(An item from the ISHN Member information service)  The use of ecological analysis of the over-lapping and inter-acting influences of individual, family, neighbourhood, school and larger community on behaviour and health status is now well-accepted in health promotion research. The ISHN has a version of this thinking that we developed with several researchers. However, it is very difficult to sort out the relative impact of these various layers. Indeed, the more "proximal" and "distal" influences are likely to vary for different individuals, at different times in their lives and events. An article in Issue #11, 2015 of Public Health Nutrition describes the relative contributions of these layers of the Social Ecological Model (SEM) when examining childhood obesity. A randomized telephone survey conducted in 2009–2010 collected information on parental perceptions of their neighbourhoods, and household, parent and child demographic characteristics. Parents provided measured height and weight data for their children. Geocoded data were used to calculate proximity of a child’s residence to food and physical activity outlets. Multiple logistic regression models were estimated to determine the joint contribution of elements within each layer of the SEM as well as the relative contribution of each layer. Layers of the SEM representing parental perceptions of their neighbourhoods, parent demographics and neighbourhood characteristics made the strongest contributions to predicting whether a child was overweight or obese. Layers of the SEM representing food and physical activity environments made smaller, but still significant, contributions to predicting children’s weight status. Read more>>

(An item from the ISHN Member information service)  A special issue (#5-6, 2015) of The Journal of Early Adolescence uses different measures to understand the early adolescents’ experience in schools. The introduction noted that "We are particularly interested in measures with direct application—providing actionable data to teachers, principals, parents, school counselors, or the students themselves, in ways that promote social-emotional and academic learning. In this introduction, we highlight the ways in which articles in this special issue offer rigorous, relevant, and feasible approaches to this measurement work". The next two articles examined the non-classroom settings within the school, hallways, cafeterias and school yards and measured items such as the density of student gatherings, verbal noise and staff perceptions, all of which were found to be significant. In the schoolyard, the researcher suggested a much greater focus on non-social students who were excluded from activities. My only question, a serious one, was whether the study included the bathrooms in the schools. Note: In the ISHN complex, ecological and systems-based model depicting the school environment, we do depict these various sub-settings within the school. Read more>>

(An item from the ISHN Member information service)  An analysis of coordination the Dutch Healthy School Approach (HSA) is reported in the July 2015 Issue of BMC Public Health. "HSA targets demand-driven practices based on the epidemiological data, a prioritization of needs, an assessment of important/modifiable determinants, the drafting and implementation of a multi-year plan, and its evaluation. All this is done jointly with multiple stakeholders. At school level, implementation is assisted by a ‘HPS advisor’, who represents various public services and providers in individual contacts with schools. At local and regional levels, the public health services (PHSs) function as a coordinator between the education, health and other services stakeholders. Their coordinating role derives from a legal responsibility for the implementation of local public health policy and youth health care financed by the municipality". The study "reports on the longitudinal quantitative and qualitative data resulting from a two-year trajectory (2008–2011) based on the DIagnosis of Sustainable Collaboration (DISC) model. This trajectory aimed to support regional coordinators of comprehensive school health promotion (CSHP) in systematically developing change management and project management to establish intersectoral collaboration. Multilevel analyses of quantitative data on the determinants of collaborations according to the DISC model were done, with 90 respondents (response 57 %) at pretest and 69 respondents (52 %) at posttest. Quantitative data showed major improvements in change management and project management. There were also improvements in consensus development, commitment formation, formalization of the CSHP, and alignment of policies, although organizational problems within the collaboration increased. Content analyses of qualitative data identified five main management styles. Read more>>

