The Impact of Health Geography on Public Health Research, Policy, and Practice in Canada.

The link between geography and health means that the places we occupy-where we are born, where we live, where we work, and where we play-have a direct impact on our health, including our experiences of health. A subdiscipline of human geography, health geography studies the relationships between our environments and the impact of factors that operate within those environments on human health. Researchers have focused on the social and physical environments, including spatial location, patterns, causes of disease and related outcomes, and health service delivery. The work of health geographers has adopted various theories and philosophies (i.e., positivism, social interactionism, structuralism) and methods to collect and analyze data (i.e., quantitative, qualitative, spatial analysis) to examine our environments and their relationship to health. The field of public health is an organized effort to promote the health of its population and prevent disease, injury, and premature death. Public health agencies and practitioners develop programs, services, and policies to promote healthy environments to support and enable health. This commentary provides an overview of the recent landscape of health geography and makes a case for how health geography is critically important to the field of public health, including examples from the field to highlight these links in practice.

Exploring Factors Contributing to the Implementation of Ontario's Healthy Kids Community Challenge: Surveys and Key Stakeholder Interviews with Program Providers.

(1) Background: To explore factors contributing to the Healthy Kids Community Challenge (HKCC) program implementation; (2) Methods: Data were collected through a quantitative survey (n = 124) and in-depth telephone interviews (n = 16) with program providers. Interviews were recorded and transcribed for thematic analysis using NVivo; (3) Results: Provincial funding and in-kind support from community partners were key. Initiatives were feasible to implement, and key messages were well-received by communities. Specific practices and process were commonly discussed, and strong local program leadership was crucial to implementation; (4) Conclusions: Results have implications for planning and implementing future multi-component, community-based health promotion programs that include similar partnerships.

Secondary School Nutrition Policy Compliance in Ontario and Alberta, Canada: A Follow-Up Study Examining Vending Machine Data from the COMPASS Study.

(1) Objective: To longitudinally assess food and beverages sold in vending machines in secondary schools (grades 9-12) participating in the COMPASS study (2015/2016 and 2018/2019) and (2) to examine if patterns and trends observed in previous years (2012/2013 to 2014/2015) are consistent with lack of policy compliance in Ontario and Alberta, Canada. (2) Methods: Policy compliance was assessed through comparing nutritional information on drink (e.g., sports drinks) and snack (e.g., chocolate bars) products in vending machines to Policy and Program Memorandum (P/PM) 150 in Ontario (required policy) and the Alberta Nutrition Guidelines for Children and Youth (recommended policy). Longitudinal results and descriptive statistics were calculated. (3) Results: Longitudinal results indicate that between Y4 (2015/2016) and Y7 (2018/2019), snack and drink vending machines remained mostly non-compliant in Ontario and Alberta, with a small proportion of Ontario drink machines changing from non-compliant to compliant. At the school level, descriptive results indicate the proportion of Ontario schools with policy-compliant snack and drink machines decreased between Y4 and Y7. Alberta schools were non-compliant for drink and snack machines. (4) Conclusions: Secondary schools continue to be non-compliant with provincial policies. School nutrition policies need to be simplified in order to make it easier for schools to be compliant. Enforcement of compliancy is also an area that deserves consideration.

Priority setting for school nutrition research: developing a collaborative research agenda.

Priority setting in health research can assist stakeholders to identify research and policies that have the greatest potential for benefits to public health. Priority setting has been utilized by researchers to identify barriers, facilitators, and recommendations for future public health research. This commentary describes how a priority-setting approach was used as part of a workshop activity on the school nutrition environment in Ontario, Canada, to facilitate brainstorming, sorting, and rating of concepts related to the school nutrition environment. This work demonstrates an interesting and concrete case of priority setting, of interest for various planning activities (both programming and research), particularly those around school-based healthy eating programs or a related research agenda.

