1
MULTIPLE INTERVENTION PROGRAM RECOMMENDATIONS FOR MHPSG TECHNICAL REVIEW COMMITTEES
MULTIPLE INTERVENTION PROGRAM RECOMMENDATIONS FOR MHPSG TECHNICAL REVIEW COMMITTEES
March 28, 2006
Submitted by:
The Community Health Research Unit
Authors:
Nancy Edwards, Lynne MacLean, Alma Estable, Mechthild Meyer
Acknowledgements
We would like to thank the following people for their contributions in the development of these Guidelines:
To our Ministry partners: Mark Ragan, Research Unit, Knowledge Management and Reporting Branch, Ministry of Health and Long-Term Care for his support and guidance in developing this project, and to the Government of Ontario for funding it; Michele Weidinger and Paulina Salamo, of Public Health Systems Transformation, Public Health Division, Ministry of Health and Long-Term Care for their input in making the guidelines as policy-relevant as possible.
Dr. Barbara Riley, University of Waterloo, for aiding in overall project development and input on the final draft revisions.
Members of the Multiple Intervention Community of Practice group (MICOP): Dr. Karen Benzies, Faculty of Nursing, University of Calgary; Dr. Ariella Lang, School of Nursing, University of Ottawa; Dr. Phyllis Montgomery, School of Nursing, Laurentian University; Dr. Michael Patterson, School of Nursing, University of Ottawa; Dr. Wendy Peterson, School of Nursing, University of Ottawa; and Dr. Sonia Semenic, School of Nursing, University of Ottawa for their discussion of ideas and input on earlier versions and for their participation in the role play application.
Monique Stewart, Director, PHRED, Ottawa Public Health and Lynda Zimmerman, PHRED, Ottawa Public Health, for their participation in the role play application. Their input from the perspective of public health practice and evaluation was invaluable.
Joanne Beyers, PHRED Program, Sudbury & District Health Unit, Charlene Beynon, Director, Research Education and Development Services, Middlesex-London Health Unit, and Ruth Sanderson, Health Unit Epidemiologist, Middlesex-London Health Unit for their review of the penultimate draft from the perspective of former Technical Reviews.
Sabrina Farmer, CHRU, University of Ottawa, for her invaluable assistance in the literature review and manuscript production.
GLOSSARY
Dose: The “amount” of an intervention given, measured in terms of “reach” and “intensity”. Key questions to ask around dose include: what dose is required to have an impact? Is there a threshold amount of reach and intensity required, below which the intervention has no impact? Do different groups require different dosages of an intervention?
Intensity: The “strength” of an intervention, in terms of its concentration of resources. For example, a breastfeeding media campaign hitting a variety of channels over a one-month period would have a greater intensity than less frequent ads spread out over a year using only a poster campaign.
Intervention: A single public health activity meant to positively affect the health of target groups.
Mandatory Health Programs and Services Guidelines (MHPSG, 1997): The standards document which specifies those programs and services which all boards of health are required to provide, or ensure the provision of, a minimum level of public health programs and services. The 1997 MHPSG outlined three crosscutting general standards including Equal Access, Health Hazard Investigation and Program Planning and Evaluation. They also outlined 14 program standards each of which included goals, objectives, and requirements and standards aimed at specific public health issues.
Multiple Intervention Program (MIPs): Programs with coordinated, interconnected intervention strategies, targeted at multiple levels of a system. Multiple intervention programs (MIPs) can be characterized as targeting at least two different levels of a system, (e.g. individual behaviour change; organizational change; municipal by-law change) even if each level has only one intervention. For the purpose of this paper, programs with more than one intervention but only in one system level are not MIPs.
Program: A funded, organized intervention or set of interventions with planned goals, objectives, activities, outcomes, and evaluation.
Reach: The number of people, subgroups, etc. reached by an intervention. “The absolute number, proportion, and representativeness of individuals who are willing to participate in a given initiative, intervention, or program”(<re-aim.org>). How much of the target group and over how many settings is the intervention intended to impact? How many actually show a useful level of impact?