(An item from the ISHN Member information service)  An article in Volume 76, 2015 of Preventive Medicine reports on a review of studies using the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate physical activity interventions aimed at youth. "A systematic search for controlled interventions conducted within the last ten years identified 50 studies that met the selection criteria. Based on Reach, Efficacy/Effectiveness, Adoption, Implementation and Maintenance criteria, most of these studies focused on statistically significant findings and internal validity rather than on issues of external validity. Due to this lack of information, it is difficult to determine whether or not reportedly successful interventions are feasible and sustainable in an uncontrolled, real-world setting. Areas requiring further research include costs associated with recruitment and implementation, adoption rate, and representativeness of participants and settings. This review adds data to support recommendations that interventions promoting physical activity in youth should include assessment of adoption and implementation issues". Read more>>

(An item from the ISHN Member information service)  A traditional approach to evaluating the effectiveness of school health promotion programs was used in a small scale study reported in Issue #4, 2015 of Health Promotion Practice. The authors report that "SH interventions are evidence based and integrated into the curriculum, while embedded in complementary healthy school policies and environment. This study evaluates the effects of such an intervention on Dutch high schools. Methods. Two Dutch high schools and two controls were followed to evaluate the intervention’s effects on health behaviors, body mass index, and psychosocial problems after 1 year (N = 969) and 2 years (N = 605). Outcomes were measured via self-report surveys and analyzed with mixed methods regression analyses. To complement information on intervention effects, structured interviews were held with a representative sample of teachers per intervention school to map their respective whole school approach implementation success. Results. After 2 years, one intervention school showed significant improvements: Body mass index and excessive screen time use were reduced. In the other intervention school, priority targets did not improve. These findings reflected their respective success in intervention implementation, for example, differences in intervention integration and tailoring." The challenges associated with this type of study, beyond the short term measurement of behavioural effects, is that we are no informed about why implementation worked in one school but not the other. Read more>>

(An item from the ISHN Member information service) A number of experts were asked to refine the concept of integrated public health policy in order to move towards better ways of measuring and monitoring this idea that is central to the recent health sector attempts to promote health in all policies and the ISHN-ASCD-EI initiative on integrating health and social programs within education systems. The authors note "While expectations of integrated public health policy (IPHP) are high, assessment is hampered by the concept's ambiguity. This paper aims to clarify IPHP as first step in further measurement development. We invited 237 Dutch experts, 62 of whom generated statements on characteristics of IPHP. Next, 100 experts were invited, 24 of whom sorted the statements into piles according to their perceived similarity and rated the statements on relevance and measurability. The concept map consisted of 97 statements, grouped into 11 clusters and five themes. Core themes were ‘integration’, concerning ‘policy coherence’ and ‘organizing connections’, and ‘health’, concerning ‘positioning health’ and ‘addressing determinants’. Peripheral themes were ‘generic aspects’, ‘capacities’, and ‘goals and setting’, which respectively addressed general notions of integrated policy making, conditions for IPHP, and the variety in manifestations of IPHP. Measurability ratings were low compared to relevance." While this article is an important first step and knowing that it is always risky to comment based only on an abstract, this article raised a flag in that the issues of capacity and setting were relegated to a peripheral status. This dismissal of the real world capacities and powerful conditions based on context seems to run counter other complexity literature suggesting that working within complex environments will always require both capacity and a firm understanding of the circumstances. Read more>>

(An item from the ISHN Member information service)  An article in Volume 36 of the Annual Review of Public Health describes some of the lessons we have collectively learned about complex interventions to improve health, especiually the ways that complex systems thinking is being used in clinical settings. "Complexity—resulting from interactions among many component parts—is a property of both the intervention and the context (or system) into which it is placed. Complexity increases the unpredictability of effects. Complexity invites new approaches to logic modeling, definitions of integrity and means of standardization, and evaluation. New metaphors and terminology are needed to capture the recognition that knowledge generation comes from the hands of practitioners/ implementers as much as it comes from those usually playing the role of intervention researcher. Failure to acknowledge this may blind us to the very mechanisms we seek to understand. Researchers in clinical settings are documenting health improvement gains made as a consequence of complex systems thinking. Improvement science in clinical settings has much to offer researchers in population health." This succinct summary, presented in the abstract, captures many of the lessons that need to be applied. Since ISHN sponsors a Wikipedia style web site that uses the slogan "where (research) evidence meets (professional) experience, and since many of the summaries in that web site attempt to explain these new ideas based on ecological, systems-based thinking, we highly recommend this article. Read more>>

