ARCHIVED - Integrated Strategy on Healthy Living and Chronic Diseases - Community Based Programming Functional Component

Introduction and Context

This formative evaluation report of the Diabetes Community-based Programming and Community Capacity Building (referred to as Diabetes CBP) presents findings based on the analysis of results of four lines of evidence: a review of performance monitoring data collected by 2006-07 funded projects using pilot Program Evaluation Reporting Tool (PERT) data; a document review; a review of the Early Outcome Evaluation of the Diabetes Community-Based Projects Report; and interviews with three program representatives. This evaluation was conducted by JLS Management Consulting Inc. under the oversight and guidedance of the Public Health Agency of Canada’s (PHAC) Centre for Chronic Disease Prevention and Control’s Evaluation Unit.

The Diabetes CBP formative evaluation serves the reporting requirements under the Integrated Strategy on Healthy Living and Chronic Disease’s (ISHLCD, or “the Strategy”) fully-elaborated Results-Based Management Accountability Framework (RMAF) developed in February 2007 (Public Health Agency of Canada, 2007f).  It is also designed to produce evidence that will feed into the overall assessment of the ISHLCD in relation to its relevance, design and delivery, and success/progress.

In the next section, a profile of the program is presented.  The remainder of the report is organized as follows: Section 2 describes the methodology for the evaluation, Section 3 presents the key findings, Section 4 presents conclusions from this evaluation, and Section 5 lists the recommendations.

1.1 Program Description

Integrated Strategy on Healthy Living and Chronic Disease

The ISHLCD was launched in October 2005 with $300 million in funding over five years (and $74.4 million ongoing).  It was designed to provide a coherent framework for federal leadership across a range of public health actions to promote the health of Canadians and reduce the impact of chronic diseases in Canada.  The three inter-related pillars of the ISHLCD are:

• Promoting health by addressing the conditions that lead to unhealthy eating, physical inactivity and unhealthy weights;
• Preventing chronic disease through focused and integrated action on major chronic diseases and their risk factors; and
• Supporting platforms for early detection and management of chronic disease.

The ISHLCD consists of integrated and disease-specific strategies, including diabetes (non-Aboriginal elements), cancer and cardiovascular disease (CVD).  It is administered through a matrix structure composed of the following 14 Program Components and six Functional Components (see Annex A for a visual description of the ISHLCD matrix):

• The ISHLCD Program Components are:
  • Coordination;
  • Healthy Living Fund;
  • Intersectoral Healthy Living Network;
  • Healthy Living Social Marketing;
  • Healthy Living Knowledge Development and Exchange;
  • Joint Consortium for School Health;
  • Mental Health;
  • Observatory of Best Practices;
  • Demonstration Projects for Integrated Chronic Disease;
  • International Collaborations;
  • Enhanced Surveillance for Chronic Disease;
  • Renewed Canadian Diabetes Strategy (non-Aboriginal element);
  • Cancer; and
  • Cardiovascular Disease.
• The ISHLCD Functional Components include:
  • Surveillance;
  • Knowledge Development, Exchange & Dissemination;
  • Community-Based Programming;
  • Public Information;
  • Leadership, Coordination and Strategic Policy Development; and
  • Monitoring and Evaluation.

The ISHLCD is delivered by the Centre for Chronic Disease Prevention and Control (CCDPC) and the Centre for Health Promotion (CHP) located within the National Office of the Public Health Agency of Canada (PHAC), and the Agency’s seven Regional Offices: British Columbia; Alberta; Saskatchewan/Manitoba; Ontario; Quebec; Atlantic region; and Northern region.

Community-Based Programming and Community Capacity Building under the Integrated Strategy on Healthy Living and Chronic Disease

The Community-Based Programming and Community Capacity Building (CBP) Functional Component of the ISHLCD has three action areas:

• Transfers to community-based organizations to plan, implement and evaluate interventions using evidence to address multiple risk factors among high-risk populations within various social, economic and physical environments;
• Partnership development and collaboration; and
• Dissemination by PHAC staff.

The CBP Functional Component includes three disease specific elements: diabetes, cancer, and CVD, as well as the Healthy Living Fund.  The overall aim of the disease-specific elements of CBP is to prevent chronic disease, and to promote early detection and management of chronic disease.  At the same time, integration is designed to take place on a number of levels within the Functional Component including: targeting common risk factors (e.g., unhealthy eating and physical inactivity); intersectoral collaboration; coordinated action across the health continuum; and a combination of approaches to high-risk populations. The Healthy Living Fund, which is part of the Healthy Living Program, aims to address effective, sustainable actions at all levels that promote healthy living, and provide a supportive social and physical environment for health.

