Priorities among effective clinical preventive services in British Columbia, Canada.

BACKGROUND: Despite the long-standing experience of rating the evidence for clinical preventive services, the delivery of effective clinical preventive services in Canada and elsewhere is less than optimal. We outline an approach used in British Columbia to assist in determining which effective clinical preventive services are worth doing. METHODS: We calculated the clinically preventable burden and cost-effectiveness for 28 clinical preventive services that received a 'strong or conditional (weak) recommendation for' by the Canadian Task Force on Preventive Health Care or an 'A' or 'B' rating by the United States Preventive Services Task Force. Clinically preventable burden is the total quality adjusted life years that could be gained if the clinical preventive services were delivered at recommended intervals to a British Columbia birth cohort of 40,000 individuals over the years of life that the service is recommended. Cost-effectiveness is the net cost per quality adjusted life year gained. RESULTS: Clinical preventive services with the highest population impact and best value for money include services that address tobacco use in adolescents and adults, exclusive breastfeeding, and screening for hypertension and other cardiovascular disease risk factors followed by appropriate pharmaceutical treatment. In addition, alcohol misuse screening and brief counseling, one-time screening for hepatitis C virus infection in British Columbia adults born between 1945 and 1965, and screening for type 2 diabetes approach these high-value clinical preventive services. CONCLUSIONS: These results enable policy makers to say with some confidence what preventive manoeuvres are worth doing but further work is required to determine the best way to deliver these services to all those eligible and to establish what supportive services are required. After all, if a clinical preventive service is worth doing, it is worth doing well.

Development of the Tiers of Service framework to support system and operational planning for children's healthcare services.

BACKGROUND: Providing access to pediatric healthcare services in British Columbia, Canada, presents unique challenges given low population densities spread across large geographic distances combined with a lack of availability of specialist providers in remote areas, leading to quality of care shortcomings and inequalities in care delivery. The study objective was to develop a framework that provides a common language and methodology for defining and planning child and youth healthcare services across the province. METHODS: The framework was developed in two phases. In Phase 1, a literature and jurisdictional review was completed using the following inclusion criteria: (i) description of a framework focusing on organizing service delivery systems (ii) that supports health service planning, (iii) includes specialty or subspecialty services and (iv) has been published since 2008. In Phase 2, a series of meetings with key provincial stakeholders were held to receive feedback on the developed Tiers of Service framework versions that were based on the literature and jurisdictional review and adjusted to the British Columbian health care context. The final version was endorsed by the Child Health BC Steering Committee. RESULTS: Ten medical articles and thirteen jurisdictional papers met the established selection criteria and were included in this study. Most frameworks were developed by the Australian national or state jurisdictions and published in jurisdictional papers (n = 8). Frameworks identified in the medical literature were mainly developed in Canada (n = 3) and the US (n = 3) and focused on maternity, neonatal, critical care and oncology services. Based on feedback received from the expert group, the framework was expanded to include community-based services, prevention and health determinants. The final version of the Tiers of Service framework describes the specific services to be delivered at each tier, which are categorized as Tier 1 (community services) through Tier 6 (sub-specialized services). Two consecutive steps were identified to effectively use the framework for operational and system planning: (i) development of a 'module' outlining the responsibilities and requirements to be delivered at each tier; and (ii) assessment of services provided at the health care facility against those described in the module, alignment to a specific tier, identification of gaps at the local, regional and provincial level, and implementation of quality improvement initiatives to effectively address the gaps. CONCLUSIONS: The benefits of the Tiers of Service framework and accompanying modules for health service planning are being increasingly recognized. Planning and coordinating pediatric health services across the province will help to optimize flow and improve access to high-quality services for children living in British Columbia.

Implementing Appetite to Play at scale in British Columbia: Evaluation of a Capacity-Building Intervention to Promote Physical Activity in the Early Years.

Childcare is a critical target for promoting children's physical activity (PA) and physical literacy (PL). With emerging evidence about the efficacy of policy and capacity-building strategies, more information about how to bring these strategies to scale is needed. This paper describes implementation at scale of Appetite to Play (ATP), a capacity-building intervention for childcare providers, and examines the implementation and impact on early years providers' capacity to address PA. The ATP implementation evaluation was a natural experiment that utilized a mixed methods concurrent parallel design framed within the Reach, Effectiveness, Adoption, Implementation, Maintenance framework (RE-AIM). Workshop and website tracking assessed reach and adoption. Surveys and interviews with workshop participants and stakeholders assessed satisfaction, implementation, and maintenance. Training reached 60% of British Columbia municipalities and 2700 early years providers. Significant changes in participants' knowledge and confidence to promote PA and PL were achieved (p >0.01-0.001). Childcare level implementation facilitators as reported by early years providers included appropriate resources, planning, indoor space, and equipment, whereas weather and space were reported barriers. The stakeholder advisory group viewed the stakeholder network and Active Play policy as facilitators and adjustments to recent shifts in childcare funding and previous initiatives as barriers to implementation. ATP was scalable and impacted provider knowledge, confidence, and intentions. The impact on actual policies and practices, and children's PA needs to be assessed along with sustainability.

