Health Promotion International, Vol. 18, No. 3, 199-208,
September 2003
© Oxford University Press 2003
Maximizing children’s physical activity: an evaluability assessment to plan a community-based, multi-strategy approach in an ethno-racially and socio-economically diverse city
1Department of Family Relations and Applied Nutrition, College of Social and Applied Human Sciences, University of Guelph, Guelph, Ontario, Canada, 2Program Policy and Planning Division, Public Health and Community Services Department, Hamilton, Ontario, Canada, 3Toronto Public Health, Toronto, Ontario, Canada, 4Hospital for Sick Children, Toronto, Canada, 5Department of Public Health Sciences, University of Toronto, Toronto, Canada, 6Toronto Parks and Recreation, Toronto, Canada, 7Toronto Catholic District School Board, Toronto, Canada, 8Toronto Children’s Services, Toronto, Canada, 9Ontario Active Living Community Action Project, Toronto, Canada and 10Access and Equity Unit, Toronto, Canada
Address for correspondence: John Dwyer, PhD, Assistant Professor, Department of Family Relations and Applied Nutrition, College of Social and Applied Human Sciences, University of Guelph, Guelph, Ontario, Canada N1G 2W1, E-mail: dwyer{at}uoguelph.ca
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONMETHODOLOGYRESULTS AND DISCUSSIONCONCLUSIONREFERENCES |
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An evaluability assessment was conducted to plan a community-based, multi-strategy approach to physical activity promotion (MSAPAP) to maximize young children’s physical activity in an ethno-racially and socio-economically diverse city. This assessment involved consultation with various stakeholders to develop a program logic model to diagrammatically describe the MSAPAP. First, published literature regarding physical activity was reviewed to describe interventions designed to increase children’s physical activity and to identify factors that contributed to program effectiveness. Secondly, key informants from mainstream service organizations and smaller community-based agencies were interviewed to determine their views on how to increase physical activity among children and families. A workgroup developed a draft logic model based on the results of the literature review and community needs assessment results. Thirdly, stakeholders were consulted about the draft model. This consisted of 12 focus groups with members of school boards (two sessions), members of community organizations (three sessions), lay home visitors who provide support to mothers of young children in ethno-racially diverse communities (one session), and parents from six cultural groups (six sessions). The logic model was revised based on the findings from this consultation. The final logic model shows children aged 3–8 years as the main target group, and parents and various community members who influence children as intermediate target groups. The MSAPAP is depicted as six strategies, which are clusters of program activities that are conceptually similar: community engagement, community assessment, accessibility, promotion, education and skill development, and inclusive programming. The logic model shows the ‘cause and effect’ relationships among program activities, shorter-term outcome objectives (e.g. to reduce user fees for physical activity programs) and longer-term outcome objectives (e.g. to increase the proportion of children who are physically active). The extensive community involvement in planning the MSAPAP facilitated a subsequent plan to develop, implement and evaluate selected program activities in the MSAPAP.
Key words: community development; evaluability assessment; logic model; physical activity
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODOLOGYRESULTS AND DISCUSSIONCONCLUSIONREFERENCES |
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The Toronto Cancer Prevention Coalition (TCPC) was formed in 1998 to coordinate primary and secondary cancer prevention initiatives in the multicultural city of Toronto, Ontario (Basrur, 1999
). The coalition comprised a steering committee and various workgroups related to the main areas of primary prevention identified in the Report of the Ontario Task Force on the Primary Prevention of Cancer (Ontario Task Force on the Primary Prevention of Cancer, 1995). Diverse organizations that address municipal cancer prevention were represented in the coalition. The areas that were addressed were tobacco use, dietary risk factors, alcohol use, physical inactivity, occupational carcinogens, environmental carcinogens, ultraviolet radiation, reproductive life and related factors, infections, medications, and socio-environmental determinants of cancer.
The Physical Activity Workgroup of the TCPC was formed in 1999. In reviewing the recommendations related to physical activity in the Report of the Ontario Task Force on the Primary Prevention of Cancer (Ontario Task Force on the Primary Prevention of Cancer, 1995), the workgroup suggested that planning and implementing action strategies to support the development of young children into physically active adolescents and adults should be a priority for cancer prevention initiatives. Specifically, the workgroup posited that the foundation for life-long physical activity is laid early in the life cycle and, hence, it should focus on examining strategies to maximize young children’s physical activity (Physical Inactivity Working Group, 2000). To this end, the workgroup recommended planning a community-based, multi-strategy approach to maximize young children’s physical activity in the ethno-racially and socio-economically diverse city of Toronto.
This article describes an evaluability assessment that was done to plan a community-based, multi-strategy approach to physical activity promotion (MSAPAP) to maximize young children’s physical activity in Toronto. This formative evaluation strategy integrates program planning, development and evaluation (Fisher and Peters, 1985), similar to that of Macaskill and colleagues (Macaskill et al., 2000) for developing a provincial restaurant health promotion program in Ontario, Canada. An evaluability assessment involves the development of a program theory, which is often referred to as a program logic model, to describe a program diagrammatically. A logic model shows the assumptions underlying a program by linking program activities and program objectives. A logic model represents the logic or conceptualization on which a program is based (Rutman, 1980; Wholey, 1987; Smith, 1989; Rossi et al., 1999).
