Voices for Healthy Kids: a multisectoral collaboration to accelerate policy changes that promote healthy weight for all children and adolescents in the United StatesBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4763 (Published 07 December 2018) Cite this as: BMJ 2018;363:k4763
- Emily A Callahan,, consultant1,
- Marla Hollander, national partnerships manager2,
- Diana V McGhie, global advocacy manager2,
- Sarah Simpson, consultant3,
- Jill Birnbaum, vice president2,
- Monica H Vinluan, senior programme officer4
- 1EAC Health and Nutrition LLC, Washington DC, USA
- 2American Heart Association, Washington DC, USA
- 3EquiACT, Lyon, France
- 4Robert Wood Johnson Foundation, New Jersey, USA
- Correspondence to M Hollander
Voices for Healthy Kids is a multisectoral collaboration that seeks public policy changes to improve food and physical activity environments to promote healthy weight for all children and adolescents in the United States. Engaging and coordinating the initiative’s many different stakeholder groups is complex and sometimes challenging, but key investments and strategies have led to enacted policy such as legislation or regulations (“policy wins”) and other achievements.
We describe implementation of the multisectoral collaboration and key factors that have enabled and benefitted it, as well as some of the challenges the collaboration has faced and the outcomes. This example of multisectoral collaboration shows how organisations are responding to the society wide problem of an increased prevalence of child and adolescent obesity. We share lessons learnt from the initiative that may inform global efforts to improve health.
A national health crisis
Overweight and obesityaffect about one in three children and adolescents in the United States.1 Inequities in prevalence exist between different population groups across race and ethnicity and by household income and education level. The prevalence of obesity (body mass index greater than or equal to the age- and sex-specific 95th centile of the Centers for Disease Control and Prevention growth charts) among non-Hispanic black (22.0%) and Hispanic (25.8%) young people aged 2 to 19 years was higher than among non-Hispanic white (14.1%) and non-Hispanic Asian (11.0%) young people, based on data for 2015-16.2 In the same age group, the prevalence in the lowest, middle, and highest income groups was 18.9%, 19.9%, and 10.9%, respectively, based on data for 2011-14. In addition, during those years, the prevalence decreased with increasing level of education of the head of household: 21.6% (high school graduate or below), 18.3% (some college), and 9.6% (college graduate).3
We use “inequities” to refer to differences in health that are deemed to be avoidable and unfair, that are strongly influenced by the actions of governments, stakeholders, and communities, and that can be addressed by public policy.45 Inequities in obesity prevalence reflect differential exposure to risk factors such as poor availability of healthy food and opportunities for safe physical activity.6 Given the inequities in obesity prevalence, Voices for Healthy Kids included from the start a commitment to address equity so that all children and adolescents are reached.7 This means organisations must identify obstacles faced by specific groups and tailor strategies to tackle the unique challenges identified for each stakeholder organisation.7
The excess weight epidemic is attributed largely to interconnected social and environmental changes that shape patterns in energy intake and expenditure. Multiple changes in US society have affected food consumption and physical activity patterns, with modern lifestyles characterised by a dependence on cars, jobs that require little physical effort, sedentary entertainment, and wide availability of relatively inexpensive, high calorie foods and beverages. These multifactoral drivers of obesity have led to consensus that there are no simple solutions for this complex problem.6 Thus, governments, scientific and professional societies, advocacy groups, and funding agencies have called for public and private stakeholders in many sectors (such as health, education, transportation, and the media) to tackle the problem at multiple levels: individual, family, community, and society as a whole.
Developing a multisectoral collaboration to tackle a shared problem
Voices for Healthy Kids was launched in February 2013 as a multisectoral, multistakeholder collaboration co-created by the American Heart Association and the Robert Wood Johnson Foundation. The goal of the initiative is to help all children and adolescents achieve a healthy weight. It does this by providing grant funding to not for profit organisations to launch campaigns that engage, organise, and mobilise advocates to improve the food and physical activity environment at state or local levels. This strategy is based on the premise that policy and environmental changes to improve food and physical activity settings are vital to support and enable individuals’ efforts to achieve a healthy weight and can also promote public health.6 The initiative also aims to avoid widening inequities between different groups by directing grants and providing support to those communities in greatest need of support first (for example, those with limited access to healthy foods).8
The initiative aims to build capacity in state and local coalitions by providing technical assistance, training, and access to science based resources. Its staff and partners support campaigns with strategic consultation, technical assistance, training, and resources such as toolkits, messaging or communication strategies, model policy language, and polling. Grant recipients may also receive support from consultants with expertise in media and grassroots advocacy, campaign development, health equity, and policy research.
