches is not new to RWJF, as evidenced for example, by its tobacco work. RWJF explicitly states when describing the foundation's aforementioned third goal that our health behaviors, level of social interaction, and other factors outside medical care are important influences on overall health.[xix]When launching ALbD, RWJF considered this to be a prime opportunity to promote healthy behaviors that have been largely removed from our daily routines and believed this approach could enable millions of sedentary Americans to integrate physical activity into their lives and as a result address other dilemmas faced by communities, such as traffic congestion, air pollution, crime and safety.[xx]
Commissioned and utilized data to make decisions and set strategies When deciding in 2007 to address this country's childhood obesity epidemic, solid research and objective evidence about the problem provided a strong rationale. [xxi] RWJF noted that more than two-thirds of adults and one-third of children in America were obese or at risk for obesity. Data regarding the alarming escalation of childhood obesity during the past four decades, increasing rates of children being diagnosed with "adult" illnesses (such as type 2 diabetes), and the increased risk of overweight and obese children for heart disease, stroke, asthma, and certain types of cancer were among the most compelling evidence used by RWJF.
When ALbD was launched, the foundation believed that strategies to promote physical activity through the built environment offered great promise and are a more meaningful approach than just advocating for traditional activities such as sports, aerobics or weightlifting because such structured activities only resonate with a small percentage of the population. [xxii]
Made efforts to connect silos. One of the major challenges faced by RWJF in implementing ALbD was that people working in the active living fields were often not well-integrated with those working in the healthy eating fields. RWJF recognized the need to build bridges and support greater integration among sectors, and incorporated such efforts into its initiative: While the full magnitude of the [health] threat finally is beyond doubt and debate;what movement we see is jerky and fragmented, with a hodgepodge of disconnected, uncoordinated efforts rising in schools, communities, businesses, youth organizations, philanthropies and government at all levels.[xxiii]
The result: Active Living portfolio of programs RWJF's suite of programs encourages research, leadership, and program strategies to address the connections between health and the built environment
RWJF's obesity initiative This effort will build on the foundation's work in improving health from a built environment perspective, focusing on improving access to affordable healthy foods and opportunities for safe physical activity in schools and communities. Special attention will be given to children in low-income communities. The funding will also go towards the foundation's past investments in research on changing school and community environments to improve physical activity and nutrition in children.
SECTION 5: RESOURCES AND ACKNOWLEDGEMENTS
RESOURCES
Below we provide select resources that the Convergence Partnership and other funders have found particularly useful in making their case; to support healthy people in healthy places, including documents that funders created while making their case, such as logic models, presentations, and conference proceedings.
We also encourage you to share resources with the Convergence Project so that we might share them with other foundations. Send us the resources you create (e.g., a theory of change, RFP, case statement, or white paper), an existing report that was particularly helpful to you, or your story - the approaches and tactics you used to expand your foundation's support for healthy eating and active living; or the challenges you encountered and how you overcame them.
Presentations
(For proper viewing, please download link to your hard drive before opening.)(For proper viewing, please download link to your hard drive before opening.) This presentation is an introduction to the importance of environmental change, including public policy and organizational practice change, in transforming norms and supporting health promoting behaviors. Health is impacted by a myriad of factors in our communities and in order to have the greatest impact in promoting healthy eating and active living we must understand how the environment impacts health and how to supplement individual-oriented approaches with environmental change approaches. The presentation also highlights success stories from around the country that illustrate important elements for achieving successful outcomes: implementing environmental change approaches to improve health; focusing on health equity; engaging in cross-sectoral collaboration; and having a comprehensive and strategic agenda. This presentation can be utilized as an informational resource or as the basis of a presentation describing the value of environmental change for various audiences. Goals associated with healthy eating and active living are often similar or related to the goals of other fields, including education, housing, transportation and economic development. This presentation targets the boards of foundations across multiple fields to demonstrate the power of interdisciplinary and multi-sectoral collaboration, the benefits of focusing on equity and environments, and the need for sustained resources to accomplish long-term community change. It offers a rationale for foundations to expand their existing approaches and generate new and exciting partnerships to achieve healthy people in healthy places. Program or executive staff can use the base slides in this presentation as-is or adopt the presentation to meet individual foundation needs. Reports and Documents
A Place for Healthier Living: Improving Access to Physical Activity and Healthy Foods (Joint Center for Political and Economic Studies/Policy Link, 2004)
Active Living By Design Primer (Robert Wood Johnson Foundation, 2006)
Banning Junk Food and Soda Sales in the State’s Public Schools (The California Endowment, 2006) Building Stronger Communities for Better Health (Joint Center for Political and Economic Studies and PolicyLink, 2004)
Childhood Obesity E-Zine (Frameworks Institute, 2007) Common Community Measures for Obesity Prevention Project Logic Model (Centers for Disease Control and Prevention, 2007)
Community Health Initiatives: Working Together to Improve Health, Building Our Shared Vision (Kaiser Permanente, November 2003 Conference Proceedings) Does the Built Environment Affect Physical Activity? Examining the Evidence (Transportation Research Board, Institute of Medicine, 2005)
Healthier Worksite Initiative Toolkits (Centers for Disease Control and Prevention)Healthy Eating Active Communities Logic Model for Community Collaboratives (The California Endowment, 2006)
Introducing the Healthy Eating Active Living Convergence Partnership, Convergence Partnership, Oakland, CA. 2008.
