Highlights from the Presentations of Individual Speakers*
- PowerUp, a long-term regional children’s health initiative that is anchored by two lead health care institutions in the St. Croix Valley, harnesses the resources and the power of social capital of 13 sectors and 130 community advisors, including schools and health departments. (Hedlund)
- Multiple levels of intervention are needed for a comprehensive approach to combating childhood obesity, including community engagement, changes in the environment, programs to change individual behavior, clinical care systems, and relationship building across sectors and levels. (Canterbury)
- Shared leadership with communities is essential for authenticity, momentum, and sustainability. (Hedlund)
- Practical and meaningful evaluation over time is key, and may include short- and long-course measurements of investment in partnership development, attitude shifts around eating and physical activity, policy, practice, and environmental change. (Canterbury)
*Highlights identified during the presentations and discussions; presenters to whom statements are attributed are indicated in parentheses.
1See Appendix E for additional information.
Situated 25 miles east of the Minneapolis-St. Paul metropolitan area, the St. Croix Valley region straddles Minnesota and Wisconsin, with the St. Croix River defining the interstate boundary. The region encompasses two counties, 12 towns, and five school district areas and is home to 22,000 households with children aged 3 to 13.
This school-aged population is the target of PowerUp, a community-wide initiative to make better eating and active living easy, fun, and popular so that youth can reach their full potential. The program, which debuted last year, reflects a 10-year commitment by the nonprofit health care organization HealthPartners and its affiliate Lakeview Health to work with the community in improving population health in the St. Croix Valley region. Two speakers presented an overview of this initiative: Sue Hedlund, former deputy director of Washington County Department of Public Health and Environment in Stillwater, Minnesota, who currently chairs the Health and Wellness Advisory Committee for the Board of Directors of Lakeview Health Foundation; and Marna Canterbury, director of community health at Lakeview Health Foundation. Donna Zimmerman, senior vice president of government and community relations for HealthPartners, participated in the discussion following these presentations.
PowerUp uses a public health approach that considers multiple determinants of health to guide its efforts to improve health behaviors, reduce social and economic barriers to health, and change the environment, Hedlund said.2 She noted that recent hospital and local public health assessments of community needs identified obesity as a top health priority for the St. Croix Valley region, and that addressing the problem will take strong cross-sector collaborations and “real relationships with real people” in the community.
The project was conceived when, in early 2011, HealthPartners formed a new affiliation with Lakeview Health, which is based in Stillwater, Minnesota, and each party made a commitment to advancing health in the areas served by the Lakeview Health system. In an unusual move, the decision on how to pursue that goal was not made by health executives but was instead “delegated to people in the community,” Hedlund said. Tasked with determining what residents thought their community’s needs were, the Board of Directors of Lakeview Health Foundation formed a Health and Wellness Advisory Committee, which came to include board members, community residents, school representatives, a pediatrician, and a nutritionist.
After learning about local health issues, the Advisory Committee
decided that preventing childhood obesity would be its priority. In 2012, it hired full-time staff, including a director, to help develop the children’s health initiative. Many community members wanted to get involved, so the organizers “adopted a flexible committee and governance structure to accommodate the growth and get our communications, activities, and intervention strategies to work,” Hedlund said. An initiative steering committee and workgroups were created. PowerUp was officially launched in May 2013 at a community event. “When we saw the enthusiasm of the community and the response from kids and parents, we knew we were on the right track at that point and were very happy with our planning process,” Hedlund recalled.
The initiative is growing. In 2014 it added two more communities—Hudson and New Richmond, both in Wisconsin—in partnership with two other hospitals affiliated with HealthPartners. The organizers are finding that they need to use “different strategies that are very specific to each of those communities, because even though we are all in this region of the St. Croix Valley, each community is unique and different,” Hedlund said.
PowerUp currently has around 130 community advisors who help lead and guide the initiative, support its strategy development, set priorities, and hold the organizers accountable for results. Approximately 13 sectors (depending on definitions) are represented in the initiative, including health care, school district administration, early childhood programs, businesses, nonprofit organizations that serve youth, civic groups, and faith community groups. Local health departments in Washington County, Minnesota, and St. Croix County, Wisconsin, have been key partners, bringing expertise in how to effect community engagement and implement obesity prevention strategies.
PowerUp’s approach to building partnerships is to find “people who are committed to our vision,” Hedlund said. “Many of our stakeholders are parents and kids. They are the ones we really need to listen to, because they are the ones telling us what the real-life experience is and what really happens.” For instance, foundation board member Jim Leonard and his wife Mandy, who have daughters, have been tireless volunteers for PowerUp. “Mandy worked with the parent-teacher association to power up their entire school carnival,” Hedlund said. “No donuts, no candy—just fruits, veggies, and a whole lot of fun for kids and adults.” And when the outdoor community ice rink needed ongoing maintenance, Jim acquired a Zamboni machine and took on the job.
A key lesson from PowerUp is that shared leadership is essential for authenticity, momentum, and sustainability. “Our communities are making this happen with a wide variety of stakeholders who are bringing innovative ideas,” Hedlund said. The stakeholders have forged many different connections and relationships, which have created a solid platform to build upon.
At the same time, the initiative needs a strong collaborative lead organization, Hedlund said, “to hold everyone true to the vision and message.” She noted that Lakeview Health and HealthPartners both have the value of collaboration ingrained in their “organizational DNA.” “Even though they have a large financial stake in this initiative, they are allowing us in the community to do the work, and yet continually provide value, support, guidance, and expertise to the partners,” she said. “Together we are sharing leadership, decision making, and recognition, and not only at the start of the initiative, but throughout as we implement the whole process.”
