Policy and Programs

• Policy – Framework of basic principles that dictate

decisions and actions (including programs)• Public (governments) – social, economic,

transportation, housing, operational, etc.• Organizational – strategic, operational, etc.

Policy

• Public policy (governments)is based on:– Demographic, social, economic realities– Research evidence– Philosophical factors / ideology / values e.g. • individual behaviour vs collective action • econometric (cost/benefit)

– Politics and power– Implementation: e.g. Window of Opportunity

(compelling problem, solution, public support)

Programs and Policies

• Programs (and Services)– Usually represent the implementation of policies– Program evaluation provides evidence for policy

Evidence-based Programs and Policies

Application of the best available informationderived from clinical, epidemiological, administrative, demographic and other relevant sources and consultations to clearly describe current and desired outcomes for an identified population or organization.

• Empirically-based/ research-derived ‘knowledge’• Reduce political; enhance objectivity as basis for

programs and policies• Is evidence apolitical?

Program Lifecycle

–Pilot – small, trial and error, experimental–Model – more formal, controlled conditions,

standard procedures, rigorous evaluation–Prototype – under realistic conditions– Institutionalized – ongoing part of services

provided

What is a Plan? (HSIP, 2006)

A plan is defined as a map or preparation, or an arrangement. Planning defines • where one wants to go • how to get there • the timetable for the journey• can also identify the journey’s milestones • complete planning sets out indicators for tracking progress and ways to

measure if the trip was worth the investment.

Charting a course, navigating and keeping a travel log are all parts of a good planning process. Broad elements of planning are therefore:

– identifying a vision and goals– undertaking strategic planning– and evaluation.

Planning

• Planning is a series of decisions: – from general and strategic decisions …..– to specific operational details; – based on the gathering and analysis of a wide

range of information. THCU, University of Toronto, 2001

Planning Hierarchy

• Strategic Planning– Organization’s map for obtaining its broad goals

(within its vision and mission). Defines its domain, stakeholders, priorities, strategies.

• Operational Planning (tactical)– On an annual basis, how organization will work

towards goals in strategic plan• Program Planning (tactical)– Specific goal and objectives, timeline, resources,

systematic process for achieving desired ends.

Assumptions underlying program planning (Issel, 2009)

• A solution / remedy / effective intervention exists or can be developed– Faith in science and capacity of planners &

stakeholders• Planning will ensure necessary resources • Everyone involved shares similar views• Planning, implementation and evaluation

occur in an orderly fashion

Program Planning Models and Steps

• Different models– Largely same steps• Emphasis is on different steps based on philosophy:

behaviour, ecological, economic, political.• Example: educational-ecological model used in health

promotion planning and evaluation – Green & Kreuter Precede-Proceed Model, 2005

Program Planning and Evaluation

• Cyclical• Interdependent• Planning includes planning for evaluation and

evaluating the plan…• Evaluation informs planning for next

stage/iteration of a program.

Why a program?

• Higher level strategic plan needs to be operationalized

• New /targeted funds (political)• Trigger event• Environmental scan / Needs assessment– May identify need for program– (Also may identify specific elements of program)

Program Planning

Environmental scan/ needs or situational assessment:– Wants, needs, assets/strengths (SWOT)– Health and service statistics– Issues that may affect program implementation– What else is going on– What has worked here and elsewhere– Data sources: many

Program Planning Steps

1. Pre-Planninga. Stakeholder engagement• They are needed for the planning process: assure

meaningful program, full participation, support.• Agree on the vision (may need to wait until further

needs assessment done)• Agree on process for making decisions - Governance

b. Project management: resources (HR, $, time); timeline for program planning, implementation, evaluation

Pre-Planning

c. Understanding the issues. Avoid identifying solution(s) before understanding issue.– Assemble relevant evidence– Assemble relevant theories and models • how things work, how people behave• guides construction of program elements• research evidence shows strength of theory

Understanding the issue(s): generic Causal Theory Model

Required antecedent

factors

Main causal factors /

determinants

Moderating factors +/-

Mediating mechanisms

Outcome

Impact

Intervention(s)

Older adults and flu shots – causal theory

Antecedents - age,

existing health

conditions, environment

Determinants – fear of flu, perceived

vulnerability

Moderators- media

attention, physician

Mediators – vaccine

availability, access, cost

Outcome – flu shot

Reduced risk

Theories and Frameworks that inform Planned Program

• See Tip Sheet from THCU • Stages of Change (Transtheroetical model)• Reasoned Action• Social Learning

Theory• Health Belief

Model

Theories and Frameworks: Health Belief Model

Concept Definition Application

Perceived Susceptibility

One's opinion of chances of getting a condition

Define population(s) at risk, risk levels; personalize risk based on a person's features or behavior; heighten perceived susceptibility if too low.

Perceived SeverityOne's opinion of how serious a condition and its consequences are

Specify consequences of the risk and the condition

Perceived BenefitsOne's belief in the efficacy of the advised action to reduce risk or seriousness of impact

Define action to take; how, where, when; clarify the positive effects to be expected.

Perceived BarriersOne's opinion of the tangible and psychological costs of the advised action

Identify and reduce barriers through reassurance, incentives, assistance.

Cues to Action Strategies to activate "readiness"

Provide how-to information, promote awareness, reminders.

Self-Efficacy Confidence in one's ability to take action

Provide training, guidance in performing action.

Glanz, K., Marcus Lewis, F. & Rimer, B.K. (1997). Theory at a Glance: A Guide for Health Promotion Practice. National Institute of Health.

