Lessons Learned

"It is difficult for communities to address policy change beyond their local jurisdiction without a larger advocacy infrastructure and resources to handle the effort. Local partnerships or advocacy organizations that identify policy opportunities at the regional, state or national level sometimes find that their influence diminishes beyond their own community and that the task proves larger than originally expected. It is important in such a situation to join an existing coalition if it exists, to secure support from a well-positioned legislative champion, or to secure dedicated resources to build a coalition. In cases where large-scale policy change is important to achieve a partnership's goals, a healthy advocacy infrastructure is a vitally important asset. "

"Even when policy solutions are crafted through a careful process of community involvement led by legitimate community leaders, the relevance or urgency of a given policy to the community can change. An organized group of parents at a school can prioritize traffic calming or menu changes in the fall only to drop the project in the spring when a larger crisis with the principal's behavior or school security requires their attention. It is important for resident-led policy initiatives to plan for change and build coalitions that can sustain themselves when key leaders are called upon to address crises. (see #25) "

"Policy and environmental change can easily ""miss the mark"" if advocates are not very carefully attuned to the perceptions and preferences of the target population. While it is quite common in social marketing to conduct focus groups, surveys and individual interviews to refine messages, it is less common in the area of policy development or environmental change where the perceptions and observations of advocates and professionals are less often checked by residents. For example, crash data or foot traffic may imply a street design solution when most residents would initially prefer and receive more benefit from an indoor place to exercise or dance. Advocates may believe in a community garden, only to discover later that parents are unwilling to work in one and much prefer affordable farm stands at the after-school program. It can be important to seek feedback from members of a target population before investing in long-term solutions like policy and infrastructure."

"Implementation of the 5Ps for HEAL seems to succeed best at a fairly small geographic scale where a certain level of intensity or ""saturation"" can be achieved. Projects within schools and workplaces, at the small neighborhood scale and to a lesser extent within smaller towns and cities, tend to have an easier time integrating the strategies than projects that are spread over a larger area such as a large city or region. In order to align the 5P strategies at a large scale, many partnerships attempt to create pilot programs that exemplify an integrated project and then take them to scale. When this is done skillfully and effectively, the evidence and models resulting from such pilots can help generate resources for larger scale efforts. Similarly, partnerships that decide to use the 5P model in multiple settings at once (e.g., workplace, school and neighborhood) or for multiple populations at once (e.g., children, employees, and people of color) also often find that it is difficult to gather, manage and sustain the resources to do all of them well. In any case, HEAL leaders and investors should understand that the 5P model can be a resource-intensive method to influence community change throughout a broad area, in more than one type of setting and/or with more than one population at a time. This understanding will allow them to assess more effectively their communities' capacity for such a comprehensive approach and set parameters accordingly."

"Efforts to improve the built environment to make opportunities for healthy eating or physical activity more safe, accessible, enjoyable or affordable are important. However, they are often never sufficient if social factors work against these goals. In addition, physical infrastructure is fixed in place while social conditions are constantly shifting, particularly in dynamic, urban neighborhoods. For example, a carefully redesigned and mapped route for a single child to travel to school won't work if aggressive dogs or gang members begin to hang out along the route and a parent is either fearful or not available. Similarly, improved facilities for walking and biking may not work if the threat of violent crime, graffiti or the existence of excessive garbage deters individuals and families from using them. A farmer's market may not work if the foods are not culturally appropriate for a growing immigrant population or if the shoppers don't know how to prepare a given food. It is important to consider and change the social environment equally with the physical environment in order to deliver fully on the promise of environmental supports for physical activity. This is a fundamental premise of the 5P model of change."

"Policy initiatives often conceal important challenges until it is actually time to implement the policy. During implementation, the implications of a policy become known to stakeholders who previously were passive or uninvolved and to advocates who failed to anticipate the consequences. Disappointments and conflicts can also arise that need to be addressed to improve the operation and impact of the policy and sustain support for it. The disconnect between the intention of a policy and its actual implementation and consequences is larger when advocates and decisionmakers are farther from the environment and people the policy affects. As a result, it is wise to pilot-test new changes, monitor and adjust as needed, and invest in greater stakeholder participation

