Understanding similarities in the local implementation of a healthy environment programme: Insights from policy studies

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Abstract

This paper reports findings from an evaluation of the local implementation of a procedural public health programme whose objective is to create healthy environments (HE) for vulnerable families in the province of Quebec (Canada) through the funding of local projects. Considering the potential issue of programme–context interaction, our research question was the following: Does the procedural nature of this HE programme result in variation between local cases in terms of the types of projects and collaborations it subsidizes? Given that the creation of healthy environments requires intersectoral health action to address social determinants of health, the data were analysed with respect to intersectorality and cooperation. Results of this qualitative multiple case study (n = 8), for the period 2004–2009, show that the majority of subsidized projects were in the health and social services sector and focused on parenting, parent–child attachment, nutrition and the social networks of families. Only a few initiatives reached beyond the health and social services sector to address social health determinants such as education, housing and transportation. Membership and mandates of the local groups responsible for programme implementation also showed little intersectorality. The limited variation between these eight cases can be attributed to the configuration of the local networks, as well as to specific issues in urban and rural areas. To explain the overall similarity of results across cases, we turned to the literature on policy instruments which suggests that particular characteristics of a programme may produce effects that are independent of its intended objective. In our study, several programme mechanisms, such as those framing the definition of «healthy environment» and budget management rules, could have encouraged the local development of initiatives that focus on individual skills related to parenting and attachment rather than the development of intersectoral health action to address social determinants of health.

Highlights

► The paper studies intersectoral health action in the implementation of a healthy environment programme in Quebec (Canada). ► As the programme is procedural and relies on local actors for implementation, significant local variations were expected. ► But results showed similarity in programme implementation, which we explained with characteristics of the programme itself. ► Some of these mechanisms limited local actors' opportunities for intersectoral action and de facto influenced implementation. ► This is consistent with policy studies research on policy instruments showing that these may produce unintended effects.

Introduction

The issue of programme–context interactions is central to programme evaluation in areas of public health that rely on complex interventions rather than on standardized programmes (Egan, Bambra, Petticrew, & Whitehead, 2009; Hawe, Shiell, Riley, & Gold, 2004; Potvin, Haddad, & Frohlich, 2001). Recognition that programmes adapt to the existing context through implementation (Howlett, 2001) has led to comprehensive methods and theories in programme evaluation (Hawe et al., 2004; Potvin et al., 2001; Potvin & McQueen, 2008). These aim to understand how contextual factors – such as the presence of strategic actors, the culture of collaborative interventions or local political dynamics – influence the processes and outcomes of interventions; or how different categories of professionals interact at the programme–context interface (Berkeley & Springett, 2006; Bisset, Daniel, & Potvin, 2009). The underlying purpose is to facilitate the generalisability of evaluation results beyond a particular programme or context.

In this study, we explore how a programme–context interaction plays out during the implementation of a particular type of public health programme, namely a procedural programme. The notion of procedural programme comes from the policy studies literature on the “tools of government” (Hood, 1986). Procedural instruments are mechanisms used by governments to indirectly orient the provision of goods and services in line with their objectives (Howlett, 2000). A procedural programme, therefore, determines guidelines and allocates resources, but it does not prescribe any specific content. It is left to the targeted public or private organizations to develop projects that will fulfil the programme's mandate. One would then expect some variation in the spectrum of implementation between sites or local communities.

The programme studied here is procedural in that central government requires local health institutions and community-based non-governmental organisations to create healthy environments (HE) for vulnerable families in their local communities. Local organizations are expected to implement intersectoral health actions; that is, collaborative processes that extend beyond the health sector to other sectors like education, housing and transportation, to address social determinants of health (Degeling, 1995; O'Neill, Lemieux, Groleau, Fortin, & Lamarche, 1997).

We have adopted a qualitative exploratory approach to examine the programme–context interaction in the implementation of this procedural programme. This study seeks to answer the following question: Does the procedural nature of the HE programme result in variation between local cases in terms of the types of projects and collaborations it subsidizes?

Section snippets

Context

The programme we studied is one of two components of a broader programme called SIPPE (Integrated Perinatal and Early Childhood Services for Families Living in Vulnerable Situations) which was created by the Ministry of Health and Social Services in Quebec to support vulnerable families, facilitate the social inclusion of parents and ensure optimal child development (Ministère de la Santé et des Services sociaux du Québec, 2004). Eligibility is defined according to either the mother's age (<20

Multiple case study design

Using qualitative research methods, we carried out a multiple case study of the implementation of the SIPPE–HE programme, between 2004 and 2009, in eight localities under the responsibility of eight different CSSSs in Quebec (Canada) (Stake, 2006).1 Given that little

Content of the action plans

Although the SIPPE–HE programme did not impose constraints on the content of the HE projects that were funded, our results highlight limited variation with respect to their goals across the eight localities studied.

The community organizers interviewed all insisted that creating HE within the SIPPE–HE programme entailed various forms of collaboration to improve the provision of and access to local services for young parents and their families. They also expressed a central belief supporting the

Discussion

This study shows that the implementation of the SIPPE–HE programme resulted in remarkably similar conceptions of what should constitute HE for vulnerable young families. The characteristics of the HE projects and the configurations of HE collectives indicate some variations across local cases in the amount of emphasis on intersectorality and collaboration. Half of the cases distinguish themselves in all or some of these dimensions, pointing to the presence of intersectoral health action.

Conclusion

This paper reports on the evaluation of the implementation of a procedural HE programme in eight local cases in the province of Quebec. Given that the local actors had substantial leeway in the implementation of the programme, we had expected significant variation due to contextual adaptation. There were some variations between the cases which could be explained, in part, due to the intensity of networking among local organizations and to specific issues that are inherent to the realities of

Role of the funding source

At the time of research, C. Clavier held a postdoctoral fellowship from the CHSRF/CIHR Chair on Community approaches and health inequalities. S. Gendron held a grant from the Ministry for Health and Social Services for the evaluation of the Programme for the Support of Young Parents, now an integral part of the SIPPE programme. The Ministry was not involved with the design of the study presented in this paper, nor with the actual study or writing of the paper. L. Potvin held the CHSRF/CIHR

Acknowledgements

C. Clavier conceived and led the study, analysis and writing. S. Gendron assisted with the analysis and writing. L. Potvin assisted with the writing. L. Lamontagne assisted with the study contacts and with document analysis. The authors wish to thank and acknowledge the support of the evaluation team, especially of Céline Goulet, PhD, Jacques Moreau, PhD and Gilles Dupuis, PhD.

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