Typology of actors' influence strategies in intersectoral governance process in Montreal, Canada.

The objective of this article is to document the strategies developed by actors from different sectors during the processes of intersectoral governance. As a case study, the article focuses on the process of renegotiating the Terms of Reference of the Montreal Initiative for Local Social Development, a regional intersectoral intervention with the mission of guiding and supporting the actions of local intersectoral coalitions referred to as Neighbourhood Round Tables. The renegotiation process was marked by crisis in intersectoral governance. Semi-structured individual interviews were conducted with 16 actors representing the four sectors involved in the intersectoral governance process, about four systematically selected critical incidents. The interviews were transcribed verbatim and coded using QDAMiner software. Interpretive and cross-sectional thematic analysis was conducted to assign meaning to the results. Results show that the actors developed intersectoral (shared or mediated) strategies and intrasectoral (creative unilateral, power-based unilateral or multilateral) strategies to influence collective decisions. The strategies, presented in a proposed typology, were distinguishable by their goals, their organizational origin, the actors involved and their fundamental mechanisms. Intersectoral strategies were developed at the regional level and aimed to promote or defend collective interests. In contrast, intrasectoral strategies sought to protect sectoral interests. The findings illustrate how actors' strategies operate within intersectoral governance processes. They show that collective decisions are shaped by the strategies created both at the boundaries of, and within, sectors. The proposed typology, if validated and applied to other cases, may help better understand how partners interact to influence collective decision-making.

Alliance members' roles in collective field-building: an assessment of leadership and championship within the Population Health Intervention Research Initiative for Canada.

BACKGROUND: The Population Health Intervention Research Initiative for Canada (PHIRIC) is a multi-stakeholder alliance founded in 2006 to advance population health intervention research (PHIR). PHIRIC aimed to strengthen Canada's capacity to conduct and use such research to inform policy and practice to improve the public's health by building PHIR as a field of research. In 2014, an evaluative study of PHIRIC at organisational and system levels was conducted, guided by a field-building and collaborative action perspective. METHODS: The study involved 17 qualitative key informant interviews with 21 current and former PHIRIC Planning Committee and Working Group members. The interviews examined how individuals and organisations were acting as champions and exerting leadership in building the field of PHIR. RESULTS: Founding PHIRIC organisational members have been championing PHIR at organisational and system levels. While the PHIR field has progressed in terms of enhanced funding, legitimacy, profile and capacity, some members and organisations faced constraints and challenges acting as leaders and champions in their respective environments. Expectations about the future of PHIRIC and field-building of PHIR were mixed, where longer-term and founding members of PHIRIC expressed more optimism than recent members. All agreed on the need for incorporating perspectives of decision-makers into PHIR directions and initiatives. CONCLUSIONS: The findings contribute to understanding alliance members' roles in leadership and championship for field-building more generally, and for population health and PHIR specifically. Building this field requires multi-level efforts, collaborative action and distributed leadership to create the necessary conditions for PHIRIC members to both benefit from and contribute to advancing PHIR as a field. Lessons from this 'made in Canada' model may be of interest to other countries regarding the structures needed for PHIR field-building.

The University-Public Health Partnership for Public Health Research Training in Quebec, Canada.

Enhancing effective preventive interventions to address contemporary public health problems requires improved capacity for applied public health research. A particular need has been recognized for capacity development in population health intervention research to address the complex multidisciplinary challenges of developing, implementing, and evaluating public health practices, intervention programs, and policies. Research training programs need to adapt to these new realities. We have presented an example of a 2003 to 2015 training program in transdisciplinary research on public health interventions that embedded doctoral and postdoctoral trainees in public health organizations in Quebec, Canada. This university-public health partnership for research training is an example of how to link science and practice to meet emerging needs in public health.

Public health strategies promoting physical activity and healthy eating in Canada: are we changing paradigms?

OBJECTIVES: To compare the extent to which Canadian public health organizations incorporated the Ottawa Charter for Health Promotion action areas in promoting physical activity and healthy eating in 2004 and 2010. METHODS: Data were available from repeat censuses of all regional, provincial, and national organizations with mandates to promote physical activity [n = 134 (2004); n = 118 (2010)] or healthy eating [n = 137 (2004); n = 130 (2010)]. Eleven strategies to promote these behaviors were grouped according to the five action areas. Descriptive analyses were conducted to document the level of involvement in each action area over time. RESULTS: The proportion of organizations promoting physical activity and "heavily involved" in creating supportive environments increased from 51 % (2004) to 70 % (2010). The proportion also increased for reorienting health services (29 % to 39 %). The proportion of organizations promoting healthy eating and "heavily involved" in building healthy public policy increased from 47 to 53 %. Individual skill building remained stable for physical activity but declined for healthy eating. CONCLUSIONS: While developing personal skills remains important in promoting physical activity and healthy eating in Canada, public health organizations increased involvement in structural-level strategies.

