In the United States, chronic diseases such as heart disease, cancer, type 2 diabetes, and obesity are the leading cause of death and disability (Boersma et al., 2018). Chronic diseases—largely driven by preventable health behaviors such as poor nutrition, physical inactivity, and tobacco use—can negatively affect our nation’s businesses, economy, and military readiness (Centers for Disease Control and Prevention [CDC], 2023a; CDC, 2023b; The Milken Institute, 2023; Ward et al., 2021). Research indicates that increasing access to healthy opportunities, such as improving physical activity and nutrition environments and implementing tobacco-free policies, can improve health behaviors and prevent chronic disease (The Guide to Community Preventive Services, 2021; U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2024; The Guide to Community Preventive Services, 2020). To prevent and reduce chronic diseases, DNPAO provides financial and technical support to states and communities to increase opportunities for healthy eating, physical activity, breastfeeding, and tobacco-free living. In September 2018, the Centers for Disease Control and Prevention’s Division of Nutrition, Physical Activity, and Obesity (DNPAO) awarded five-year funding to 62 states, universities, and communities through the three following cooperative agreements: State Physical Activity and Nutrition (SPAN, DP18–1897), Racial and Ethnic Approaches to Community Health (REACH, DP18–1813), and the High Obesity Program (HOP, DP18–1809). In 2020, an additional five REACH recipients were funded for three years, and in 2021, four additional REACH recipients were funded for two years. This totaled 71 SPAN, REACH, and HOP recipients advancing evidence-based strategies to increase opportunities for healthy eating, physical activity, breastfeeding, and tobacco-free living during 2018–2023.

This paper highlights the evaluation approach and program impact of three 2018–2023 cooperative agreements: SPAN, REACH, and HOP. While some DNPAO cooperative agreement findings have been published in the past, they have been limited to mid-progress findings (Vaughan et al., 2017) or a singular cooperative agreement (Murriel et al., 2020). DNPAO has not published a paper that describes portfolio-level impact across multiple cooperative agreements inclusive of work at the state and community levels. The findings described in this paper can advance public health program implementation and evaluation by describing the extent to which states and communities increased access to healthier food, places to be physically active, breastfeeding support, and tobacco-free living—by implementing evidence-based strategies to prevent chronic disease and improve health outcomes.

To develop the evaluation approach, DNPAO used an inclusive and transparent process in both the design and implementation stages of the evaluation.

During the design stage of the evaluation, the principles of engagement, usability, and co-creation drove the approach. Before the cooperative agreement began, DNPAO engaged internal staff who served as evaluators, project officers, and subject matter experts. Drawing on their scientific expertise, wisdom from program implementation, and lessons learned from previous cooperative agreements, DNPAO drafted an initial evaluation design. Each evaluation component was designed to clearly outline how data would be used and analyzed. Once recipients were onboarded, DNPAO engaged them in a co-creation phase eliciting their feedback on the relevance, feasibility, and potential burden of evaluation reporting. This process of engagement ensured the evaluation design was context-driven and aligned with the experiences and needs of recipients and the communities they serve.

This collaboration led to refinements of the initial draft and the decision to adopt a mixed methods design. The cooperative agreement evaluation questions were answered through a variety of quantitative and qualitative data: performance measures, leveraged funds, contextual questions, and long-term outcome evaluations. Recipients self-reported evaluation data annually using a two-way cloud-based platform which allowed DNPAO and recipients to view the data simultaneously and allowed DNPAO to provide feedback directly in the system in a timely fashion. The quantitative methods used to collect performance measures and leveraged funds are the primary focus of this paper.

DNPAO asked recipients to report annual progress on intervention strategies through two types of performance measures: 1) those that counted the progress made in settings or policies, and 2) those that counted the population of people potentially reached through those activities. In the interest of brevity, only the latter performance measure data are reported here. “People potentially reached” was defined as those who could benefit from a new or improved policy, systems, or environmental change. DNPAO provided guidance to recipients on methods to calculate potential reach, such as counting all the residents of a census tract near a new or enhanced place for physical activity or counting all new births that occurred in a hospital after a breastfeeding-friendly practice was implemented. All findings are presented as potential reach except for the community-clinical linkage strategy, which required recipients count the actual number of patients referred to locally available health and preventive programs. Within a strategy, individuals were counted only once; for example, if a community implemented one change to the physical activity environment and later made an additional physical activity improvement in the same community, those individuals were counted as having been potentially impacted by that strategy once.

DNPAO also requested recipients track and report leveraged funds, which were defined as “a financial representation of resources, goods, or services from a source other than the granting organization to amplify current program efforts and help establish a foundation to sustain efforts beyond the funding period.” Categories, definitions, and instructions for estimating leveraged funds were initially developed and piloted by DNPAO during a previous funding cycle of HOP (Murriel et al., 2020) and refined during this cycle.

Once evaluation data were collected, the principles of data quality, timeliness, and transparency drove DNPAO’s approach. After reporting was received each year, DNPAO evaluators engaged recipients in a collaborative process to validate performance measures and leveraged funds. To ensure data integrity and quality, DNPAO evaluators used a rigorous, multi-step process for data cleaning, management, and analysis. Following validation, data underwent deduplication to ensure sites or population reach were not double counted from previous program years. Rather than waiting until the end of the five-year cooperative agreement cycle, DNPAO annually committed to aggregating data both at the portfolio level and by various subgroups to communicate mid-progress impact. DNPAO used this commitment to real-time data collection and analysis to facilitate agile decision-making. Transparency was also embedded in the evaluation process. DNPAO shared details of the review, validation, and data cleaning processes with recipients along the way. DNPAO held an annual webinar wherein recipient findings were transparently shared, fostering a culture of openness and collaboration.

This paper focuses on quantitative data findings for SPAN, REACH, and HOP from 2018 to 2023 reported in performance measures and leveraged funds. Qualitative findings from other recipient deliverables, such as contextual questions and long-term outcome evaluations, will be shared separately and used to complement the findings presented here.

There were 71 recipients: 16 SPAN, 40 REACH, and 15 HOP. Sixty-two of the total recipients were funded for the entire five-year cooperative agreement period (2018–2023), and nine were funded for either two or three years. Funded recipients consisted of state and local entities such as health departments, universities, and community-based organizations in diverse geographic locations ranging from rural to urban.

Table 1 illustrates the seven strategies for SPAN, REACH, and HOP, and their cumulative potential population reach during the five-year cooperative agreement period. Validated and cleaned annual performance measure counts were aggregated for each strategy and presented by cooperative agreement. Because strategies varied by cooperative agreement, and some strategies were required while others were optional, certain items in the table are marked as N/A if they were not applicable. All aggregated counts are presented as potential reach, except for community clinical linkages which was calculated as actual reach since the activity was implemented directly with patients. For the tobacco strategy, while recipients could elect to conduct activities in worksites or multi-unit housing, all three recipients chose worksites; therefore, the count is presented for employees only. Each cumulative performance measure count includes N, the number of recipients implementing and reporting on that measure.

For leveraged funds, during the 2018–2023 funding period, SPAN recipients reported over $175 million leveraged (N = 16), over $200 million leveraged for REACH (N = 40), and over $23 million leveraged for HOP (N = 15) across all reported sources. In total, SPAN, REACH, and HOP recipients leveraged almost $400 million.