Implementing the Essentials for Childhood Initiative: Establishing Safe, Stable, Nurturing Relationships and Environments in North Carolina:

  • Meghan E. ShanahanEmail author
  • Michelle Ries
  • Catherine Joyner
  • Adam J. Zolotor
Original Paper


Achieving population level reductions in children maltreatment may require a statewide, systems level approach to create safe, stable, nurturing relationships and environments for all children. To assess this approach, the Centers for Disease Control and Prevention funded five states from 2013 to 2018 to implement a collective impact approach centered around four goals 1) Raise awareness and commitment to promote safe, stable, nurturing relationships and environments and prevent child maltreatment; 2) Use data to inform action; 3) Create the context for healthy children and families through norms change and evidence-based, trauma-informed programs; 4) Create the context for healthy children and families through policies. This paper describes North Carolina’s approach to achieving these goals, including the functions of the backbone organization(s), how the initiative identified stakeholders and developed a shared agenda, how the workgroups operated and what they achieved, communication strategies implemented, and other accomplishments achieved by the initiative. We also discuss successes and challenges faced by the NC Essentials for Childhood initiative.


Child maltreatment Prevention Collective impact 


North Carolina is a burgeoning state. In 2013, there were 9,849,812 residents (U.S. Census Bureau 2018), a number that increased by 4.3% between 2013 and 2017. Approximately 22% of the state’s population are children less than 18 years of age, slightly less than three-quarters are white (U.S. Census Bureau 2017), and 22.2% are black or African American (U.S. Census Bureau 2017). While roughly 15% percent of all North Carolinians are impoverished, children are disproportionately affected by poverty (22% of children; US Census Bureau 2016). Politically, North Carolina tends to be a “red” state with approximately 64% of the General Assembly representing the Republican party (North Carolina General Assembly 2017a, b). However, North Carolina has had only one Republican governor in the past 25 years.

North Carolina has a strong history of collaboration to address issues around child and family well-being. In 2005, the North Carolina Institute of Medicine (NCIOM) published New Directions for North Carolina: A Report of the NC Institute of Medicine Task Force on Child Abuse Prevention (NC Institute of Medicine & Prevent Child Abuse North Carolina, 2005). This report was based on a Task Force convened in partnership with Prevent Child Abuse North Carolina (PCANC) and the North Carolina Department of Health and Human Services (NCDHHS). North Carolina was able to partially or fully implement 75% of the recommendations from this report by 2008 (NC Institute of Medicine & Prevent Child Abuse North Carolina, 2008), and it served as the basis for a public health oriented approach to child maltreatment prevention for several years that followed. Child maltreatment prevention efforts, especially around the dissemination of evidence-based home visiting and Triple P had accelerated greatly since 2005, but in some ways progress slowed, program reach was limited, attention to fidelity was variable, and outcomes had remained stubbornly resistant to change.

In 2013, leadership at NCDHHS, PCANC, and NCIOM among other partners saw the request for proposals issued by the Centers for Disease Control and Prevention (CDC) known as Essentials for Childhood as an opportunity to re-frame and re-energize our effort around child maltreatment prevention and childhood well-being. NCDHHS successfully competed for funding under Essentials for Childhood and used those resources to fund a backbone organization, a new Task Force at the NCIOM, increased cross-agency collaboration, and evaluation. The Task Force was intended to serve as a platform for a collective impact process and a mechanism for developing shared goals over year one of the project.

This case study will describe the process and progress of the Essentials for Childhood initiative in NC. We acknowledge that this initiative was rife with challenges as the majority of it took place during recovery from the US and NC recession, as well as during a time when the legislative and executive branches of the North Carolina government were focused on reducing taxes, limiting regulations, and growing North Carolina’s economy. Additionally, most involved agencies had significant staff and leadership turnover and ultimately the work of most people on the Essentials for Childhood initiative was voluntary or in addition to their usual work responsibilities.


We relied on multiple data sources for our process evaluation of the NC Essentials for Childhood initiative. These include meeting agendas and summaries, progress reports, and stakeholder interviews. Whenever possible, we used multiple summaries from the same meeting to ensure accurate reporting and interpretation. We collected and synthesized data through three main methods: document review, survey of Task Force members, and stakeholder interviews. Each method is described below.