Socio-Ecological Models: Models attesting that health is determined by complex interactions between behavioural, biological, cultural, social, environmental, economic, and political factors. Determinants do not work independently but interact, and may mitigate or compound the effects of other determinants. Effective population health approaches reflect a socio-ecological framework (Edwards, Mill, & Kothari, 2004).
Sustainability: The degree to which a program or intervention can be maintained after withdrawal of temporary funding, infrastructure, or other resources used to establish it.
Synergy: The interaction of two or more interventions such that their combined effect is greater than the sum of their individual effects.
Systems Theory: A theory designed to understand whole systems, including socio-ecological systems. In a system, levels are linked in interdependent and interacting ways. Systems are dynamic and evolving - the result of changes in any one level of the system do not result in changes there alone but affect other levels of the systems, through balancing and reinforcing feedback loops (Horner & Hirsch, 2006). This results in a change in the system affecting the next iteration of intervention. Sometimes the feedback loop is built in through system structures, other times it is self-regulating (Chin, 1985). Further, systems thinking has been suggested as one possible alternative to further understanding the order of cause and effect, feedback loops, and synergistic relationships that do indeed occur in public health programming (Green, 2006), and which must be better understood in order to optimize that programming.
Technical Review Committee (TRC): A committee charged with the review and suggestion of modification to the Mandatory Health Programs and Services Guidelines of the Ontario Ministry of Health and Long-Term Care. They were established during the last review of the Mandatory Health Programs and Services Guidelines. TRCs were composed of members from stakeholder groups such as public health professionals[RS1], researchers, and Ministry decision-makers. They typically were supported in their deliberations by access to relevant literature and key documentation to supplement their experience and judgement.
TABLE OF CONTENTS
Acknowledgements
GLOSSARY
INTRODUCTION
Definition of Multiple Intervention Programs (MIPs)
Background
MIPs and Public Health Programs
Development of Recommendations for MHPSGs
Features that may account for lack of effectiveness of some MIP programs
Caveats from the Literature
Characteristics of Stronger MIP Programs
Recommendations
Ensure MIPs are Theory-based and Evidence-based
Extracting Information from the Literature: Theory and Evidence Base for MIP Programs
Capitalizing on Synergy
Vertical and Horizontal Integrity
Strengthen Horizontal Integrity
Strengthen Vertical Integrity
MIP Duration and Sustainability
Resources: Dosage, Intensity, Reach, Costs
Program Monitoring and Evaluation
Balancing Requirements with Local Contexts
Examples and Performance Indicators Reflecting MIPs
Table 1. Example 2. Measurement Indicators for Falls and the Elderly
Implications for the Review Process: An Example of Use
Table 2. Summary Framework of MIP Recommendations to support Technical Review Process
REFERENCES
APPENDIX A
APPENDIX B
APPENDIX C
APPENDIX D
INTRODUCTION
This document provides recommendations on how best to address design concerns related to the incorporation of Multiple Intervention Program (MIP) approaches into the review of the Mandatory Health Programs and Services Guidelines. Missing from the current Guidelines are suggestions around the best ways to coordinate programming at more than one system level, in order to capitalize on the impacts and synergies from programming at one system level working in concert with another. Ideally, this should result in more effective programming and more efficient use of limited human and financial resources by boards of health that oversee the development and implementation of Multiple Intervention Programs?
We discuss the importance of MIPs to public health programming, the development of the recommendations, caveats regarding MIPs from the literature, features of stronger MIPs, and recommendations based on principles for designing them. We also suggest how best to access the existing literature to support this design.Further, we apply the principles of MIP design to examples in the areas of injury prevention and falls and the elderly. Finally, we apply MIPs to the previously used Technical Review process in order to illustrate ways that the principles and recommendations may support such a process.
Definition of Multiple Intervention Programs (MIPs):Programs with coordinated, interconnected intervention strategies, targeted at multiple levels of a system. Multiple intervention programs (MIPs) can be characterized as targeting at least two different levels of a system, (e.g. individual behaviour change; organizational change; municipal by-law change) even if each level has only one intervention. For the purpose of this paper, programs with more than one intervention but only in one system level are not MIPs (Edwards et al., 2004).