There have been two major events related to CVD that have had an impact on the CBP Functional Component: the October 2006 announcement by the Health Minister of the development of a Canadian Heart Health Strategy Action Plan, led by an external Steering Committee of experts; and the November 2006 announcement by the Prime Minister to create the Canadian Partnership Against Cancer (CPAC) to implement the Canadian Strategy for Cancer Control. Consequently, this formative evaluation focuses on the one active disease-specific element – Diabetes CBP. The Healthy Living Fund CBP element will be included in the broader Healthy Living Program evaluation.

Diabetes Community-Based Programming and Community Capacity Building

Diabetes CBP falls under the renewed Canadian Diabetes Strategy (CDS) Program Component of the ISHLCD.  The renewed CDS builds on the original Canadian Diabetes Strategy (1999 to 2005) with a budget of $115 million.  In the February 2005 budget, the non-Aboriginal component of the CDS was renewed for an additional five years as part of the ISHLCD, and is managed by CCDPC.

The renewed CDS is focused on the prevention of type 2 diabetes among high-risk populations, early detection of type 2 diabetes, and management of type 1 and 2 diabetes. The Logic Model for the renewed CDS can be found in Annex B.

Diabetes CBP is one of the six elements of the renewed CDS, which include:

• National Diabetes Surveillance System (NDSS);
• Knowledge Development and Exchange for Diabetes Prevention and Management (Diabetes KD&E);
• Diabetes CBP;
• Diabetes Public Information;
• Diabetes Coordination; and
• Monitoring and Evaluation.

Diabetes CBP provides funding for project Gs&Cs to develop, implement, and evaluate community-based initiatives at both the national and regional levels.  It is designed to promote a positive shift in health status in high-risk populations, through supporting community-based programs tailored to the particular needs of communities, taking into account cultural and ethnic diversity, demographics, and other existing high-risk conditions such as obesity and physical inactivity.

Projects funded under Diabetes CBP must share the following objectives:

• Plan, implement and evaluate interventions using evidence to address multiple risk factors among high-risk populations within various social, economic and physical environments;
• Facilitate and expand links among health practitioners, planners, researchers, and policy-makers within and across organizations, sectors and jurisdictions to: better align strategic directions; address diabetes priorities; enhance surveillance and knowledge uptake; and exchange best practices;
• Collaborate to integrate systems of prevention, detection and management of diabetes; and
• Develop and/or advocate for healthier public policies addressing prevention, early detection and management of diabetes.

To demonstrate how projects undertake work to achieve program objectives, an illustrative sample of initiatives is provided below:

• An awareness and prevention project targeted to women at highest risk of developing diabetes during pregnancy (Healthy Start for Mom & Me) developed a community process that included two focus groups with women living with diabetes and a consultation with community partners.
• For a high risk group of seniors, the Attitude Makes a Difference project identified best practices in diabetes prevention and treatment among seniors to understand how those with pre-diabetes and type 2 diabetes feel about their disease. The project identified key actions needed to enhance prevention, treatment and support.
• The Prevention, Detection and Management of Diabetes for Canadians with a Disability project worked with recreation therapists and physiotherapists to establish strategies and approaches to educate stakeholders about the prevention, detection and management of diabetes among those living with a disability.

Program Reach/Intended Beneficiaries

Diabetes CBP is designed to ultimately benefit populations who are at higher risk for developing type 2 diabetes as well as those living with diabetes.  These may include, but are not limited to, people who:

• Have diabetes;
• Have pre-clinical or asymptomatic conditions (i.e., pre-diabetes);
• Are overweight/obese;
• Are over age 40;
• Have high blood pressure and/or high cholesterol;
• Have a family history of diabetes;
• Are of certain high-risk ethno-cultural populations (e.g., Aboriginal, African, Hispanic, South Asian);
• Have a history of gestational diabetes; or
• Have given birth to a baby weighing over 9 lbs.

To reach these groups, Diabetes CBP may fund projects that target health practitioners, researchers, policy-makers or planners.  Eligible applicants for funding include: Canadian non-government, non-profit, voluntary organizations; regional health authorities/health units; hospitals; community health centres; and educational (Kindergarten to Grade 12) and post-secondary institutions.

Guiding Principles

Projects funded under Diabetes CBP are expected to address the following two principles in project development and implementation:

• Promoting community participation: Members of the population being served should play an active role in developing, planning, implementing and evaluating the project, as well as in disseminating the results.
• Supporting intersectoral collaboration:  Strong collaboration among volunteer and community groups, government, the business community, labour, and professional organizations should be supported at local, municipal, P/T and federal levels to mobilize resources for effective action.  As well, partnerships between the health sector and other sectors of the community are strongly encouraged to support the population health approach to diabetes prevention and management.