Issues for policy change are selected based on evidence that suggests they are likely to have the greatest potential for impact6; state and local context helps determine what policy changes are pursued. Examples of policy issues (suppl 1 on bmj.com) include: ensuring that restaurant meals marketed to children meet nutrition standards; securing funding allocations to create walking and biking infrastructure—eg, sidewalks and trails; supporting sufficient amounts of physical education and physical activity in schools; and establishing statewide nutrition, physical activity, sugary drink, water access, and screen time standards for early childcare providers.
Implementation of the collaboration model
Before launching the initiative, many global and US stakeholders across a range of sectors were working together to tackle the obesity epidemic. To extend the work for a broader diversity of state and local advocacy efforts (box 1), the Robert Wood Johnson Foundation acted to fund a collaborative initiative linking a variety of stakeholders.
Context of state and local advocacy activities of Voices for Healthy Kids
The federal system of government in the United States delegates substantial authority to regional governments (the 50 states) in a system in which central planning and control is not held completely at either the federal or state level.9 Operating in this largely decentralised system, Voices for Healthy Kids pursues policy changes at both state and local levels. State level changes apply to all the state’s localities and can maximise reach, while local efforts where there is readiness and capacity for a particular issue can help establish and increase support for state level campaigns and policy changes. US law permits the American Heart Association, a non-profit organisation legally structured as a 501(c)3 public charity, to promote and influence public policy but limits the amount of organisational resources that can be spent on these activities. Accordingly, the American Heart Association closely monitors and reports lobbying expenditures.10 Federal tax laws prohibit the use of funds from the Robert Wood Johnson Foundation for lobbying activities.11RETURN TO TEXT
The American Heart Association is the coordinating agency for the more than 140 stakeholder organisations that make up Voices for Healthy Kids. These stakeholder organisations come from the social justice, physical activity, nutrition, education, transportation, food access, school health, and other sectors, and they seek to advance policy changes in the food and physical activity environment. In the national collaboration model, stakeholders engage through organisational membership in one or more national groups: a strategic advisory committee, issue specific coalitions, a media core team of communications experts, and a research policy network of leaders in academia. The organisations also engage as trusted collaborators with formal roles on ad hoc committees, or as technical assistance providers (suppl 2 on bmj.com). This article focuses on the national collaboration model, but the initiative also includes grant recipients that have built local and state coalitions of community groups, smaller non-profit organisations, and special interest groups that advance campaigns.
The model was initially centralised and in the beginning was perceived by some as inflexible because of an insistence on following certain operating procedures. For example, grant recipients had to request technical assistance through their regional campaign manager rather than being able to approach the initiative’s technical assistance providers directly.12 As the initiative has evolved, procedures have been established such as a technical assistance portal where grant recipients can access technical assistance providers directly; it also provides a system for documenting and tracking requests to technical assistance providers. The initiative has evolved to include a coalition model that funds stakeholder organisations to lead workgroups on specific issues and task forces that provide national level support for state and local policies. This supports collaboration between a wider group of organisations.
