Healthy People 2020
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BOX 5.2 Healthy People 2020: Objectives
Educational and Community-Based Programs
Goal: Increase the quality, availability, and effectiveness of educational and community-based programs designed to prevent disease and injury, improve health, and enhance quality of life.
Objective: ECBP-10 Increase the number of community-based organizations including local health departments, tribal health services, nongovernmental organizations, and state agencies) providing population-based primary prevention services in the following areas:
ECBP 10.8 Nutrition
Target: 94.7%
Baseline: 86.1% of community-based organizations (including local health departments, tribal health services, non governmental organizations, and state agencies) provided population-based primary prevention services in nutrition in 2008.
Target-setting method: 105 improvement.
Data source: National Profile of Local Health Departments (NACCHO Profile), National Association of County and City Health Officials (NACCHO)
ECBP 10.9 Physical Activity
Target: 89.5%
Baseline: 80.5% of community-based organizations
(including local health departments, tribal health services. nongovernmental organizations, and state agencies) provided population-based primary prevention services inphysical activity in 2008
Target-setting method: 10% improvement.
Source: Data are from National Profile of Local Health Departments (NACCHO Profile), National Association of County and City Health Officials (NACCHO),
Note: Other areas covered by this objective include: 10.1 Injury, 10.2 Violence. 10.3 Mental Itiness, 10.4 Tobacco Use, 10.5 Substance Abuse. 10.6 Unintended Pregnancy, and 10.7 Chronic Diseases Programs.
For Further Thought
If you had the opportunity to write one more objective to deal with the implementation of health promotion programs for use in Healthy People 2020, what would it be? What is your rationale for selecting such an objective?
Source US Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2016) earthy People 2020 Available at https//www.healthypeople.gov/2020/topics objectives/topic/educational-and-community-batud-programm
a good model for developing goals and objectives for a new program. In fact, these goals and objectives can be adapted for use in most community and public health promotion programs.
Creating an Intervention That Considers the Peculiarities of the Setting
The next step in the program planning process is to design activities that will help the priority population meet the objectives and, in the process, achieve the program goals. These activities are collectively referred to as an intervention, or treatment. This intervention or treatment is the planned actions designed to prevent disease or injury or promote health in the priority population.
The number of activities in an intervention may be many or only a few. Although no minimum number has been established, it has been shown that multiple activities are often more effective than a single activity. For example, if the planners wanted to change the attitudes of community members toward a new landfill, they would have a greater chance of doing so by distributing pamphlets door to door, writing articles for the local newspaper, and speaking to local service groups, than by performing any one of these activities by itself. In other words, the size and amount of intervention are important in health promotion programming. Few people change an attitude or behavior based on a single exposure, instead, multiple exposures are generally needed to create change. It stands to reason that “hitting” the priority population from several angles or through multiple channels should increase the chances of making an impact.
Two terms that relate to the size and amount of an intervention are multiplicity and dose. Multiplicity refers to the number of components or activities that make up the intervention, while dose refers to the number of program units delivered. Thus, if an intervention has two activities-say, an educational workshop and the release of a public service announcement via social networking sites-they define multiplicity, while the number of times each of the activities is presented defines the dose
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The actual creation of the intervention should begin by asking and answering of questions. The first two are: What needs to change? and, Where is change needed? The answers to these questions come from the needs assessment and the resulting goals and cha tives. The third question is: At what level of prevention (Le., primary, secondary, or tertiary wa the program be aimed? The approach taken to a primary prevention need, that is, preveling has existed for a while. The fourth question asks: At what level of anagng a problem before it begins, would be different from a tertiary prevention need of n after it has e problem to be focused? The various levels of influence (.e., intrapersonal, i the intervention the inter The vario end will interpersonal institutional or organizational, community, public policy, physical environment, and cu that were presented earlier in this chapter as part of the socio-ecological approach need to be considered. These levels provide the planners with a framework from which to think cons how they will “attack” the needs of the priority population. For example, if the goal of a pro gram is to reduce the prevalence of smoking in a community, the intervention could attaq the problem by focusing the intervention on individuals through one-on-one counseling va groups by offering smoking cessation classes, by trying to change policy by enacting a state law prohibiting smoking in public places, or by attacking the problem using more than one u these strategies.
The fifth question asks: Has an effective intervention strategy to deal with the focus of the problem already been created? “In other words, what does the evidence show about the effective ness of various interventions to deal with the problem that the program is to address?” Thre sources of guidance for selecting intervention strategies-best practices, best experiences and best processes. Best practices refers to recommendations for an intervention, based critical review of multiple research and evaluation studies that substantiate the efficacy of the intervention in the populations and circumstances in which the studies were done, if not s effectiveness in other populations and situations where it might be implemented. Examples al best practices related to health promotion programs are provided in The Guide to Community Preventive Services: What Works to Promote Health, also know as The Community Guide (see Box 5.3 3 for other sources of evidence).
