Measuring impact amidst the complexity of childhood obesity: a conversation with Sarah Hickey

Sarah Hickey is programme director at Guy’s and St Thomas’ Charity, leading their childhood obesity programme, one of their four programmes, all of which are focused on urban health. She oversees a portfolio of projects and partnerships in the Boroughs of Lambeth and Southwark in South London. “My original training,” she said, “was as a social researcher. I worked in the charity sector, helping organisations to measure their impact. Then I spent nine years in the civil service, the last four focused on social investment policy. I’ve always been interested in how you learn and improve when trying to create positive social change, and in partnerships between the public, social and private sectors. Because the issues we’re facing in the world are too big for a single sector to tackle alone.”

“I’m also interested in how you bring the end user into a project from the beginning, and start testing as soon as possible what would work for them in real life,” she continued. “At Guy’s & St Thomas’ Charity, it’s about sharing our hypotheses and ideas as early as possible, and then getting people to build on them. We think carefully about what we’re measuring, and we include only those metrics that have value to us or our partners.”

We stay close to our partners on the frontline, because the informal sharing of lessons is important. We’re currently building a digital platform that partners can view and feed data into, which is immediately visible to all of us. By being open and transparent, we can share our lessons and failures.

“We’re not the first people to try to tackle childhood obesity, people all over the world are doing it. We build on what others have learned, and experiment around how an international evidence base can best be applied to a local context – e.g. what has to stay constant and what has to be adapted to a local place. Our theory of impact is that we add back into that global evidence space, especially insights and resources around implementation, and hopefully speed up overall progress in tackling the issue.”

Learning in local spaces

Sarah draws on the evidence base in a way that respects and acknowledges local context. “For example, we have a project in our local area with a charity called Oasis Hub Waterloo. We’re running a programme together that aims to redesign a local neighbourhood to support nutritious diets and physical activity, in order to reduce obesity among schoolchildren. Oasis are collaborating with community members, as they do whenever they design and set up a project. They have a similar approach to ours: get stuff started and refine as you go along. The focus is on how a school and surrounding neighbourhood layout, playground design, and food options can prompt healthy eating and physical activity. We provided specialist evaluation expertise to help set up the measurement of what they were doing. Oasis ran it for a pilot year – which has just ended – and then we came together, reviewed the pilot, and planned for a four-year rollout.”

Guy’s & St Thomas’ Charity are hoping to learn lessons from this project about how similar neighbourhoods can replicate this approach by looking at the evidence, getting ideas from each other, and adding new ones. They are not replicating the exact portfolio of activities, but taking a process that prioritises the evidence base, empowers local knowledge, and looks for continuous improvement. “The evaluation needs to be easily adapted,” she said, “by people who want to try and replicate the impact somewhere else.”

A distinctive approach to complex problems

Guy’s and St. Thomas’ Charity have a creative way of dealing with the complexity in their projects. “We’re running four programmes,” she explained, “all focused on specific complex health issues, because our major unique asset as an independently-funded health foundation is time. We value our independence; we’re not subject to government timelines; we’re accountable only to our trustees. This is helpful because the issues require time, ase they’re complicated and difficult. They require innovation – trying and failing – and often require multi-sector, multifactor responses. As an independent organisation, we work with anyone who can help us address these health issues. She admitted:

With child obesity programmes, you’ve got these massive spaghetti diagrams showing all the interlinked and interdependent parts of the system you need to change. It can be quite overwhelming.

“We’re constantly asking: how can you hold a systems view but make action as uncomplicated as possible? Our idea is that the system may be complex, but many of the component parts are not. People can get on with doing the particular bit that’s important in their sphere of influence. We find something to anchor around that gives people the simplicity they need to get things done.”

Foresight Obesity Map

Measuring small contributions to the wider picture

Guy’s & St Thomas’ Charity’s childhood obesity programme is all about changing food and activity environments, ensuring that the spaces where children spend their time – and the food options they have there – are as healthy as possible. “Obviously, lots of different decision-makers influence these spaces,” Sarah explained. “So when we embark on a project, we ask our partners to measure as rigorously as possible the changes they make to the particular space that they control. We don’t ask them to guess what contribution those changes make to child obesity; they just need to measure their particular area of focus. And we estimate the different contributions towards our end-goal. A single project isn’t going to make a huge difference on childhood obesity rates, it’s adding up all those differences that creates the step-change impact.”

