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You are here: Home Modules Module 3: Optimize Potential Impact Module 3 Activity Case Example
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Module 3: Optimize Potential Impact

With this hypothetical case example, we want to illustrate how you can use the MIP Tool Kit Activities to help work with inner and outer context considerations in planning a multiple intervention program. We give you a description of the process that people planning a school-based healthy living program might go through in thinking about context, and provide a filled-in Activity sheet to guide you along. To make it easier to connect the text with the Activity sheet table when we refer to it, we have numbered each column.

Healthy Living Programming and Context

An Ontario Health Unit is launching a new healthy living program to prevent overweight and obesity among school-aged children. The MIP Tool Kit is being used to help plan and implement the program - a joint undertaking with the local School Board, volunteer schools and local community organizations. The program's goal is to positively impact children's eating habits and physical activity levels on an ongoing basis. It is hoped that the program will become an integral part of the Board's healthy living initiatives.

The coordinated effort is being guided by a cross-program working group and the program is successfully underway in a small number of committed schools. The working group includes the Health Unit's coordinator of the Chronic Diseases and Injury Prevention Program, a vice-principal and parent representative from each of the volunteer schools, a Parks and Recreation Committee representative from local government, a Health Unit dietician, a municipal planner and a representative from the local food industry sector. A team within each school has also been established and each is working collaboratively with the working group to make sure the program is implemented effectively.

In using the Tool Kit, the working group has come to Module 3 and is especially interested in working through the context activities as they relate to the schools' programs. Group and school team members have already expressed concern about recent and changing circumstances that are likely to affect their programs and they feel that the schools are likely to benefit from learning how to adapt to contextual influences. All have agreed to use the framework of inner and outer context presented in the Tool Kit and the activity sheet about adapting to context to assist in their work.

The program, similar to other school-based obesity prevention programs such as the Annapolis Valley Health Promoting Schools Project (see Module 2 - Example 12 and Module 3 - Example 16), includes several simultaneous interventions to promote healthy eating and physical activity. These interventions have been implemented across several system levels and in some cases, within system levels. For example, the School Board has provided policy support through a nutritious food policy that requires, among other things, selling healthy snacks and drinks in school vending machines (policy level), while schools have added fresh fruit and vegetables to their snack programs (organizational level), and are working with their School Councils to communicate information about healthy meals to parents and children (interpersonal and intrapersonal levels). With new physical activity initiatives being offered by trained parent and community volunteers during school hours and after school (community level), students have been able to increase their participation in physically active activities (intrapersonal level). The relevant system levels have been put in the first column of the Context Adaptation Activity Sheet and the program interventions in Column 2 (see the Sample Activity Sheet below). Next, the working group and school teams have started to look at inner context and how adaptation can be planned for and acted upon. This information will be added in Columns 3 and 4.

Inner Context

The working group began by looking at the various aspects of inner context discussed in the Tool Kit, identifying one that all agreed was extremely important to consider first: system readiness, in particular, schools' ability and willingness to provide dedicated resources to support and maintain the program. The group recognizes that there are other important inner contextual influences, but agrees that these should be examined after they have learned more about adaptation as they work through the process focusing on this aspect of system readiness and capacity. The group also checks the Ontario Public Health Standards (OPHS) to see if there are any issues related to inner context that they need to consider. They decide that because the OPHS are provincially mandated standards, they form part of the program's outer context. In particular, the OPHS Principles, Foundational Standard and Chronic Disease requirements and the Population Health Assessment and Surveillance Protocol are important to this undertaking. It is agreed that these aspects of the Standards will be reconsidered when work on outer context and adaptation begins.

The group decides to take some time to learn more about and describe their understanding of this feature of inner context. Members want to be able to better understand inner contextual influences so that they can clearly explain and discuss them with the school program teams. They agree to define dedicated resources and identify criteria that will help establish some boundaries, as they look beyond to adaptation processes and actions, where possibly difficult decisions will have to be made.

The group defines "dedicated resources" at a very broad level to include the skills of involved individuals, groups and organizations (human resources); financial and material resources; and the structures that support implementation and adaptation. With the help of the Health Unit member, they review some of the health promotion and school-based prevention literature that confirms their view that the resources committed to the programs must be dedicated on an ongoing basis with an annual review and renewal process in place to ensure that programs are resourced and maintained at an acceptable level (Ebbesen, Heath, Naylor, & Anderson, 2004; Laurence, Peterken, & Burns, 2007; Thaker et al., 2008). It is also clear from the literature that although lack of resources can impact both educational and health outcomes, it is often given low priority. For example, staff turnover and limited staff time and training (often a very low priority) can adversely affect ongoing implementation of programs (Franks et al., 2007; WHO Expert Committee on Comprehensive School Health Education and Promotion, 1997). The OPHS also reinforces the importance of capacity, being one of the principles that the Standards are guided by.