When best best practice recommendations are not available for use, planners need to look for information on best experiences. Best experience intervention strategies are those of prior or existing programs that have not gone through the critical research and evaluation studies and that fall short of best practice criteria but nonetheless show promise in being effective. Best experiences can often be found by networking with others professionals and by reviewing the literature
If neither best practices nor best experiences are available to planners, then the third source of guidance for selecting an intervention strategy is using best processes. Best processes intervention strategies are original interventions that the planners create based on their knowledge and skills of good planning processes including the involvement of those in the priority pope lation and the theories and models used to change behaviors, such as Social Cognitive Theory or the Transtheoretical Model of Change.”
BOX 5.3 Sources of Evidence
The Campbell Collaboration
http://www.campbelicollaboration.org/ Centre for Reviews and Dissemination; University of York
http://www.york.ac.uk/crd/ The Cochrane Collaboration
Canadian Task Force on Preventive Health Care
Health Evidence. McMaster University, Canada http://healthevidence.org
National Cancer Institute. Research-tested intervention Programs (RTIPs)
http://rtips.cancer.gov/rtips/index/do Substance Abuse and Mental Health Services, National
Registry of Evidence-based Programs and Practices http://nrepp samhsa.gov
U.S. Preventive Task Force
http://www.ahra.gov/professionals/clinicans-providers /guidelines-recommendations/uspstf
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Once that it is known whether best practices, best experiences, or best processes will be used three more questions need to be asked. The sixth question asks: Is the intervention an appropriate fit for the priority population? In other words, does the planned intervention meet the specific characteristics of the priority population such as the educational level, development total stages, or the specific cultural characteristics of the people being served?
The seventh question that needs to be asked i Are the resources available to implement the intervention selected? Planners need to evaluate the amount of money, time, personnel,and/or space that is needed to carry out the various interventions and make a determination if such resources are available to implement the intervention.
The eighth, and final, question that needs to be asked is: Would it be better to use an intervention that consists of a single strategy or one that is made up of multiple strategies? A single strategy would probably be less expensive and time consuming, but multiple strategies would probably have a greater chance for change in the priority population.
Implementing the Intervention
The moment of truth is when the intervention is implemented. Implementation is the actual carrying out or putting into practice the activity or activities that make up the intervention. More formally, implementation has been defined as “the act of converting planning, goals, and objectives into action through administrative structure, management activities, policies. procedures, regulations, and organizational actions of new programs.
To ensure a smooth-flowing implementation of the intervention, it is wise to pilot test it at least once and sometimes more. A pilot test is a trial run. It is when the intervention is presented to just a few individuals who are either from the intended priority population or from a very similar population. For example, if the intervention is being developed for fifth graders in a particular school, it might be pilot tested on fifth graders with similar educational backgrounds and demographic characteristics but from a different school.
The purpose of pilot testing an intervention is to determine whether there are any problems with it. Some of the more common problems that pop up are those dealing with the design or delivery of the intervention: however, any part of it could be flawed. For example, it could be determined during pilot testing that there is a lack of resources to carry out the intervention as planned or that those implementing the intervention need more training. When minor flaws are detected and corrected easily, the intervention is then ready for full implementation. However, if a major problem surfaces-one that requires much time and many resources to correct-it is recommended that the intervention be pilot tested again with the improvements in place before implementation.
An integral part of the piloting process is collecting feedback from those in the pilot group. By surveying the pilot group, planners can identify popular and unpopular aspects of the intervention. how the intervention might be changed or improved, and whether the program activities were effective. This information can be useful in fine-tuning this intervention or in developing future programs.
Once the intervention has been pilot tested and corrected as necessary, it is ready to be disseminated and implemented. If the planned program is being implemented with a large i priority population and there is a lot at stake with the implementation, it is advisable that the intervention be implemented gradually rather than all at once. One way of doing so is by phasing in the intervention. Phasing in refers to a step-by-step implementation in which the intervention is introduced first to smaller groups instead of the entire priority population. Common criteria used for selecting participating groups for phasing in include participant ability, number of participants, program offerings, and program location.²
The following is an example of phasing in by location. Assume that a local health department wants to provide smoking cessation programs for all the smokers in the community (priority population). Instead of initiating one big intervention for all, planners could divide the priority population by residence location. Facilitators would begin implementation by offering the smoking cessation classes on the south side of town during the first month. During the second month, they would continue the classes on the south side and begin implementation on the west side of town. They would continue to implement this intervention until all sections of the town were included.