Impact of the collaboration
Increasing the prevalence of healthy weight in young people is expected to decrease obesity prevalence. Changes in the prevalence of obesity could be used as success indicators in the longer term (although there are limitations to this approach, for example, causality cannot be established).13
A core measure of the success is that campaigns result in state and local policy changes that improve food and physical activity environments (box 2). Selected policy wins are included in a timeline of milestones (suppl 3 on bmj.com), and the initiative also documents “success stories” of the work to engage, organise, and mobilise communities.17
Selected results from Voices for Healthy Kids
Voices for Healthy Kids tracks campaign outcomes as well as key processes that support campaigns and facilitate policy wins. To date, the collaboration of multisectoral stakeholder organisations has led to:
157 grants awarded to state and local coalitions, totaling $24.5m (£16.6m; €19.0m)
In states with the funding from the initiative, the bill enactment rate was 50% higher than in states without initiative funding 14
The number of childhood obesity bills introduced and enacted increased in the United States between 2013 and 2016. The evidence based advocacy supported by the initiative appears to be greatly associated with the introduction of more state level bills to tackle childhood obesity but not enacted legislation 15
18 advocacy toolkits 16 created for different policy issues and 16 100 toolkit requests from the field (toolkits contain materials and resources to help advocates conduct policy change campaigns)
142 policy wins reaching more than 167 million people in the United States. Examples include:
Securing funding for planning and infrastructure improvements that make it safer for students to walk and bike to school, such as safer street crossings and bike trails (state of Minnesota)
Passing legislation that creates healthier “default” beverage options for kids meals in restaurants (city of Baltimore, Maryland)
Securing funding to reduce food insecurity, including hiring a food access coordinator and providing funds to open large grocery stores or improve existing stores (city of Austin, Texas)
Source: Voices for Healthy Kids internal statistics tracking and Strategic Advisory Commitee Dashboard, 1 February 2013 to 9 August 2018
Stakeholders expressed that, in addition to policy wins, other important indicators demonstrate the collaboration’s effectiveness. These include connecting advocates, engaging community members (box 3), and integrating equity such as building the capacity of grant recipients to develop policy strategies that address social determinants of health and to better reach groups experiencing health inequities.
Public engagement in campaigns
Community involvement throughout the policy change process is important for setting goals and strategies, obtaining influencer support, and if the policy is passed and enacted, ensuring intended implementation. Through grants, Voices for Healthy Kids positions and equips not for profit organisations with the resources and guidance they need to advocate for policy change. An example is the community advocates program created by DC Greens, a community based not for profit organisation in Washington, DC, using a grant received from the initiative. The community advocates program seeks to overcome barriers that prevent people who are experiencing food insecurity from participating in the decision making processes that shape their lives, their city, and their food. The main goal of the community advocates program is to build the power of communities most affected by food injustice to influence food policy at the city level.18 Local recipients of federal nutrition assistance funds who have benefited from incentives to purchase and consume more fruits and vegetables can undertake paid training over six months to gain the tools, connections, skills and information to effectively advocate for policy change in their communities. These individuals advocate at city council meetings for increased support for similar incentives to benefit other residents facing food insecurity. The community advocates have contributed to the success of the grant recipient in securing $1.2m (£0.9m; €1.1) in municipal funding for food access.19RETURN TO TEXT
We report an analysis that aimed to establish the factors that enable the multisectoral collaboration and which may have contributed to policy and environmental changes to improve food and physical activity settings, which are vital to enable all children and adolescents to achieve a healthy weight. Findings came from a detailed review of documentation of the initiative’s development, implementation, outcomes, and evaluation, including annual reports, key informant interviews, and findings from a multistakeholder dialogue held in June 2018 (suppl 4 on bmj.com).
Analysis of factors enabling multisectoral collaboration
The case study identified four factors that enable and benefit the work of the multisectoral collaboration.
Formalising opportunities to convene and connect stakeholders
The broad vision of Voices for Healthy Kids attracts many different stakeholders. This shows that healthy weight can be pursued through various strategies, including equitable access to healthy foods and beverages and physical activity opportunities. Action in these areas predates the initiative’s launch, but stakeholders were not then always aware of each other’s efforts. Many organisations shared similar goals related to improved nutrition, increased physical activity, and healthy weight, although their motivations and methods for achieving these goals sometimes differed.
The initiative found that a key driver of stakeholder engagement is the connection between stakeholders’ missions and the initiative’s goals—shared interests. This is the driver of engagement most frequently reported by stakeholders in surveys about the initiative. Other factors driving engagement include access to resources and funding opportunities, connections to other advocates and stakeholders, and opportunities to build organisational capacity, learn about strategies and research, and promote and support health equity.
Key informants report that involvement in Voices for Healthy Kids enables exposure, communication, and relationship building between multisectoral stakeholders with no previous relationships. One interviewee described it as “exceptionally helpful” to be part of the strategic advisory committee noting: “It helps all of us [to] connect on areas of commonality to make sure our messages are aligned and our work is complementary.”