With this background understanding and recognizing the importance of partnership and collaboration, also a principle of the OPHS, the working group, and school and community partnership teams, begin to identify a process that will address several important issues related to program resourcing and adaptation. Their list, based on the background work and reading the Inner Context section of Module 3 in the Tool Kit, includes:

  • Identifying resources required to operative and maintain the programs.
  • Identifying needed resources that do not currently exist or are not available.
  • Identifying barriers to obtaining these resources.
  • Identifying actions to address these barriers, thus initiating the adaptation processes.
  • Developing monitoring systems to track potential and real changes in the schools and broader environments that will affect resourcing levels and flag important and timely opportunities for adaptation to change. These systems will support the program evaluation activities of Module 4 of the Tool Kit.

The working group then refers back to the Adaptation Activity Sheet and uses it to organize the tasks in Columns 3 and 4 by system level and intervention. This work is also undertaken collaboratively with the school teams. Each team will work through the process and prepare an adaptation plan to bring back to the working group for discussion. Differences in individual school needs and resource assessment are important to this process. This helps specify exactly what adaptive action needs to be taken and where it should be aimed in each school. In doing this, the working group and school team members will begin to see how adaptive actions differ in likely impact and the amount of effort each requires. Each school team has also agreed to set up a monitoring process to regularly scan relevant environments for changes that may impact on the program's resources.

This information will be used to assign priorities to actions, especially given that all of them cannot be undertaken simultaneously. For example, in one school, a staffing change that means the loss of a teacher who had a key role in managing the program, necessitates a change that must be dealt with immediately, and before other adaptive actions. It will also help the group and school teams to see if there are any interventions where adaptation can be similarly dealt with, thus avoiding duplication of effort. Perhaps changing the contents of the vending machines and the snack programs can be managed simultaneously as the some of the same healthy foods will be used for both.

Outer Context

At this point, the teams undertake a situational assessment in accordance with the Population Health Assessment and Surveillance Protocol of the OPHS. The Tool Kit will help and this is a place where outer context is important. This information will assist in identifying the key aspects of outer context and their influence on the school's programs.

The working group and school team members then carry out a similar process to the one they undertook for inner context. Again, from the Tool Kit, one key aspect is chosen as critically important to the programs currently: socio-political climate - especially the political and policy-making environments at the provincial government level. This aspect of outer context will be the group's first priority as they begin to work with and understand the process of adaptation to outer contextual influences.

It is agreed that the policy-making environment at the provincial level is an aspect of outer context that is extremely important and influential to the schools' healthy living programs; in particular, funding and policy direction including the recent Ontario Public Health Standards. Members also recognize that their role is primarily one of policy implementor, although they feel that there may be opportunities for ‘bottom-up' policy input that is part of the adaptation process but which have not previously been identified or acted upon. It is anticipated that work on this aspect of outer context may initiate thinking about how the schools can be more proactive in their relationships with the School Board and the Provincial Ministries of Health and Long-Term Care, and Education.

In defining their role and how political and policy-making environments impact the programs and how they adapt, the working group goes back to the Activity Sheet and begins to identify factors related this specific aspect of outer context. Similar to the process used in examining inner context, they develop a list of tasks that will help, including:

  • Documenting known and potential policy changes likely to impact the programs.
  • Identifying positive and negative impacts and their implications for the programs.
  • Identifying actions to address these impacts, thus initiating the adaptation processes.
  • Developing monitoring systems to track potential and real changes in the policy environments that will affect the programs and flagging important and timely opportunities for effective adaptation to change. These systems will support the program evaluation activities of Module 4.

Because as change occurs at one level, other levels must also adapt, members agree that the political system level can have significant implications for other levels of the system. For example, a new funding initiative from the Ministry of Education at the provincial policy level that provides School Boards with funds to purchase additional resources and equipment to augment their physical activity initiatives will see the flow of money to the Board and school levels, while the purchasing and resourcing may take place at either or both levels, and the impact of the policy will be felt directly by students as new opportunities to become more physically active are made available. On the other hand, an unexpected policy change that reduces program funding might mean that program activities have to be curtailed or eliminated, thus negatively affecting the program and its ability to improve healthy eating and physical activity among students.

Thus contextual influence is felt at all system levels and adaptation to that influence, as in the examples of positive and negative provincial policy changes, again spans all system levels, although the impact of adaptive change is experienced most directly by the schools and their students. Simultaneous contextual influences such as resource reductions in one area and expansions in another are likely to produce both synergistic effects (e.g., a policy change that benefits both board and program) or possibly antagonistic effects (e.g., a policy change that benefits the board, perhaps a required budget reduction, but is detrimental to the school's program). However, if contextual change is neither identified nor its impact monitored, critical positive and negatives influences on programs may be overlooked. Filling in Columns 5 and 6 will help the working group and school teams identify how to effectively adapt to critical policy changes.