Document Review

We reviewed meeting agendas, summaries, and progress reports to identify dates of important meetings and decisions, attendance, and agencies represented. We reviewed documents to describe the recommendations developed by the Task Force, the strategies developed by the work groups to implement the recommendations, and assess the implementation of recommendations and strategies.

Qualtrics Survey

Five months into the NCIOM Task Force process, we developed a Qualtrics survey to assess perspectives on the Task Force process. Questions were informed by a previous Task Force evaluation conducted by Cranwell and colleagues (Cranwell et al. 2004). A link to the survey was emailed to the 48 voting members of the Task Force. A reminder email was sent out approximately 1 week later. Five people completed the survey in response to the first email and 19 answered in response to the reminder for a total of 24 surveys (response rate = 50%).

Stakeholder Interviews

Towards the end of the initiative, we interviewed seven representatives of key stakeholder agencies to assess their perceptions of the implementation of the initiative in North Carolina. The stakeholder agencies were identified by examining the membership lists for the Steering Committee and work groups. The interview consisted of 15 open-ended questions that asked stakeholders to reflect on the implementation process, the successes and challenges of the initiative, how participating in the initiative influenced agencies, and the reach of the initiative. We analyzed the content gained from these interviews for key themes, particularly focused on successes of the NC Essentials for Childhood initiative, as well as challenges it faced.

The University of North Carolina at Chapel Hill Institutional Review Board determined that these activities did not constitute human subjects research.


Backbone Organization

The original backbone organization selected to oversee the implementation of the Task Force recommendations and guide the collective impact initiative was PCANC. This agency was chosen during the development of the proposal and continued to serve as the backbone organization during the first 3 years of the NC Essentials for Childhood initiative. By design, as the third year of the initiative came to a close, there was an open Request for Applications (RFA) process where other organizations applied to serve as the backbone organization. The North Carolina Institute of Medicine (NCIOM) was selected to be the backbone organization for the last 2 years of the initiative. Given that NCIOM is a neutral convener with broad stakeholder connections through the state and has expertise in facilitation and project management, they were well positioned to assume the backbone organization role. Additionally, as NCIOM led the 2014 Essentials for Childhood Task Force, the staff were familiar with the initiative and were able to continue to move it forward in the state.

Both backbone organizations worked closely with the Steering Committee to prioritize recommendations, ensuring the initiative made progress, and addressed challenges as they arose. The backbone organizations convened and staffed all meetings, with the exception of the NCIOM Task Force meetings which were organized by the NCIOM staff prior to becoming the project backbone. When the NCIOM Task Force ended, the Steering Committee met in person less frequently, although they received updates as needed through email and phone communication. Meetings with the Steering Committee became more frequent when the NCIOM became the backbone organization due to a variety of factors both internal and external to the NC Essentials for Childhood initiative. The NCIOM worked with the Steering Committee to develop the vision statement, mission, goals, and conceptual model (see Fig. 1). Over a series of three meetings in early 2017, in collaboration with the Steering Committee, NCIOM staff developed an action-oriented, collaborative vision, and mission statement to drive the work:
Fig. 1

NC Essentials for Childhood initiative's conceptual model, vision statement, mission, and goals

Vision: Children, youth, and families thrive in safe, stable, nurturing, and healthy relationships and environments and are able to reach their full potential within their community.

Mission: Promote child and family well-being in North Carolina by implementing the collective statewide strategic plan for preventing child maltreatment and securing child and family well-being developed by the 2014 Essentials for Childhood Task Force.

Key Goals:
  • Raise awareness and commitment to promote safe, stable, nurturing relationships and environments and prevent child maltreatment

  • Use data to inform action

  • Create the context for healthy children and families through norms change and evidence-based, trauma-informed programs

  • Create the context for healthy children and families through policies

The steering committee also identified an additional goal to support improved agency coordination and across-state alignment. Throughout the collective impact work, NCIOM staff used the vision, mission, and goals to structure and drive stakeholders’ priorities and strategies.

Further, in response to feedback from a work group member, these items were reviewed at the beginning of each work group meeting. This ensured that everyone kept the “big picture” in mind as they focused on the details of the initiative. The vision statement, mission, goals, and conceptual model anchor all NC Essentials for Childhood activities.