Association between organizational capacity and involvement in chronic disease prevention programming among Canadian public health organizations.

In the context of the emerging field of public health services and systems research, this study (i) tested a model of the relationships between public health organizational capacity (OC) for chronic disease prevention, its determinants (organizational supports for evaluation, partnership effectiveness) and one possible outcome of OC (involvement in core chronic disease prevention practices) and (ii) examined differences in the nature of these relationships among organizations operating in more and less facilitating external environments. OC was conceptualized as skills and resources/supports for chronic disease prevention programming. Data were from a census of 210 Canadian public health organizations with mandates for chronic disease prevention. The hypothesized relationships were tested using structural equation modeling. Overall, the results supported the model. Organizational supports for evaluation accounted for 33% of the variance in skills. Skills and resources/supports were directly and strongly related to involvement. Organizations operating within facilitating external contexts for chronic disease prevention had more effective partnerships, more resources/supports, stronger skills and greater involvement in core chronic disease prevention practices. Results also suggested that organizations functioning in less facilitating environments may not benefit as expected from partnerships. Empirical testing of this conceptual model helps develop a better understanding of public health OC.

Building the capacity of health authorities to influence land use and transportation planning: Lessons learned from the Healthy Canada by Design CLASP Project in British Columbia.

OBJECTIVES: The main objective of the Healthy Canada by Design CLASP Initiative in British Columbia (BC) was to develop, implement and evaluate a capacity-building project for health authorities. The desired outcomes of the project were as follows: 1) increased capacity of the participating health authorities to productively engage in land use and transportation planning processes; 2) new and sustained relationships or collaborations among the participating health authorities and among health authorities, local governments and other built environment stakeholders; and 3) indication of health authority influence and/or application of health evidence and tools in land use and transportation plans and policies. PARTICIPANTS: This project was designed to enhance the capacity of three regional health authorities, namely Fraser Health, Island Health and Vancouver Coastal Health, and their staff. These were considered the project's participants. SETTINGS: The BC regions served by the three health authorities cover the urban, suburban and rural spectrum across relatively large and diverse geographic areas. The populations have broad ranges in socio-economic status, demographic profiles and cultural and political backgrounds. INTERVENTION: The Initiative provided the three health authorities with a consultant who had several years of experience working on land use and transportation planning. The consultant conducted situational assessments to understand the baseline knowledge and skill gaps, assets and objectives for built environment work for each of the participating health authorities. On the basis of this information, the consultant developed customized capacity-building work plans for each of the health authorities and assisted them with implementation. Capacity-building activities were as follows: researching health and built environment strategies, policies and evidence; transferring health evidence and promising policies and practices from other jurisdictions to local planning contexts; providing training and support with regard to health and the built environment to health authority staff; bringing together public health staff with local planners for networking; and participating in land use planning processes. OUTCOMES: The project helped to expand the capacity of participating health authorities to influence land use and transportation planning decisions by increasing the content and process expertise of public health staff. The project informed structural changes within health authorities, such as staffing reallocations to advance built environment work after the project. Health authorities also forged new relationships within and across sectors, which facilitated knowledge exchange and access of the public health sector to opportunities to influence built environment decisions. By the end of the project, there was emerging evidence of a health presence in land use policy documents. CONCLUSIONS: The project helped to prioritize, accelerate and formalize the participating health authorities' involvement in land use and transportation planning processes. In the long term, this is expected to lead to health policies and programs that consider the built environment, and to built environment policies and practices that integrate population health goals, thereby reducing the risk of chronic diseases.

Healthy Canada by Design CLASP: Lessons learned from the first phase of an intersectoral, cross-provincial, built environment initiative.

