Healthy Living Matters

State: TX Type: Promising Practice Year: 2014

Harris County Public Health and Environmental Services (HCPHES) is located in Houston, Texas and serves the third most populous county in the United States. The HCPHES jurisdiction primarily includes 2 million people within Harris County’s unincorporated areas and over 30 small municipalities located in Harris County (not including the city of Houston).In fall 2011, with funding from the Houston Endowment, HCPHES became the oversight agency for the Houston/Harris County Obesity Prevention Collaborative to achieve the mission of curbing childhood obesity through policy. With rates of childhood overweight and obesity exceeding 50% in some communities and some school campuses, a smaller group of leaders decided that policy action would be pursued to improve access to healthy food and physical activity opportunities. The group also determined that a 2-year, robust planning process would provide a roadmap to achieve that mission, and that community and stakeholder engagement, capacity building, and mobilization efforts must be done concurrently with the planning process to build a sustainable community action plan. The Collaborative later became Healthy Living Matters (HLM) in summer 2012, and has since grown its membership to include over 125 leaders representing over 80 organizations across health and non-health sectors. The HLM Project Charter, akin to an organization’s bylaws, outlines the following planning objectives: Conduct an assessment of food access and the built environment within Houston/Harris County Provide learning opportunities related to childhood obesity, its impact on the community and policy strategies to address it Scan and monitor federal, state, and local policy trends and developments Identify local issues and prioritize policies that have an impact on childhood obesity Develop a community action plan, which serves as a road map for policy implementation Ensure an evaluation process is in place that establishes accountability measures The planning objectives were (and continue to be) implemented using the MAPP (Mobilizing for Action Through Planning and Partnerships) and PACE-EH (Protocol for Assessing Community Excellence in Environmental Health) tools; however, HCPHES designed and implemented a "mobilizing" component, not included in the design of MAPP or PACE-EH. A Community and Stakeholder Engagement function was created to usher a movement that promotes healthy living across sectors and neighborhoods, and foster momentum for the launch a community action plan. All of our planning objectives have been met except the community action plan. Some of the objectives are iterative and continuous in nature, so some activities are still underway. The community action plan will be released in January 2014 at a launch event. Examples of milestones that have been achieved: The release of the HLM Built and Food Environment report that details food access and community design issues and opportunities within a 2 mile radius of 4 elementary schools where childhood overweight/obesity exceeds 40% in the community. A policy scan report covering federal, state and local policies/standards relevant to childhood obesity, their status, policy champions and potential opposition. The report is organized into four chapters – early childcare, schools, family settings and community issues (e.g. built environment). A brief YouTube, infographics video that shows why Healthy Living Matters. It was featured on the RWJF "New Public Health" blog website. Speaker invitations from national and regional organizations –Women In Government (national entity of state women legislators), and the Conference of Southwest Foundations. New relationship with Representative Alma Allen, who sponsored a Healthy Living Matters House Resolution (H.R. 1135) in the 83rd session of the Texas Legislature. An HLM legislative briefing during the 83rd Texas Legislature to raise awareness of childhood obesity and the initiative. Development of Youth Ambassadors from various high schools who are promoting healthy living in their schools and communities.One Ambassador was recently recognized as a Finalist for the Rising Star Award of the Michael and Susan Dell Center for Healthy Living. Several community forums with average attendance around 100 participants – residents and organizations – all participating in a policy prioritization process. These milestones are all necessary to build momentum in support of healthy eating and active living – two factors related to the nation’s leading causes of death. The policy focus ensures that efforts will impact the public’s health across various populations in Houston/Harris County. The primary factors that led to the success of these milestones all relate to the strength of the Collaborative – their expertise and commitment, the relationships and networks that each member holds, a well-designed planning process and dynamic project staff supporting the Collaborative. For supplemental materials,including the infographics