Identifying Stakeholders

In early 2014, the NCIOM, in collaboration with PCANC and NC Division of Public Health, convened a statewide Task Force on Essentials for Childhood, charged with studying and developing a collaborative, evidence-based, systems-oriented, public health-grounded initiative to address the issue of child maltreatment prevention and family well-being in North Carolina. Chaired by Kenneth A. Dodge, PhD, founding director of the Duke Center for Child and Family Policy, and Katherine V. Pope, vice chair and program and policy committee co-chair of the Board of Directors for PCANC, the Task Force on Essentials for Childhood sought to develop an integrated, comprehensive strategic plan to coordinate and prioritize the services, programs, and policies and build on the momentum of work in these areas outlined in New Directions for North Carolina, the previously mentioned earlier statewide plan for the prevention of child maltreatment, which was published in 2005 by the NCIOM (NC Institute of Medicine & Prevent Child Abuse North Carolina, 2005). The Task Force explored work currently underway in North Carolina and examined ways to expand upon and enhance this work.

The NCIOM recruited several partners who had been involved in the 2005–2008 work to serve on a small Steering Committee to advise and guide the work of Essentials for Childhood. The multidisciplinary Steering Committee was comprised of senior program level staff from NCDHHS, including the Division of Public Health (DPH) and the Division of Social Services (DSS), Benchmarks (an alliance of child serving agencies), North Carolina Partnership for Children, The Duke Endowment, and PCANC. The Steering Committee met on a monthly basis between scheduled Task Force meetings and assumed responsibility for planning Task Force meetings, identifying issues of relevance for the Task Force, and arranging speakers to present expert research at Task Force meetings.

The Steering Committee’s first task was to identify state stakeholders to serve on the Task Force. NCIOM staff and the Steering Committee identified and invited 48 individuals to serve on the Task Force. These members represented a broad cross-section of state experts in child maltreatment, child health, family/parenting support services, and early care and education. The Task Force included representatives from the NCDHHS, the North Carolina Department of Public Instruction (DPI), the North Carolina Department of Public Safety (DPS), the North Carolina General Assembly, health care providers, community-based service organizations, universities, and youth and parent organizations. Task Force membership was selected using an iterative process based on the networks of steering committee members with careful attention to geographic, racial/ethnic, and professional diversity.

Developing a Shared Agenda

This 48 member Task Force met ten times from January 1, 2014 to December 31, 2014. The six members of the Steering Committee, as well NCIOM staff, also attended the meetings. There were an additional 28 individuals who attended some of the meetings as guests (18 guests only attended one meeting). On average, Task Force members attended five meetings (range 0–10) and each meeting had on average 23 Task Force members in attendance. The first meeting had the highest number of attendees (35) and the last meeting had the lowest (15). There were six individuals who never attended a meeting. Removing these individuals from the analysis did not have an impact on the average number of meetings attended (4.6 versus 5.2).

The Task Force used the four goals of the CDC’s Essentials for Childhood initiative as an organizing structure for the meetings (i.e., (a) raise awareness and commitment to promote safe, stable, nurturing relationships and environments and prevent child maltreatment; (b) use data to inform actions; (c) create the context for healthy children and families through norms change and programs; and (d) create the context for healthy children and families through policies).

Typically, experts presented material related to one of the goals and the Task Force would examine the information shared through small and large group activities and discussions. Starting in the fifth meeting, in addition to presentations from experts, Task Force members also began developing recommendations based on the presentations and discussions of the evidence. The focus of the last three meetings was to select and finalize the recommendations. Additionally, the chapters of the NCIOM report were discussed during these final meetings.

Overall, the Qualtrics survey of Task Force members indicated NC’s strategy of using a NCIOM Task Force to develop a common agenda worked well. Respondents reported they were satisfied with how the Task Force was going (mean = 4.05 on scale of 1–5; 4 = satisfied; range = 3–5) and how the Steering Committee communicated with the Task Force (mean = 4.0 on scale of 1–5; 4 = satisfied; range = 2–5). Additionally, 62.5% of respondents indicated they understood that the goal of the NC Essentials Task Force was to establish a common agenda to promote safe, stable, and nurturing relationships and environments for children. The majority (79.2%) of respondents reported they had sufficient opportunity to participate in the decision-making process and 83% indicated they felt welcomed and included. That said, when asked what could be improved regarding the Task Force, one quarter of respondents (n = 6) indicated they would appreciate clarification regarding the process of developing a common agenda and achieving the ultimate goal of the Task Force.

