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 information derived 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 Operational Planning (tactical) 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 Pre-Planning 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 Project management: resources (HR, $, time); timeline for program planning, implementation, evaluation

Pre-Planning 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

Perceived Susceptibility 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 Severity One's opinion of how serious a condition and its consequences are Specify consequences of the risk and the condition Perceived Benefits One'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 Barriers One'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 Application Autonomy Personal right to self-determination Individual 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 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 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 Planning 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 Identify strategies, activities, resources Use theories, frameworks to guide strategies Identify resource requirements Start/stop/continue elements of existing programs 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 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 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 Determining the quality of life or social problems and needs of a given population. Identifying the health determinants of these problems and needs. Analyzing the behavioral and environmental determinants of the health problems. Identify factors that predispose to, reinforce, and enable the behaviors and lifestyles. 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 Interventions identified in phase five are implemented. Process evaluation of those interventions. Impact evaluation of the interventions on the factors supporting behavior, and on behavior itself. 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* Health education Policy regulation organization Public Phase 5 Administrative & policy assessment Predisposing Reinforcing Enabling Phase 4 Educational & ecological assessment Behavior Environment Phase 3 Behavioral & environmental assessment Health Phase 2 Epidemiological assessment Quality of life Phase 1 Social assessment Phase 6 Implementation Phase 7 Process evaluation Phase 8 Impact evaluation Phase 9 Outcome evaluation Input Process Output Short-term impact Longer-term health outcome Short-term social impact Long-term social impact *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.