HCPHES is located in Houston, Texas and serves the third most populous county in the United States. The HCPHES jurisdiction primarily includes approximately 2 million people within Harris County’s unincorporated areas and over 30 small municipalities located in Harris County (not including the city of Houston). Certain services and projects such as Healthy Living Matters (HLM) span the entire county, serving just over 4 million people. Harris County covers over 1700 square miles, and its land area is larger than the state of Rhode Island. The Harris County population is younger and more ethnically diverse than both the Texas and U.S. population according the 2010 U.S. census. Healthy Living Matters (HLM) is a county-wide planning initiative that aims to influence policy to curb childhood obesity. In Harris County, 34% of children ages 12-17 are overweight or obese according to the 2010 Health of Houston Survey. Even further, certain communities within the county are experiencing even higher rates. A one-size-fits-all approach to addressing the issue may further contribute to health inequities in these communities, so HLM operates at both the county level and the neighborhood level in two priority communities – Near Northside/Fifth Ward and Pasadena, where overweight and obesity rates in children are 57% and 65% respectively. At both levels, the target populations are: infants and children ages 0-18, families, racial/ethnic minorities and persons of low income. Race/ethnicity and income are risk factors for overweight/obesity. The minority population (African-American and Hispanic) in Near Northside/Fifth Ward is 86% and 43% have household income less than 100% the federal poverty level (FPL). In Pasadena, the minority population is 57%; 36% have household income less than 100% the FPL. The extent of our reach has not been fully analyzed given the size of the population served and multiple direct and indirect methods used for outreach. However, a combination of evaluative data and anecdotal observations indicate that HLM successfully reached its intended audience across numerous focus groups, surveys, community meetings, key informant interviews, social media and a web presence to engage both children and adults. Several great examples exist in pockets of Harris County where programs have effectively improved nutritional intake, improved physical activity levels or stabilized increasing rates of childhood obesity. For example in 2005-2008, HCPHES led a consortium of stakeholders to implement the CATCH (Coordinated Approach to Child Health) program in 19 independent school districts across the county in a 3 year period, resulting in a 25% increase in physical activity and stabilized rates of overweight/obesity among elementary school students. Other programs such as Recipe for Success are successfully integrating healthy food preparation and community gardening lessons in the classroom on several school campuses. However, there has never been a county-wide policy initiative that comprehensively targets physical activity and nutrition across the lifespan of a child, starting in infancy through young adulthood, while also targeting the various environments children live in or spend much of their time. Neither has an umbrella network for several stand-alone initiatives existed to supports synergy across the work of a broad diversity of stakeholders from both health and non-health sectors, all interested in healthy nutrition or physical activity for reasons that include but are not limited to childhood obesity. Members represented in the Collaborative range from breastfeeding advocates and early childhood educators to engineers, architects and transportation planners. HLM stands on the premise that “the whole is better than the sum of its parts,” thus creating better value to Harris County that otherwise would be not be realized when initiatives work alone. It is unclear if the approach that HLM has taken is new to the field of public health. A similar approach has not yet been identified for a childhood obesity prevention project out of a local health department with a jurisdiction as large as that of HCPHES. That aside, we consider this practice innovative primarily for the reasons outlined below: A robust “mobilization” component has been built into the design of the planning process that is currently absent in the MAPP and PACE-EH models. So often, local health departments convene stakeholders to develop a plan that risks falling flat once it is developed because influential leaders or residents outside the group have not been engaged and do not have ownership into the plan. Through HLM’s Community and Stakeholder Engagement (CSE) team, deliberate efforts have been made within two years of planning to facilitate ownership of the issue across various sectors to mobilize support for the plan before it is launched. Akin to the public health system assessment from MAPP, key sectors whose policy decisions can directly