Realizing Collective Impact for Community Health: A Wilmington Case Study.

As our state and nation face increasingly tight program budgets and more limited funding sources, collaboration has come to the forefront as a critical mechanism to promote health and well-being. The Collective Impact framework is an emerging approach to guide larger scale changes at a community or regional level. Through the establishment of 5 core tenants including establishing a backbone organization/central infrastructure, shared agenda, shared measurement systems, mutually reinforcing activities and continuous communication the CI framework advances the work of prior theorists and creates a foundation for health promotion. In this article we discuss the foundations of the approach and describe how the tenants are applied using examples from a case study of the Wilmington Collective Community Impact Study. Finally we reflect on the evidence to date for the CI approach and offer critical points of discussion to advance community-engaged programming in a small city.

Introduction

Collective impact (CI) approaches are increasingly being used locally and globally to more efficiently and collaboratively address the need for large scale social change., The CI framework seeks to maximize available resources, both public and private, by bringing together what might otherwise be independent efforts. While strategies for collaboration, and an emphasis on community engagement is certainly not new in the fields of public health and community development, the CI framework provides a core infrastructure for collaboration.

The practice of community engagement is now well-established as part of large and small foundation funding efforts,– health promotion programming and research supported by the Centers for Disease Control and Prevention, Institute for Education Sciences and the National Institutes of Health,– among others. Such mechanisms build on tested theoretical frameworks with wide-spread application including Community-based Participatory Research, Theory of Collective Efficacy,, and Community Coalition Action Theory (CCAT).,

The CI method while originally developed by industry, largely advances the earlier work of Butterfoss and Kegler’s CCAT but applies a 5 pillar framework. These pillars include partners coming together to define 1) a common agenda, 2) shared measurement, 3) mutually reinforcing activities and maintain 4) continuous communication, guided by an identified, strong 5) backbone organization. At the same time, the approach emphasizes the importance of advocacy, equity and supports a culture that fosters trust, respect, and regard for the local context.

Alignment is at the centerpiece of the CI model. In so doing it attempts to reduce or eliminate duplicative activities and achieve measures and programming which more intentionally address a problem across sectors, through coordination and sharing.

Despite its growing application and use, there remains few applied examples of the approach in the peer-reviewed literature. Early examples from the grey literature however demonstrate the impact that collective impact can have on underserved communities. For example, in 2011 the Campbell Soup Company made a $10 million commitment to reduce hunger and obesity in the Camden, NJ community, the location of its World Headquarters. The city of Camden is home to 74,500 residents, 32% of which are children, and 45% which speak a language other than English at home. Nearly 40% of its residents live in poverty making, on average, $14,100 a year, per capita. Yet, despite challenges, agencies including the YMCA, The Food Bank, Camden Coalition for Healthcare Providers, and The Food Trust committed resources to achieve strong programming and support services in the area guided by a Collective Impact Framework. Since this time a number of other funders and community leaders have joined the collective, further leveraging the common agenda for their own work.

Here we describe the early phases of a Wilmington, DE model which is working to build a collective impact framework. In it we will describe how the 5 pillars of the collective impact model can work to promote healthy diets in a local community.

The Wilmington Context

The University of Delaware’s Center for Research in Education and Social Policy (CRESP), although not based in the city of Wilmington, is committed to community engagement to support and address inequities faced by residents across the state. In 2018 the Center was awarded a USDA AFRI grant in order to pilot and test a collect impact approach to improving fruit and vegetable consumption on the west-side of Wilmington. The project, “Realizing a Community’s Collective Impact” or CCI, sought to leverage existing efforts on the west-side of the city to test whether or not the collective could improve fruit and vegetable consumption. Wilmington is home to 71,000 residents, 25% of whom are children with a growing senior population (13%). Twenty-six percent of Wilmington residents live in poverty, with an average per capita income of $26,263.

