1. 1 Designing Effective Healthy Lifestyle Programs Consumer Health Foundation Healthy Lifestyles Collaborative Session I

2. 2 Four Steps for Program Design 1. Specify your target outcomes 2. Specify your theory of change 3. Develop your program design 4. Capture your program design in a logic model

3. 3 1. Plan with outcomes in mind

4. 4 What do we mean by outcomes? Outcomes are changes in the people, organizations, or systems that we aim to serve

5. 5 What do we mean by outcomes? Changes in people –Knowledge –Attitudes & beliefs –Skills –Behavior –Health status

6. 6 What do we mean by outcomes? Changes in organizations –Vision –Mission –Strategies –Capacity –Capabilities –External Relationships –Internal Culture

7. 7 What do we mean by outcomes? Changes in systems –System capacity –System cost –System organization –System coordination –System quality –System accessibility

8. 8 What does it mean to “plan with outcomes in mind?” Begin by specifying what outcomes we want to achieve for people, organizations, or systems Make sure we are operating under sound theory of change Work backward to design a program that could achieve these outcomes Capture the essentials in a logic model

9. 9 2. Specify your theory of change

10. 10 What is “theory of change?” Theory of change, sometimes called program theory, is the set of theoretical assumptions about why your program will benefit particular service population. In other words: –What makes you so sure this will work?

11. 11 Why is theory of change important? Every behavioral change program in the world has a theory of change –Some are more explicit than others –Some are more sound than others –Flawed theory of change is one of four basic reasons why programs fail: Flawed theory of change Flawed program design Flawed program implementation Flawed program evaluation –If your theory of change is seriously flawed your program is bound to fail

12. 12 Examples of theory of change Discuss whether the following statements are sound or unsound –If you immunize a child against MMR, then that child will avoid MMR –If you educate adolescents about the risks of tobacco, they will avoid smoking –If you provide a family with Medicaid, they will take their children in for EPSDT visits –If you teach a family how to make better food choices, their children will better control their weight

13. 13 An integrated theory of change for healthy lifestyles programs A theory of change to help you answer seven questions: –Who is your service population? –What outcomes do you want to help them achieve? –Which stage of behavioral change are they in? –What are the pros and cons of change for the service population? –What change processes will help them move toward change? –What influences can help them change? –What interventions will your program provide?

14. 14 Service Population / Desired Changes or Outcomes Maintenance Working to prevent relapse Action Making specific changes Preparation Intending to take action in next month Contemplation Intending to take action in next six month Pre- contemplation No intention to take action An integrated view Five Stages of Individual Behavior Change Pros of Change Cons of Change Decisional Balance Behavioral Reengineering * Support * Counter conditioning * Rewarding * Committing Experiential Increasing awareness * Emotional arousal* Social reappraisal * Environmental opportunities * Self reappraisal Change Processes Messaging * Education * Counseling * Physical Activity * Skill Training * Organizational Change * Community Change * Policy Change Change Interventions Interpersonal * Organizational * Community * Public Policy Environmental Influences

15. 15 Who is your service population? By: –Age –Race –Ethnicity –Sex –Geography –Health status –Economic status –Environmental status

16. 16 What specific outcomes do you want to help them achieve? Changes in: –Eating –Exercise –Substance use –Other The knowledge, attitudes, skills required to achieve the above

17. 17 What stage of change are they in? Pre-contemplation –No intention to quit smoking Contemplation –Contemplating quitting within six months Preparation –Preparing to quit within one month Action –Taking action to quit Maintenance –Maintaining non-smoking and preventing relapse

18. 18 What is their “decisional balance”? What are the pros of change for this population? What are the cons of change for this population? How do we affirm the pros and overcome the cons so that people move toward action and maintenance and stay there?

19. 19 What change processes could help? Experiential Processes (Knowledge, Attitudes) –Increased awareness Smoking can hurt me –Emotional arousal Smoking scares me –Social reappraisal My smoking could hurt my family if I get sick –Environmental opportunities I see most public places disallow or limit smoking –Self re-appraisal I am disappointed in myself for smoking Most helpful in pre- contemplation, contemplation, preparation

20. 20 What change processes could help? Behavioral Processes (Skills, Behaviors) –Stimulus control I avoid situations that trigger a craving to smoke –Helping relationship I talk with someone who listens when I need to talk about my smoking –Counter conditioning I do something else with my hands as a substitute for smoking –Rewarding I treat myself when I go without smoking –Commitment I make an explicit commitment not to smoke Most helpful in preparation, action, maintenance

21. 21 What environmental influences could help? Social-ecological model of change Personal behavior can be affected by: –Interpersonal influences Family, friends, social networks –Organizational influences School, work, faith community, health care organization, supermarkets, restaurants, public agencies –Community influences Relationships between organizations, cultural environment, built community –Public policy influences Local, state, federal