OBJECTIVES: The Healthy Canada by Design (HCBD) CLASP (Coalitions Linking Action and Science for Prevention) Initiative promotes the building of communities that support health by 1) facilitating the integration of health evidence into built environment decision-making; 2) developing new, cross-sector collaboration models and tools; and 3) fostering a national community of practice. PARTICIPANTS: A coalition of public health professionals, researchers, professional planners and non-governmental organization (NGO) staff from across Canada developed, implemented and participated in the Initiative. SETTINGS: In the first phase, HCBD interventions took place for the most part in large urban and suburban settings in Quebec, Ontario and British Columbia. National knowledge transfer and exchange (KTE) activities were delivered both locally and nationally. INTERVENTION: Project participants developed tools or processes for collaboration between the health and the community planning sectors. These were designed to increase the capacity of the health sector to influence decisions about land use and transportation planning. Tool or process development was accompanied by pilot testing, evaluation, and dissemination of findings and lessons learned. On a parallel track, NGOs involved with HCBD led national KTE interventions. OUTCOMES: The first phase of HCBD demonstrated the potential for public health organizations to influence the built environment determinants of cancer and chronic diseases. Public health authorities forged relationships with several organizations with a stake in built environment decisions, including municipal and regional planning departments, provincial governments, federal government agencies, researchers, community groups and NGOs. The Initiative accomplished the following: 1) created new relationships across sectors and across health authorities; 2) improved the knowledge and skills for influencing land use planning processes among public health professionals; 3) increased awareness of health evidence and intent to change practice among built environment decision-makers; and 4) facilitated inclusion of health considerations in local plans, policies and decisions. CONCLUSIONS: The first phase of HCBD engaged built environment stakeholders, including public health professionals, planners, researchers, community groups and NGOs, in ways that would be expected to influence health risk factors and population health outcomes in the long term.

Does level of tobacco control relate to smoking prevalence in Canada: a national survey of public health organizations.

OBJECTIVES: To describe levels of tobacco control "effort" in public health organizations across provinces, and to test the hypothesis that "effort" is associated with the prevalence of daily smoking. METHODS: Data were drawn from a national survey (Oct 2004-Apr 2005) of all public health organizations engaged in chronic disease prevention in Canada in 2004. We investigated the association between "effort" and decline in smoking prevalence (CTUMS, 1999-2009) across provinces in an ecologic study design. "Effort" was assessed using two indicators: percent of public health organizations engaged in tobacco control, and mean level of involvement in engaged organizations. RESULTS: Of 216 organizations, 88% had undertaken tobacco control activities in the three years prior to data collection and were categorized as "engaged". Level of involvement in tobacco control was highest in community-at-large settings; and it was generally higher for population- than for individual-level strategies. Nova Scotia reported higher levels of involvement than other provinces. There was substantial variability in "effort" across provinces. High-"effort" provinces (BC, NS, ON, QC) experienced, on average, improvement in the "change in smoking prevalence" score (1999 to 2009). CONCLUSION: The findings provide evidence that provincial tobacco control "effort" relates to declines in smoking prevalence. Given that smoking remains a critical public health issue, the kinds of data reported herein are needed to inform the debate on how best to invest in tobacco control infrastructure to combat the most important public health threat of our times.

A national survey of organizational transfer practices in chronic disease prevention in Canada.

Underuse of best practices in chronic disease prevention (CDP) represents missed opportunities to promote healthy living and prevent chronic disease. Better understanding of how CDP programs, practices and policies (PPPs) are transferred from 'resource' organizations that develop them to 'user' organizations that implement them is crucial. The objectives of this work were to develop psychometrically sound measures of transfer practices occurring within resource organizations; describe the use of these transfer practices and identify correlates of the transfer process. Cross-sectional data were collected in structured telephone interviews with the person most knowledgeable about PPP transfer in 77 Canadian organizations that develop PPPs. Independent correlates of transfer were identified using multiple linear regression. The transfer practices most commonly used included: identification of barriers to PPP adoption/implementation, tailoring transfer strategies and designing a transfer plan. Skill at planning/implementing transfer, external sources of funding specifically allocated for transfer, type of resource organization, attitude toward process of collaboration and user-centeredness were all positively associated with the transfer process. These factors represent possible targets for interventions to improve transfer of CDP PPPs.

Organizational capacity for chronic disease prevention: a survey of Canadian public health organizations.