impact healthy eating and active living opportunities among children were identified and sector summaries were developed for each of these sectors. Summaries were developed for early childcare, schools, health plans/healthcare providers, built environment stakeholders, business and economic development and youth to capture sector-based messaging, (e.g. effective language, preferred methods of communication, etc) names of individual or organizational stakeholders and specific outreach strategies. This information formed the basis of our targeted sector engagement beyond the Collaborative membership. Additionally, efforts went into getting on the agenda of meetings held by stakeholders to introduce HLM, and encourage future involvement. The HLM video and branding materials were typically used in these meetings. Key informant interviews, community forums, social media (e.g. Facebook and Twitter), the HLM website, radio interviews, focus groups, workshops and other special meetings were all used as opportunities to raise awareness about childhood obesity, assess issues suggested by MAPP and PACE-EH, build capacity for stakeholders to address childhood obesity through a policy lens, and encourage involvement in the HLM Collaborative. Each of these tasks further advanced the goal of mobilizing a movement where people would begin to expect and demand more support for environments that foster healthy eating and physical activity. The HLM Collaborative structure is one that directly links broad, county-wide leadership and planning to neighborhood/community level action planning occurring at the same time. It is not unusual to find coalitions, councils or collaboratives attempt to include representation from lay community member so that decisions are not made without consideration of the affected community. As an alternative to this approach, we engaged families and other community residents in several focus groups and community forums across Harris County, meeting them at locations convenient to them, to be sure the voices of the community are represented in the county-wide action plan. Furthermore in our priority communities, neighborhood level planning had been going on simultaneously, resulting in the HLM Built and Food Environment report noted in the Overview section. Recommendations in the report addressing healthy food and active living improvements were specific to areas surrounding 4 elementary schools in Near Northside/Fifth Ward and Pasadena. They were also based on a comprehensive boots-on-the-ground audit of the area as well as resident input and priorities identified through a voting process. This parallel planning at both neighborhood and county-wide levels allowed HLM to identify unique, specific needs that could be addressed in more tangible ways (e.g. adding a walking trail to an existing school park in Near Northside/Fifth Ward), while also providing insight into issues that should be addressed in the county-wide action plan. This also allows HLM to be more knowledgeable and sensitive to potential health inequities that may result from policy ideas being considered by Collaborative members at the county level. Finally, action at the neighborhood level will accelerate as leaders in those communities are able to leverage resources available through the influential network of decision-makers within the broader Collaborative. For example, the founder of the Brighter Bites, a school-based nutrition education program that provides 50 servings of fresh produce weekly to children and families, recently expanded its program to one of the elementary schools featured in the HLM Built and Food Environment report. This is an example of a policy decision made from a local leader who willfully directed resources to one of the HLM priority communities in response to a need and priority expressed by the residents. The founder has shared with us anecdotally that this elementary school is one of her most active, successful sites. In conclusion, HLM is a practice that makes creative use of two best practice public health planning tools – MAPP and PACE-EH – to address childhood obesity. HLM aligns with two of the CDC Winnable Battles: Nutrition, Physical Activity, and Obesity, and more indirectly, Motor Vehicle Injuries A county-wide community action plan is scheduled to be launched in January 2014, and will contain action strategies that will be prioritized on the basis of community and stakeholder input; potential impact on healthy eating, active living and childhood obesity suggested by scientific evidence; feasibility and health equity. To date, over 80 policy strategies have been identified, and are currently being vetted and prioritized. These strategies were informed by various assessment activities, a comprehensive policy scan, an understanding of successful practices implemented in other states and expert reports such as the Institutes of Medicine’s Early Childhood Obesity Prevention Policies report and the Accelerating Progress in Obesity Prevention report.