The recommendations presented in this document are for those charged with the reviews of the Mandatory Health Programs and Services Guidelines of the Ontario Ministry of Health and Long-Term Care (MOHLTC). It is hoped that the recommendations will supplement revisions of the Mandatory Programs in a way that supports the identified benefits of providing scientific technical advice into public health policy and practice (AITF, 2005). We have developed the recommendations consistent with the guiding principles of the MHPSG (1997) for setting strategic directions for minimum standards: 1. Need: How big is the problem; 2. Impact: How much can we fix it; 3. Appropriateness: Are we the best people to do it; and, 4. Capacity: Are we able to do it. While not directly addressing the prioritization of needs over programs, we hope our recommendations will help scope out the size of problems. For impact, we consider issues such as evidence of effectiveness and impacts of health interventions, and maximizing impact through strategic combinations. We address appropriateness of jurisdiction, including suggesting working with other jurisdictions at other system levels, and finally, for capacity, we consider the issues of resources, cost, dose, intensity, and local needs and priorities.
The MHPSG for some programs are already structured such that Ontario boards of health are instructed to conduct activities at various system levels, from the individual, to family, to community, to region; and through various channels such as schools or workplaces. The recommendations put forward in this document are intended to go beyond the broad suggestion that multiple strategies at multiple levels of the system or via multiple channels are required. These new recommendations are intended to provide more explicit guidance for design of synergistic multiple intervention programs that have adequate reach, dose and intensity.
Background
The Community Health Research Unit leads a program of research on multiple interventions. Current applications of multiple intervention program design are being undertaken in relation to a diverse set of public health issues including injury prevention (Edwards, Sveistrup, Lockett, Patterson, Aminzadeh), heart health (Riley, Blanchard, Edwards, Fortier, Lockett), HIV/AIDS (Leonard, Mill, MacLean), chronic disease prevention (Blanchard, Riley, Murphy), tobacco (Edwards, Zimmerman, MacLean), physical activity (Fortier), child health (Peterson, Benzies), bereavement (Lang), healthy aging (McDowell, Edwards, Murphy, O’Hagan, Aminzadeh). Members of the Unit have been involved with issues surrounding the MHPSGs and multiple intervention programming. Previous involvements have included work with the Ontario Public Health Association’s development of indicators for measurement of the Equal Access General Standards (Engdasaw, Estable, MacLean, Meyer, Tomcik, & Gupta, 2001), work on developing benchmarking systems and indicators for public health programs (Dunkley & Stewart), and work on costing elements of the MHPSG for the public health system (Dunkley, Edwards, Moloughney & Spasoff, 2002; Edwards, 2005). These projects highlighted the complexity of the MHPSG when multiple systems are involved. In particular, the costing project demonstrated the level of detail required regarding scope and combinations of interventions, players, and settings; as well as the importance of clarifying the reach and intensity of interventions. (See Appendix D for executive summary of the costing project).
MIPs and Public Health Programs
MIPs are of substantial programming interest in public health (Merzel & D’Aflitti, 2003; Edwards, Mill & Kothari, 2004). Research and policy documents tackling complex issues such as physical activity and obesity prevention (Raine, 2005), tobacco control (Cushman & Medline, 2001), chronic disease prevention (Riley, Edwards, & d’Avernas, 2004), consistently identify multiple intervention programs as foundational approaches. MIPs have proven to be effective approaches of choice in areas as diverse as tobacco programming (Cushman & Medline, 2001) child obesity, nutrition and physical activity (e.g., Kafatos, Manios, & Moschandreas, 2005; Veugelers & Fitzgerald, 2005; Perry et al., 2004; Story et al., 2000; Manios, Moschandreas, Hatzis, & Kafatos, 1999); and heart health (Dobbins et al., 2001).