Members should also take into consideration the amount of effort and impact of adaptation that may be shared by several interventions. For example, additional resources and equipment may simultaneously support a new integrated play area that incorporates activities for younger students and supervisory experiences, as well as increased physical activity for older students. Or perhaps the new equipment is modular and multi-functional, so that it can be used by different groups of students at different times during and after the school day. Thus the adaptation may provide a broad application of resources (to more than one intervention and one group of students) and create potential cost-savings that can be re-directed to other interventions.

The working group and school teams have found this first cycle of identifying contextual influences and how to adapt to them challenging but full of insights and novel responses that had not previously received sufficient attention. They are ready to move forward with the next steps in their planning process, with a clearer perspective on the context surrounding them.

Sample Context Adaptation Activity Sheet:

School Healthy Living Program Adaptation

To a Key Aspect of Inner and Outer Context

1
System Level/ Sector

2
Intervention

3
Inner Contextual Influence

4
Adaptation to Inner Contextual Influence

5
Outer Contextual Influence

6
Adaptation to Outer Contextual Influence

Policy

School Board Nutritious Food Policy requiring selling of healthy snacks & drinks in school vending machines

First priority at all levels: Dedicated resources

 

NOTE: The steps below follow the process identified in the bulleted list on inner context on pg. 3:

  • Identify resources required to operative & maintain the programs.
  • Identify needed resources that do not currently exist or are not available.
  • Identify barriers to obtaining these resources.
  • Identify actions to address these barriers, thus initiating the adaptation processes.
  • Develop monitoring systems to track potential & real changes in the school & broader environments that will affect resourcing levels & flag important & timely opportunities for adaptation to change. This information will support the program evaluation activities of Module 4. Program evaluation is one of the required areas in the OPHS Foundational Standard.

  • Costing of nutritious foods & drinks for vending machines indicates that revenue generated will support additional costs.
  • Existing/potential sources for foods/drinks identified – food industry representative offers to negotiate with vending machine operator.
  • Few barriers are anticipated as vending machine operator has indicated willingness to support policy & work with the School Board to provide healthy foods/drinks.
  • Monitoring systems are developed by working group & school teams to track changes & flag opportunities for further adaptation at all levels for all interventions. These systems will provide key information for the program evaluation activities in Module 4 of the Tool Kit.

First priority at all levels: Political & policy-making environments

Policy input is required by the OPHS.

Health Units are required to work with educators to implement policies & create supportive environments.

NOTE: The steps below follow the process identified in the bulleted list on outer context on pg. 4:

  • Document known & potential policy changes.
  • Identify positive & negative impacts & their implications for the programs.
  • Identify actions to address these impacts, thus initiating the adaptation processes.
  • Develop monitoring systems to track potential & real changes in the policy environments that will affect the programs & flag important & timely opportunities for effective adaptation. This information will support the program evaluation activities of Module 4. Program evaluation is one of the required areas in the OPHS Foundational Standard.

  • Policy changes likely to impact the programs are identified by working group & reviewed with school teams. Most immediate and mandatory is the implementation of the Ontario Public Health Standards (OPHS).
  • Public Health Unit member assists groups identify impacts of OPHS, seeing them as positive in their support of school-based healthy eating & physical activity initiatives. The OPHS requires that the Health Unit work with school boards and/or staff, using a comprehensive health promotion approach, to influence the development and implementation of healthy policies, and the creation or enhancement of supportive environments to address healthy eating, healthy weights and physical activity
  • Through the OPHS, the Health Unit can provide additional support in needs assessment, curriculum support & the enhancement of supportive environments for the schools’ programs.
  • The vending machine policy is viewed as an appropriate initiative for Health Unit support.
  • Through the OPHS, the Health Unit will also be able to provide data on trends over time, emerging trends & priority populations. These information sets will be included in the monitoring systems developed to track changes & flag additional opportunities for program enhancement & adaptation. These systems will provide key information for the program evaluation activities in Module 4 of the Tool Kit.

Organizational

Schools adding fresh fruit & vegetables to snack programs

First priority at all levels: Dedicated resources

  • Costing of healthy snacks indicates that additional resources are required to provide nutritious snacks to all students on an ongoing basis.
  • Potential sources of fresh fruit & vegetables at low cost to be contacted, including local Food Box Programs, grocery chains, local farmers & community gardens.
  • Barriers include unavailability of local fresh produce year round & high cost of imported fresh produce during winter, as well as the recent rising costs of healthy foods.
  • Once firm arrangements are in place for ongoing supply of fresh produce, barriers will be discussed with produce providers to determine what affordable produce can be provided during winter months.
  • The rising costs of healthy foods will require creative strategies to obtain ongoing subsidization, for example, from local food companies, special school funds or fundraising by the School and Student Councils.
  • Monitoring systems will include tracking changes in produce availability, new & changing sources depending on season, & ability to keep within budget. These systems will provide key information for the program evaluation activities in Module 4 of the Tool Kit.

