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What Works in Nutrition Promotion? Documenting Nutrition Practice Profiles



I Introduction



Like other health promotion practitioners, nutrition professionals are increasingly being challenged to implement programs that have evidence of positive effect on the individual behaviours of participants or the environments in which they make eating choices. Profiling initiatives that have been shown to be effective in similar contexts demonstrates a commitment to evidence-based health promotion. By using a centrally produced, consistently assessed, peer-reviewed catalogue of "what works in nutrition promotion" resources, practitioners in communities across Ontario can potentially save scarce resources by not having to conduct independent research to establish an understanding of successful interventions. As well, practitioners are spared the costs of developing new materials for their community that may already exist elsewhere.



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II The Project



The purpose of the "What Works in Nutrition Promotion Project" was to provide detailed profiles of community nutrition promotion programs that have been demonstrated to be effective according to an established set of criteria and a related peer-review assessment process. The resulting resource is intended to increase the capacity of nutrition practitioners to implement nutrition promotion programs, by providing details on recommended interventions and where to go for more information.



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III Process



Step 1: Contracting consultants & setting the context



The NRC worked with a group of consultants (Nancy Dubois and Annamaria Feltracco on behalf of Larry Hershfield & Associates) on the development of this resource. This involved determining the context and parameters for the review, e.g., the types of programs to be reviewed, areas of emphasis. Time and resource realities resulted in limitations to the number of programs that could be included in this first "phase" of work for the NRC.



Other initial decisions in the process included the identification of terms. For example, for the purposes of this catalogue, the term "program", was defined as "a well-organized series of activities designed to facilitate change in a well defined target group." As well, a variety of principles were determined in order to focus the program review. It was decided that in order to be considered for review, programs should

* take a population health approach

* be a program as defined above

* focus on primary prevention of chronic diseases

* have a solid grounding in social behaviour change theory

* use approaches beyond awareness raising

* include a primary emphasis on nutrition

* not be a private sector intervention and

* have sufficient supporting materials available to provide adequate information for review.



Step 2: Securing and orienting assessors to review the programs



A team of field practitioners were then recruited and oriented to the purpose of the project as well as the assessment tools. This Assessment Review Team (ART) was comprised of individuals from a variety of types of organizations, areas of expertise related to nutrition and health promotion and communities.



Step 3: Identifying potential programs



Programs were identified for potential review using several methods. The ART was asked to nominate potential programs, a review of existing program catalogues was conducted, key stakeholders and field practitioners were asked for suggestions, and a request for input was circulated to various list servs and electronic bulletins. This search resulted in a potential sixty four programs to review.



The pre-set parameters and selection criteria were applied to these sixty four programs to determine which programs should be followed up for detailed assessment. This number of programs was eventually reduced to forty two and then to a further thirteen when various selection criteria were applied as well as logistical considerations such as availability of materials and a contact person.



Step 4: Program Assessment



Best Practices criteria were available through work done previously by the Heart Health Resource Centre. The main adjustment to these criteria was a more detailed breakdown of the final ranking categories -- namely, the addition of "Very Promising." Intervention to the already existing list of "Best," "Promising," "Not Recommended" and "To Be Tracked".



These criteria and a decisional flow chart were applied to the 13 programs to assess levels of effectiveness, plausibility and practicality. In summary, the process included the following steps:



1. Recruitment & Orientation of Assessment Review Team

2. Adaptation of Assessment Criteria & Decision Flowchart

3. Identification of Programs for Review

4. Creation of Program Profiles for Review

5. Program Assessment

6. Program Profile Revisions for Publication



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IV The Findings



This process resulted in the ranking of one program as "very promising," ten programs as "promising," and a further two were "not recommended". None of the programs reviewed were ranked as "best practice." This finding certainly contributed to the resource being viewed as a "What Works" approach rather than a more rigid "Best Practices" piece. The primary factor in a program not being ranked as a "best practice" is the lack of well-designed randomized control trial evaluation with accompanying significant results. This result was not unexpected.



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V What Worked Well



There are many examples of what worked well in the development of this resource. The creation of the Assessment Review Team was a good process that involved recruitment of a number of individuals with different expertise from a variety of organizations. Care was taken to ensure diversity in geography and type of organization represented, i.e., public health units, community health centres, government, academic and non-governmental organizations. This team worked efficiently and effectively to determine many of the process elements of this project -- from nominating programs for review, reviewing the assessment criteria and documentation formats as well as actually reviewing programs and providing recommendations.