NCIOM staff took the lead on developing the report of the Task Force recommendations, eliciting feedback from Task Force members and members of the steering committee. The Task Force developed 15 recommendations and 30 sub-recommendations in the four Essentials for Childhood goal areas. These recommendations served as the shared agenda and statewide plan for child maltreatment prevention. The full Task Force report and recommendations were published on March 3, 2015 in conjunction with the Prevent Child Abuse North Carolina (PCANC) Learning and Leadership Summit. The NCIOM sent the report to a total of 980 individuals including legislators, NCIOM members, state/local agency officials, and former and current Task Force members. Additionally, the NCIOM sent a press release about the report to ten media outlets. The Task Force report can be viewed online at:

The PCANC Learning and Leadership Summit: Collective Effort – Collective Impact took place in Chapel Hill, NC on March 3 and 4, 2015. There were a total 315 total registered guests in attendance. Adam Zolotor, then interim-president of the NCIOM, presented the full Task Force recommendations in a keynote address. Additionally, three workshops were held that exposed participants to more information about the recommendations, as well as allowed for feedback regarding their implementation. The titles of these workshops were as follows:
  1. a.

    Recommendations on Social Norms Change and Policy Solutions: NC Institute of Medicine Task Force on Essentials for Childhood

  2. b.

    Recommendations on Evidence-Based Practices: NC Institute of Medicine Task Force on Essentials for Childhood

  3. c.

    Process and Outcome Evaluation in the Context of a Collective Impact Framework


The recommendations were also presented to other audiences, such as an UNC Injury Prevention Research Center seminar, a Collective Impact Forum, and a School Board Conference.

On March 5th, 2015, select members of the Steering Committee, Task Force, and NCIOM leadership met with the then-Secretary of NCDHHS to discuss the recommendations. During this meeting, the Secretary expressed concerns that some aspects of the recommendations duplicated ongoing work of state agencies and might lead the reader of the report to the conclusion that state agencies were not engaged in this work. The Secretary also expressed concerns that some recommendations were counter to department priorities at the time, including smaller bureaucracy and decreased government spending. The Steering Committee had tried, unsuccessfully, to schedule a meeting with the Secretary before the report was finalized, so unfortunately this feedback was not able to be incorporated into the report and recommendations. However, based on this conversation, the Steering Committee decided to prioritize and implement recommendations in ways that built upon work already being done by various Divisions within DHHS, as well as other agencies and organizations across the state. Given the collective impact framework guiding the initiative it made sense to generate synergy around the four goal areas through these collaborations. However, while NC Essentials addressed the then-Secretary’s concerns by working to collaborate with existing projects and initiatives and was able to identify mutually reinforcing activities, the Secretary’s response to the Task Force report presented a challenge to the Steering Committee and Backbone Organization as they worked to implement the common agenda. Given they had intended to develop a strategic plan to implement the recommendations, the Secretary’s response had an impact on the progress made in the second year of the initiative.

The majority (5/7) of key stakeholders interviewed indicated that the recommendations represented a clear plan of action for child maltreatment prevention. One stakeholder stated that the initiative brought a strategic plan for child maltreatment prevention back to the state and once again raised the importance of preventing child maltreatment. Additionally, stakeholders mentioned numerous ways the shared agenda affected the work of agencies across the state. For example, one stakeholder mentioned that the NCIOM recommendations and report were extremely useful, particularly because they can be used a reference as the state develops strategies to ensure healthy childhoods. Other stakeholders mentioned that the common agenda gave their agency a clear direction in their work and that the recommendations have been incorporated into the Early Childhood Action Plan, a strategic plan under development by NCDHHS as a result of a 2018 proclamation by the current Governor.