Backbone Organization

Backbone organizations, defined as those that create and manage collective impact programs, require an organization with dedicated staff to manage the work of the collective. In Wilmington the decision to have CRESP serve as the backbone organization was largely decided due to the financial support available for the project. In both, the backbone organization is responsible for ensuring activities are mutually reinforcing, that partners receive continuous communication, and that evaluation strategies are implemented in alignment with the goals of the collective:

A common agenda,

Shared measurement,

Mutually reinforcing activities, and

Maintain continuous communication,

Common Agenda

There are a variety of resources available publicly to help organizations and projects develop a common agenda, though all emphasize the importance of achieving common principals to guide the group and its decisions, a common understanding of the problem, a measurable goal to help define success (and how it is measured), a clear framework for how the collective will operate and how the group will split up the work, and an understanding for how progress will be tracked and lessons will be learned. Embedded within these conversations the group is also encouraged to work within an asset-based (rather than deficit-based) approach, identify opportunities to achieve shared responsibility, emphasize the importance of empowerment for the collective and the community and to think holistically about health and community well-being. Other important tenants of the approach include transparency, achieving sustainable relationships and respectful communication.

Shared Measurement

Measurement strategies require use of common metrics, collectively agreed upon objectives, and partners willing to incorporate common measurement strategies and reporting format to benchmark results. While there is no one size fits all approach to changing the health of communities, it is possible to nest the work being done and set targets for improved outcomes. Metrics should include at minimum the size of the total investments including leveraged funding, the volume of community programming underway (time by activity and number of individuals impacted) as well as the behavioral outcomes resulting from programs including changes in knowledge, attitudes and behaviors relevant to each of the three categories of effort noted above. Three steps to the development of shared outcome measurement include Step 1: Identifying and Agreeing on Objectives, Step 2: Leveraging Existing Instruments and Approaches, and Step 3: Launching the Resources and Protocol (see figure 1).

Figure 1

Creating Shared Outcome Measurement

Step 1: Identify & Agree on Objectives

Common objectives used in prior collective impact work include improving the quantity and quality of physical activity, improving the quality and diets of children, increasing awareness of the importance of physical activity, achieving meaningful and sustained parent involvement in schools and children’s activities, creating a culture of support for eating well and exercising and effectively engaging community leaders. In the Wilmington example, partners recognized that families did not consume the recommended servings of fruits and vegetables, and partners agreed that a core metric for impact of the intervention would be to measurably improve fruit and vegetable consumption.

Step 2: Leverage Existing Instruments

In order to understand the collective impact across stakeholder groups a review of existing instruments was undertaken by the backbone organization in consultation with the collective. Ultimately one tool which would be administered by the backbone itself was selected for community use. In other examples, however a set of questions, or indicator metrics have been identified which allows each organization to independently measure impacts using common wording such that data can be combined to report on the impact of the collective as a whole. Most typically impacts include output metrics including quantity of programming and participation, as well as outcome metrics such as change in physical activity, food insecurity, economic stability or similar. In addition, efforts to understand the total amount of funds invested and those that were leveraged as a result of the collective are often valuable. In the case of Wilmington measures included data collected from the collective programs as well as randomly sampled household outcome data collected from the community for which programming was intended to benefit. Because the CCI effort included a research component as well, additional data was collected from a control community in the nearby city of Bear, DE.

Furthermore, it is important to note that existing secondary data, that is data that is already being collected nationally, could be used strategically to leverage on-the-ground data collection approaches. For example, where mature and intense programming is occurring, examination of shifts in hunger or obesity or other national indicators relative to other, similar areas in the US could be considered. Depending on the scope of the initiative, leveraging existing, valid and reliable metrics can generate greater support in the academic community for understanding the impact of the work and, at the same time, may alleviate data collection stress on the ground. One potential resource for this type of data collection is the National Collaborative on Childhood Obesity Research (NCCOR). NCCOR has established a measures registry which catalogues existing survey measures and the reliability and validity information supporting their use.