Stakeholders appreciate the opportunity to align their respective advocacy messages and complement each other’s efforts. Pooling and leveraging resources (such as talent, expertise, and tools) expands stakeholders’ collective power and capacity to advocate for policy changes around shared goals to improve food and physical activity environments (box 4).
Pooling resources for a policy research network
As Voices for Healthy Kids evolved, it became clear that a forum was needed for the policy research community to discuss important issues. Academic organisations within the Robert Wood Johnson Foundation and American Heart Association research circles were invited to attend the initiative’s first policy research summit in December 2014.2021 The summit led to the identification of research gaps in the policy priorities shared by Voices for Healthy Kids and academics. The summit also led to routine communications and gatherings of research organisations to continue dialogue and align work efforts. This has resulted in a better informed research agenda for researchers, advocates, and funders which aligns resources to study topics that are relevant to advocacy campaigns as they develop.RETURN TO TEXT
A third party assessment including more than 50 confidential stakeholder interviews concluded that because the initiative has become a recognised and trusted convener, this is helping to build unity and minimise competition between those working in the field of healthy weight. It also reported that this strengthens stakeholders’ capacity to guard against threats to the healthy weight movement, such as concern that public policies to change environments will limit personal freedom of choice.22
The collaboration also stimulates cross pollination of ideas and strategies. Collaborators take new perspectives, tools, and resources back to their organisations. Strategic advisory committee members report that their involvement in the initiativeI has contributed to changes in how both they, as individuals, and their organisations approach health equity. Another benefit reported by stakeholders who first connected through the initiative is opportunities to work together on other projects.
Investing in infrastructure to support the collaboration
The Robert Wood Johnson Foundation provided a four month planning grant for the American Heart Association to establish an infrastructure to coordinate and support the collaboration. The American Heart Association had an advocacy presence in all 50 states, but its policy work included only informal, ad hoc consultation or engagement of external organisations. To support a systematic approach to stakeholder engagement, staff were designated to recruit stakeholders, manage the forums where stakeholders are engaged (suppl 2 on bmj.com), and collect stakeholder feedback through an annual survey. Since the first survey in 2015, the proportion of stakeholders reporting satisfaction with their engagement experience has increased (from 57% to 81%), the proportion reporting a neutral experience has decreased (from 37% to 16%), and the proportion reporting dissatisfaction has remained consistently low (6% or less).
Key informants have expressed that investing in permanent staff who are trained and dedicated to managing stakeholder engagement is essential for nurturing strategic relationships, providing direct lines of communication to support and build capacity in advocacy campaigns, and enabling reliable, consistent partner support. For example, a staff relationship manager is assigned to each strategic advisory committee member. This individual provides a formal orientation, holds routine follow up meetings, and sets annual goals for engagement.
A commitment to health equity
From its inception, the initiative committed to integrating health equity across its processes, strategies, and activities so that equity is the driver “and not just a passenger we pick up at our final destination.”7
Health equity is a familiar concept to the missions and practices of some advocates and organisations, but for many stakeholders, the initiative found that it is vague and difficult to put into practice. Achieving acceptance for the “why” of integrating equity has been easy compared with determining the “how.”
To help implement this commitment, health equity and social justice leaders were recruited to the strategic advisory committee. They inform and advise the initiative and hold it accountable for implementing equity into policy approaches, for example by identifying policy language or funding decisions that could unintentionally widen inequities (box 5). Key informants noted:
Practical strategies to put health equity into practice
Dedicated American Heart Association staff to integrate equity across the initiative’s activities, including the grant making process (grant applications must describe how work plans will incorporate health equity), campaign development, message research, and creation of technical assistance materials such as guidelines on incorporating health equity
Including a health equity performance measure for the staff of the initiative
Training stakeholders (through webinars, in-person events, and individual coaching sessions) to incorporate health equity into proposals, campaigns, and work plans
Engaging health equity experts to audit the initiative’s equity centred vision, framework, and action plan
Piloting and scaling up a grant making project to increase funding for grant recipients that reflect and serves populations of greatest need
Targeting grants for priority populations, such as improving access to healthy foods in the state of Ohio. Mapping of the state’s communities identified areas of greatest need, including one county where residents had to travel 30 miles to access a store selling healthy food. An advocacy campaign resulted in $2m (£1.5m; €1.8m) in 2015 to fund a healthy food financing initiative23
“The initiative has pushed us to find better partners with a stronger health equity focus. ... I think this has been an experience we will better be able to carry forward now in future advocacy campaigns and even those outside of the childhood obesity arena.”
