(An item from the ISHN Member information service) A special issue (Issue 2-3, 2015) of Journal of Educational and Psychological Consultation examines the use of school psychologists as systems-level consultants as a strategy to deal with the complexities of the multi-level changes required to introduce and sustain comprehensive approaches to school mental health promotion. An interdisciplinary perspective is used to select the articles which cover topics such as Interdisciplinary Collaboration Supporting Social-Emotional Learning, Ecologically Based Organizational Consultations, the Competencies for Systems-Level Consultants, Multi-Tiered Systems of Support, Collaboration Between School Psychologists and Administrators and Critical Features and Lessons Learned for Implementation. Read more>> Readers may also be interested in a similar ISHN description of a systems-based approach to SMH that is based on capacity and capacity-building at this web page.
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(An item from the ISHN Member information service) ISHN has been critical of the "training then hoping" strategies that are often the default option for improving practice and introducing new health and social programs in schools. This blog article pulls together three recent articles on how health professionals use knowledge (or not) when modifying their practice. The first article, published in the May 2015 Issue of the International Journal for Equity & Health, "was to identify existing knowledge to action models or frameworks and critically examine their utility for promoting or supporting health equity. Forty-eight knowledge to action models or frameworks were identified. All of the models were then assessed across six characteristics relevant for supporting health equity. While no models scored full marks, the highest scoring models were found to have features relevant to advancing health equity. In the assessment, we propose six characteristics that could be important markers: 1) an explicit mention of equity, justice or similar concept; 2) the involvement of various stakeholders; 3) an explicit focus on engagement across multiple sectors or disciplines; 4) the use of an inclusive conceptualization of knowledge; 5) the recognition of the importance of contextual factors; and, 6) a proactive or problem-solving focus. Specific populations, topics and solutions are marginalized, ignored, or not acted upon when, for example, only certain knowledge is considered valuable, when we don’t have a specific focus on equity or justice, and when we don’t work across sectors or consider contextual determinants of health." The authors concluded that "Each could be strengthened in some way to make them more useful in supporting health equity by considering the six characteristics used in this review. Of particular interest is knowledge brokering as well as the use of holistic and cross-sector models of knowledge to action that consider environmental and contextual determinants. These are specific future avenues identified in this project." In other words, using "knowledge to action" frameworks, even if they are adapted to suit equity purposes, was not sufficient to improve efforts related to equity.
The second article, published in Issue #1, 2015 of Health Technology Assessment, was to identify the impacts and likely impacts on health care, patient outcomes and value for money of Cochrane Reviews published by 20 NIHR-funded CRGs during the years 2007–11. The authors note that "we found 40 examples where reviews appeared to have influenced primary research and reviews had contributed to the creation of new knowledge and stimulated debate. Twenty-seven of the 60 reviews had 100 or more citations in Google Scholar™ (Google, CA, USA). Overall, 483 systematic reviews had been cited in 247 sets of guidance. This included 62 sets of international guidance, 175 sets of national guidance (87 from the UK) and 10 examples of local guidance. Evidence from the interviews suggested that Cochrane Reviews often play an instrumental role in informing guidance, although reviews being a poor fit with guideline scope or methods, reviews being out of date and a lack of communication between CRGs and GDs were barriers to their use. Cochrane Reviews appeared to have led to a number of benefits to the health service including safer or more appropriate use of medication or other health technologies or the identification of new effective drugs or treatments. However, whether or not these changes were directly as a result of the Cochrane Review and not the result of subsequent clinical guidance was difficult to judge." The authors of this second article concluded that " The clearest impacts of Cochrane Reviews are on research targeting and health-care policy, with less evidence of a direct impact on clinical practice and the organisation and delivery of NHS services". In other words, systematic reviews and possibly even the practice guidelines that try to use such Cochrane Reviews as their basis, may or may not affect practice. The third article, published in the April 2015 Issue of the Cochrane Database of Systematic Reviews, examined "whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants...Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants." The authors conclude that "The findings continue to indicate that tailored interventions can change professional practice, although they are not always effective and, when they are, the effect is small to moderate. There is insufficient evidence on the most effective approaches to tailoring, including how determinants should be identified, how decisions should be made on which determinants are most important to address, and how interventions should be selected to account for the important determinants. In addition, there is no evidence about the cost-effectiveness of tailored interventions compared to other interventions to change professional practice." Our take away from these three and other studies we have been reading is that knowledge about better practices or better programs is insufficient to implement or sustain improvements in professional or organizational practices. The answers lie within the organizational or community context, likely based on their current core mandates, perceived and real constraints, traditions and routines and current system-level and adopter concerns at various levels. In other words, we may need to make a significant shift away from "evidence-based practice" towards auch better understanding of "practice-based experience". (An item from the ISHN Member information service) A multiple case history and systematic review of adoption, diffusion, implementation and impact of provincial daily physical activity (DPA) policies in Canadian schools was reported in the April 2015 Issue of BMC Public Health. "The purpose of this study was to understand the processes underlying adoption and diffusion of Canadian DPA policies, and to review evidence regarding their implementation and impact. Publicly available documents posted on the internet were reviewed to characterize adopter innovativeness, describe the content of their DPA policies, and explore the context surrounding policy adoption. Diffusion of Innovations theory provided a conceptual framework for the analyses. A systematic literature search identified studies that had investigated adoption, diffusion, implementation or impact of Canadian DPA policies. Results Five of Canada’s 13 provinces and territories (38.5%) have DPA policies. Although the underlying objectives of the policies are similar, there are clear differences among them and in their various policy trajectories. Adoption and diffusion of DPA policies were structured by the characteristics and capacities of adopters, the nature of their policies, and contextual factors. Limited data suggests implementation of DPA policies was moderate but inconsistent and that Canadian DPA policies have had little to no impact on school-aged children’s PA levels or BMI." Read more>>
(An item from the ISHN Member information service) An article in Issue #2, 2015 of Health Education Research reports on a cohort study of the adoption of obesity prevention policies and practices by Australian primary schools: 2006 to 2013. The authors reports that "The prevalence of all four of the healthy eating practices and one physical activity practice significantly increased, while the prevalence of one physical activity practice significantly decreased. The adoption of practices did not differ by school characteristics. Government investment can equitably enhance school adoption of some obesity prevention policies and practices on a jurisdiction-wide basis. Additional and/or different implementation strategies may be required to facilitate greater adoption of physical activity practices. Ongoing monitoring of school adoption of school policies and practices is needed." A slide presentation of tghe results is available here. Read more from the abstract of the article here.
(From the ISHN Member information service) As we learn more about the sustainability of multi-intervention approaches and programs, we are seeing the development of various techniques to measure and monitor such sustainability. An article in Issue #2, 2014 of School Psychology Quarterly reports o the development of "the School-Wide Universal Behavior Sustainability Index: School Teams (SUBSIST; McIntosh, Doolittle, Vincent, Horner, & Ervin, 2009) a measure of school and district contextual factors that promote the sustainability of school practices, demonstrated measurement invariance across groups of schools that differed in length of time implementing school-wide Positive Behavioral Interventions and Supports (PBIS; Sugai & Horner, 2009), student ethnic composition, and student socioeconomic status (SES). School PBIS team members and district coaches representing 860 schools in 14 U.S. states completed the SUBSIST. Findings supported strong measurement invariance, for all items except 1, of a model with two school-level factors (School Priority and Team Use of Data) and 2 district-level factors (District Priority and Capacity Building) across groups of schools at initial implementation, institutionalization, and sustainability phases of PBIS implementation. Schools in the sustainability phase were rated significantly higher on School Priority and Team Use of Data than schools in initial implementation." 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) An article in Issue #3, 2014 of Health Promotion Practice illustrates the challenges of working in loosely-coupled education and health systems. This Canadian study examined policy documents on school nutrition and education in Canada at the federal, provincial and regional or local authority levels. The researchers note that "Results reveal distinct differences across federal, provincial, and regional levels. The availability of nutritious food in schools and having nutrition education as part of the curriculum were key components of the physical environment across federal and provincial levels. Federal and provincial priorities are guided by a health promotion framework and adopting a partnership approach to policy implementation. Gaps in regional-level policy include incorporating nutrition education in the curriculum and making the link between nutrition and obesity." Read more>>