RéSUMé: L'établissement de priorités de recherche en santé peut aider les acteurs à déterminer la recherche et les politiques les plus susceptibles de présenter des avantages pour la santé publique. Les chercheurs utilisent l'établissement des priorités pour repérer les éléments favorables et défavorables et pour formuler des recommandations de recherche en santé publique à mener à l'avenir. Nous décrivons ici l'utilisation d'une démarche d'établissement des priorités lors d'un atelier sur la nutrition en milieu scolaire tenu en Ontario (Canada) dans le cadre d'une activité ayant consisté à animer une séance de remue-méninges et à trier et évaluer des concepts liés à la nutrition en milieu scolaire. Cela représente un cas concret d'établissement des priorités qui pourrait être intéressant pour diverses activités de planification (de programmes ou d'études de recherche), surtout celles qui s'articulent autour de programmes d'alimentation saine en milieu scolaire ou de priorités de recherche connexes.

An early implementation assessment of Ontario's Healthy Kids Community Challenge: results from a survey of key stakeholders.

BACKGROUND: In Ontario Canada, the Healthy Kids Community Challenge (HKCC) is a program intended to reduce the prevalence and prevent childhood overweight and obesity through community-based initiatives to improve health behaviours. Guided by the RE-AIM framework and Durlak and DuPre's Ecological Framework for Understanding Effective Implementation, the evaluation focused on two objectives: 1) to describe the organization of the program at the community level; and, 2) to identify opportunities for improvement through an early assessment of factors contributing to implementation. METHODS: Participants (n = 320) - members of the HKCC local steering committee, including the local project manager - completed a cross-sectional survey using SurveyMonkey and descriptive statistics were calculated. A sample (20%) of qualitative open-ended responses was thematically analyzed. RESULTS: Results indicated strong respondent agreement that the HKCC enhanced individual knowledge of access to health-promoting programs (88.3%) and messaging regarding healthy behaviours for healthy kids, with less for its effectiveness in reducing weight (53.1%). There was a high-level of adherence to HKCC social marketing messages and overall program structure, with few Local Project Manager reports of adaptations to theme one (9.2%) and theme two messages (15.4%). Fewer Local Project Managers (50%) reported the existence of private partnerships. While most respondents agreed they had the appropriate information to complete mandatory reporting, the usefulness of the HKCC online networking platform was in question (only 47% of Local Project Managers agreed that it was useful). Results reveal sufficient funding from the province to support program implementation, with a moderate level of local political commitment (63% of respondents). CONCLUSIONS: Results indicate that the HKCC was considered beneficial for enhancing access to health promoting programs, could be feasibly implemented with adherence to centrally-developed social marketing messages, and was amendable to local adaptation. Despite this, few private partnerships were reported. Going forward, there is opportunity to further evaluate factors contributing to HKCC program implementation, particularly as it relates to buy-in from intervention providers, and strategies for forming private sector partnerships to support long-term program sustainability.

Can knowledge exchange support the implementation of a health-promoting schools approach? Perceived outcomes of knowledge exchange in the COMPASS study.

BACKGROUND: Despite the potential population-level impact of a health-promoting schools approach, schools face challenges in implementation, indicating a gap between school health research and practice. Knowledge exchange provides an opportunity to reduce this gap; however, there has been limited evaluation of these initiatives. This research explored researchers' and knowledge users' perceptions of outcomes associated with a knowledge exchange initiative within COMPASS, a longitudinal study of Canadian secondary students and schools. Schools received annual tailored summaries of their students' health behaviours and suggestions for action and were linked with knowledge brokers to support them in taking action to improve student health. METHODS: Qualitative semi-structured interviews were conducted with COMPASS researchers (n = 13), school staff (n = 13), and public health stakeholders (n = 4) to explore their experiences with COMPASS knowledge exchange. Key issues included how knowledge users used school-specific findings, perceived outcomes of knowledge exchange, and suggestions for change. RESULTS: Outcomes for both knowledge users and researchers were identified; interestingly, knowledge users attributed more outcomes to using school-specific findings than knowledge brokering. School and public health participants indicated school-specific findings informed their programming and planning. Importantly, knowledge exchange provided a platform for partnerships between researchers, schools, and public health units. Knowledge brokering allowed researchers to gain feedback from knowledge users to enhance the study and a better understanding of the school environment. Interestingly, COMPASS knowledge exchange outcomes aligned with Samdal and Rowling's eight theory-driven implementation components for health-promoting schools. Hence, knowledge exchange may provide a mechanism to help schools implement a health-promoting schools approach. CONCLUSIONS: This research contributes to the limited literature regarding outcomes of knowledge brokering in public health and knowledge exchange in school health research. However, since not all schools engaged in knowledge brokering, and not all schools that engaged discussed these outcomes, further research is needed to determine the amount of engagement required for change and examine the process of COMPASS knowledge brokering to consider how to increase school engagement.