Program Coordination and Support

Diabetes CBP is a diverse and dynamic program, funded federally, coordinated regionally, and delivered locally in communities across Canada.  The interplay of these layers of influence has led Diabetes CBP projects to evolve in different ways across the country.

In December 2007, the Diabetes Community-Based Network integrated with the Healthy Living Fund to become the Community-Based Network.  This Network is a PHAC-based national and regional information exchange and advisory group, designed to assist in the coordination of community-based activities under the renewed CDS and the Healthy Living Fund.  The Network meets monthly, and its membership consists of representatives from the National and Regional Offices engaged in the following Functional Components: CBP; Surveillance; KDED; Evaluation; and Public Information (Communications). This communication system links the National Office to staff in Regional Offices, who in turn link directly to communities. This enables national and regional staff to respond to the diverse needs of community groups.

Regional and National Office evaluators working in the areas of Diabetes and the Healthy Living Fund also integrated in December 2007 to form the Diabetes and Healthy Living Evaluation Working Group. This group meets monthly to discuss and exchange information on issues related to monitoring and evaluation of CBP, including use of a common performance monitoring tool for funded projects under the two programs.

Program Resources

Diabetes CBP has an annual budget of approximately $6.4 million.  Of this amount, approximately $4 million is allocated for Gs&Cs to community-based projects.  The number of staff allocated to Diabetes CBP is 15.5 full-time equivalents (FTEs), which consists of 5.0 in the National Office and 10.5 in the Regional Offices.  The level of staff varies among the regions, primarily to reflect the operation and maintenance budget allocated to each Regional Office.  In 2006-07, the actual number of staff allocated to the program was 11.0 FTEs (3.0 in the National Office and 8.0 in the Regional Offices).

Currently, PHAC Program Consultants in the regions manage diabetes and healthy living Gs&Cs, and also provide a federal link with the provinces and territories.  The three positions in the National Office manage the overall diabetes program coordination function, the diabetes community-based program Gs&Cs, as well as the associated briefings, correspondence, program planning and reporting.

In terms of Gs&Cs funded projects, in 2005-06, there were sixteen projects, which consisted of seven new projects and enhancements to nine projects being funded under the original CDS. Funding details for the 2005-06 projects were not available at the time of data collection.

Table 1 presents actual funding to community-based projects in 2006-07 by PHAC region.

With regard to 2007-08 funded projects, funding information was not available at the time of the evaluation.

1.2 Evaluation Context

The Diabetes CBP formative evaluation is designed to assist the program to meet its reporting requirements under the fully-elaborated RMAF for the ISHLCD.  The fully-elaborated RMAF was developed in February 2007 and contains a comprehensive monitoring and evaluation plan for the Strategy.  Activities outlined in the plan include evaluations of key Functional and Program Components, including CBP, with a focus on progress towards achieving immediate outcomes, and early progress towards intermediate outcomes.

It is expected various pieces of evaluation work, including formative evaluations of key Functional and Program Components, will be synthesized into one overarching evaluation scheduled for completion in 2011.  This formative evaluation of Diabetes CBP is designed to produce evidence for the overall synthesis evaluation of the ISHLCD in relation to its relevance, program design and delivery, and success/ progress, in addition to informing senior management on the progress of the initiative.

Objectives and Scope for the Evaluation

The objectives of the Diabetes CBP formative evaluation are to examine issues related to relevance, design and delivery, and to determine the success/progress of the CBP Functional Component. Findings will be used to propose improvements to CBP as well as to the ISHLCD as a whole.

The evaluation covers the first three years of program implementation - fiscal years 2005-06, 2006-07 and 2007-08 (until November 2008) - and, as identified above, it focuses on Diabetes CBP as part of the ISHLCD.

The evaluation is based on the detailed Community-Based Programming and Community Capacity Building Monitoring and Evaluation Plan and the Logic Model, which is presented on the following page.  The overarching evaluation questions guiding this evaluation are:

• Relevance: Does the Component continue to be consistent with departmental-wide priorities, and does it realistically address an actual need?
• Program design and delivery: Are the most appropriate and effective means being used to achieve objectives?
• Success/Progress: Is the Component effective and without unwanted outcomes?

For a complete list of detailed evaluation questions and linkage to indicators and data sources, please refer to the Community-Based Programming and Community Capacity Building Monitoring and Evaluation Plan in Annex C.

Figure 1: ISHLCD Community-Based Programming and Community Capacity Building Functional Component Logic Model

Figure 1: ISHLCD Community-Based Programming and Community Capacity Building Functional Component Logic Model