(An item from the ISHN Member information service) One of the trends we have noted in recent articles about physical activity & schools is a focus on improving quality through a number of incremental changes, much like a total quality approach. Several articles in Issue #1, 2014 of Research Quarterly for Exercise & Sport are part of this trend, as they discuss teacher effectiveness in physical education. The set of articles are published in response to previous articles in the December 2013 issue of the same journal. The first article examines how student behaviours and expectations affect teaching, noting that "The most vocal students in physical education classes appear to thrive in the current multiactivity, recreation-oriented sport culture that dominates many U.S. physical education programs. They expect lessons with minimal skill and tactical instruction and with maximum opportunities to play ball". The article concludes by contesting an earlier claim that the goals of PE are "muddled". The second article suggests that PE is changing dramatically from the previous three decades of curriculum control led by PE teachers and researchers to one led by education ministries and education faculties. The third article suggests that high quality, daily PE is threatened by current increased demands on schools to be accountable for student performance. The fourth article examines how PE teachers can be accountable for student outcomes as one measure that also includes class observation, student activity levels and student engagement. The final article examines constraints imposed on PE teachers such as administrator support, limited curriculum time, student ability levels and other factors. Read more>>
(An item from the ISHN Member information service) An article in the February 2014 issue of Public Health Nutrition reports on the use of the RE-AIM implementation model was used to monitorreach, effect, implementation and maintenance of two different streams of an elementary school nutrition education program. Most noteworthy is that "Thirty-seven per cent of third-grade teachers in the dissemination sample reordered SMC materials during the subsequent school year thereby reporting on the likely maintenance of the program after the trial. The authors also noted that "Results In the evaluation sample, differences between the control and intervention groups were observed for nutrition knowledge, self-efficacy, outcome expectancies, and intakes of vegetables, fruit (girls only), soda, and low-nutrient high-energy foods from pre- to post-survey. Group differences in change in knowledge, outcome expectancies and vegetable intake were sustained through the 3-month follow-up (efficacy). One hundred per cent of intervention teachers in the evaluation sample implemented all of the lessons (implementation). The dissemination sample represented 42 % of third-grade students (reach) and 39 % of third-grade classrooms in public elementary schools in California during 2010–2011 (adoption)." The value of this RE-AIM framework is that it provides an indication of likely ongoing uptake of this program without any specific funding or technical support. Consequently, the authors conclude that the program demonstrates a moderate to high potential impact. Read more>>
(An item from the ISHN Member information service) The research supporting multi-intervention approaches and programs in school health promotion is abundant and long standing. Recent research is underlining the need for long-term, systemic planning and investments in capacity-building in areas such as coordination, work force development, inter-agency agreements, coordinated policy development and joint issue management. However, experience in the real world suggests that local health authorities (LHA) do not follow that research and instead, constantly try to implement short-term, project-style interventions based on a "training, then hoping" strategy. Four articles in Issue #6, 2013 of American Journal of Preventive Medicine examine evidence-based decision-making in LHA's and provide clues for this cognitive dissonance. One article examines the factors that affect evidence-based decision-making (EBDM) and found that "Although most people understood the concept, a relatively small number had substantial expertise and experience with its practice. Many indicated that they applied EBDM unevenly. Factors associated with use of EBDM included strong leadership; workforce capacity (number and skills); resources; funding and program mandates; political support; and access to data and program models suitable to community conditions." A second article found that "Local decision-making authority was perceived as greatly restricted by what public health activities were legally mandated and the categoric nature of funding sources, even as some leaders exercised deliberate strategic approaches. One’s workforce and board of health were also influential in making decisions regarding resource allocations. Programmatic mandates, funding restrictions, local stakeholders, and workforce capacity appear to trump factors such as research evidence and perceived community need in public health resource allocation." A third article suggested that LHA participation in a "Practice-based Research Network" will help in the implementation of research. A fourth article introduced the idea that LHA's could make use of local taxation revenue. Read More>>
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