"Now What?" Perceived Factors Influencing Knowledge Exchange in School Health Research.

Increasing the uptake of school health research into practice is pivotal for improving adolescent health. COMPASS, a longitudinal study of Ontario and Alberta secondary students and schools (2012-2021), used a knowledge exchange process to enhance schools' use of research findings. Schools received annual summaries of their students' health behaviors and suggestions for action and were linked with a knowledge broker to support them in making changes to improve student health. The current research explored factors that influenced COMPASS knowledge exchange activities. Semistructured interviews were conducted with researchers (n = 13), school staff (n = 13), and public health stakeholders (n = 4). Interestingly, knowledge users focused more on factors that influenced their use of COMPASS findings than factors that influenced knowledge brokering. The factors identified by participants are similar to those that influence implementation of school health interventions (e.g., importance of school champions, competing priorities, inadequate resources). While knowledge exchange offers a way to reduce the gap between research and practice, schools that need the most support may not engage in knowledge exchange; hence, we must consider how to increase engagement of these schools to ultimately improve student health.

Compliance with school nutrition policies in Ontario and Alberta: An assessment of secondary school vending machine data from the COMPASS study.

OBJECTIVES: We investigated the extent to which a sample of Ontario and Alberta secondary schools are being compliant with their respective provincial nutrition policies, in terms of the food and beverages sold in vending machines. METHODS: This observational study used objective data on drinks and snacks from vending machines, collected over three years of the COMPASS study (2012/2013-2014/2015 school years). Drink (e.g., sugar-containing carbonated/non-carbonated soft drinks, sports drinks, etc.) and snack (e.g., chips, crackers, etc.) data were coded by number of units available, price, and location of vending machine(s) in the school. Univariate and bivariate analyses were undertaken using R version 3.2.3. In order to assess policy compliancy over time, nutritional information of products in vending machines was compared to nutrition standards set out in P/PM 150 in Ontario, and those set out in the Alberta Nutrition Guidelines for Children and Youth (2012) in Alberta. RESULTS: Results reveal a decline over time in the proportion of schools selling sugar-containing carbonated soft drinks (9% in 2012/2013 vs. 3% in 2014/2015), crackers (26% vs. 17%) and cake products (12% vs. 5%) in vending machines, and inconsistent changes in the proportion selling chips (53%, 67% and 65% over the three school years). Conversely, results highlight increases in the proportion of vending machines selling chocolate bars (7% vs. 13%) and cookies (21% vs. 40%) between the 2012/2013 and 2014/2015 school years. CONCLUSION: Nutritional standard policies were not adhered to in the majority of schools with respect to vending machines. There is a need for investment in formal monitoring and evaluation of school policies, and the provision of information and tools to support nutrition policy implementation.

Stakeholder Perspectives on Implementing Menu Labeling in a Cafeteria Setting.

OBJECTIVES: Mandatory and voluntary menu-labeling policies are increasingly common to support informed food choices among consumers. This study sought to examine stakeholder perspectives of developing, implementing, and maintaining a voluntary menu-labeling program in a hospital cafeteria setting. METHODS: Semi-structured qualitative interviews were conducted with 9 key cafeteria stakeholders. Data were coded by 2 independent researchers. Themes were generated deductively around 4 key themes: (1) motivation for the program; (2) program and menu development; (3) program implementation process; and, (4) "lessons learned," and inductively as they emerged from interview transcripts. These themes were mapped onto Damschroder's Consolidated Framework for Implementation Research. RESULTS: Motivations for the program were both internal and external to enable consumers to make educated food choices. Barriers to implementation included financial resources, digital menu board maintenance, and availability of healthy options from providers. Supports included availability of nutritional analysis software and nutritional information, and controlled food preparation. Ownership, program adaptation, a supportive collegial environment, a program champion and a culture valuing healthy eating were conducive to successful implementation. CONCLUSIONS: Both internal and external factors can support the voluntary implementation of menu-labeling programs.