The Multiple Intervention Framework shown in Appendix A, designed for developing MIPs by Edwards, Mill, and Kothari (2004), fits well with the review process of the MHPSG, or at least how the process has proceeded in the past. The TRCs examine the socioecological determinants of the problem (“Describe and assess socio-ecological features of the problem”). From this analysis, evidence-based intervention options are identified. “Optimizing potential impact” involves consideration of which other system levels and sectors need to be involved, as well as feasibility issues such as dose, intensity, reach, and cost. Finally, consideration of program evaluation standards and requirements are reflected in the “Implement program and monitor process, impact and spin-offs” element of the Framework. The feedback of changes as a result of intervention, gleaned through evaluation activities, leads to ongoing assessment of changes in the socio-ecological features of the public health environment.
Examples of system levels that have been described as being important to MIPs in public health include interpersonal, community and organizational levels (individual, social network, organizational, and interorganizational, Riley, Garcia, & Edwards, 2006); and policy at all levels of government and across sectors (Edwards, 2005).
In addition to being multi-strategy and multi-level, critical features of MIPs include adequate duration, based on a set of integrated theories, tailored to subgroups, multi-pronged and multi-sectoral, and supported by implementing organizations (Edwards et al., 2004). For example, school-based programs can incorporate curricula change (organizational level), cafeteria and vending machine supplier changes (inter-organizational level), teacher training (organizational level), parental (social network level) and community involvement (inter-organizational level) as well as individual child-focused efforts (individual and interpersonal levels). Providing contexts supportive of change and maintaining program coherence at all system levels strengthens program design.
MIPs also try and make use of synergies among different interventions conducted in a coordinated fashion. A synergy is the interaction of two or more agents or forces so that their combined effect is greater than the sum of their individual effects. An example of synergy occurred in the 5-A-Day Power Plus program (Perry et al, 2005; Story et al., 2000) in which they found that the synergism of classroom curricula providing nutrition information and activities, cafeteria change to provide healthy choices in line with what the curricula was emphasizing, and parental involvement in supporting these changes in the home were most efficacious in improving fruit and vegetable consumption in children than any of these single interventions alone. In terms of tobacco programming, stronger and more comprehensive legislation of Environmental Tobacco Smoke in North American jurisdictions, following the lead of the Ontario government’s Tobacco Control Act (MOHLTC, 2006), combined with the success of municipal level smoking control by-laws have led to the more aggressive province-wide banning of smoking in public places through the Smoke-Free Ontario Act (MOHLTC, 2006). From 1998 to 2004, public support for complete bans in restaurants and bars grew from 24% to 57% and from 10% to 34% respectively (Ontario Tobacco Research Unit, 2006). It is unlikely that this provincial level change would have happened without changes occurring at the other system levels. And change at legislative levels in terms of tobacco protection has been cited as being helpful to the success of approaches at other levels in tobacco cessation and prevention (Cushman & Medline, 2001).
As the role of public health continues to evolve in ways requiring a focus on determinants, looking across whole populations, and applying principles of social change (Canadian Institutes of Health Research, 2003), the Multiple Intervention Program approaches will become more important as we search for ways to impact at all levels. More and more, governments and non-government organizations at provincial, federal and international levels are suggesting a coordinated, comprehensive approach to public health programming (e.g., Chronic Disease Prevention Strategy- Next Steps, Nova Scotia Office of Health Promotion, 2004; The Population Health Template Working Tool, Health Canada, Strategic Policy Directorate, Population and Public Health Branch, 2001; Integrated Chronic Disease Prevention: A Brief Synthesis of Canadian Initiatives, Chronic Disease Prevention Alliance of Canada, 2004; Reproductive Health Strategy, World Health Organization, 2004). Yet, there is little guidance on how best to do this.
Development of Recommendations for MHPSGs
The recommendations here are based on a search of the literature around MIPs in general and for some specific public health issues in particular (tobacco, CDP, obesity, injuries). They were also developed and revised through consultation with stakeholders, including public health unit managers, epidemiologists, former MHPSG technical review committee members, decision makers, and MIP researchers. A more detailed description of our process can be found in Appendix B.