“The prioritization of equity has been mutually reinforcing for the collaboration, and the influence of the initiative, together with Robert Wood Johnson Foundation, gives me cover to introduce equity in my own organization.”
Collecting evaluation and feedback data to inform continuous improvement
The Robert Wood Johnson Foundation has funded third party evaluations since the beginning of the initiative to help assess its impact and share lessons learnt.12141524 These use various techniques to measure changes in state policy related to the goals of the initiative, examine factors that help or hinder campaigns, and assess the effectiveness of the technical assistance provided. Evaluation results help identify measures of success and improve campaigns and their operational processes such as tracking requests for technical assistance.
The initiative also collects feedback through the annual survey. It assesses stakeholder awareness of the initiative’s goals and activities, identifies the resources that stakeholders value most, and provides insight on stakeholder commitments to align resources to the initiative. A 2017 third party review drawing on confidential interviews with more than 50 stakeholders was another source of feedback. One interviewee noted, “It was brave [of the American Heart Association] to open themselves up to having so many of their internal and external partners assess their value.” Results from these feedback mechanisms inform the communications, messaging, and ongoing engagement practices of the initiative.
The feedback mechanisms are important because there was not time to test different approaches or plan extensively for the collaboration’s operation when it was set up. The feedback keeps the American Heart Association informed of stakeholder experiences as the collaboration grows and expands. For example, in an annual stakeholder survey, the initiative received feedback on the shortcomings of integrating health equity. This resulted in the creation of forums to consider innovative equity practices, led and supported by stakeholders with equity expertise.
Limitations and challenges
Stakeholders report that there were challenges with trust and transparency between the American Heart Association and collaborating organisations early on. For example, survey feedback in 2015 noted that a “culture of confidentiality” about the initiative’s policy strategies was inhibiting collaboration. Additional feedback revealed a perceived lack of opportunity to contribute to policy development.
To increase trust and transparency, the American Heart Association now provides more opportunities to solicit and discuss stakeholder input on policy formulation and includes key stakeholders in an annual policy review process. An example of how trust was built with collaborators by undertaking food and nutrition efforts outside of the initiative is described in box 6.
One size does not fit all
The Native American population has some of the highest levels of obesity in the United States.25 Voices for Healthy Kids commissioned a report in 2015 surveying the history and current state of Native American food access and health disparities.26 It found that the initiative’s model was not a good fit for the Native American population and an entirely different approach was needed. This was because action on policy change in the Native American population takes place at federal or reservation level, not at state level, so the initiative’s approach to state and local action did not align. Furthermore, the American Heart Association recognised its lack of expertise in this area so its first step was to invest time and resources into learning and discussing. This led the American Heart Association and the Shakopee Mdewakanton Sioux community to partner to tackle the serious food, nutrition, and health problems in Native American communities throughout the United States. The two groups organised national conferences in 2015 and 2016 to bring together potential funders and discuss essential needs. Several funders have since provided support for work on food and nutrition with the Native American population.
This required trust on both sides: “Look how far we have come in three years. This needs to be uplifted as an example, particularly in terms of the investment that has been made in a period for learning, for creating a space outside of the initiative to pursue this work, and as an example of where the [American Heart] Association has partnered with tribal government as equal partners to pursue equity in healthy weight outcomes.” (Key informant interview)RETURN TO TEXT
Several stakeholders have recognised the initiative’s progress in putting equity into practice and noted room for improvement, while others have indicated that equity efforts are not yet meeting their expectations. Suggested ways forward included involving organisations that represent additional groups such as people with disabilities, undertaking a more detailed analysis of the underlying and structural determinants of inequities, and identifying measures of success that better reflect health equity. While the initiative seeks to remedy existing health inequities by prioritising grants to communities most in need, it is not clear what contribution this is making to reducing inequities in these communities or population groups.
Finally, stakeholders reiterated the need for other measures of success in addition to policy wins. They suggested more nuanced and comprehensive indicators of a campaign’s impact such as the relative impact of policy change—for example, making progress in a state or community where the policy environment was previously not receptive to change. We suggest that ongoing evaluations of the effect of the initiative should also examine progress in enacting and implementing policies that promote healthy weight in an equitable way so that all children are reached.