"Lead agencies can be tempted by a grant to drift into work that is not consistent with their mission, particularly when multiple fields or goals are built into a project. For instance, a pedestrian/bicycling group may be tempted to pursue healthy eating, or a community development leader may be tempted to try health promotion in the course of seeking resources for their more familiar work. Concerns about ""mission drift"" may lead some nonprofit boards of directors to balk at leading HEAL initiatives. In order to sustain a strong commitment at lead agencies that are not health-centered, regular updates should be provided about the nature of the lead agency's commitment, the contributions of partners, and the direct benefits that accrue to the agency's constituents. In the case of initiatives that integrate healthy eating and active living, appropriate co-leadership should be secured for each issue, and structures should be established to protect a lead agency from drifting outside its area of strength. Funders should accommodate this by allowing flexible contracting and reporting arrangements and avoiding requirements that inadvertently make shared and effective leadership difficult."

"Communication audits and communications subcommittees can be important tools for coordinating and improving communications efforts, particularly for large partnerships. Partnerships can take advantage of partners' enthusiasm to tap into the internal communication resources so that expensive outsourcing of communication work can be limited to situations that require particularly high speed or quality. Many organizations have their own communication staff. Some may have graphic artists or video production capabilities. There may be extra space on a web server or web staff to support the partnership's website. Each partnering organization may have a unique relationship with the media that will help the partnership in a different way. By utilizing their internal resources, partnerships can cut costs and improve teamwork. One of the best ways for partnerships to coordinate their communication efforts and resources is to create a communications subcommittee made up of communication representatives or experts from partnership members. (Footer: Coaching in this context can be defined as a collaborative process, guided objectively from the outside, to develop individual and team capability to achieve desired goals. The process often includes assessment of strengths, weaknesses and behaviors, leveraging of strengths, focus on applying learning in a daily context, setting and clarifying goals for increased effectiveness, and establishing accountability for progress.) "

"Many partnerships plan large public events, because they are a good way to generate fun, awareness and a lot of media. These events usually demand significant time, energy and funds from the partnership. Each event should be scrutinized to make sure the benefits to the overall promotional effort are not outweighed by the costs in time, energy, money and good will. Event planners should develop their own systems for increasing efficiency and sustaining the event in the future through ongoing sponsorships, fees and sales, committee structures, volunteer training, careful database and mailing list management and other methods. Some partnerships have ""piggybacked"" their event on a large gathering or partnered with other organizations to reduce costs and reach more people. In such a case, it is important to ensure that: the message is not overshadowed by a larger event; the target audience wants to participate; and competing events don't threaten visibility or success."

"Effective leaders determine at the early stage of partnership development the best way to connect with partners (e.g. newsletter, email, calls, a webpage, meetings, text message or others). They often segment the communication, using a more intensive method with an active core group and more standardized method with a larger ""advisory"" or ""support"" group that participates for shorter periods on more specific projects. Efforts to promote two-way communication with all partners allow leaders to get a range of important feedback and ideas. This can prevent misunderstanding or conflict and utilize partners' assets more effectively."

"People generally already know they're supposed to be more active and eat better. While health information can be useful to people, they often need other reasons and motivators. When it comes to changing behavior, people respond best to specific promotions tailored and directed to them. Partnerships may hope that a PSA or news story will reach their target audience but it is rarely as effective as audience-centered communications (i.e. social marketing) that systematically determines, through research (e.g. surveys) and direct connection (e.g. focus group interviews), the best message, messenger and outlet to reach that specific audience. Examples of audience-centered communication outlets include: street plays, lay communicators (barbers, beauticians, teachers), text messages, sermons, church bulletins, Spanish language television, hip hop radio, peer testimonials, and others."

"Effective partnerships carefully select promotional tactics to support their work in Programs, Policy and Physical Projects. Potential program participants, public decisionmakers, and designers and builders of facilities and the general public all respond to well crafted messages that ask them to pursue a new decision, practice or behavior. When partnerships understand messaging as a fundamental support for all aspects of their initiative, they pursue a wider diversity of promotional tactics and tend to have a broader range of achievement."