BACKGROUND: There are no national data on levels of organizational capacity within the Canadian public health system to reduce the burden of chronic disease. METHODS: Cross-sectional data were collected in a national survey (October 2004 to April 2005) of all 216 national, provincial and regional-level organizations engaged in chronic disease prevention through primary prevention or healthy lifestyle promotion. Levels of organizational capacity (defined as skills and resources to implement chronic disease prevention programmes), potential determinants of organizational capacity and involvement in chronic disease prevention programming were compared in western, central and eastern Canada and across three types of organizations (formal public health organizations, non-governmental organizations and grouped organizations). RESULTS: Forty percent of organizations were located in Central Canada. Approximately 50% were formal public health organizations. Levels of skill and involvement were highest for activities that addressed tobacco control and healthy eating; lowest for stress management, social determinants of health and programme evaluation. The few notable differences in skill levels by provincial grouping favoured Central Canada. Resource adequacy was rated low across the country; but was lowest in eastern Canada and among formal public health organizations. Determinants of organizational capacity (organizational supports and partnerships) were highest in central Canada and among grouped organizations. CONCLUSION: These data provide an evidence base to identify strengths and gaps in organizational capacity and involvement in chronic disease prevention programming in the organizations that comprise the Canadian public health system.

Implementation and outcomes of a comprehensive worksite health promotion program.

BACKGROUND: This paper reports on the implementation and results of a three-year comprehensive worksite health promotion program called Take care of your health!, delivered at a single branch of a large financial organization with 656 employees at the beginning of the implementation period and 905 at the end. The program included six educational modules delivered over a three-year period. A global health profile was part of the first and last modules. The decision to implement the program coincided with an overall program of organizational renewal. METHODS: The data for this evaluation come from four sources: analysis of changes in employee health profiles between the first and last program sessions (n=270); questionnaires completed by participating employees at the end of the program (n=169); organizational data on employee absenteeism and turnover; and qualitative interviews with company managers (n=9). RESULTS: Employee participation rates in the six modules varied between 39% and 76%. The assessment of health profile changes showed a significant increase in the Global Health Score. Participants were significantly more likely to report more frequent physical activity and better nutritional practices. The proportion of smokers among participants was significantly reduced (p = 0.0147). Also reduced significantly between the two measurements were self-assessment of high stress inside and outside the workplace, stress signs, and feelings of depression. Employees were highly satisfied with the program and felt that it had impacts on their knowledge and capacities to manage their health behaviour. During the same period, absenteeism in the organization declined by 28% and turnover by 54%. From the organization's perspective, program implementation was very successful. CONCLUSIONS: This study's results are in line with previous findings of significant benefits to organizations and employees from worksite health promotion. The close relationship between the program outcomes and the overall process of organizational renewal that it accompanied supports previous arguments that worksite health promotion will be most effective when it promotes overall organizational health.

Building the backbone for organisational research in public health systems: development of measures of organisational capacity for chronic disease prevention.

BACKGROUND: : Research to investigate levels of organisational capacity in public health systems to reduce the burden of chronic disease is challenged by the need for an integrative conceptual model and valid quantitative organisational level measures. OBJECTIVE: To develop measures of organisational capacity for chronic disease prevention/healthy lifestyle promotion (CDP/HLP), its determinants, and its outcomes, based on a new integrative conceptual model. METHODS: Items measuring each component of the model were developed or adapted from existing instruments, tested for content validity, and pilot tested. Cross sectional data were collected in a national telephone survey of all 216 national, provincial, and regional organisations that implement CDP/HLP programmes in Canada. Psychometric properties of the measures were tested using principal components analysis (PCA) and by examining inter-rater reliability. RESULTS: PCA based scales showed generally excellent internal consistency (Cronbach's alpha = 0.70 to 0.88). Reliability coefficients for selected measures were variable (weighted kappa(kappa(w)) = 0.11 to 0.77). Indicators of organisational determinants were generally positively correlated with organisational capacity (r(s) = 0.14-0.45, p<0.05). CONCLUSIONS: This study developed psychometrically sound measures of organisational capacity for CDP/HLP, its determinants, and its outcomes based on an integrative conceptual model. Such measures are needed to support evidence based decision making and investment in preventive health care systems.

Impact of a diabetes prevention program on body size, physical activity, and diet among Kanien'keha:ka (Mohawk) children 6 to 11 years old: 8-year results from the Kahnawake Schools Diabetes Prevention Project.

OBJECTIVES: Report the 8-year impact on body size, physical activity, and diet of a community-based diabetes prevention program for elementary-school children in a Kanien'keha:ka (Mohawk) community in Canada. METHODS: Follow-up (1994-1996) of subjects in the intervention and comparison community and repeat cross-sectional measurements in the intervention community alone from 1994 to 2002. Measures included triceps and subscapular skinfold thicknesses, body mass index (BMI), weekly number of 15-minute episodes of physical activity, run/walk test times, television watching, and consumption of sugared foods, fatty foods, and fruits and vegetables. RESULTS: The longitudinal data of 1994-1996 showed some early positive effects of the program on skinfold thickness but not on BMI, physical activity, fitness, or diet. Repeat cross-sectional measures from 1994 to 2002 showed increases in skinfold thickness and BMI. Physical activity, fitness, and television watching showed favorable trends from 1994 to 1999 that were not sustained in 2002. Key high-fat and high-sugar foods consumption decreased, as did consumption of fruits and vegetables. CONCLUSIONS: Although early results showed some successes in reducing risk factors for type 2 diabetes, these benefits were not maintained over 8 years.