Over the course of the NC Essentials for Childhood initiative, there were numerous work groups formed and disbanded, depending on the needs of the initiative. After the release of the NCIOM report and the meeting with the then DHHS Secretary, the backbone organization (PCANC) examined the current child and family well-being initiatives across the state, with the goal of identifying those whose goals were well aligned with the NC Essentials for Childhood initiative’s goals. Based on this assessment, and aligned with the recommendations of the Task Force, NC Essentials for Childhood decided to form the following work groups: Public Awareness Committee, Policy Work Group, Data Work Group, and Evidence-Based Family Strengthening Programs Work Group. The Public Awareness Committee met the most frequently with six meetings occurring between September, 2015 and August, 2016. This group focused on developing a shared message to communicate the goals of NC Essentials, but struggled to achieve consensus on a shared message or social norms campaign. Additionally, the group discussed the results from the Social Norms survey that was purchased by the CDC. The project evaluator (author MS) completed analysis of the data to assist the steering committee and work groups to better understand how these data could be utilized most effectively. Based on questions from the work group, the project evaluator refined the analysis on parent help-seeking and differential responses between parents and non-parents. Stakeholders have been very interested in these data and the results have been shared widely. The Steering Committee continues to explore routes for further dissemination and utilization of these data, and strategies for using these metrics and data to inform action and assess outcomes for NC Essentials for Childhood. The Evidence-Based Family Strengthening Programs work group met three times between August, 2015 and August, 2016. This group developed and disseminated a survey to assess the activities and needs of agencies who fund evidence-based programs in the state. The Data work group met three times between July, 2014 and September, 2015. This group focused on identifying shared measures. Additionally, PCANC identified the following existing state initiatives with aligned strategies and goals: Child Sexual Abuse Prevention Work Group/Project NO REST and Infant Mental Health Core Stakeholders Work Group. In addition, there were other initiatives across the state engaging in mutually reinforcing activities, including the Child Fatality Task Force and the DHHS Child Well-Being Task Force. Members from PCANC and other NC Essentials for Childhood partners attended these initiatives’ meetings and monitored opportunities to collaborate towards common goals.

As previously mentioned, NCIOM became the backbone organization in September, 2016. Upon becoming the backbone organization, NCIOM worked with the Steering Committee to assess progress and prioritize next steps for the implementation of the Task Force recommendations.

Based on this meeting, as well as subsequent Steering Committee meetings, NC Essentials for Childhood decided to move forward with the following work groups: Evidence-based Practices, Trauma-informed Practices, Public Awareness and Social Norms. The Steering Committee and work group members then refined the scope of work (including goals and desired outcomes) for each of the work groups to ensure they aligned with the prioritized Task Force recommendations. This work also consisted of identifying additional partner organizations and individuals to serve on the work groups, in order to ensure the most appropriate stakeholder engagement.

The Evidence-Based Practices work group met ten times during the last 2 years of the initiative. One of the main foci of this group was to create an aligned RFP process for many of the agencies in the state who fund programs to support families and prevent child maltreatment. This strategy was informed by the results of the previously mentioned survey of agencies who fund evidence-based programs. Work from this group helped lead to the launch of two pilot home visiting initiatives, in Cleveland and Johnston counties in July 2018. The pilots use Medicaid funds to pay for home visiting programs; the Cleveland County pilot will use the Nurse Family Partnership model, and the other county will use a hybrid model focused on high-risk pregnancies. The work group assisted Medicaid in developing shared strategies and evaluation of these payment pilots. If the General Assembly decides to extend Medicaid payment for intensive home visiting to other counties, this would represent a significant change for financing home visiting and allow statewide scale up services to be offered to many more families.

The Trauma-Informed Practices work group met two times in the fall of 2017. This group focused on developing a shared understanding of trauma-informed practices, assessing the current trauma-informed work being conducted in NC, and discussing evaluation strategies specific to trauma-informed practices in schools and early education settings. Additionally, this group is developing a literature review regarding trauma-informed practices which will be disseminated in the fall of 2018.

The Public Awareness and Social Norms work group met two times during the fourth year of the initiative. In late winter of 2017, the Steering Committee, decided to disband this work group and instead had the concept of awareness underscore the work of each of the other work groups.