The 2018 political declaration on non-communicable diseases reaffirmed the need for governments to develop adequate national multisectoral responses for the prevention and control of non-communicable diseases, as well as the importance of pursuing whole of government and whole of society approaches.27 We have highlighted the experience of and challenges involved in creating and implementing a multisectoral collaboration to advocate for public policy changes to improve food and physical activity environments to promote healthy weight for all children and adolescents in the United States. Our analysis found that the conditions that enabled and benefited the multisectoral collaboration included the establishment of forums for stakeholders with shared interests to meet and connect, investment in staff to support the collaboration, a commitment to health equity, and collection of evaluation and feedback data to guide continuous improvement and build trust. Reflecting on the progress made, one stakeholder recalled another stakeholder once describing the collaboration as messy and noted that “despite this there is magic in the messy!” We hope that this paper provides insights for those interested in multisectoral collaboration and in improving the health of children and adolescents across the world as part of wider efforts to prevent and control non-communicable diseases.
The multisectoral collaboration model of Voices for Healthy Kids enables more than 140 stakeholder organisations to align resources in pursuit of shared goals. These stakeholders advocate for public policy changes to improve food and physical activity environments to promote healthy weight for all children and adolescents in the United States
The collaboration is supported by ongoing commitments to regularly bring stakeholders to together, engage with , and collect their feedback
A focus on equity in all the processes, strategies, and activities of Voices for Healthy Kids has strengthened the collaboration and is expected to contribute to remedying existing health disadvantages of target populations
We acknowledge support from the stakeholder organisations that made the development of this case study possible and thank them for sharing their time and information, including (in alphabetical order): Afterschool Alliance, Alliance for a Healthier Generation, American Academy of Pediatrics, American Heart Association Mid-Atlantic Affiliate, Center for Science in the Public Interest, Centers for Disease Control and Prevention, Child Care Aware of America, DC Greens, Echo Hawk Consulting, Horizon Foundation, Lakeshore Foundation, NAACP, Public Health Law Center, Rudd Center for Food Policy & Obesity, Safe Routes to School National Partnership, Smart Growth America, The Food Trust, The Praxis Project, UnidosUS, and YMCA of the USA.
See www.bmj.com/multisectoral-collaboration for other articles in the series.
Contributors and sources:This article is based on findings from a review of the multisectoral collaborative work of Voices for Healthy Kids, commissioned by the Partnership for Maternal, Newborn & Child Health (PMNCH) Secretariat. All authors contributed to the article: MH gathered the initiative’s documentation to be reviewed; EAC and SJS reviewed the documentation; EAC wrote a draft working paper with inputs from other authors; SJS and MH conducted key informant interviews; JB and MHV served as key informants; MH, SJS, and DVM planned and facilitated the multistakeholder dialogue and developed corresponding planning documents; EAC and SJS developed the article outline; EAC wrote the first draft with inputs from SJS, MH, and DVM; EAC and SJS revised the manuscript; and MH, DVM, JB, and MHV provided feedback and key inputs on drafts. All authors contributed intellectual content and approved the final version of this article for submission. EAC is the guarantor.
Competing interests: We have read and understood BMJ policy on declaration of interests and have the following interests to declare: funding from the PMNCH Secretariat (SJS) and the American Heart Association (EAC) for a consultancy to undertake the case study; funding from the Robert Wood Johnson Foundation (SJS) through its international donor advised fund through the Charities Aids Foundation of America for consultancy work on two separate projects on lessons for the United States on (a) primary care and (b) social participation in health.
Provenance and peer review: Commissioned; externally peer reviewed.
This article is part of a series proposed by the Partnership for Maternal, Newborn and Child Health (WHO PMNCH) hosted by the World Health Organization and commissioned by The BMJ, which peer reviewed, edited, and made the decision to publish the article with no involvement from WHO PMNCH. Open access fees for the series are funded by WHO PMNCH.
This is an Open Access article distributed under the terms of the Creative Commons Attribution IGO License (https://creativecommons.org/licenses/by-nc/3.0/igo/), which permits use, distribution, and reproduction for non-commercial purposes in any medium, provided the original work is properly cited.