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.