How Cross-Sector Coalitions Can Improve Public Health

A new study by researchers at the Friedman School of Nutrition Science and Policy at Tufts University and others shows how bringing together coalitions of individuals from government, public health, healthcare, public education, and other arenas to address a public health issue can result in better policies, systems, and environments for change.

Their research, published recently in the journal BMC Public Health, focuses on the epidemic of early childhood obesity affecting kids ages 2-5. It shows not only that the shift from working in silos to working across sectors works, but how it works.

“Bringing people together from across sectors helps them develop a shared understanding of the problem and devise whole of community cross-system solutions,” says Christina Economos, dean ad interim of the Friedman School and the study’s first author. “This ‘systems thinking’ increases knowledge and cooperation. Perhaps more importantly, it diffuses that knowledge into the coalition members’ social and professional networks.”

The result, this new research demonstrates, is increased knowledge among more people in multiple sectors that leads to better policies, systems, and environments to create change.

14% of Young Children Are Obese

Almost 14% of children 2-5 years old have obesity, making them more likely to experience obesity during adolescence and adulthood and increasing their risk for diabetes, hypertension, cardiovascular disease and even some cancers in later life. Early childhood obesity rates are significantly higher among Hispanic and African American children compared to white children.

These statistics and the health disparities they highlight haven’t changed in recent years, says Larissa Calancie, research assistant professor at the Friedman School and one of the study’s co-authors. “Anecdotally, and in small-scale studies, we know that encouraging parents to praise healthy behaviors in children, educating parents to continue breastfeeding or reduce screen time for kids, and engaging healthcare providers to talk about healthy weight with their young patients’ caregivers can be effective,” she says.

Barriers across Communities

Unfortunately, parents, healthcare providers, and early childcare education professionals frequently experience barriers in adopting evidence-based obesity prevention strategies like these unless there are environmental and policy changes within the broader systems and community, Calancie says.

For example, the Women and Infant Children program provides vouchers for individuals with children under the age of 5 who have low-income to buy more nutritious foods. But parents need to know about the program and how to apply. Encouraging caregivers to praise healthy eating choices is an option only for those who have access to those healthier eating choices. Breastfeeding for working mothers can be a challenge unless there are accommodations in the workplace for mothers to pump breast milk.

'How' Is the Big Question

While researchers have seen that cross-system collaborations can create change in small settings before, “we didn’t have hard evidence demonstrating how those cross-sector collaborations affect change, and how to use that knowledge to bring about lasting improvement,” says Calancie.

To answer that “how” question, the Tufts team designed the Somerville, Massachusetts, “Shape Up Under 5“ program. The program examined the effects of pulling together a 16-person committee of individuals working in the early childhood space from across sectors (early childhood education and care, healthcare, parks and recreation, local public health, and public schools). The committee met 16 times—every 4 to 6 weeks—in sessions facilitated by the Tufts team using group model building methods.

With the Tufts team’s help, the group gained a shared, comprehensive view of what influences early childhood obesity, what modifiable factors can influence the childhood obesity rate, what resources are available, and how to intervene effectively as someone who is involved at an individual or community level with young children.

Factors that can reduce early childhood obesity include breastfeeding; avoiding or reducing the consumption of sugar-sweetened beverages and promoting a diet of fruits, vegetables, whole grains and lean protein; and decreasing screentime and increasing physical activity. The group learned about these influences, modeled potential interventions, and ultimately established priorities as to what type of program should be developed based on this process.

“They became systems thinkers, rather than thinking in their own silos,” says Economos.

Through this process, the coalition decided to a community-wide communications campaign in four languages that was culturally appropriate and simplified for a broad audience. Materials were disseminated across the community of Somerville where children and caregivers spend their time.

Using new tools designed to measure if and how the coalition process was effective, the researchers observed that over the two years of the program, knowledge and engagement increased both among the coalition members and nearly 200 members of their social networks. Participants also reported significant changes in policies, systems, and environments that support childhood obesity prevention.

Among the changes those involved in the study said they witnessed were an increased commitment to different aspects of the built environment, such as workplace accommodations for breastfeeding; increased use of public parks and swimming pools in Somerville; availability of health promotion materials at workplaces; and training and support for health promoting activities in a variety of venues.

Increasing Equity in Health

“Frequently programs are set up in a short-term way, for use in a single sector, and disadvantage people who are already disadvantaged by structural racism, poverty, and other forces,” notes Dean Economos. “Figuring out how to solve a problem like early childhood obesity is also about increasing equity. Moving beyond siloed approaches to systems thinking gives people a way to operate that uses a similar language to talk about how systems advantage or disadvantage certain groups in health."