The process used for soliciting nominations of programs was also an element of this project that worked well as evidenced by the numbers or programs initially considered. The use of a number of simultaneous search methods seemed to be a positive factor in this regard.



A further positive element of this project relates to the methods employed for gathering program information. The consultants and community practitioners made excellent use of the most accessible methods as the case determined. In many cases, this was through electronic means, but in some cases, creating program profile information involved numerous and lengthy telephone conversations.



The program profile format created for this project will go beyond this resource. The amount of information requested was very comprehensive and included specific details about development, implementation and evaluation. The consultants worked with the ART to refine the format for the profiles -- an essential element of the review process. In the end, the amount of information required for the profile was often not available in sufficient detail to further proceed. However, it is hoped that the documentation format may be used as a template for program documentation in the future.



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VI Challenges



Given the pre-set parameters and limitations, the NRC and the project consultants certainly recognized that this project could not be exhaustive and fully comprehensive in its efforts in collecting all potential programs for review. It must be also recognized that this type of review of Ontario based nutrition promotion programs had not previously been attempted and was being viewed very much as a "first step" and an opportunity for learnings about community nutrition practice in the province.



The NRC and the consultants were also cognizant of the fact that there is much ongoing work and debate in the area of "best practices" as applied to the health promotion context. Some of this debate centres on the criteria used to rank effectiveness, the quality and type of evidence needed to determine effectiveness and the role of local programmers in determining if, and how, programs labeled as "best practice" can actually be applied in their communities. Given this context, the NRC decided to go ahead with previously accepted criteria rather than attempt to tackle the task of developing or selecting appropriate criteria for nutrition best practice, in isolation from any number of key stakeholders and experts in this field.



In the case of the "What Works in Nutrition Promotion" Project, some of the reasons for a lack of "best practice" programs appear to be more fundamental than even the lack of evaluation research. One of the main reasons that nominated programs did not make it to the "Best Practice" assessment stage was that there were insufficient details available for the assessment. This speaks to a number of issues affecting nutrition practice at the community level in Ontario.



The format used to develop the Program Profiles for this resource were also adapted from pre-existing templates -- specifically the format used in the HHRC process combined with the information captured in the Canadian Heart Health Initiative G8 Database. Two separate program abstract formats were employed -- one for descriptive program information and implementation details and the other format for program evaluation details. The lack of such detailed information was considerable. The descriptive information sought included information about goals, objectives, rationale, underlying theory, behaviour change principles employed, and implementation steps. The documentation formats used for creating program profiles in this project are provided as part of the catalogue.



The lack of descriptive program information immediately disqualified a program from further consideration in this process. This speaks to a need for a greater emphasis at the field level on documenting and collecting information about programs being delivered. It is only once this documentation becomes more commonplace that more community nutrition promotion programs and health promotion programs in general make it through to the stage of actually being considered for review in a best practices, effective practices or "what works" process.



There were further challenges when it came to considering programs developed by the private sector. It was again difficult to gather detailed information regarding development and implementation, mainly because it was not considered public domain. Accessibility to some of these programs was also a perceived barrier. In the end, a decision was made not to include private sector programs as part of this review. This decision was made jointly by the members of the ART.



Overall, it is hoped that "What Works in Nutrition Promotion" A Catalogue of Nutrition Practice Profiles will serve as an example of the type of information and documentation that is essential in order to have more programs reviewed for effectiveness and subsequently affect the uptake of programs in the community by practitioners.

VII References



The Catalogue of Nutrition Practice Profiles



What Works in Nutrition Promotion: A Catalogue of Nutrition Practice Profiles is one of several initiatives of the Nutrition Resource Centre (NRC) whose goal is to increase the capacity of nutrition practitioners in communities across Ontario to implement nutrition programs and strategies in a health promotion context.



Email info@nutritionrc.ca if you if you would like an electronic copy of this report. A full copy of the report will be posted on http://www.nutritionrc.ca in the very near future. Printed copies will also be available in the coming month. Call (416) 367-3313, ext 22, or 1-800-267-6817 for more information.