Framing the Food System: A Frame Works Message Memo (Frameworks Institute, 2006)
Kaiser Permanente’s Framework for Community Health Initiatives (Kaiser Permanente, 2004)
Kaiser Permanente’s Community Health Initiative Logic Model for Evaluation (Kaiser Permanente, 2004)
Mapping Change: Using a Theory of Change to Guide Planning and Evaluation (Grant Craft, 2006).
Moving Upstream: Working Together to Create Healthier Communities (BlueCross and BlueShield of Minnesota Foundation’s report on a statewide policy forum on the social determinants of health, 2006)
Preventing Childhood Obesity: Health in the Balance (Institute of Medicine, 2004)
Profiles of Innovative Work: Regional and Organizational Profiles (Healthy Eating Active Living Convergence Partnership, 2006) Request for Applications: Healthy & Active Communities Initiative Policy Assessment (Missouri Foundation for Health, 2007) Request for Applications: Healthy & Active Communities Initiative Model Practice Building (Missouri Foundation for Health, 2007) The Impact of the Built Environment on Community Health: The State of Current Practice and Next Steps for a Growing Movement (PolicyLink, 2007) Toward Total Community Health: Kaiser Permanente’s Healthy Eating/Active Living (HEAL) Initiative (Kaiser Permanente, September 2006. Internal PowerPoint presentation) We Will Reverse the Epidemic of Childhood Obesity (President’s Message in the Robert Wood Johnson Foundation Annual Report, 2006) Why Place Matters: Building A Movement for Healthy Communities (produced by PolicyLink for The California Endowment) Making the Case: Why Support Healthy People in Healthy Places? The Healthy Eating Active Living Convergence Partnership, 2008.
Websites The websites of all organizations involved in the Convergence Project and some of the foundations interviewed for this toolkit are full of useful resources. In particular, the following sections of their websites will prove particularly helpful for foundations seeking information and models to guide their efforts in support of healthy people in healthy places.
Centers for Disease Control and Prevention: Division of Nutrition, Physical Activity, Overweight, and Obesity;Designing and Building Healthy Places; Overweight and Obesity Trends; State Based Nutrition and Physical Activity Programs; and Healthier Worksite Initiative
Prevention Institute: Nutrition and Physical Activity and the Strategic Alliance for Healthy Food and Activity Environments: Environmental Nutrition and Activity Community Tool (ENACT)
Robert Wood Johnson Foundation: Active Living By Design, Active Living Research, and the Childhood Obesity program area
WK Kellogg Foundation Food & Fitness Initiative and Food Systems Framing Research
Acknowledgements
Thanks to those who graciously gave their time and expertise to inform this document: Jamie Bussel (Robert Wood Johnson Foundation), Joan Cleary (The Blue Cross and Blue Shield of Minnesota Foundation), Kathryn DeForest (Missouri Foundation for Health), Dinah Dittman (Kaiser Permanente), Linda Jo Doctor (W. K. Kellogg Foundation), Jasmine Hall-Ratliff (Missouri Foundation for Health), Gail Imig (W. K. Kellogg Foundation), Robin Mockenhaupt (Robert Wood Johnson Foundation), Amy Solomon (Bullitt Foundation), Loel Solomon (Kaiser Permanente), and Marion Standish (The California Endowment).