Motor Vehicle Injuries|Nutrition, Physical Activity, and Obesity
The HCPHES Director of the Office of Policy Planning serves as the Project Director for Healthy Living Matters (HLM) and directs a team of project staff to manage, lead and implement major objectives and milestones. Shortly following the announcement of Houston Endowment’s decision to fund the project (before staff were brought on), the Project Director reconvened the small group of stakeholders mentioned in the Overview section to formalize the group into a steering committee, expand its composition and make key decisions to establish the project governance. Over the course of several months, the mission, vision, project scope and “brand” of the initiative were determined; recruitment efforts were made to expand the steering committee to ensure broader, multi-sector representation (e.g. added individuals from the transportation, arts, early childhood education and business sector); guidelines regarding operations and decision-making were developed; and a multi-sector community planning team (CPT) was assembled to carry out the mission. The Collaborative soon thereafter became Healthy Living Matters. Key decisions that established the project governance were written into the HLM Project Charter. Akin to an organization’s bylaws, the Project Charter keeps the project in focus, sets parameters on what is in-scope versus out-of-scope, describes the Collaborative structure and decision-making authorities and outlines the following planning objectives: Conduct an assessment of food access and the built environment within Houston/Harris County Provide learning opportunities related to childhood obesity, its impact on the community and policy strategies to address it Scan and monitor federal, state, and local policy trends and developments Identify local issues and prioritize policies that have an impact on childhood obesity Develop a community action plan, which serves as a road map for policy implementation Ensure an evaluation process is in place that establishes accountability measures When the Project Charter was adopted by the HLM Steering Committee (SC) in May 2012, a flexible Collaborative structure was created to allow various levels of engagement in terms of time commitment and specific interests. This structure is described below: Steering Committee – this 30-member governing body primarily consists of executive and senior leadership across various organizations in Harris County. They established the governance structure outlined in the Project Charter, and currently provide broad strategic direction, honing in on key strategic decisions.Executive Committee – this group is an extension of the Steering Committee, and consists of the Steering Committee Chair, Vice-Chair, Member-at-Large and the HLM Project Director. They act on behalf of the Steering Committee, particularly for expedited decision-making. Community Planning Team (CPT) – approximately 30 leaders from Harris County serve on this team, and are responsible for carrying out major tasks of the Collaborative – multiple cross-sector assessments, issue identification, policy strategy prioritization and action plan development. CPT members participate in activities organized into the following teams: Assessment, Policy, Community and Stakeholder Engagement and Evaluation. Resource Panel – consists of leaders and other stakeholders in Harris County, in the state of Texas and across the nation. They promote the Collaborative, provide valuable connections, lend credibility to efforts, and/or provide technical or policy expertise on an ad-hoc basis. Additionally, to ensure that the Collaborative has the proper sector representation and leadership, recruitment efforts for steering committee (SC) and CPT participation are ongoing and rely on the following criteria to ensure certain characteristics reflect the Collaborative body as a whole: Executive level leadership experience (Executive Directors, Directors, CEOs, Board Members, etc.) Demonstrated leadership/interest in health and well-being and/or children’s issues Reach/influence across multiple Harris County jurisdictions Reach/influence across multiple, priority sectors Reach/influence into the general public, including priority populations Relevant professional association membership As noted above, the nuts and bolts of planning is done at the level of the CPT, with substantial support of project staff (employees of HCPHES and contractors). While some of the progress is made during monthly held CPT meetings, the bulk of the work occurs in between these meetings and is managed by project staff leading the Assessment, Policy, Community and Stakeholder Engagement (C SE) and Evaluation teams. Each CPT member serves on at least one team, providing advisory and/or logistical support to various activities to keep the planning process moving forward. Depending on the task at hand, SC or Resource Panel members also contribute to the work. Key steps and activities performed to accomplish the planning objectives stated above. The role of stakeholders is also highlighted. Objective 1: Conduct an assessment of food access and the built environment within Houston/Harris