The Data work group's scope of work was aligned with the Pathways to Grade Level Reading initiative. Over the course of a few meetings, the Steering Committee decided to work with the Pathways to Grade Level Reading initiative led by the North Carolina Early Childhood Foundation (NCECF) to identify and develop shared measurement, which would be the goal of the Data work group. In the spirit of aligning the Essentials for Childhood Initiative with others in the state, the Steering Committee decided to use the shared measures developed as indicators of success for Pathways to Grade Level Reading as a framework for the indicators used to measure the success of the Essentials for Childhood initiative.

To identify measures of success, Pathways to Grade Level Reading engaged experts from across the state in a two-step process. First, a Data Action Team conducted a landscape survey of population-level outcomes focused on three goals: (a) health and development on track, starting at birth; (b) supported and supportive families and communities; and (c) high quality early care and education. Once the indicators were identified, Learning Teams examined data trends, including inequities, connections between indicators, and data gaps that exist in the state. This process resulted in a list of 15 measures of success. NCIOM facilitated exercises with the Essentials for Childhood steering committee to map the indicators identified in Pathways to Grade Level Reading with the data goals and recommendations from the Task Force and to the short- and long-term outcomes identified by the CDC for the Essentials for Childhood initiative. This work is ongoing. Additionally, as part of NC Essentials for Childhood, NCIOM has convened two meetings of a revised Data Action Team to review the existing data and collection methods of the Pathways to Grade Level Reading indicators and identify data gaps and new resources needed to improve data quality and collection methods. NCIOM facilitated this process to inform both Essentials’ data goals and the next phases of the Pathways to Grade Level Reading work. As a result of these collaborations, some of the shared metrics were integrated into the annual Child Health Report Card, which is co-published with NC Child.

Continuous Communication

The Backbone Organizations kept Steering Committee members, as well as other key partners up-to-date through numerous strategies, including phone meetings, in-person meetings, and emails. The NCIOM scheduled regular meetings with the Steering Committee (8 in-person and 14 phone calls) during their time as the backbone organization. These meetings provided an opportunity for the Backbone organization to provide updates to the Steering Committee, elicit feedback on implementation strategies, and for the Steering Committee to inform the Backbone Organization of new initiatives in the state that align with the NC Essentials for Childhood work. NCIOM staff prepared and distributed a quarterly newsletter to statewide NC Essentials for Childhood partners. To ensure the newsletter included information that was of interest to key partners, staff contacted stakeholders in advance of the newsletter publication and requested submissions of recent work and initiatives to highlight in the newsletter. Newsletters also included updates on legislation, summaries of work group activities, and other recent work of interest. The newsletter was distributed to approximately 300 NC Essentials for Childhood partners and child advocates, as well as highlighted on social media (Facebook and Twitter). NCIOM also created and maintains an NC Essentials for Childhood website ( This website has a description of the collective impact initiative, links back to original Task Force membership and report/recommendations, meeting summaries and materials for all work group meetings, and all NC Essentials for Childhood newsletters. NCIOM also actively promoted NC Essentials for Childhood goals, strategies, and partners’ activities through social media (Twitter and Facebook), along with the newsletters.

NCIOM is able to utilize the North Carolina Medical Journal (co-published by NCIOM and the Duke Endowment) for dissemination of research and commentaries. The March/April 2018 issue of the NCMJ was cosponsored by NC Essentials for Childhood and focused on Responses to Adverse Childhood Experiences. The issue covered various topics, including building resilient communities, trauma-informed juvenile justice, and considering poverty as an adverse childhood experience. NCIOM/NCMJ staff also worked with NC Essentials for Childhood stakeholders to identify ways to cross promote the Journal issue, using specific articles to boost advocacy efforts, enhance messaging on trauma and adverse childhood experiences, and raise awareness of strategies to ensure safe, stable, and nurturing relationships and environments. Since the issue went live in March of 2018, the online issue has been viewed 13,857 times on the NCMJ website.

Other Accomplishments

Because of the Task Force’s recognition of the need for more integrated cross-sector collaborations to meet the goals of Essentials for Childhood, much of the initiative’s recent work has been focused on refining vision, convening of topic-specific working groups to further refine recommendations, aligning activities with other state agency and stakeholder work, and establishing and enhancing partnerships. Key activities in this area have included:

Assessing Progress on Recommendations

In May 2018, NCIOM brought together the 2014 Task Force to review recommendations and identify new priorities and strategies for additional implementation. Eighty percent of the Task Force recommendations have been fully or partially implemented, and Task Force members identified policy priorities for ongoing work, including policies that promote economic mobility for families and ensure family friendly workplaces.

