Action Planning EvidenceBased Public Health: Improving Practice at the Community Level

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Action PlanningEvidence-Based Public
HealthImproving Practice at the Community Level

• Beth Baker
• Saint Louis University
• School of Public Health

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Learning Objectives

• Identify key characteristics and principles in
  successful action planning.
• Generate list of criteria important in
  implementing physical activity interventions in
  racial/ethnic minority communities.
• Understand the purpose and use of logic models.
• Describe steps used in constructing logic models.
• Describe steps used to develop and respond to a
  request for application (RFA).

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Learning Objectives

• Identify key characteristics and principles in
  successful action planning.

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Action versus ongoing planning

• Action planning
• for a defined program or policy with specific,
  time dependent outcomes
• Ongoing or strategic planning
• a regular function within an organization

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Importance
Changeability
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Key characteristics of effective action planning

• Plans that clearly spell out and make linkages
  across
• goal
• objectives
• action strategies
• Roles and responsibilities of important
  stakeholders clarified (timetables, training)
• Clear mechanisms for tracking progress
  (evaluation)
• Action plans based on evidence and assessment

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A Simple Planning Cycle
Planning
Evaluation
Implementation
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In planning, remember to link evidence with
programs
Data
Program Interpretation
Evaluation Data
Information Program Analysis
Dissemination Implementation
Data Program Collection
Planning
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Key Principles of Planning

• Assessment should guide the development of
  programs.
• Community members should participate in the
  process.
• Participants should develop a comprehensive
  intervention strategy- but may implement one step
  at a time

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Key Principles of Planning (cont)

• Evaluation should emphasize feedback and program
  improvement.
• The community capacity for health promoting
  changes should be increased skill transfer
  between community academic/practice partners
  (two way).coalitions/partnerships

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Step1 What is the goal of your program

• What are the health issues facing your community?
• What is the magnitude of the problem? Who is most
  affected, geographic differences, time trends?
• What are the consequences of the problem?
• What causes it?
• How do you find the answers to these questions?

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Step 2 Prioritization

• Group process to prioritize which problem(s) to
  work on
• key components
• priorities

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Helpful websites

• Community Engagement Community Analysis and
  Needs Assessment
• See the Community toolbox
• http//ctb.ku.edu/

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Step 3 Setting specific objectivesa. What are
objectives?

• There must be sound scientific evidence to
  support the objectives, should be appropriate for
  community.
• The result to be achieved should be important and
  understandable to a broad audience.
• Objectives should be prevention-oriented.
• Objectives should drive action and suggest a set
  of interim steps (intermediate indicators).

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Step 3 Setting specific objectivesa. What are
objectives?(cont)

• The language of objectives should be precise,
  avoiding use of general or vague verbs.
• Objectives should be measurable and may include a
  range of measureshealth outcomes, behavioral
  risk factors, health service indicators, and
  assessments of community capacity.
• Specific timetables for completion of objectives
  should be described.

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Step 3 Setting specific objectivesa. What are
objectives?(cont)

• Example of a sound objective.
• To reduce the percent of people, ages 35 to 55,
  who are overweight (BMIgt24.9) from 80 in 2000 to
  70 in 2010.
• Objectives are achievements, not activities.
• The what, not the how.

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Step 3 Setting specific objectivesa. What are
objectives?(cont)

• Consider intermediate objectives
• if we promise too much in outcomes, we are
  destined to fail
• What are intermediate objectives for the BMI
  example?
• more on this in evaluation

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Step 3 Setting Intermediate Objectives

• Based on theory
• Consider strategies others have used

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Step 3 Setting specific objectivesa.Consider
strategies based on theory

• Theories
• explain behavior
• suggest ways to effect change
• guide intervention strategies
• guide development of objectives (e.g.,suggest
  what needs to be done to change behavior)

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Stages of Change

• Individual level theory
• Precontemplation - information
• Contemplation information, cognitive
  restructuring identity as being physically
  active
• Preparation- skill building, equipment (shoes)
• Action- skill building, environmental cues,
  access
• Maintenance- above plus social norms

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Strategies at Various Levels
Individual Interpersonal Organizational Objectiv
es - knowledge - practices - programs Address -
attitudes - social support - practices -
behavior - social networks - policies Approaches
- brochures - develop new - org change -
training social ties - networking -
counseling - lay health advisors -
development - peer support groups
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Strategies at Various Levels (cont)
Community Policy/Governmental Objectives -
programs - regulations Address - environment -
ordinances - policies - policies -
legislation Approaches - infrastructure -
political action - media advocacy -
lobbying - community - policy advocacy
development
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Step 3 Setting specific objectivesa. What are
objectives?(cont)

• Examples of intermediate objectives (promoting
  activity) based on theoretical constructs
• Knowledge
• Increase the percentage of individuals reporting
  they understand the health benefits of physical
  activity from 40 in 1998 to 50 in 2002.
• Attitudes/intentions to change
• Increase the percentage of people reporting they
  intend to become physically active in the next
  six months from 12 in 1998 to 22 in 2002.