(From the ISHN Member information service)  An article in Issue #2, 2015 of Psychological Bulletin describes how any multiple intervention program such as school health promotion will need to determine how many health issues need to be addressed in their context, how many interventions will likely achieve an optimal affect and which issues being addressed are more relevant/proximal to the population being served. The " meta-analysis of 150 research reports summarizing the results of multiple behavior domain interventions examined theoretical predictions about the effects of the included number of recommendations on behavioral and clinical change in the domains of smoking, diet, and physical activity. The meta-analysis yielded 3 main conclusions. First, there is a curvilinear relation between the number of behavioral recommendations and improvements in behavioral and clinical measures, with a moderate number of recommendations producing the highest level of change. A moderate number of recommendations is likely to be associated with stronger effects because the intervention ensures the necessary level of motivation to implement the recommended changes, thereby increasing compliance with the goals set by the intervention, without making the intervention excessively demanding. Second, this curve was more pronounced when samples were likely to have low motivation to change, such as when interventions were delivered to nonpatient (vs. patient) populations, were implemented in nonclinic (vs. clinic) settings, used lay community (vs. expert) facilitators, and involved group (vs. individual) delivery formats. Finally, change in behavioral outcomes mediated the effects of number of recommended behaviors on clinical change. These findings provide important insights that can help guide the design of effective multiple behavior domain interventions". Read More>>

(From the ISHN Member information service) We all know that context matters in almost everything but an article in Issue #1, 2014 of the International Journal of Public Health helps to explain how context influences the process and outcomes. This narrative systematic review explored how neighbourhood interventions promote positive youth development (PYD) and the role played by the local context for these interventions. The authors analyzed 19 articles using a framework integrating standards of health promotion evaluation and elements of the ecological systems perspective. They report that "First, results highlight the key characteristics of interventions that promote PYD. An intervention’s atmosphere encouraging supportive relationships and an intervention’s activities aiming to build skills and that are real and challenging promoted PYD elements including cognitive competences, confidence, connection, leadership, civic engagement, and feelings of empowerment. Secondly, this review identified facilitators (e.g. partnerships and understanding of the community) and constraints (e.g. funding and conflicts) to an intervention’s integration within its context. They conclude that their review confirmed other reviews that suggested that interventions’ characteristics affected outcomes. But their findings indicate that context is an important element of effective interventions because context interacts with the characteristics of the intervention to create a good or poor fit with those particular circumstances. Read more>> 

