Improving Community Health through Healthy People, Healthy Carolinas

Challenge

According to the Centers for Disease Control and Prevention, the environments of many American communities inadequately support healthy diets and regular physical activity. Healthy diets and physical activity can lower the risk for heart disease, Type 2 diabetes and some cancers. In addition, excess calorie intake and physical inactivity contribute to obesity, which is associated with some of the leading preventable chronic diseases, including heart disease, stroke, Type 2 diabetes and some cancers. In North Carolina and South Carolina, the rates of obesity and related conditions impact a large percentage of Carolinians, placing them at higher risk for adverse events and reduced life expectancy.

There is increased recognition that demographic disparities have a profound impact on health and highlights the importance of authentically engaging marginalized communities and organizations.

• Black and Hispanic individuals are over-represented among the population living in poverty
• Obesity is linked to lower education and income, as is place of residency
• Food insecurity and lack of access to healthy foods are linked to economic conditions
• Minority adults have higher rates of obesity than white adults
• Minorities are up to two times more likely than white individuals to have major long-term medical conditions

“In order to improve health, we must recognize that where we work or go to school, how we spend our free time — even our ability to access fresh food and exercise in a safe environment — all contribute to our health and well-being,” says Rhett Mabry, president of The Duke Endowment. ​“To improve health within a community, we have to expand how we think about what affects it locally. We need to address health improvement on the ground, at a very local level.”

Response

The Duke Endowment has been a longtime supporter of statewide health improvement efforts.

In 2008, for example, the Endowment helped support a task force to research and study ways to improve public health by focusing on prevention. Led by the North Carolina Institute of Medicine, the task force examined underlying causes of death and morbidity, looked at systemic health disparities in the state and recommended dozens of prevention strategies to address root causes of poor health. 

Based on the findings, the North Carolina Division of Public Health produced Healthy North Carolina 2020, a list of 13 key prevention focus areas for the state. They include promoting healthy eating, physical activity, prevention of obesity and education about chronic diseases. This effort continues today with the funding of Healthy North Carolina 2030, which reinforces the importance of healthy behaviors.

In South Carolina, the Endowment has supported Alliance for a Healthier South Carolina, a coalition of more than 50 executive leaders from diverse organizations working together to ensure that all people in the state have the opportunity to have healthier bodies, minds and communities. Live Healthy South Carolina, the current State Health Improvement Plan, highlights the importance of addressing chronic disease.

The Duke Endowment launched its Healthy People, Healthy Carolinas (HPHC) Initiative in 2015 to help communities in North Carolina and South Carolina address chronic health issues such as obesity, diabetes, and heart disease.

The Endowment recognizes that health and well-being are created and sustained not through individual and clinical efforts alone but through the cooperation and support of the extended local community. Shaped by the Division of Public Health’s 2020 objectives to reduce obesity and chronic disease, the initiative brings together diverse leaders to implement programs and policies that promote healthy behaviors through a collective impact model. Through this mutual work, opportunities to engage in physical activity and healthy nutrition become more prevalent in the places where people spend time, such as child care, school, work, church and recreation.

Healthy People, Healthy Carolinas began with coalitions in five North Carolina regions that have currently received seven years of funding. There are 24 coalitions in North Carolina and South Carolina. As the first cohort of coalitions becomes self-sustaining, the Endowment plans to add additional coalitions across the Carolinas. The Endowment has, to date, invested $18.6 million in the coalitions. The local coalitions engage leaders from a wide spectrum of area organizations in aligning existing programs and developing ways to help residents get involved in improving their health. 

Healthy People, Healthy Carolinas builds on those successful efforts by targeting resources to communities with considerable health needs and the proven ability to take on local challenges. The model will help those communities tackle complex social problems to stimulate sustained improvement in population health.

The program is designed to support coalitions through collective impact and to enhance community capacity to implement evidence-based and informed interventions. Performance metrics will be monitored throughout to help the coalitions improve and learn.

Program goals include:

• Increase the number of highly effective community coalitions
• Increase the number of health-promoting programs adopted in communities
• Increase the adoption of policies by government and non-government agencies that promote health
• Increase the community infrastructure necessary to engage in healthy behaviors
• Increase the number of organizational changes that make the healthy choice the easy choice
• Increase the number of community residents engaged in health-promoting activities
• Document the impact of health improvement efforts

Data about the HPHC coalitions, their interventions and outcomes are publicly available and can be found at the Duke Endowment HPHC online dashboard.

Healthy People, Healthy Carolinas Coalitions

In November 2015, the Trustees of The Duke Endowment approved funding for five initial North Carolina communities to participate in the Healthy People, Healthy Carolinas program. Selected coalitions serve Catawba, Chatham, Granville/​Vance, Montgomery/​Richmond, and Wilkes counties. 

In November 2016, the Trustees approved five additional communities: Henderson, Pitt, Rowan, Robeson, and Brunswick counties. In May 2017 the Trustees approved funding to expand to five regions in South Carolina: Greenville, Kershaw, Fairfield, Chesterfield/​Dillion/​Marlboro, and Orangeburg/​Calhoun/​Bamburg counties. 

In 2018, they expanded to five more South Carolina regions: York, Barnwell, Georgetown, Spartanburg, and the Charleston/​Berkeley/​Dorchester area. In 2021, based on prior learnings, a new readiness phase was added that allows for potential expansion in Durham, Forsyth, and eight western counties (Cherokee/​Graham/​Clay/​Macon/​Swain/​Jackson/​Haywood/​Transylvania).

The North Carolina Healthcare Association, together with Population Health Improvement Partners, is providing technical assistance to North Carolina Cohorts. The South Carolina Hospital Association has assembled a team to provide technical assistance to South Carolina Cohorts. 

Technical assistance teams support the coalitions in:

• Mapping assets in their communities
• Better understanding the landscape
• Adopting the tools necessary for an effective coalition
• Bringing diverse voices and stakeholders to the table
• Selecting interventions to move upstream to policy, systems and environmental changes
• Creating learning opportunities across coalitions

The coalitions selected by the Endowment are intentionally diverse and unique. While there will be many opportunities for exchanging ideas, each community will receive support to pave its own path forward. The hope is that the lessons of the earlier coalitions can inform the work of others throughout the Carolinas. Representatives from those coalitions are sharing information as they develop best practices for organizing, planning and implementing evidence-based and informed interventions known to improve health.

The Endowment Trustees also approved $4.7 million in additional funding to support the technical assistance components of the program. 

Lessons Learned

Insights

Healthy People, Healthy Carolinas has identified the following insights over the past several years:

• Community health challenges are longstanding and complex and cannot be effectively or efficiently addressed by organizations acting alone.
• Community-based work takes time and trust, and it is important to establish clear guidance such as bylaws. As observed during COVID-19, this social capital can be leveraged to mobilize the community.
• Aligning coalitions’ efforts with existing work such as Community Health Improvement Plans will reduce siloed community efforts that can compete for scarce resources.
• Community engagement in health decision-making is critical to improving community participation in health promotion and disease prevention efforts.
• Community organizations can maintain a new intervention or policy, but having dedicated backbone staff is critically important to support the partner organizations in the heavy lift of implementing new evidence-based and ‑informed interventions. 
• Technical assistance is critical to support communities in using formal quality improvement methods, adopting policy changes, applying evidence-based and ‑informed interventions, standardizing data collection and addressing health disparities.
• Recognition that increasing the voice of minority populations and individuals with lived experience will strengthen the coalition’s ability to implement effective interventions in marginalized communities.