Shaping the Children’s Cabinet Discussion

In July 2017, NCIOM convened a group of broad stakeholders to develop a shared understanding of the advantages and disadvantages of a statewide leadership body to lead policy decisions for child and family serving agencies and organizations, a shared vision for the optimal structure for North Carolina, and consensus on next steps. This resulted in continued involvement in the development of North Carolina’s Children’s Council, under the 2017 Rylan’s Law legislation.

Alignment with Early Childhood Action Plan

Due to the work of the NC Essentials for Childhood partners and many stakeholders more broadly, our state currently has a unique opportunity for successful alignment of the NC Essentials for Childhood goals with other statewide and local initiatives. NCDHHS is undertaking a significant strategic focus on early childhood (the Early Childhood Action Plan), through which NCDHHS will align work and programs across divisions to implement upstream approaches to address social determinants of health to ensure optimum health and well-being for our state’s children. NCDHHS outlines the Early Childhood Action Plan in three categories: safety, health, and development and education. In these categories, NCDHHS will use the NC Essentials for Childhood recommendations as its priority strategies to meet 2025 outcomes including: decrease rate of CAN, increase percentage of children in foster care who obtain family permanency, increase in social-emotional well-being and resilience in young children, decrease infant mortality, increase percentage of infants born at healthy birth weight, increase percentage of young children with food security, increase percentage of children with language skills on track; increase percentage of children who enter kindergarten developmentally on track, increase percentage of children achieving third grade reading proficiency. Further aligning with NC Essentials for Childhood work, these outcomes are also a subset of the shared measures previously mentioned that were developed in collaboration with Pathways to Grade-Level Reading.

Inclusion of Essentials for Childhood Staff on Other State Initiatives

Staff from the NCIOM have been invited to represent Essentials for Childhood on aligned state initiatives, including the Think Babies Leadership Team and the Whole Child/Whole School/Whole Community initiative. Think Babies, funded by the Pritzker Children’s Initiative, is an initiative of Zero to Three focused on raising awareness of the importance of healthy beginnings, supported families, and high-quality early care and education experiences in the long-term health and well-being of children and their families. In North Carolina, the NC Early Education Coalition is coordinating a state-wide Think Babies Leadership Team to create a shared policy agenda to promote these critical aspects for children ages 0–3. Whole Child/Whole School/Whole Community is a DPI initiative aimed at creating alignment, and collaboration between education and health to improve each child’s development and well-being. Having NC Essentials for Childhood representation at these meetings ensures that opportunities to align implementation strategies among the numerous initiatives in the state focused on improving the health and well-being of children.

A timeline of accomplishments is presented in Table 1.
Table 1



Date Completed

Hired a project manager or coordinator

September 2013

Completed your environmental scan or landscape assessment of who was doing what

April 2014

Convened first steering committee or Leadership Action Team meeting

December 2013

Accomplished a “shared understanding” of “the problem”, what was in/out for what age group

January 2014 – December 2014

Agreed on a shared vision

December 2014

Agreed on shared goals

December 2014

Agreed on shared metrics

May 2017

Identified strategies for implementation

December 2014

Created the workgroups

May 2015 - ongoing

Workgroups developed work plans

May 2015 – ongoing


Overall, the NC Essentials for Childhood initiative has had success building on the strong foundation of commitment to child and family well-being in our state, and in engaging with multi-sector stakeholders and partners. This has positioned us well to align quickly as other initiatives have formed and legislative and executive opportunities have developed. In addition, due to their broad network of partners in health systems, public health, social services, education, advocacy, and other sectors, the backbone organizations proved instrumental to help NC Essentials for Childhood bridge silos and help partners identify new areas for collaboration.