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Step 3 Setting specific objectivesb. Consider
strategies that others have used and the local
population and context

• Guide to Community Preventive Services (The
  Community Guide)
• Systematic evidence review performed according to
  rules of evidence
• Consensus panel and/or meta-analysis follows
  standard protocol for reviewing and summarizing
  evidence
• Complicated search strategy of published
  literature to avoid selection bias
• System for rating strength of evidence and
  strength of recommendation

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Search Outcomes
Medline Search with Limits Age 65 and over,
Years 1980-2000, Language English, in
multiple databases N12,312
Medline Search Exercise (1980-2000) N73,752
Following application of inclusion criteria the
final data set 2,334 studies
Currently 100 of this sample has been reviewed.
673 papers were annotated and scanned.
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Community Guide Criteria

• Execution of study/implementation
• Study design
• Number of studies evaluating the type of
  intervention
• Consistency of findings across studies
• Size of the change observed
• Sampling
• Measurement exposure and outcome

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Community GuideRankings

• Strongly recommend
• Recommend
• Recommend based upon expert opinion
• Insufficient Evidence
• Discouraged

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There are two types of Insufficient Evidence

• Too few studies to reach a conclusion
• Sufficient number of studies, but results are
  inconsistent
• Insufficient Evidence does NOT Mean Recommending
  Against

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Evidence-based Community-Level Interventions to
Promote PA (1)

• Informational
• Community Wide Campaigns
• Point of Decision Prompts (to increase stair
  usage)

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Evidence-based Community-Level Interventions to
Promote PA (2)

• Behavioral and Social
• School-based PE
• Non-family social support
• Individually adapted behavior change

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Environmental and Policy Interventions of the
Community Guide

• Environmental and Policy Interventions (Issued in
  2001 on website)
• Access to places for physical activity with
  outreach/promotion is recommended
• (Issued in 2004 (publication pending not on
  website)
• Urban design
• Transportation

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Creation and/or enhanced access to places for
physical activity with outreach/promotion

• Built environment - trails and/or facilities
  access
• Reducing barriers - safety, affordability
• Training incentives
• Site-specific programs

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Interventions with Insufficient Evidence (2001)

• Health education
• TV/video game turn off
• College health education
• Family-based social support
• Mass media

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How are the PA Recommendations of the Community
Guide Useful to Communities?

• Guidelines
• Provides information for designing and
  prioritizing community initiatives to promote
  physical activity
• Not the only basis for informed decision-making.
  E.g., reasonable to do a transportation
  intervention that has funding community
  support, with good evaluation
• Information on cost /cost-effectiveness useful

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How are the PA Recommendations of the Community
Guide Useful to Communities?

• Guidelines
• Not formulated in terms of community needs,
  cultural appropriateness, and politics
• Most useful when used in conjunction with
  community needs assessment and planning
• Relatively little information on effectiveness of
  specific policies (reflects lack of research)
• Much to know and learn about translating research
  interventions into practice

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Step 3 Setting specific objectivesb. Consider
the local population and context

• Feasibility/Practicality
• Adapt to local environment, policies, cultures,
  norms

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Feasibility and Practicality Criteria

• Number and types of partners needed
• Capacity to work with partners
• Leadership
• Availability of intervention materials and
  implementation protocol
• Certification and training required
• Resources required (staff, money, equipment)

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Feasibility and Practicality Criteria (cont)

• Technology required
• Support from the community affected by the
  intervention
• Support from key decision makers
• Organizational support

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Physical Activity work conducted in racial/ethnic
minority populations

• 233 articles reviewed (not unique may have more
  than one article per intervention one
  intervention may have included multiple groups
  total 79 just over 30)
• 43 African American
• 4 American Indian
• 8 Asian/Pacific Island
• 24 Hispanic

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Other criteria?