(From the ISHN Member information service)   An article in the April 2014 issue of BMC Public Health discusses a longitudinal study and knowledge development project in Canada (The COMPASS Study) that will enable researchers to assess the cumulative impact of several school health policies and programs on multiple issues over time. The authors describe the study as "COMPASS is a prospective cohort study designed to annually collect hierarchical longitudinal data from a sample of 90 secondary schools and the 50,000+ grade 9 to 12 students attending those schools. COMPASS uses a rigorous quasi-experimental design to evaluate how changes in school programs, policies, and/or built environment (BE) characteristics are related to changes in multiple youth health behaviours and outcomes over time. It is the first study with the infrastructure to robustly evaluate the impact that changes in multiple school-level programs, policies, and BE characteristics within or surrounding a school might have on multiple youth health behaviours " The researchers note that "In Year 1 (2012–13), data were collected from 43 Ontario schools and over 24,000 grade 9 to 12 students. In Year 2 (2013–14), the cohort was increased by 47 additional schools to reach our target of 90 schools (79 in Ontario and 11 in Alberta), with more than 50,000 grade 9 to 12 students participating. Given the hierarchical longitudinal nature of the data, the cohort of 90 secondary schools are being followed over time through annual school data collection of the program and policy environment within each school, the built environment characteristics within each school, and the built environment characteristics in the community immediately surrounding each school. At the student-level, the cohort of grade 9 to 12 students within the 90 schools are followed over time using annual surveys that assess obesity, healthy eating, physical activity, sedentary behaviour, tobacco use, alcohol and marijuana use, school connectedness, bullying, and academic achievement using scientifically supported measures.COMPASS can evaluate the ‘real-world’ effectiveness of evidence-based interventions that are implemented in COMPASS schools throughout the course of the study. Considering that schools also often implement innovative and unique programs or policies that are not yet evidence-based, 
COMPASS can start to generate practice-based evidence by evaluating those natural experiments throughout the course of the study." In order to help foster health promoting schools to develop stronger links and engagement with participating schools, and track knowledge use as it unfolds from inception through decision-making, adoption, adaption and implementation in participating schools, the COMPASS study developed the COMPASS School Health Profile (SHP) and connects participating schools with a COMPASS knowledge broker.The hierarchical longitudinal nature of the COMPASS data allows for a number of different analytical strategies for examining each of the outcomes in COMPASS. For instance, both cross-sectional and longitudinal core analytical approaches to examining the data will be used. Cross-sectional analyses include, but are not limited to: 1. Identification of high-risk individuals or high-risk school environments; 2. Examination of between-school variability in the different student-level outcomes among students; 
3. Examination of the co-occurrence of different outcomes; and,4. Hierarchical analyses examining the student- and school-level characteristics associated with each outcome. Longitudinal analyses include, but are not limited to: 1. Examination of the temporal sequence for the development of individual outcomes or the co-occurrence of outcomes; 2. Hierarchical examination of how changes in school-level characteristics (programs, policies, or built environment resources) are related to changes in school-level prevalence or individual student-level outcomes over time; 3. Evaluation of how the different knowledge exchange strategies impact the provision of school-level prevention activities or resources; and, 4. Examining how the trajectories of different outcomes are predicted by other outcomes (e.g. declines in physical activity over time impact obesity) and the available sociodemographic characteristics of students and/or schools.
The authors conclude that "In conclusion, the COMPASS study is among the first of its kind internationally to create the infrastructure to robustly evaluate the impact that changes in school-level programs, policies, and built environment resources might have on multiple youth health behaviours and outcomes over time. Determining the school-level characteristics that are related to the development of multiple modifiable youth health behaviours and outcomes will provide valuable insight for informing the future development, tailoring, and targeting of school-based prevention initiatives to where they are most likely to have an impact [46], and will provide the opportunity to understand how the school environment can either promote or inhibit health inequities among subpopulations of at-risk youth. Such insight could save valuable and limited prevention/promotion resources. Developing the ability to evaluate natural experiments that occur within schools will substantially add to the breadth of our understanding of what interventions work, for which students, and in which context." Read more>>