County Under the auspices of the Assessment team, in Fall 2012, consultants were contracted to conduct assessments of both the built and food environments within a two mile radius of four elementary schools; two in Near Northside/Fifth Ward and two in Pasadena. The selection of the communities was determined by CPT members after considering a number of factors such as childhood obesity rates, location within a food desert, walkability, geo-political infrastructure, community assets and overall potential for successful implementation of recommendations based on assessment findings. These assessments included a combination of HLM sponsored public meetings, presentations at meetings held regularly by organizations within the respective communities, pedestrian-bicycle counts at strategic locations, key stakeholder interviews, a series of focus groups with parents and surveys of over 68 food stores. In April 2013, the assessments were completed, and the findings were reported back to the community through a series of engagements at locations where community members regularly convene. Along with the findings, recommended strategies were provided based on community input and best practices that have been implemented in communities facing similar challenges. The strategies were listed on poster-sized voting boards, and residents placed a sticker next to the strategies they wish to see prioritized in their communities. The assessment results, including measures of community support for various recommendations are published in the HLM Built and Food Environment report mentioned earlier. To strengthen the relationship that HCPHES developed with residents and stakeholders who granted HLM entry into the community, a portion of the assessment budget was devoted to providing seed grants through an RFP process to immediately begin implementation of the recommendations in the report. Objective 2: Provide learning opportunities related to childhood obesity, its impact on the community and policy strategies to address it. Significant effort went into engaging sectors and stakeholders who were not Collaborative members (or loosely connected), but could potentially play a key role in advancing the HLM mission. Populations and sectors that we engaged more in-depth are described below: Youth – HLM would be remiss if the planning process failed to taken into account the youth perspective. The CSE team worked with Alliance for a Healthier Generation to apply their youth engagement methodology to develop youth ambassadors who could champion healthy living in their schools and neighborhoods. The engagement consisted of a series of capacity-building workshops that conveyed the implications of childhood obesity, the role of the school and built environment and their connection to policy. High school youth also participated in a PhotoVoice project, where they took photos of opportunities and barriers to healthy eating and physical activity in their community. A CPT member from CAN DO Houston, another childhood obesity initiative funded by the Robert Wood Johnson Foundation, facilitated the workshops as well as a youth panel discussion that later took place as part of the HLM Youth Summit held in May 2013. The photographs were prominently featured during the youth-led event where over 80 youth, family members, and organizational stakeholders attended. Organizations that sponsored the youth – Wheatley High School and the Youth Police Advisory Council (YPAC) – both received seed awards to help youth begin implementing changes they desired for their school or neighborhood. Additionally, HLM sponsored travel to send four youth and two chaperones, one from Wheatley and the other from YPAC to the Safe Routes to School Conference in Sacramento, CA in August 2013 to get ideas about how these changes could be made. Early Childcare – Early in the process, several Collaborative members expressed an interest in addressing the issue of childhood obesity early, however very little was known about policies and practices that govern nutrition and physical activity in day care/early childhood education centers. The HLM CSE team contacted the Children’s Learning Institute to learn more about this sector, and it was discovered that there was mutual interest in this subject matter. Children’s Learning Institute subsequently granted HLM access to their network of in-home child care providers, and HLM later set up an agreement with University of Texas (UT) to conduct focus groups with this population in June 2013 to achieve two goals: To provide a learning opportunity to childcare providers and build their capacity to help children eat healthy and be more physically active while in their care. To obtain a better understanding of the opportunities and barriers to healthy eating practices and physical activity in the in-home childcare setting from a policy perspective. Twenty-nine child care providers participated, and steps are underway to determine how UT can develop a nutrition and physical activity training curriculum for in-home child care providers based on the focus group findings. Legislators/staffers – In preparation for future legislative sessions where HLM will put into