• You will help to identify others important for
  implementing physical activity interventions in
  racial/ethnic minority communities

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Brainstorming session
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Learning Objectives

• Identify key characteristics of successful action
  planning.
• Understand the purpose and use of logic models.

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Logic model Definition

• Diagram depicting interrelationships between
• goal -longer term public health outcomes
• objectives -shorter term intervention impacts
• action strategies
• Also called
• Analytic framework
• Causal frameworks

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Purpose of logic model

• Aids in program planning
• Guides steps of data collection
• Defines evaluation process
• Map to linkages on which to base conclusion about
  intervention effectiveness
• Linkages represent causal pathways
• Identifies primary and intermediate effects

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Learning Objectives

• Identify key characteristics of successful action
  planning.
• Understand the purpose and use of logic models.
• Describe steps used in constructing logic model.

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See Project Define Logic Model
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Aspects of Effective Coalitions

• Build a sense of community
• Enhance resident engagement mechanisms for true
  involvement
• Strong leadership decision making, conflict
  management
• Provide vehicle for community empowerment
• Diversity valued and celebrated
• Incubator for innovative solutions to large
  problems - flexible and responsive

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Aspects of Failed Coalitions

• Individuals/organizations have different
  expectations of coalition
• No clear direction or goals
• Ineffective or unchanging leadership
• No involvement of those effected by the
  programs/policies
• Focus on unrealistic, distant outcomes
• Lack measures that are valid indicators of change
• Alternative explanations for effects not taken
  into account

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Example

• In order to decrease diabetes (goal)
• We need to increase knowledge about the benefits
  of being physically active and access to places
  to be physically active (objective)
• To increase knowledge we will (action strategy)
• To increase access we will (action strategy)

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Step 4 Developing Action Strategies

• Be sure to show the link between goals,
  objectives strategies (check using logic model)
• Developing the evaluation plan (covered later)
• Consider specific costs associated with each of
  the action steps planned

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Step 4 Developing Action Strategies

• Developing the work plan and timetables
• Basic time line construction includes
• A complete listing of activities, grouped by
  major categories
• Deciding which activities need to be done first
• Determining how long each activity will take
• Determining when each and every activity is to
  begin and finish
• Establishing the time units that are most
  appropriate (e.g., weeks, months, years)

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Step 4 Developing Action Strategies

• Assessing resource needs
• Available funds direct funds,limitations on how
  and when funds can be spent
• Personnel how many and what types of personnel
  are needed? What type of training will be needed
  for program staff? What personnel do
  collaborating organizations bring to the project?
• Equipment and materials what types of equipment
  and supplies are needed for the program? Are
  there certain pieces of equipment that can be
  obtained in-kind from participating partners?

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Step 4 Developing Action Strategies

• Assessing resource needs (cont)
• Facilities
• Travel local, conferences

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Step 4 Developing Action Strategies

• Identifying and training workers
• In which areas does each staff member need
  training?
• Who should conduct the training?
• Do some people have unused skills that could be
  useful to your program?
• How best should community members be oriented and
  trained regarding your program?
• How can training be time efficient?

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Step 4 Developing Action Strategies

• Reasons for piloting
• Refine the original hypotheses and/or research
  questions
• Produce information that will help improve
  evaluation approaches
• Improve curriculum materials or evaluation
  instruments

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Step 4 Developing Action Strategies

• Reasons for piloting (cont)
• Uncover politically sensitive issues
• Estimate costs for people, equipment, materials,
  and time
• Determine the cultural appropriateness of
  interventions in diverse populations by inclusion
  on program development

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Resources

• Turn to ready-made resources
• Community tool box
• http//ctb.ku.edu/
• Community Health Promotion Kit
• http//www.health.state.mn.us/divs/fh/chp/hpkit/
• Guidelines for Comprehensive Programs to Promote
  Healthy Eating and Physical Activity
• http//www.astphnd.org/programs/guidelines.htm

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Request for Proposal - RFA
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Writing a RFA

• Project Title
• Project Description what is the problem, why
  does it exist ( type 1 evidence)
• Content requirements for the proposal
• Format requirements for the proposal
• Length of proposal, font size, formatting
• Funds available
• Due date

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Responding to an RFA

• Background what is the problem (type 1
  evidence)
• The nature of the problem in your community
  (community assessment)
• Given the problem, and the way it exists in your
  community, what is the best general approach
  (persuasive argument based on type 2 evidence)
• Project Activities- specific plans, activities,
  and methods that will be used to intervene
  (program planning)
• Evaluation plan
• Budget and timeline