22. 22 What interventions? Given your answers to the first six questions: –Will you work directly with the service population, with influencers, or both? –What interventions will your program provide to: Move the service population to action and maintenance Keep the service population in action and maintenance

23. 23 What interventions? Some common interventions: –Messaging –Education –Counseling –Physical activity –Skill training –Organizational change –Community change –Policy change

24. 24 3. Develop your program design

25. 25 Elements of Program Design Service Population Theory of Change Outcomes Outputs Activities Inputs

26. 26 4. Construct a logic model

27. 27 What is a logic model? In its simplest conception, it is simply a graphic or tabular description of your program. Looking deeper, the best logic models illustrate the underlying theory of the program, or "theory of change."

28. 28 Acme Child Health Enrollment Program Theory of Change InputsActivitiesOutputsOutcomes Theoretical assumptions about why a program will work The resources needed to deliver the program Key actions of program staff and clients Products of the program Changes in the target population Uninsured children who are eligible but not enrolled will become enrolled if their parents/ caregivers: Know they are eligible Value coverage Know how to enroll Have assistance with enrollment process Complete enrollment process 10 CBOs 20 outreach workers 2 training experts Client families with children $5,000 mini-grant to each organization Train CBO staff CBO staff: Interview parents/ caregivers about child health insurance status Educate about Medicaid-S-CHIP Offer assistance with application Guide through application process Monitor enrollment Parents/ caregivers of 500 children interviewed 100 educated and offered assistance 70 accept application & assistance 50 are enrolled Families have peace of mind Children have access to needed health services Children have better health status Target Population: Uninsured children eligible for Medicaid or S-CHIP in Anytown, USA

29. 29 Acme Child Health Enrollment Program Theory of Change Uninsured children who are eligible but not enrolled will become enrolled if their parents/ caregivers: Know they are eligible Value coverage Know how to enroll Have assistance with enrollment process Complete enrollment process 10 CBOs with total of 20 outreach workers 2 training experts Inputs $5,000 mini- grant to each organization Client families with children Target Population Uninsured children eligible for Medicaid or S-CHIP Interview parents/ caregivers Educate eligible parents/ caregivers Activities Train outreach workers Provide application assistance 500 interviewed 100 educated Outputs 50 enrolled 70 accept assistance Families have peace of mind Children have access to needed services Outcomes Children have better health status 20 trained Monitor enrollment

30. 30 Why are funders so interested? Logic models promote program improvement –The process of constructing a logic model forces the funded organization to develop more theoretically sound programs Logic models are efficient –When properly constructed, a logic model can convey the basic blueprint of a program in one or two pages. Logic models promote understanding and communication –Once funding organizations adopt the terminology of logic models -- terms like assumptions, inputs, activities, outputs, outcomes -- it gives them a common for understanding and discussing the relative strengths and weaknesses of diverse programs.

31. 31 Why are funders so interested? Logic models provide the basis for practical program evaluation –A properly constructed logic model helps the funder identify the most important focal points for process evaluation and outcome evaluation. Logic models promote organizational learning –As funders review and compare logic models, they learn valuable information about the theory and practice of health and human service programming. –This helps the funder make better decisions and become a more valuable partner in their ongoing relationship with community health and human service programs.

32. 32 Why are grantees so interested? Because funders are interested! –Programs with a well constructed logic model may give themselves a competitive advantage in fundraising. Because logic models improve program planning –The process of constructing a logic model forces programs to ask themselves a number of questions about their target population, assumptions, desired outcomes, etc. To the extent that these questions are raised and answered during the planning phase, the chances of successful implementation are increased.

33. 33 Why are grantees so interested? Because logic models support program implementation. –Many organizations that develop logic models for funders also find that periodic review of the logic model in staff or board meetings can help the organization stay focused on its mission assure that its resources are being directed toward the most important outcomes. Because logic models support practical program evaluation –By using the logic model as the basis for evaluation objectives, both the funder and the funded organization can assure themselves that the evaluation is focused on the most essential aspects of the program.

34. 34 If you can answer these questions.. –Who is your service population? –What outcomes, or personal changes do you want to help this population achieve? –What level of output do you hope to achieve, in terms of people served, products produced, etc. –What activities will be required to produce these outputs? –And what inputs, or resources, will be required to complete the necessary activities? –What is the theory of change or theory of change that leads you to believe that people exposed to this program will achieve the desired outcomes?

35. 35..you can construct a logic model! A logic model is simply a way of illustrating what you should already know about your program or plan The most important purpose of the logic model is program improvement. –If, in the course of constructing a logic model, you identify gaps in your knowledge or planning, you simply problem-solve until you can fill those gaps as best you can

36. 36 Constructing your own logic models