(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>>
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Assessing the Cumulative Impact of School Health Policies and Programs on Multiple Health Issues7/3/2014 (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) A systematic review published in Volume 24, 2013 of Health & Place describes the various theories that explain how the social and physical environment of the school impacts student health. A composite model has been developed by the reviewers. The authors note that "We included 37 reports drawing on 24 theories. Narrative synthesis summarised and categorised theories. We then produced an integrated theory of school environment influences on student health. This integrated theory could inform complex interventions such as health promoting schools programmes. Using systematic reviews to develop theories of change might be useful for other types of ‘complex’ public-health interventions addressing risks at the individual and community levels." Their "Integrated theory of school environment explains influences on students. A figure illustrates the integrated theoretical model of the ways in which the ‘school environment’, at the top of the figure, influences at multiple inter-acting levels: (1) student–school commitment; (2) students–peer commitment; (3) student cognitions; and (4) students’ behaviours. Key theoretical concepts addressing upstream, medial and proximal pathways are identified in italics. The ‘feedback’ loops in the diagram illustrate how both the school environment influences health, but also the enactment of health behaviours influences the school environment and each preceding pathway." 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..
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