Qualitative investigation of young smokers' and ex-smokers' views on smoking cessation methods.

The analysis reported in this paper was conducted to further explore initially negative findings of a study intended to help orient the development, implementation, and evaluation of smoking cessation programs for junior college students. A total of 69 students (39 males and 30 females) participated in nine focus group discussions held at one French-speaking and one English-speaking college in central Montreal. Three groups consisted of ex-smokers, and the remainder were current smokers. Group participants were asked to react to a series of proposed smoking cessation interventions identified from the literature. Qualitative analysis was undertaken of verbatim transcriptions of five of the focus group discussions, with input from the four others. Second-level analysis of the focus group data suggested that the students' reactions to proposed smoking cessation interventions could be understood using Eriksonian developmental theory, in particular how the cessation programs could contribute to the process of consolidating personal and social identity. Implications for the design of cessation programs were then identified. The results of these exploratory analyses suggested that to attract and maintain participation of college students, smoking cessation interventions should not necessarily be centered on smoking but rather (a) provide opportunities and support for exploration of, and commitment to, personal and social identities that exclude smoking, (b) target naturally occurring social groups while responding to students' needs for social support and validation, and (c) help students cope with stress and life demands and not add to these.

Making youth tobacco control programs more ecological: organizational and professional profiles.

PURPOSE: To identify the organizational and professional correlates of the integration of the ecological approach in Canadian public health organizations' tobacco control programs for youth. DESIGN: Cross-sectional survey. SETTING: Canadian public health organizations. SUBJECTS: One hundred and ten tobacco control programs implemented in 90 organizations. The response rate for the organizations was 87%. MEASURES: Descriptions of programs were obtained by telephone interviews. An analytical procedure was applied to the program data to identify intervention settings, targets and strategies for each program. Using this information, a summary score of the integration of the ecological approach was estimated for each program. Organizational and professional variables were assessed by self-administered questionnaires to managers and professionals involved in these programs. RESULTS: The level of integration of the ecological approach in programs was related to organizational (frequency of contacts and collaborations with external partners, team composition) and extraorganizational factors (size of the city in which the public health unit is located). Cognitive attributes of the practitioners (knowledge and beliefs) also emerged as significant predictors. Finally, positive associations were observed between practitioners' personal characteristics (educational achievement, working status in health promotion [full vs. part-time], previous experience, gender, and disciplinary/professional background) and cognitive predictors. CONCLUSIONS: Organizational environment and staff preparation play a critical role in the adoption of the ecological approach in tobacco control programs.

The hardest thing is the habit: a qualitative investigation of adolescent smokers' experience of nicotine dependence.

The aims were to explore adolescent smokers' understanding and their physiological and psychological experience of addiction to nicotine and to assess the content validity of the Hooked on Nicotine Checklist (HONC), a 10-item measure of nicotine dependence in youth. Six focus group interviews were conducted with male and female smokers recruited by school staff from among known smokers at one English and two French high schools in Montreal. Participants were 64 high-school students aged 14-17 years. Measurements were focus group discussion of smoking patterns and levels for self and others; feelings and sensations while smoking; physical and mental experiences of urges, feelings and sensations when smoking is prohibited; the physical, psychological, and social meanings of being hooked, dependent, or addicted; levels of dependence, desire to quit, and quit attempts. Participants readily identified nicotine dependence as relevant to their smoking experience. Dependence was described as the need to smoke, sometimes experienced as sensations of emptiness in the chest or blood and sometimes as a feeling in the mind. Smoking urges were often situationally determined and associated with hunger. With the exception of feeling sad, blue, or depressed on smoking withdrawal, participants endorsed almost all the symptoms in the HONC as relevant to their experience of dependence and identified several other symptoms as well. Adolescents are able to provide self-reports of symptoms of dependence that are consistent with a theoretically driven conceptualization of nicotine dependence. The HONC demonstrates content validity among adolescents but could be improved through removal of the item related to depression on withdrawal and possibly addition of items related to stress and appetite.