One of the lessons we learned from the process of implementing a statewide collective impact project is the importance of garnering support from high-level leadership. The NC Essentials for Childhood initiative took place in a state, political, and organizational climate that significantly influenced buy-in and speed of work. Over the past 5 years, NC has seen two different Governors (of different parties), three different Secretaries of NCDHHS, four different state health directors, two different Executive Directors of PCANC, two different President/CEOs of NCIOM, and turnover of most Deputy Secretariats and Section Chiefs within NCDHHS. The steering committee and authors of this paper have been constant, although some have changed positions. With this degree of change there will be inconsistent leadership buy-in and the challenge of engaging new people in the initiative. This was first apparent upon completion of the NCIOM Task Force and the response of the then Secretary of DHHS to the recommendations. The lack of executive leadership extended beyond this response from the then-Secretary. During the key stakeholder interviews, respondents mentioned that the initiative never had the leadership support needed to drive the work forward. Additionally, stakeholders indicated that the lack of high-level decision makers engaged in the process lessened the progress and impact of the initiative. Further, one respondent also mentioned that there wasn’t a lot of support in either political party to push forward policies to improve the lives of children and families. NC conceptualized Essentials for Childhood as a systems-level intervention and it was challenging to make changes to the state system without the buy-in from high level leadership. That said, it is important to note that this shifted towards the end of NC Essentials for Childhood, as there were changes in state-level leadership and state priorities shifted to include early childhood health and well-being. As this shift occurred, NC Essentials for Childhood was able to make progress on many strategies that had stalled.

Another lesson learned is the importance of generating, or capitalizing on, a sense of urgency. Numerous stakeholders indicated that a lack of urgency around preventing child maltreatment, aside from those closely involved in the work, hindered the progress of NC Essentials for Childhood. Stakeholders mentioned that this was particularly challenging given the collective impact nature of the initiative. As one key stakeholder stated “Without a sense of urgency, collective impact is just mice on a treadwheel.”

Despite some of the challenges mentioned, North Carolina’s Essentials for Childhood initiative made considerable progress during the 5 years of the project. This was mostly due to developing a clear plan of action that was also flexible enough to meet the changing dynamics within the state. Another pathway to success was optimizing mutually reinforcing activities to increase the reach of the work.

North Carolina was recently selected by the CDC, through a competitive renewal process, to continue the Essentials for Childhood Initiative. Over the next 5 years, North Carolina will enhance the state action plan to prevent child abuse and neglect, aligning much of the work with the Early Childhood Action Plan previously mentioned. Additionally, NC Essentials for Childhood will continue to leverage cross-sector partnerships and resources, including continuing to partner with the Pathways to Grade Level Reading initiative and Think Babies. Additionally, NC Essentials for Childhood will engage in three complementary approaches to prevent child abuse and neglect. The first approach will be to strengthen financial security for families by supporting and aligning with NCDHHS’s Medicaid transformation strategy to address social determinants of health and to support NC Child’s plan to raise the visibility of child poverty in North Carolina and to build public will for policy solutions that address it. The second approach will be to support family friendly work policies by partnering with the NC Early Childhood Foundation to support the Family Forward Initiative, a business-led change to increase the availability of family friendly workplaces in North Carolina. The third approach is to support PCANC’s public engagement and education campaign, Connections Matter: Developing Brain-Relationships-Community, to engage community members in building caring connection to improve well-being, with the ultimate goal of supporting positive parenting and preventing child abuse and neglect. Given the past 5 years of strategic planning, goal setting, and collaboration, North Carolina is well positioned to continue this important work to ensure the health, safety, and well-being of all children in the state.



The initiative described was funded by the Centers for Disease Control and Prevention cooperative agreement #H28CE002379. The content is solely the responsibility of the authors and does not necessarily represent the views of the CDC or the North Carolina Department of Health and Human Services.

Compliance with Ethical Standards

Conflicts of Interest

The authors have no conflicts of interest to disclose.


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Meghan E. Shanahan
    • 1
    • 2
    Email author
  • Michelle Ries
    • 3
  • Catherine Joyner
    • 4
  • Adam J. Zolotor
    • 3
    • 5
  1. 1.UNC Injury Prevention Research CenterUniversity of North Carolina at Chapel HillChapel HillUSA
  2. 2.Department of Maternal and Child Health, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillUSA
  3. 3.North Carolina Institute of MedicineMorrisvilleUSA
  4. 4.Women and Children’s Health SectionNorth Carolina Division of Public HealthRaleighUSA
  5. 5.Department of Family Medicine, UNC School of MedicineUniversity of North Carolina at Chapel HillChapel HillUSA

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