Community representatives or "connectors" can play a critical role in helping health services and schools to reach out and engage disadvantaged and minority communities. Often these connectors are elders or key leaders in the local communities being served. An article in Volume 232, 2019 of Social Science & Medicine describes the "boundary spanning practices of community connectors for engaging ‘hardly reached’ people in health services.... The institutionalised nature of health services with associated professional and organisational boundaries create ongoing challenges to achieving this policy aim. We present an approach to this challenge by exploring how health services can tap into the existing boundary spanning activities of community members we term as ‘community connectors’ who undertake valuable boundary work within the community to include people who are hardly reached. We address the research questions: what are the behaviours and characteristics of community connectors?; to what extent are they motivated to help out with health?; and how can health service personnel identify community connectors? We identified the three key roles of ‘noticer and responder’, ‘connector’ and ‘provider’ that make connectors a valuable asset for health services. Community connectors seek opportunities to negotiate new boundaries with health services that support their boundary spanning with people hardly reached and also enable health services to transgress their own boundaries and access people who are hardly reached. We conclude that by paying attention to their own production, maintenance and transgression of boundaries, health services can apply this approach, noting that the local and iterative nature of identifying community connectors means that each cohort of community connectors will be unique as determined by local boundaries and relationships. Read more...
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Since about 2005, our attention in school health and social development has included a focus on the country, community and neighbourhood contexts as a key factor in selecting the issues to be addressed, the programs to be used and the capacities to be strengthened. ISHN has worked with others to develop frameworks for indigenous communities, disadvantaged communities in high resource countries and more recently, in low resource countries. But those efforts are ahead of the good research required to guide practice. So we were pleased to note the article in the September 2015 Issue of Implementation Science describing a project to Identify the domains of context important to implementation science. "This research program will result in a framework that identifies the domains of context and their features that can facilitate or hinder: (1) healthcare professionals’ use of evidence in clinical practice and (2) the effectiveness of implementation interventions. The framework will increase the conceptual clarity of the term “context” for advancing implementation science, improving healthcare professionals’ use of evidence in clinical practice, and providing greater understanding of what interventions are likely to be effective in which contexts." Read more>> (An item from the ISHN Member information service)
(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>>
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>> (From the ISHN Member information service) One of the major challenges in sustaining and integrating health and social programs within education systems is the tendency in government to create and maintain "silos" of programs, often delivered in isolation or even competition with each other. Most governments create committees to encourage coordination but they often fail, or they focus on only one problem at a time. The Manitoba Healthy Child Agency, a strategy established in law in 2007, is an exception to this rule. The slogan on Manitoba license plates tells the world about "Friendly Manitoba". More than just words, this slogan actually reflects a culture and customs in the province, one which was born in Canada's harshest winters and bred by generations of immigrants who had to rely on each other. So, perhaps, it is this culture of cooperation that enables Healthy Child Manitoba (HCM) to be as effective as an inter-ministry agency, coordinating several ministers and ministries, in a "whole of government" strategy. Other factors could include their requirement to report results every five years, its research, innovation and knowledge development capacity, and its combination of programs (as opposed to framework documents) that are delivered hands-on and delegated ways. As well, the Healthy Child inter-ministry program has its own legislation, entitled the Healthy Child Manitoba Act, thereby giving its coordination work legal authority and requirements to report every five years on progress.
The HCM web site describes its work as follows: " in 2000, the provincial government implemented the Healthy Child Manitoba (HCM) Strategy – a network of programs and supports for children, youth and families. This nationally recognized strategy was set in legislation under The Healthy Child Manitoba Act in 2007.Led by the Healthy Child Committee of Cabinet, Healthy Child Manitoba bridges departments and governments and, together with the community, works to improve the well-being of Manitoba's children and youth. HCM focuses on child-centred public policy through the integration of financial and community-based family supports.In addition to these cross-sectoral government structures, The HCM Act also continues the work of cross-sectoral community structures, including Parent-Child Coalitions and the Provincial Healthy Child Advisory Committee (PHCAC). HCM researches best practices and models and adapts these to Manitoba's unique situation. It strengthens provincial policies and programs for healthy child and adolescent development, from the prenatal period to adulthood. HCM then evaluates programs and services to find the most effective ways to achieve the best possible outcomes for Manitoba children, families, and communities." (An item from the ISHN Member information service) The Transition Year (TY) program in Ireland is an optional one-year program that can be taken in the year after the Junior Certificate in Ireland and is intended to make the senior cycle a three year program encompassing both Transition Year and Leaving Certificate.[The mission statement of the Transition Year is to promote the personal, social, educational and vocational development of pupils and to prepare them for their role as autonomous, participative and responsible members of society.. The TY was introduced as a pilot project in September 1974 and was introduced as a mainstream option in 1994. Students in the TY do not have exams but are assessed, The program s intended to be a broad educational experience which assists in the transition from the school environment by encouraging creativity and responsibility for oneself. Approximately 75% of second-level schools offer TY. It consists of both education and work experience. Schools generally set admissions criteria and design the program based on local needs in accordance with departmental guidelines. The year focuses on many non-academic subjects, such as life skills including: First Aid, cooking, self-defense, driving and typing. A lot of sport goes on, with many different types including: rock-climbing, hill-walking, horse-riding, kayaking and orienteering. Voluntary Work is a requirement in many schools, with students helping out in local communities and charities. It is not possible to fail Transition Year overall: all students continue to their next year of education no matter what their results. However, if a student does not do the set work or is absent for a large amount of time, there is a chance that the school will request that they leave. An article in Issue #2, 2013 of Irish Educational Studies documents the development of the program since its inception.The use of the TY to offset economic or other disadvantages is also discussed. Read more>>
(An item from the ISHN Member information service) Several articles in a Supplementary Issue of Public Health Reports provide a comprehensive reframing of sexual health promotion, moving away from disease-focused, preventive strategies towards a holistic and health promoting approach. One article in the issue presents an excellent ecological analysis and then presents the principles that could underlie ecology-based actions. These principles include contextualizing the issues, using systemic thinking, focusing on relationships, acknowledging sexuality and emphasizing wellness. Another article reports on how the state or Oregon is shifting from a teen pregnancy strategy to a sexual health promotion approach. Two articles present indicators for monitoring progress in the US and Canada. Two articles discuss the impact of socio-economic status on teen pregnancy and early initiation of sexual activity. Read more>>
Recent Review of SH Approaches Suggest Integration within education, Context, Capacity, Coordination7/8/2013 (An item from the ISHN Member information service) A review of the research on multi-intervention approaches to school health promotion reported in the July 2013 issue of the Journal of School Health suggests that effective approaches included stronger consideration of integration within the school system. the local context, building capacity for sustained implementation and ensuring coordination. The authors report that "Findings indicated that, for adequate implementation, an intervention should be integrated in pre-existent school settings, fine-tuned to its target population or environment, involve family and the community, and be led by the school itself, with there being a “healthy school coordinator” to coordinate the program." Read more>>
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