Ethical Framework (Issel, 2009)Approach Principle ApplicationAutonomy Personal right to

self-determinationIndividual choice takes priority, no coercion

Criticality Worst-off benefit most

Greatest problem

Egalitarian Minimize disparities Target most marginalized

Resource Sensitive Resource scarcity Cost-effectiveness as the standard

Utilitarian Greatest good for the greatest number

Collective benefits outweigh individual choices

Program Planning

d. Setting priorities – Brainstorming – Nominal Group Techniques (and DELPHI) - iterative

• Stakeholders solicited for priority issues• Collected, ranked by frequency

– Grid of Importance vs Changeability

Highly Important Low Importance

Highly changeable High priority Low priority unless resources available

Low changeability High priority if innovative program can be created

No program warranted

Program planning – priority-setting cont’d

• PEARL : which solutions ……..– Propriety: are our responsibility?– Economic: can we afford?– Acceptability: will they be OK with (culture,

specific group)?– Resources: do we have enough staff, time, etc?– Legality: does the law permit?

Program Planning

2. More assessment– Wants, needs, assets/strengths (SWOT)– Health and service statistics– Issues that may affect program implementation– What else is going on– What has worked here and elsewhere– Data sources: many

Program Planning3. Set program foundations– Based on assessment, and in alignment with directions of

organization, decide on • Mission : inspire to act

– What are you going to do and how– Brief, focus on outcome, broad – Example: To prevent injury in older British Columbians by

developing effective community-based programs• Goal : global statement of what want to achieve

– Target i.e. specific population of interest– Example: Ensure the safe and effective use of

pharmaceuticals by British Columbians over the age of 75 years.

Objectives

• Objectives – multiple for each goal– Specific (What?) Reduce reportable adverse drug

reactions…– Measurable (How much?) … by 50%– Attainable /realistic (capability- with such a

program) … by 20%– Relevant (make sense)….. in vacationing ….. in

British Columbians over the age of 75 years living in residential care…..

– Time-bound (By when?) ….. by 2018

Program Planning

4. Identify strategies, activities, resources• Use theories, frameworks to guide strategies• Identify resource requirements• Start/stop/continue elements of existing

programs5. Prepare Work Plan• Steps, timeline, who is responsible• Links among steps : Critical path, Gantt Chart

Strategies (Bower, 2009)

• Approach to getting things done• Good strategies:– Consistent with mission, goals, objectives, ethical

framework– Point to the overall path and specific ways of

doing things– Fit resources, opportunities, public opinion, assets– Minimize resistance, gain allies & support

Program Planning

5. Identify stages where evaluation warranted• Planning• Implementation• Specific milestones• Routine monitoring for ongoing programs• End of intervention• Post intervention• Meta-evaluation

Program evaluation

• Not done consistently in programs• Often not well-integrated into the day-to-day

management of most programs• A tool for using science as a basis for :– decision-making and action, – making efforts outcome-oriented, – being accountable

• Programs must routinely conduct practical evaluations that inform their management and improve their effectiveness.

Program Planning

6. Review the plan using Logic Model– Shows the relationships among all parts of a

program – Effective overview for program review• Does everything fit together and make sense?

– Useful communications tool• Explains program to stakeholders, others

Planning

• Where does research enter the picture?– See red

• Example of an evidence-based health promotion planning model

Green, LW & MM Kreuter (2005) Health program planning: An educational and ecological approach.

PRECEDE-PROCEED MODEL -phases

1. Determining the quality of life or social problems and needs of a given population.

2. Identifying the health determinants of these problems and needs. 3. Analyzing the behavioral and environmental determinants of the

health problems. 4. Identify factors that predispose to, reinforce, and enable the

behaviors and lifestyles.5. Which health promotion, health education and/or policy-related

interventions would best be suited to encouraging the desired changes in– behaviors – environments – factors that support those behaviors and environments.

PRECEDE-PROCEED MODEL –phases cont’d

6. Interventions identified in phase five are implemented.

7. Process evaluation of those interventions. 8. Impact evaluation of the interventions– on the factors supporting behavior, and on

behavior itself.

9. Outcome evaluation - determining the ultimate effects of the interventions on the health and quality of life of the population.

Surveillance, Planning and Evaluating for Policy and Action: PRECEDE-PROCEED MODEL*

Quality of life

Phase 1 Socialassessment

Health

Phase 2Epidemiological assessment

Healtheducation

Policyregulation

organization

PublicHealth

Phase 5Administrative &

policy assessment

Output Longer-termhealth outcome

Short-termsocial impact

Short-term impact

ProcessInput Long-termsocial impact

Phase 6Implementation

Phase 7Process evaluation

Phase 8Impact evaluation

Phase 9Outcome evaluation

Predisposing

Reinforcing

Enabling

Phase 4Educational &

ecologicalassessment

Behavior

Environment

Phase 3Behavioral &environmentalassessment

*Green & Kreuter, Health Promotion Planning, 4th ed, 2005.

• PRECEDE and PROCEED function in a continuous cycle.• Information gathered in PRECEDE guides the development of program

goals and objectives in the implementation phase of PROCEED. • This same information also provides the criteria against which the

success of the program is measured in the evaluation phase of PROCEED.

• Data gathered in the implementation and evaluation phases of PROCEED clarify the relationships examined in PRECEDE between the health or quality-of-life outcomes, the behaviors and environments that influence them, and the factors that lead to the desired behavioral and environmental changes.

• These data also suggest how programs may be modified to more closely reach their goals and targets.