Exploring the school nutrition policy environment in Canada using the ANGELO framework.

Excess body weight has become a major public health issue. Given the link between poor nutrition, obesity, and chronic disease in youth, increasing attention is being paid to the school as an ideal setting for promoting nutritious eating practices. Informed by the ANGELO (Analysis Grid for Environments Linked to Obesity) framework, we employ a documentary analysis to investigate the context of school nutrition in Canada, particularly the relationship between regional- and upper-level policies. In doing so, we examine policy documents and technical reports across three levels. We used mixed methods to analyze relevant English language policy documents and technical reports across Canada (n = 58), published between 1989 and 2011. Results reveal distinct differences across federal, provincial, and regional levels. The availability of nutritious food in schools and having nutrition education as part of the curriculum were key components of the physical environment across federal and provincial levels. Federal and provincial priorities are guided by a health promotion framework and adopting a partnership approach to policy implementation. Gaps in regional-level policy include incorporating nutrition education in the curriculum and making the link between nutrition and obesity. Policy implications are provided, in addition to future research opportunities to explore the connections between these environments at the local level.

Examining local-level factors shaping school nutrition policy implementation in Ontario, Canada.

OBJECTIVE: Increasing numbers of overweight and obese youth draw attention to the school as an important setting for targeted nutrition interventions, given that it is where they spend a majority of their waking time. The objective of the present study was to explore local-level factors shaping the implementation of a school nutrition policy. DESIGN: In-depth, semi-structured interviews were conducted in person or via the telephone (a maximum of 60 min). An interview guide was informed by the Analysis Grid for Environments Linked to Obesity (ANGELO) framework, research objectives and literature. Key themes centred on policy implementation, including facilitators and barriers (i.e. resources, capacity), user satisfaction (i.e. students) and communication strategies. SETTING: Secondary schools in Ontario, Canada. SUBJECTS: Twenty-two participants from local agencies supporting school nutrition programming (n 8) and secondary-school principals, vice principals and teachers (n 14) from nine schools across three Ontario school boards. RESULTS: Results are organized according to environments outlined in the ANGELO framework. The cost of healthy food for sale, revenue loss (economic), proximity of schools to off-site food outlets (physical), the restrictive nature of policy, the role of key stakeholders (political), the role of stigma and school culture (sociocultural) act as local-level barriers to policy implementation. CONCLUSIONS: Gaps in policy implementation include the high cost of food for sale and subsequent revenue generation, the close proximity of internal and external food environments, the need for consultation and communication between stakeholders, and strategies to reduce stigma and improve the school nutrition culture.

Exploring Implementation of the Ontario School Food and Beverage Policy at the Secondary-School Level: A Qualitative Study.

PURPOSE: The purpose of this study was to explore the implementation of the Ontario School Food and Beverage Policy (P/PM 150) from the perspective of secondary-school students. METHODS: This research, informed by the ANGELO framework, undertook three focus groups with secondary students (n = 20) in 2 school boards representing both high- and low-income neighbourhoods in fall 2012. Focus groups were transcribed verbatim for subsequent analysis. Key themes were generated deductively from the research objectives and inductively as they emerged from transcripts. RESULTS: Perceived impacts of P/PM 150 included high-priced policy-compliant food for sale, lower revenue generation, and food purchased off-campus. Limited designated eating spaces, proximity to external, nonpolicy-compliant food, and time constraints acted as key local level barriers to healthy eating. CONCLUSIONS: Pricing strategies are needed to ensure that all students have access to nutritious food, particularly in the context of vulnerable populations. Recognition of the context and culture in which school nutrition policies are being implemented is essential. Future research to explore the role of public health dietitians in school nutrition policy initiatives and how to leverage local resources and stakeholder support in low income, rural and remote populations is needed.