motion a legislative agenda to implement its community action plan, a legislative briefing was held at the State Capitol during the 83rd Texas legislature in February 2013 to raise awareness about the issue of childhood obesity, and to introduce HLM as a resource. This was made possible through a relationship that one of our CPT members has with State Representative Alma Allen. Representative Allen sponsored the event, as well as House Resolution 1135, establishing HLM in the Texas Legislature. During the briefing, a compilation of childhood obesity-relevant bills filed during the session was discussed with 25-30 legislative staff. No positions on the bills were taken. Maps displaying rates of childhood obesity and related indicators (e.g. daily soft drink consumption) by Senate and House district in Houston/Harris County were also displayed. A staffer from Representative Alvarado’s office later requested these maps to support legislation related to childhood obesity prevention that she sponsored.There are several other cases where activities were performed to satisfy this objective, particularly during Collaborative meetings where expert panel discussions were held to cover topics ranging from health equity to the financing of policy decisions. HLM also sought opportunities to get placed on the agenda for external events, such as a legal symposium recently held in October 2013 by one of HLM’s Collaborative members Children at Risk. In this instance, HLM sponsored the keynote speaker, Dr. Robert Olgivie from Change Lab Solution to add the issue of childhood obesity from a law and policy perspective into a dialogue that typically covers other areas of child welfare, namely education, juvenile justice and human trafficking. Objective 3: Scan and monitor federal, state, and local policy trends and developments Under the auspices of the Policy team, a comprehensive policy scan was performed to better understand the policy environment relevant to childhood obesity at the federal, state and local levels. Policies were primarily legislative, regulatory, and voluntary (e.g. standards). Policy gaps and opportunities, as well as policy champions and opposers were identified. The scan initially applied a framework that looked at relevant policies at different ages across the lifespan: infant, toddler, elementary school age, middle school age and high school age. The scan was later organized into broader categories: early childcare, schools, family settings and community issues (e.g. built environment) each representing a unique chapter. Policies included in the scan, supplemented by recommendations put forth from various assessment and CSE activities, formed the basis of the policy prioritization process that community residents, external stakeholders and Collaborative members all have taken part in. Objective 4: Identify local issues and prioritize policies that have an impact on childhood obesity Meeting each of the three objectives described above allows the “identify local issues” portion of the objective to be met. The prioritization process hinges on having a solid understanding of various issues across multiple sectors and in different communities. There were several additional assessment activities, some still ongoing that added to our understanding of local issues relevant to childhood obesity. In partnership with the YMCA of Greater Houston, the Community Healthy Living Index (CHLI), a tool developed by the Robert Wood Johnson Foundation, was administered to conduct a high-level assessment in an additional 8 neighborhoods and 8 after-school programs across Harris County. In partnership with Collaborative for Children, an online survey was administered and completed by 526 early childhood education/day care facilities to assess policies and practices related to nutrition and physical activity in those settings. In partnership with Children at Risk, a school district survey and campus level survey is currently underway to assess policies and practices related to nutrition and physical activity. An HLM Survey was administered county-wide to better understand opportunities and barriers to healthy eating and active living; 901 residents responded to the survey.Objective 5: Develop a community action plan, which serves as a road map for policy implementation Meeting each of the four preceding objectives supports the completion of this objective. As noted earlier, the community action plan is scheduled to be launched in January 2014. Objective 6: Ensure an evaluation process is in place that establishes accountability measures The Evaluation team leads several evaluation activities, which will be further detailed in the next section. HLM staff projected to complete all planning objectives in a 2-year period, from November 2011 to November 2013. The timeline has been extended to January 31, 2014. All planning activities are supported by a $2.5 million dollar grant fund provided by the Houston Endowment. It is anticipated that $1.5 million will be spent between November 2011 and January 31, 2014. Houston Endowment has approved a no-cost extension whereby the remaining $1 million will be spent on implementation of the community action plan.