Constraints to implementing guidelines for the identification, assessment, and management of childhood obesity in the clinical care setting: Prevention and treatment framework.

The "Pathway for the Identification, Assessment and Management of Overweight and Obese Children & Youth" was developed to support healthcare providers in identifying and treating childhood obesity in British Columbia (Canada). PURPOSE: The study aimed to determine the feasibility and effectiveness of using the Pathway in clinical settings. METHODS: 13 healthcare providers (7 family physicians, 2 pediatricians, 2 registered dietitians, and 2 nurse practitioners) assessed the Pathway and participated in semi-structured interviews in 2015. A direct constant comparative analysis guided the coding of the interviews in the NVivo 9 software. RESULTS: The interviews uncovered the complexity of factors that influenced practices of healthcare providers. Three broad issues were identified as required if the "Pathway" were to be used and fully implemented in practices. First, the "Pathway" needs to be modified in terms of how it is presented and explained and be supplemented with appropriate documentation and resources for its implementation, Second, the constraints that limit implementation need to be addressed and should include a focus on both individual (i.e., the healthcare providers themselves) and environmental (i.e., factors within and outside of providers' organizations) factors. Lastly, there is a need to establish processes and/or infrastructure for adapting the "Pathway" to the local context as resources and supports vary by organizations and regions. CONCLUSION: Healthcare providers should be involved in screening and managing childhood obesity. Addressing the challenges found in this study will enable healthcare providers to take a more active role in addressing childhood obesity in their day to day practices.

Chronic disease prevention policy in British Columbia and Ontario in light of public health renewal: a comparative policy analysis.

BACKGROUND: Public health strategies that focus on legislative and policy change involving chronic disease risk factors such as unhealthy diet and physical inactivity have the potential to prevent chronic diseases and improve quality of life as a whole. However, many public health policies introduced as part of public health reform have not yet been analyzed, such as in British Columbia and Ontario. The purpose of this paper is to present the results of a descriptive, comparative analysis of public health policies related to the Healthy Living Core Program in British Columbia and Chronic Disease Prevention Standard in Ontario that are intended to prevent a range of chronic diseases by promoting healthy eating and physical activity, among other things. METHODS: Policy documents were found through Internet search engines and Ministry websites, at the guidance of policy experts. These included government documents as well as documents from non-governmental organizations that were implementing policies and programs at a provincial level. Documents (n = 31) were then analysed using thematic content analysis to classify, describe and compare policies in a systematic fashion, using the software NVivo. RESULTS: Three main categories emerged from the analysis of documents: 1) goals for chronic disease prevention in British Columbia and Ontario, 2) components of chronic disease prevention policies, and 3) expected outputs of chronic disease prevention interventions. Although there were many similarities between the two provinces, they differed somewhat in terms of their approach to issues such as evidence, equity, and policy components. Some expected outputs were adoption of healthy behaviours, use of information, healthy environments and increased public awareness. CONCLUSIONS: The two provincial policies present different approaches to support the implementation of related programs. Differences may be related to contextual factors such as program delivery structures and different philosophical approaches underlying the two frameworks. These differences and possible explanations for them are important to understand because they serve to contextualize the differences in health outcomes across the two provinces that might eventually be observed. This analysis informs future public health policy directions as the two provinces can learn from each other.

"It's a feel. That's what a lot of our evidence would consist of ": public health practitioners' perspectives on evidence.

This article describes how evidence is defined and used in two British Columbia public health departments during the implementation of a Healthy Living initiative in 2009. Through interviews with 21 public health staff and decision makers, the author sought to investigate how "evidence" was defined by both frontline and management staff and how it was used in decision making. The authors found public health staff, particularly frontline practitioners, to be drawn to grassroots and local "lived experience" evidence. This tacit wisdom, in combination with evidence from academia and clinical evidence accessed through disciplinary or professional networks, offered a knowledge transition opportunity to inform decision making, rather than what can be characterized in the literature as unidirectional knowledge translation. It is often difficult for staff to digest and interpret research as part of their work day because of the volume and density of information that typically counts as evidence. Moreover, there exist challenges to identify and gather indicators as evidence of their work.