(From the ISHN Member information service) An article in the June 21, 2014 issue of The Lancet calls for systems thinking from governments and Un agencies when they decide on the set of goals to replace the existing MDG goals. The authors assert that "Global priorities have progressed from the Millennium Development Goals (MDG) that will expire in 2015 to global sustainable development. Although there is not yet a consensus on the specific goals for the post-MDG era, the post-2015 investment agenda for health will probably emphasise social determinants of health, sustainable development, non-communicable diseases, health systems strengthening, universal health coverage, the health of women and children, and ageing."  They then go on to make the case for "systems thinking". " The MDGs were undoubtedly successful in focusing international donor financing and domestic investments to achieve the targets set in these goals. Yet, undue emphasis on financing narrow disease programmes used to achieve disease-specific targets in the MDGs often missed opportunities to effectively strengthen health systems.1 Consequently, several low-income countries with weak health systems have struggled to reach the targets set in health-related MDGs and will not achieve them by 2015.2 An important lesson from the MDGs is that current and emerging global health challenges require action that embraces interdisciplinary and intersectoral approaches to development,3 which acknowledge the path-dependence and context-dependence of implementation." 
A table in the article underlines the differences between "selective approaches" (linear thinking) focused on preventing specific problems and "systems thinking" In linear thinking, the program is developed from a blueprint, developed by trials in controlled circumstances, that are top-down in nature, often without considering local contexts or potential unintended consequences. In systems-based approaches, learning and context drive the action and selection of issues to be addressed as well as the programs. In linear thinking, the programs target disease-specific, quick-wins. Planners develop a specific program for a specific population and assess its ability to produce specific short-term outcomes. In systems-based approaches, the action is across various sectors, with key stakeholders involved from the beginning to develop and implement approaches across the relevant sectors. In selective thinking, there is a reliance on isolated, quantitative measures. Single snap shot data points are used by specialized experts to assess if the programs are meeting their objectives. In systems thinking, multiple interative measurements and synthesis as well as relationships are used to assess progress. Longitudinal, real-world data from multiple qualitative and quantitative sources are used to monitor relevant effects.  Read more>>      

(An item from the ISHN Member information service) Two articles in Volume 93, 2013 of Social Science & Medicine indicate that complexity theory is emerging as a planning and analysis tool in public health and health promotion. the two examples are a public health response TB outbreak in London, UK and a disaster management planning & response in five Canadian communities. Some of the complexity concepts that emerged in the two articles include self-direction, inter-connectedness, culture as a backdrop, dynamic contexts, situational awareness and connectedness, and others. Read more>>

(An item from ISHN Member information service) Working across multiple systems to prevent a problem or promote health is not easy, even with collaboration mandated from above. An article in Issue #1, 2013 of Critical Public Health describes some of those challenges in an analysis of alcohol abuse prevention partnerships in England. The authors report that: "Tackling alcohol-related harms crosses agency and professional boundaries, requiring collaboration between health, criminal justice, education and social welfare institutions. It is a key component of most multi-component programmes in the United States, Australia and Europe. The findings are based on a mix of open discussion interviews with key informants and on semi-structured telephone interviews with 90 professionals with roles in local alcohol partnerships. Interviewees reported the challenges of working within a complex network of interlinked partnerships, often within hierarchies under an umbrella partnership, some of them having a formal duty of partnership. The new alcohol strategy has emerged at a time of extensive reorganisation within health, social care and criminal justice structures. Further development of a partnership model for policy implementation would benefit from consideration of the incompatibility arising from required collaboration and from tensions between institutional and professional cultures. A clearer analysis of which aspects of partnership working provide ‘added value’ is needed. Read more>

(An item from ISHN Member information service) An article in Issue #1, 2012 of Health Promotion International presents a framework to better understand complexity in health promotion research and practice. The authors note that "Health promotion addresses issues from the simple (with well-known cause/effect links) to the highly complex (webs and loops of cause/effect with unpredictable, emergent properties). Yet there is no conceptual framework within its theory base to help identify approaches appropriate to the level of complexity. The default approach favours reductionism—the assumption that reducing a system to its parts will inform whole system behaviour. Such an approach can yield useful knowledge, yet is inadequate where issues have multiple interacting causes, such as social determinants of health. To address complex issues, there is a need for a conceptual framework that helps choose action that is appropriate to context. This paper presents the Cynefin Framework, informed by complexity science—the study of Complex Adaptive Systems (CAS). It introduces key CAS concepts and reviews the emergence and implications of ‘complex’ approaches within health promotion. It explains the framework and its use with examples from contemporary practice, and sets it within the context of related bodies of health promotion theory. The Cynefin Framework, especially when used as a sense-making tool, can help practitioners understand the complexity of issues, identify appropriate strategies and avoid the pitfalls of applying reductionist approaches to complex situations." Read more. 