"Crime is a very complex and persistent issue that is often closely related to larger social and economic conditions in a community. The perception of crime and other risks to personal security have a major influence on an individual's calculation of the ""marginal cost"" of a behavior like outdoor physical activity. It is possible to implement the 5P model and still fail to change population behavior as long as people remain fearful of their environment. Given the prevalence of fear in many of the most distressed communities in which health disparities are often greatest, partnership leaders should understand and be prepared to propose and implement a full range of crime prevention techniques, including Crime Prevention Through Environmental Design (CPTED), increased police presence, ""eyes on the street"", group activities, complementary messages and programs. Still, it may be difficult to achieve large-scale changes in behavior if partnerships do not have the capacity to address the underlying causes of crime. Partnerships may at times be tempted to retreat from the streets and conduct activities in more controlled indoor environments, but most believe that this is not an effective long-term strategy for increased community-wide physical activity. Communities with a history of effective organizing and an existing network of block clubs, neighborhood watch groups or other means of effectively addressing safety issues as they arise have a distinct advantage in addressing the difficult issue of crime. Communities undergoing gentrification and/or large-scale redevelopment also have some demographic and environmental advantages at the community level, but not necessarily in supporting the most disadvantaged families. Regardless of the underlying conditions and trends related to crime, it is important for HEAL partnerships to test perceptions early, include partners who can be helpful in the area of public safety, be aware of larger trends, and respond to resident concerns."

"Ideas about healthy eating within partnerships can differ widely and sometimes diverge from existing nutritional research and professional guidelines. For example, some messages and programs focus only on fresh, local and/or organic produce, but do not mention affordable, practical, nutritious and often more familiar alternatives such as frozen and canned fruits and vegetables. This reflects in some ways a difference of perspective that has not yet been bridged between those partners who focus on changing the larger food system and those who focus on individuals' current access to affordable and nutritious alternatives. Healthy eating partnerships should define goals and messages as early as possible and seek efficient ways to combine traditional public health wisdom about nutrition and short-term behavior change with larger systems change that supports better long-term access to healthy foods."

"ALbD received few strong proposals from the rural Southeast (i.e. ""strokebelt"") and other rural regions of the country with high incidence of obesity and chronic disease. Few other funders of HEAL work currently invest in these areas. A focus on addressing health disparities by region, as well as by race and income, may require that alternative approaches be taken to project selection in the future."

"Schools are stretched very thin and confront many distractions and challenges, particularly in low-income communities. It is much more difficult to elevate active living and healthy eating in low-performing schools that have other priorities, overcrowded and deteriorating facilities, overburdened teachers, and difficult neighborhood environments. In schools of all kinds, the quality and consistency of the principal's leadership and district-level support is important for a sustainable and credible effort."

"In communities with severe shortages of open space, recreational facilities or civic space, schools' playgrounds, fields, gyms and parking lots can serve as important locations for physical activity, markets or farm stands and events. Joint-use agreements that either permit public use of school facilities or permit schools to use adjacent public facilities allow communities to make the most efficient use of existing assets. Schools and local governments should be encouraged to look for opportunities to share facilities and cut overall costs. "

"The 5E model used by SRTS programs (Education, Encouragement, Engineering, Enforcement, Evaluation) is very similar to the 5P model of ALbD, and some partnerships' SR2S pilot programs have demonstrated increasing, multi-year success at shifting travel behavior of children. With the introduction of the new federal Safe Routes to School grant program, the development of supportive tools and the growth of SR2S programs and advocates throughout the nation, partnerships should be encouraged to look at this opportunity as a key way to address childhood obesity and promote children's health. "

"Home is an important place to include when pursuing place-based approaches to behavior change, particularly for children. Certain key issues reflected in the academic literature such as ""screen time"" and the influence of family culture and parent behavior on children's behavior are not well reflected in current active living and healthy eating grant portfolios. Since home is considered a private place and less often considered as part of community organizations' ""territory"", many initiatives do not naturally address the home environment unless it is highlighted by funders as a concern. Funders should highlight home as a setting for intervention when they are concerned with children's behavior. "

"Some leaders of partnerships sometimes express reluctance to engage potential funders directly or communicate carefully with partners who use the same funding source. They do not like fund raising and do not understand it as a process that is primarily about relationship building for their cause. As a result, these leaders tend to fall back on written grant proposals and anonymous processes for proposal review, and may not engage in strategic fund raising with partners that could potentially build excitement with funders. More training, guidance and support in this area would help partnership leaders to engage funders and partners more forthrightly, creatively and productively."