Background and Purpose
Obesity rates have tripled over the last three decades among U.S. children and adolescents, rising to 17% by 2009-2010.1-3 In response, the Robert Wood Johnson Foundation (RWJF) created a national program, Healthy Kids, Healthy Communities (HKHC), designed to support 49 communities throughout the United States and Puerto Rico in implementing healthy eating and active living policy, system, and environmental changes. This initiative placed emphasis on reaching children who are at highest risk for obesity on the basis of race/ethnicity, income and/or geographic location. The evaluation of the communities combines participatory and evaluation methods, tools, and resources to document practical considerations for adopting, implementing, and sustaining system, policy, and environmental initiatives as well as to assess the impact. Value frameworks were created as part of the HKHC evaluation to document and describe the value of common childhood obesity prevention strategies. These frameworks were designed to help communities translate the value of their work to advocates, policy- and decision-makers, practitioners, and community residents and prepare communities for implementation of the strategies in an effort to revitalize and sustain these initiatives into the future.

Description
Value frameworks were created for three commonly implemented active living strategies: childcare physical activity standards, active transportation, and parks and play spaces. For each strategy, data was collected through policy and cost interviews with leaders, partners, and/or community residents involved with day-to-day implementation of the active living strategies. In addition, the evaluation team incorporated knowledge from an evidence review project,4 a committee to assess cost-effectiveness,5 and an integrated framework for assessing the value of community-based prevention.6 Value was summarized at four ecological levels: individual, organizational/agency, community, and societal through a comprehensive understanding of inputs (i.e., investments/resources, economic/financial investments, and social/environmental resources) and outcomes (i.e., costs/savings and benefits/harms) at each ecologic level. The assessment of value takes into context the available investments and resources (inputs) as well as the costs and savings associated with planning, implementing, and maintaining the strategy and potential benefits or harms as a result (outcomes).

Lessons Learned
From 49 HKHC communities, 9 (18%) were implementing child care physical activity strategies, 30 (61%) active transportation strategies, and 29 (59%) parks and play space strategies. Within child care physical activity standards (defined as a policy/practice or environment change that takes place in public or private child care settings to increase moderate and vigorous levels of physical activity), both implementation efforts (e.g., advocacy and organizing, policy development, and/or policy implementation and enforcement activities) and potential impacts (e.g., policies, environments and services, and/or populations) are considered.  Examples of inputs and outcomes for child care physical activity standards are illustrated in figure 1. As an individual investment, parents and guardians contribute financially to support a child care facility and pay for oversight and education of their children. Agency/organizational level resources may include donated meeting space or equipment suitable for training staff. Community-level costs/savings include those related to local committee and taskforce meetings that recommend policy changes related to physical activity standards in child care settings to elected or appointed officials . Societal-level benefits and harms include incorporating minimum levels of physical activity into the daily schedule of young children can produce healthier adolescents and adults and increase equity of physical activity opportunities across the system, regardless of income level or social demographics.

Conclusions and Implications
The value frameworks provide a novel rubric for presenting how active living strategies impact individuals, organizations, communities, and societies. These value frameworks represent an initial effort to respond to the demand for resources that can be used by communities to express the value of their childhood obesity prevention efforts. The frameworks were designed to be customized for different community contexts in order to identify the range of inputs and impacts associated with local childhood obesity prevention strategies.

Next Steps
In evaluation, customized value frameworks can be used by communities to develop measures of strategy dose and impact. In collaboration with economists, communities may assign monetary values to some or all of these measures to weigh and summarize the overall value of the prevention strategies. These efforts bring communities another step closer to engaging in value-based decision-making for childhood obesity prevention. Additionally, the frameworks introduce the longer-term effects of social determinants of health into the “cost” and “value” inputs and outputs, encouraging investigation into health disparities and inequities that interfere with positive, sustainable outcomes. Further research needs to be done to quantify the value frameworks to further the benefit-cost analysis for policy, system, and environmental approaches to reducing childhood obesity. Additionally, creating methods and process to measure each level of value will move us closer to demonstrating the impact of childhood obesity prevention strategies. Moving forward, the use of value frameworks will enable practitioners to plan and prepare for advocacy initiatives; policy adoption, implementation, enforcement, and sustainability efforts; and changes to the built environment for healthy communities.

References

1. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA 2004;291(23):2847-50.
2. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006;295(13):1549-55.
3. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of Obesity and Trends in Body Mass Index Among US Children and Adolescents, 1999-2010. JAMA 2012.
4. Brennan LK, Brownson RC, Orleans CT. A review of the evidence for policy and environmental strategies to prevent childhood obesity: Findings and directions for future research, practice, and policy. Am J Prev Med under review.
5. Gortmaker SL, Swinburn B, Levy D, Carter R, Mabry P, Finegood D, Huang T, Marsh T, Moodie M. Changing the Future of Obesity: Science, Policy and Action, Lancet. 2011; 378(9793): 838–847.
6. IOM (Institute of Medicine). 2012. An integrated framework for assessing the value of community-based prevention. Washington, DC: The National Academies Press.

Support / Funding Source
Support for the Evaluation of Healthy Kids, Healthy Communities came from the Robert Wood Johnson Foundation grant #67099.