(An item from ISHN Member information service) An article in Issue #5, 2012 of Prevention Science uses ecological analysis to identify the bullying prevention interventions that are more effective in the school context. The researchers report that" Data for this study are drawn from the School-Wide Information System (SWIS) with the final analytic sample consisting of 1,221 students in grades K – 12 who received an office disciplinary referral for bullying during the first semester. Using Kaplan-Meier Failure Functions and Multi-level discrete time hazard models, determinants of the probability of a student receiving a second referral over time were examined. Of the seven interventions tested, only Parent-Teacher Conference (AOR = 0.65, p < .01) and Loss of Privileges (AOR = 0.71, p < .10) were significant in reducing the rate of the reoccurrence of bullying and aggressive behaviors. By using a social-ecological framework, schools can develop strategies that deter the reoccurrence of bullying by identifying key factors that enhance a sense of connection between the students’ mesosystems as well as utilizing disciplinary strategies that take into consideration student’s microsystem roles. Read more. 

(An item from ISHN Member information service) An article in the October 2012 issue of the International Journal of Behavioral Nutrition and Physical Activity offers a detailed analysis of the reasons why parents choose to have their child walk or bike to school. Using Canadian HBSC data and Google Street View, the researchers examined why the 3,997 students living within one mile of their schools (26,078 students attended these schools) followed active transportation routes to schools and what kinds on interventions could encourage more to do so. The factors that influenced that choice were: the gender of the child, not living with both parents, socioeconomic status, perceived neighbourhood safety, proportion of roads with sidewalks, vacant or shabby buildings, rainy, cold or hot climates. School policies and programs to encourage active transportation (special days, bike racks etc) seemed to not have a positive effect, so the contradictory data was discarded as was the counter-intuitive finding that higher speed limits were correlated with more active transport. Actions to improve neighbourhood safety and calm traffic were suggested in the conclusions. It is also noteworthy that a small minority of total students attending these urban Canadian schools were within one mile and within that minority about 60% of students walked or biked to school. The analysis offers an excellent example of multi-level analysis to unravel the complex ecological factors affecting behaviours.  Read more.

(An item from ISHN Member information service)  An article in the September 2012 Issue of Educational Policy discusses how school systems both respond to new small demands while resisting large scale reforms. The article is actually a review of the 2010 book, Someone Has to Fail, which examines while many efforts to reform school systems have failed. The authors note that: "Someone Has to Fail offers a reinterpretation of the complexities of education reform, one that is full of useful counterpoints to many of the most common claims made by today’s business-minded reformers. Thus, the work is well worth reading. However, we still wish that Labaree had more deeply explored the contexts within which his education “consumers” were making their system-shaping decisions. Such an effort would have offered a more compellingly critical assessment of the importance of curriculum and the struggles over knowledge and culture. It would have brought the experiences and movements of the marginalized closer to the center of its account. And in the process, it might have engendered a somewhat less gloomy perspective regarding the roles that schools might still play in efforts to create a more just society." Read more..

(An item taken from the daily/weekly/monthly ISHN Member information service)  Sarah Stewart-Brown, a prolific writer of systematic reviews has ignited a debate about the appropriateness of using Random Controlled Trials as the methodology to evaluate multi-intervention approaches and strategies that seek to modify complex, adaptive, loosely-coupled systems such as schools and public health. She argues that "Randomised controlled trials are likely to be at their best in the evaluation of interventions that do not require the active engagement and personal development of participants. The latter may depend on a series of interventions and events that potentiate each other over time. Randomised controlled trials are likely to be least valuable in evaluating universal level interventions that aim to change population norms. Because of the challenges involved in conducting RCTs in this setting they cannot be relied upon to give accurate estimates of programme effect and therefore do not deserve the privileged position that has been accorded them in the hierarchy of evidence".  For a listing of the articles in the debate, go to Issue #4, 2011 and Issue #2, 2012 of the Journal of Children's Servies.