First priority at all levels: Political & policy-making environments

 

  • Similarly, broader policy support from the OHPS reinforces the schools’ initiative to provide healthy snacks to their students.
  • Monitoring again will provide additional information about impact & identification of further opportunities for adaptation & program enhancement, as well as support the program evaluation activities in Module 4 of the Tool Kit.

 

Community

Trained parent & community volunteers providing new physical activities to students

First priority at all levels: Dedicated resources

  • School teams request School Councils & local government & community organizations to make this a priority initiative that they will support & assist with.
  • Barriers include availability of trained volunteers during school & after school hours. For example, it may be difficult to find volunteers who are both trained to provide specialized activities & can be available at times that work for students.
  • Trained parent & community volunteers are identified in each school with assistance of School Council members. For example, recent programs have been offered at the local Y training parents and volunteers in physical activity coaching skills for a recent, community-wide mini-olympics. With the assistance of the YMCA/YWCA, these people are contacted to see if they could be available immediately.
  • Optional approaches include having a roster of volunteers who can cover all activity times & arranging schedules to best meet availability of all volunteers.
  • Monitoring systems will keep track of how well schedules are working for both students & volunteers to adapt to changing circumstances as well as seek out new opportunities. These systems will provide key information for the program evaluation activities in Module 4 of the Tool Kit.

First priority at all levels: Political & policy-making environments

 

  • Funding from the Provincial Ministry of Education flows through the School Board to schools to obtain additional resources & purchase equipment to augment physical activity initiatives.
  • While both provincial funding & the policy support and direction of the OPHS for services and programs will positively impact physical activity levels in the school setting, the working group sees this initiative as operating at the community level.
  • However, the impact of the policy that funds the use of new equipment & additional human resources is felt directly by students as opportunities to become more physically active are made available.
  • Monitoring will provide additional information about impact & identification of further opportunities for adaptation & program enhancement, as well as support for for the program evaluation activities in Module 4 of the Tool Kit.

 

 

 

 

 

Interpersonal

Schools working with School Councils to communicate information about healthy meals to parents & children

First priority at all levels: Dedicated resources

  • School teams meet with School Councils to discuss initiative & identify resources required to develop information packages & decide that two different approaches are needed for parents & students. One will consist of handout material & guidelines for parents. The other will be an online learning activity that students can access on each school’s website.
  • It is decided that these initiatives will be developed in-house by School Council members experienced in this kind of work & know parents who might be willing to assist. If similar approaches can be used by all schools, the effort required to produce these materials will be significantly reduced.
  • With the development process in place, barriers of time & cost are significantly reduced. The schools agree to help with the production of the print materials in order to reduce costs. Teachers & students will take on the website work, using it as an in-class project with dual purposes of learning about healthy living practices & technology applications.
  • Team members also think about the need to track changes in information to ensure that it is up to date & accurate. This will be added to the monitoring systems, which will provide key information for the program evaluation activities in Module 4 of the Tool Kit.

First priority at all levels: Political & policy-making environments

  • Policy support and direction at the government & Health Unit levels via the OPHS requirements are important to these initiatives, but the interpersonal & intrapersonal levels are predominantly action-oriented, aimed at impacting the healthy eating behaviours of students.
  • Monitoring of the policy environments will continue to ensure that support is not withdrawn or diminished to the detriment of the schools’ programs.

 

Intrapersonal

New opportunities for students to eat nutritiously & be more physically during & after school

First priority at all levels: Dedicated resources

  • Barriers to participation of all students are identified, including affordability, access, self-esteem issues & obesity stigma. For example, some students may not be able to stay for an after-school program due to their bussing schedule or other transportation limitations, or choose not to participate due to their weight and/or feeling socially uncomfortable.
  • School teams work with working group to implement remedial actions to assist all students participate.
  • Monitoring systems will track student participation & results of remedial actions. These systems will provide key information for the program evaluation activities in Module 4 of the Tool Kit.

First priorit at all levels: Political & policy-making environments

  • Policy support at the government & Health Unit levels via the requirements in the OPHS is important to these initiatives, but the intrapersonal level is predominantly action-oriented, aimed at impacting the healthy eating & physical activity levels of students.

 

Last Updated on Wednesday, 23 September 2009 19:13