An evaluation plan was completed prior to initiating the planning process as a logic model for the project was being constructed. Process measures were primarily identified, given the nature of the project. For example, the early work of the steering committee (SC) in laying the foundation for the initiative (e.g. establishing the governance structure) had several evaluation questions that in many ways served as a checklist. Examples include: Were guidelines and bylaws created to govern initiative? Do teams consist of the right skills and interests? Were meeting agendas and minutes made available to all? Was consensus reached from all sectors on mission and vision? What measures were taken to recruit representatives from each sector? What was their response?Data sources were primary, and included observations and team meeting briefings; email and other written correspondence, the Project Charter, meeting notes and a stakeholder matrix As the early work of the SC nearing completion, an external evaluator conducted phone interviews with the SC to gauge any issues or concerns that needed to be addressed. Examples of questions and summaries of responses were captured in a report and are noted below: Q1. How well does the focus of this project resonate with you? or What does this project mean to you? “Overall, responses reflected a sense of optimism for the project and its focus. Respondents indicated they not only wanted more visible collaboration between other initiatives, they also wanted this process to meaningfully address the challenge of childhood obesity in Harris County.” Q2. Tell us how you think things are going. “Responses ranged from the pace of the project and meetings being slow to the need for additional clarity around the initiative’s organizational structure. Overall, SC members expect that their role will be one of major decision-making with detailed and day-to-day movement of the project occurring outside of regularly scheduled meetings.” Q3. We value your contribution to this work and want you involved. Is there anything you can think of in general that will improve our process? “In general, respondents felt that more clarity is needed on what exactly is the HLM project. Responses reflected a general consensus that confusion surrounds the project’s identity. A concise message of what is in and out of scope is needed.” In response to some of the issues raised, the Project Charter was revised to address areas that needed further clarity. Additionally, the evaluation findings shaped an orientation that was later provided to both the SC and newly created community planning team (CPT). Once the work of the CPT began, the evaluation shifted focus where the pace and timeliness of key project tasks and the completion of the planning objectives were being more closely monitored using project management tools, such as a Gantt chart. Those objectives are: Conduct an assessment of food access and the built environment within Houston/Harris County Provide learning opportunities related to childhood obesity, its impact on the community and policy strategies to address it Scan and monitor federal, state, and local policy trends and developments Identify local issues and prioritize policies that have an impact on childhood obesity Develop a community action plan, which serves as a road map for policy implementation Ensure an evaluation process is in place that establishes accountability measures Additionally, there was more effort being put into evaluating activities related to mobilization and capacity-building to see if we were successfully raising awareness about the issue of childhood obesity and developing interest and/or skills to have stakeholders do something about it. Questions had to be tailored to the population being targeted; however, there are some similarities in the evaluation questions across the various engagements. While some of the evaluation data are still being compiled for several engagements, results from the youth engagement activities are very positive. The evaluation questions were pre-determined by Alliance for a Healthier Generation. They also analyzed the data. Highlighted below are some of the findings from surveys completed by the youth: 83% of respondents answered “yes” to the question, “Has your awareness regarding ways to prevent and delay obesity changed over the course of the program?” 75% of respondents indicated they are “unlikely to create a plan to address a problem in my community” pre-test compared to only7% indicating this in the post-test. The findings are taken with some degree of caution because 30 students from one of the schools did not complete the post test.  
HLM stands a greater chance at operating for several years to come because sustainability was at the helm as the mission of curbing childhood obesity through policy was crafted. Policy is more difficult to change or un-do once it is in place, depending on the type of policy in question and the priorities of those responsible for putting it into effect. Additionally, programmatic interventions are more likely to be sustained if there is a policy in place that more formally reflects an organization’s accountability and commitment to that effort. This further holds true if such efforts do not function in isolation, but rather find ways to leverage resources across a supportive, like-minded network where synergies can be created across various initiatives. A tremendous effort has gone into getting community members and other stakeholders to care enough about the issue of childhood obesity to make it a priority, to assume some ownership in doing something about it and to stay connected to HLM as a broader, county-wide effort that can further advance any individual effort. This is all part of the mobilization component described earlier that was built into the design of the planning process to better position the community action plan for sustainable implementation. This reduces the risk of the plan sitting idle, and is therefore a better practice to adopt compared to a planning process that does not invest in community and stakeholder mobilization. This is the key piece that has yielded ongoing and new stakeholder commitment to HLM. “What’s next?” is a common question we get. As we are nearing the end of the planning phase, the HLM project team is compiling a wish list, comprising of various “asks”, or specific commitments we would like to see organizations within the Collaborative make. A formal cost-benefit analysis had not been done, although cost-benefit language is being communicated regularly as part of our messaging to underscore the cost of doing nothing. Some may be asked to champion the HLM mission as a leader within their particular sector, to serve as model policy change agent that others may replicate. Other members may be asked to redirect programming and or other resources to the HLM priority communities. This is all part of the transition planning that is currently underway as we shift from operating in a planning phase to the action phase. In the first year of implementation, from January 2014 to January 2015, and robust sustainability plan will be developed.