Mutually Reinforcing Activities

In Wilmington, the project, “Realizing a Community’s Collective Impact” or CCI, builds on the Wilmington, DE-based knowledge, experience, and presence of the staff and leaders of 11 non-profit and institutional partners. The effort draws on existing efforts of these community partners but aligns efforts around a common theme and purpose, to encourage consumption of fruits and vegetables, specifically tomatoes and apples. Specifically partners’ representatives implement their existing and on-going nutrition education and healthy living programs while at the same time tailoring the work to encourage consumption of these particular items during the same month, and overlaying an additional common evidence-based zoo-animal messaging campaign (“Tastimals”) as part of their work in both English and Spanish. The Tastimals animal characters were previously shown to positively influence healthy food choices and through the common framework, a greater impact at the community level can be achieved. Some examples of how the collective can work within a common agenda (Tastimals and tomato/apple promotion) while leveraging existing resources between mutually enforcing activities including:

SNAP-Ed cooking programs (Food Bank of Delaware);

Inclusion with bagged tomato or apple patient give-a-ways (Westside Family Healthcare);

Dissemination at an event for the Friends of Father Tucker Park (West Side Grows);

Pick-up during Mobile Pantry events (St. Francis Hospital); and,

Distribution by St. Francis Hospital and the Delaware Zoological Society (the Society supported the original Tastimals research) as part of the “Zoo WalkBy” held during the “Healthy Kids, Brighter Futures” event.

Prior to the CCI project, most partners were aware of the other partners and their activities, and had, in some cases, sporadically collaborated to deliver nutrition education programs. However, the CCI partnership has created new bonds among the various partners: for example, the Food Bank of Delaware now delivers nutrition education programs at both St. Francis Hospital and Westside Family Healthcare; these organizations had not formally worked together prior to the CCI project.

Continuous Communication

In a time where many forms of work rely almost exclusively on email, texting, and other electronic forms of communication, CCI implementation occurs largely through frequent and regular forms of face-to-face contact. For example, in Wilmington CCI partners meet locally in person at a site hosted by a CCI partner. These approximately two-hour meetings have generated important and useful feedback to project leaders (e.g., regarding Tastimal design, or study timing), and established new working partnerships. Also, the two CCI partners (i.e., Woodlawn Library, Adams Fresh Grocer) that do not host active nutrition education programs are nonetheless important community focal points within the study area. As such, staff from the CCI lead organization visits these two sites weekly to deliver a range of CCI program materials for pick up by these partners’ clients. During these visits, Library and Grocer staff provide information regarding those program materials that generated interest, how the materials were used, and other key points of feedback.

Notwithstanding personal contacts, CCI leaders and staff use email to update partners on key and timely points such as delivery of program materials. Also, an e-newsletter is used to regularly update CCI’s Advisory Community which is comprised of the Wilmington area’s key funders of and policy makers for nutrition education efforts.

Reflections and Conclusions

In smaller cities and communities like Wilmington, DE, a collective approach is increasingly needed; both our nation’s fiscal climate and interest in cross-sector community-engaged research and programming require it.

Particularly in smaller geographic areas, non-profit, government and foundation efforts to improve health and well-being can result in overlapping efforts and unintentionally approaching the same partners with similar asks from the same institutions. At the same time, smaller institutions may undertake very similar activities but without the benefit of common metrics or coordination in the approach such that the resources brought to bear are less robust than could be achieved collectively. Further, once a collective approach is established the framework provides a foundation from which additional efforts can build and grow. In its most robust form, the collective is then working to both achieve its own common agenda, and that agenda can become a backbone for extending the work to other investors, researchers, and collaborations from additional sectors.

Prior research on the CI approach emphasizes the importance of the backbone organization’s leadership to provide an effective means of communication and staffing. A strong backbone, which ideally comes from a single organization, has been found to further the collective’s credibility, outreach in terms of its range of contacts, and effective technical assistance to its partners. The backbones effectiveness also lies in its ability to attract additional partners and share lessons learned.

As efforts to expand University and Hospital-based intervention and research continues to expand into the community, efforts to develop and sustain partnerships both with each other, and across sectors will be of increasing importance. Perhaps most importantly however, will be our efforts to sustain and engage community partners in these efforts. A collective impact framework for this work will support more intentional, collaborative and sustained efforts which can help shape effective policy while maintaining stable and ongoing data collection efforts which can further advocate for needed programs, and to assist in closing gaps in disparities.