[i]Why Place Matters: Building A Movement for Healthy Communities (produced by PolicyLink for The California Endowment) provides a framework to understand the relationship between community conditions and health, analyzes the connections among all of the environmental factors that contribute to a healthy community, and identifies both protective and negative environmental effects on community health. Available at: http://www.policylink.org/documents/WhyPlaceMattersreport_web.pdf
[ii]“Introducing the Healthy Eating Active Living Convergence Partnership”, page 1. Convergence Partnership, Oakland, CA. 2008.
[iii]Joint Center for Political and Economic Studies/Policy Link (2004). A Place for Healthier Living: Improving Access to Physical Activity and Healthy Foods; available at http://www.policylink.org/pdfs/JointCenter-Healthyliving.pdf and W.K. Kellogg Foundation Food and Fitness Overview, available at http://www.wkkf.org/default.aspx?tabid=75&CID=383&NID=61&LanguageID=0
[iv]Robert Wood Johnson Foundation (2006). Annual Report President’s Message, available at http://www.rwjf.org/pr/product.jsp?id=18649&topicid=1024
[v]Morland, K., Wing S., Diez R.A., Poole C. Neighborhood Characteristics Associated With The Location of Food Stores And Food Service Places. American Journal of Preventive Health. 2001;22(1):23-9. As cited in: Prevention Institute (2007). Healthy Eating, Physical Activity: Addressing inequities in Urban Environments, p.4; available at http://www.preventioninstitute.org/sa/pdf/RWJNC.pdf
[vi]Robert Wood Johnson Foundation. Active Living by Design website, www.activelivingbydesign.org/filealbd_primer_low.pdf
[vii]“Introducing the Healthy Eating Active Living Convergence Partnership”, page 3. Convergence Partnership, Oakland, CA. 2008.
[viii]Introducing the Healthy Eating Active Living Convergence Partnership”, page 3. Convergence Partnership, Oakland, CA. 2008.
[ix]“WK Kellogg Foundation website. Program Directors: Committed to improving the quality of life for kids and families in a way that will last a lifetime; http://www.wkkf.org/Default.aspx?tabid=90&CID=383&ItemID=5000410&NID=5010410&LanguageID=0
[x]From this Convergence Partnership Document: General Roles for Funders, pp 11-12.
[xi]More information about the Spectrum of Prevention is available at (1) Cohen, L, Chehimi S. Beyond Brochures: The Imperative for Primary Prevention. In: Cohen, L, Chavez V, Chehimi S, eds. Prevention is Primary. San Francisco: Jossey-Bass; 2007: 3-24. (2) Cohen, L, Swift, S. The spectrum of prevention: developing a comprehensive approach to injury prevention. Inj Prev. 1999;5:203-207.
[xii]Missouri Foundation for Health (2007). Request for Applications-Healthy & Active Communities Initiative-Model Practice Building.
[xiii]Interview with Jasmine Hall-Ratliff, Missouri Foundation for Health (October 2007)
[xiv]Interview with Kathryn DeForest, Missouri Foundation for Health (October 2007)
[xv]ibid
[xvi]Kaiser Permanente Community Benefit leadership news release: http://kp.org/newsroom/national/archive/people/nat_020227_baxter.html
[xvii]Kaiser Permanente (2004). Framework for Community Health Initiatives; http://xnet.kp.org/communitybenefit/chi/tools/docs/background/CHIFramework.pdf
[xviii]Interview with Dinah Dittman, Kaiser Permanente (October 2007)
[xix]Robert Wood Johnson Foundation website; http://www.rwjf.org/about/mission.jhtml
[xx]Robert Wood Johnson Foundation (2002). RWJF Launches $16.5 million Active Living program www.rwjf.org/programareas/resources/product.jsp?id=21703&pid=1138&gsa=pa1138
[xxi]Robert Wood Johnson Foundation website. Obesity Epidemic Continues to Grow http://www.rwjf.org/newsroom/activitydetail.jsp?productid=20431&type=109
[xxii]Robert Wood Johnson Foundation website. Robert Wood Johnson Foundation Provides $20 Million Dollar Grant To Support Expansion of Healthy Schools Program, www.rwjf.org/programareas/features/feature.jsp?id=21184&typeid=151&pid=1138
[xxiii]Robert Wood Johnson Foundation (2006). Annual Report President's Message, http://www.rwjf.org/pr/product.jsp?id=18649&topicid=1024
[xxiv]Robert Wood Johnson Foundation (2006). Active Living By Design Primer http://www.activelivingbydesign.org/fileadmin/template/documents/primer/Prime
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