Finally, dedicated project staff have been critical in advancing the initiative’s efforts. Their contributions have included convening and listening to the community advisors, facilitating consensus, building community relationships, and providing expertise in evaluation.
Canterbury described the PowerUp initiative’s community-based, multilevel operating framework (see Figure 9-1). As noted earlier, PowerUp is centered within the community, with community advisors providing guidance on its efforts. The initiative’s multiple levels of effort include changing the environment of food and physical activity, engaging the community, providing programs to change individual behavior, and connecting with clinical systems that can identify and help higher-risk individuals. Building connections and engaging across these multiple levels of work also is important, Canterbury said.
Each partner in PowerUp brings unique strengths and perspectives to the table. For instance, Lakeview and HealthPartners contributed know-how in communications that was critical for community engagement. One goal was to ensure that the initiative’s public health messages were positive and fun rather than finger-wagging “should” messages. The end result was a communications campaign featuring a cartoon carrot “superhero” named Chomp. “Children love him,” Canterbury said. “They hug him. They write him letters. . . . While it is a great marketing tool, the reality is that this character brings kids in.”
The real, on-the-ground progress of the initiative is being achieved through partnerships, whether with the local health department, early childhood centers, or hospital cafeterias. One example is the Open Gyms program, which came about because Wisconsin and Minnesota are cold and dark for many months of the year. This climate creates an issue for parents: Where do they go for a free or affordable place to be active with their children when it is too cold or unsafe outside? Starting in the Stillwater School District, PowerUp developed partnerships to make school gyms
FIGURE 9-1 The PowerUp framework encompasses multiple levels within communities.
SOURCE: HeathPartners, Inc., 2013. Reprinted with permission.
and pools more accessible to families. “This year, five communities through school districts or their community centers will be opening up Open Gyms weekly,” Canterbury said. “They are almost always free; occasionally, low cost. We have had up to 120 people come on one given evening, and parents are telling us how important it is.”
PowerUp also has worked with Valley Outreach—a client-centered local “food shelf” organization that feeds hungry families—to increase its offerings of healthful foods. Valley Outreach serves more than 400 households a month, and 80 percent of its clients have children. The partnership led to a few key changes, such as bringing in frozen vegetables, with funding support from external grants. “We insisted that we figure out a way to have vegetables available in more forms than just canned and fresh,” Canterbury said. Produce was arranged in bright baskets to improve how it looked; volunteers repainted the walls and shelves.
The real “magic,” however, was revamping the food lists from which clients choose the foods for their families. Before the makeover, the first four ingredients on the list were pancake mix, pancake syrup, baking
ingredients, and oil. “We completely restructured the order of everything,” said Canterbury. “The list now starts with fruits and vegetables and less processed foods. It is making a huge difference.” Canterbury noted that data from a survey of Valley Outreach clients show that 79 percent want to eat better. Because almost 90 percent of clients get at least half of their fruits and vegetables from the food shelf organization, Canterbury said the team has much more work to do.
One key lesson learned from the initiative is the need for practical and meaningful evaluation, Canterbury said. PowerUp tracks the number and types of its outreach efforts on an ongoing basis. More important, it measures what difference the initiative is making, such as through surveys of parents on awareness, priorities, and their children’s eating behaviors.
During the discussion, panel facilitator Bill Dietz of George Washington University asked how the project’s evaluation metrics have evolved, noting that although the initiative focuses on obesity, body mass index (BMI) is not one of the outcome measures. Canterbury responded that, as others had mentioned earlier in the workshop, it is necessary to look at mid-term measures of behavior changes in children and families. Evidence indicates that such changes can and should result in changes in BMI, which PowerUp’s organizers do indeed plan to look at, she said.
Canterbury and her colleagues also are tracking how much time is invested in partnership development and how many policies, practices, and environments are changing. For instance, the Stillwater School Board adopted a wellness statement for pupils, which could set the stage for long-term health improvements in students. Measuring over time is critical, Canterbury said.
Some of the anecdotal accounts of partners and community residents can say much more than her graphs of evaluation data, Canterbury concluded. Such accounts show “the gratitude that people have for somebody taking the lead and taking action, and then they invariably say, ‘How can I get involved?’ That is how community engagement grows.”
During the discussion, Dietz asked what assurances there are that PowerUp will be sustained. Donna Zimmerman of HealthPartners replied that Lakeview will be serving these communities for a long time and has committed to the initiative for 10 years at a minimum. Canterbury added that community partners often initially assumed that the project would last just 2–3 years and that its organizers would have to write grants to continue its operations. When they learned that was not the case, the dynamic of the conversation changed. With longer-term funding assured, the focus
became, “What can we do together? What parts do you bring to this partnership? . . . Better ideas, better work happens,” Canterbury said.
Dietz commented that the “power of social capital” characterizes what is happening in the St. Croix Valley with PowerUp. He wondered whether that social capital is indigenous to Minnesota and Wisconsin as opposed to Washington, DC, or elsewhere. “Are people in Minnesota and Wisconsin just nicer and more committed?” he asked.
There is a joke in Minnesota that it “is the home of 10,000 collaborations,” Hedlund replied with a smile. “It is somewhat of our nature.” Minnesota has a strong health care system, a public health system built on statewide partnerships, and a vibrant nonprofit community that works together. However, “you have to still provide opportunities for people to get engaged” in whatever way they can, she said. “Social capital needs to meet people where they are at and give them those opportunities on what they can do, because that will grow.”
“In this country when we agree about something this important, and when we engage together, we have always been successful.”
—Bill Purcell, Former Mayor, Nashville, Tennessee
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