We don’t seek metrics that are outside a partner’s control, but we try to understand how each local partner is contributing towards the overall progress. That’s something other organisations can learn from.

Sarah then elaborated on her role as a systems convener. “We don’t have this amazing, innovative view of childhood obesity,” she pointed out. “There are lots of ways to describe the issue of childhood obesity because it is so complex. Deciding to cut a complex issue some way – and then testing that with stakeholders to make sure it makes sense – is really helpful in catalysing coordinated action, rather than staying in a theoretical conversation.”

We think it’s important to be willing to try and fail. In the face of complex challenges, we don’t let a fear of failure lead to inertia.

“We recognise the complexity and decide what’s practical. We have time to learn and share that learning coherently and strategically, and to create systems for capturing insights and sharing them.”

Understanding the reality of people’s lives

Sarah shared some of the core learnings that informs their approach. “Two important perspectives we bring to our projects are informed by behavioural science and collective impact,” she said. “Behavioural science shows us that behaviour change is easiest when you have to make as little effort as possible – that’s why we focus on changing food environments around people, rather than trying to increase individuals’ motivation, and on getting ‘healthier’ through small steps, rather than big leaps. From a collective impact perspective, we understand that we ultimately need to influence decision makers of food environments. We partner with these decision makers to better understand the operational considerations, as well as those around impact. This we hope gives initiatives the biggest chance of scale and replication.”

Sarah went on to describe two successful relationships with implementing partners that put these learnings into practice. “We have a project to tackle childhood obesity with the Consumer Goods Forum,” she said, “which represents most of the major supermarkets and many of the biggest food manufacturers in the UK. We’re working with them to improve in-store environments. The outcome that the project focuses on is one measurable in this setting – the ‘healthiness’ of people’s baskets, their nutritional value. We’re scaling it down to the key part of the puzzle and seeing how that fits into the wider programme – it’s the most practical and impactful area in which supermarkets can play a role. We’re creating a programme that’s based on people’s real lives, so every single project has an initial filter of assuming people have limited budgets, time and headspace. You want to change as little as possible in someone’s life and just make it easier for them to do things that are healthier.

“In a lot of our work,” she added, “we bring together data, academic literature, and the lived experience of people in our area, and together that can be really powerful. Data can give you the big picture of what is happening – child obesity is hugely correlated with area-level income, and the data demonstrates this very clearly. The academic literature shows you some of what works and what doesn’t. Trying to change people’s minds doesn’t achieve much on its own; changing the space around them is much more effective.

Throughout our programmes, we do research with people to understand their lived experience. When you spend time with families, then it’s so clear how local space is shaping their eating decisions.

“For example, what we found in the scoping stage of our work was that families were looking for healthy food options – but they also needed options to be affordable, convenient and tasty. Most options meet the last three but are also unhealthy. We want them to have more food options that don’t entail a compromise on health.”

She then described Framing childhood obesity, a communications project with the Frameworks Institute to design and test large-scale messaging that changes public understanding about childhood obesity as an issue. “It may be one of the most powerful things we do, in that there’s a huge disconnect between what the evidence base indicates are the solutions for child obesity and the public’s understanding of the issue. Language can be very powerful in reshaping and reinforcing public understanding. We use – and we’re trying to get other communicators to use – a set of communications principles that prime people to think of childhood obesity as one about children’s health and equal access to good food. Also not as an issue of willpower or knowledge, it’s one of food environments.  This project has the potential to channel energy and resources into evidence-based solutions. Creating a public good of that nature feels an activity that a  charitable foundation is in a unique position to fund,” she concluded, “and it’s another area where we can play a hugely important role.”

A learning oriented approach to addressing complexity

We were hugely impressed with Sarah and Guy’s & St Thomas’ Charity’s broader approach to addressing a problem as complex as childhood obesity. We have heard many describe “complexity inertia” – the feeling that given the difficulty of attributing impact to any intervention or program, it is difficult to know what to do and how to best achieve impact. Sarah and her team address this challenge head on, by taking bold evidence-based stances and remaining open that they may be wrong and adapt based on local contexts. Failure is viewed not as something to be swept under the rug or hidden, but rather as an important opportunity to learn. Their robust measurement capabilities allow them to understand what is working and what is not, so they can nimbly adapt and improve to better meet the needs of those they serve. 

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