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METHODOLOGY |
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TOPSUMMARYINTRODUCTIONMETHODOLOGYRESULTS AND DISCUSSIONCONCLUSIONREFERENCES |
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Literature review
A review of published literature regarding children’s physical activity promotion assisted in the development of the logic model. The literature review aimed to identify effective interventions designed to increase physical activity in high-risk children groups (e.g. native children) and the general population, and to identify factors that contributed to program effectiveness. Most interventions focused on multiple factors affecting health, including physical activity, nutrition, and smoking prevention. The intervention studies that were reviewed included: Go for Health Texas project (Parcel et al., 1989
; Simons-Morton et al., 1991); Nebraska project (Donnelly et al., 1996); a cardiovascular project in North Carolina (Harrell et al., 1996; Harrell et al., 1998; Harrell et al., 1999); Child and Adolescent Trial for Cardiovascular Health project (Edmundson et al., 1996; Luepker et al., 1996; McKenzie et al., 1996; Nader et al., 1999); Stanford obesity prevention project (Robinson, 1999); a health and nutrition program in Greece (Manios et al., 1998; Manios et al., 1999); Kahnawake diabetes prevention project in a Mohawk community in Canada (Macaulay et al., 1997); and Pathways Health project in American-Indian communities (Caballero et al., 1998; Going et al., 1999; Teufel et al., 1999). Also, some key longitudinal studies that tracked physical activity from childhood to adult life (Dennison et al., 1988; Kuh and Cooper, 1992; Kelder et al., 1993; Trudeau et al., 1999) were reviewed.
Community needs assessment
The Physical Activity Workgroup then conducted a community needs assessment to determine key informants’ views about how to increase physical activity among children (3–8 years old) and families in Toronto. Thirty-minute face-to-face interviews were conducted with 30 key informants in the year 2000. Sixteen of the interviewees were from mainstream service organizations in Toronto, which deliver physical activity promotion or programming to the general population of young children and their families/caregivers. These organizations included Toronto Parks and Recreation, Toronto Children’s Services, Toronto Public Health (TPH), YMCA, Toronto District School Board, Toronto Catholic District School Board, and Metro Toronto Housing Authority. The remaining 14 interviewees were from smaller community-based agencies in neighborhoods across the city, which serve a range of ethno-racially diverse communities and offer recreation to young children and their families/ caregivers. These agencies included Boys and Girls Clubs and community/neighborhood centers. The findings from the community needs assessment were also integrated in the development of a draft logic model depicting the proposed MSAPAP to maximize young children’s physical activity.
Stakeholder consultation about the logic model
The protocol to consult with stakeholders was reviewed and approved via TPH’s research review process. The protocol included voluntary participation, confidentiality and verbal informed consent. Focus groups with various stakeholders were conducted in the autumn of 2000 (see Table 1) to share information about the proposed MSAPAP and to obtain feedback on the feasibility of the MSAPAP as depicted in the logic model.
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First, the school board representatives on the Physical Activity Workgroup identified key people to participate in two 2-h sessions for members of the city’s Public and Catholic school boards. Participants consisted of superintendents, principals, physical activity consultants and others, such as staff responsible for equity issues. An experienced facilitator presented details of the logic model to participants. They were asked: (i) whether the desired outcomes and program activities were clear and realistic; (ii) which outcomes and activities should be revised, added or omitted; (iii) about factors that might challenge and facilitate the implementation of the MSAPAP; and (iv) about their interest in participating in the MSAPAP. An assistant took notes and audio-taped the sessions for accuracy. A member of the Physical Activity Workgroup attended the sessions to provide background information about the MSAPAP. This process was also used during the sessions for members of community organizations and home visitors.
Secondly, three neighborhoods in Toronto were selected because of their ethno-racially diverse and socio-economically disadvantaged populations. Statistics Canada 1996 census data indicated that each neighborhood had at least 20% more children than the city’s average percentage, at least five ethnic groups, with diversity in languages, and at least 20% more children living in poverty than the city’s average percentage. Members of the Physical Activity Workgroup identified key community organizations in these neighborhoods that should be represented at three 2-h focus group sessions. Generally, the focus groups included Public and Catholic elementary school principals, teachers and school council representatives from local elementary schools, TPH staff, Toronto Parks and Recreation staff, staff from community centers and community health centers, and staff from other community organizations that provide services such as social, recreation and prevention programs. Some school representatives who were interested in the MSAPAP did not participate in specific sessions because of a labor dispute regarding provincial legislation to increase teacher workload and to require teachers to supervise extracurricular activities. Participants were asked the same questions as given above.
Thirdly, a 2-h focus group session was held with lay home visitors who were employed by TPH to provide support to mothers of young children. Lay home visitors were consulted because they have diverse ethno-racial backgrounds and are familiar with parenting issues. Consultants were hired to ensure that the moderator’s guide and supplementary handouts were in plain language. Participants were asked the same previously mentioned questions.
Fourthly, members of the Physical Activity Workgroup and staff from the Urban Alliance on Race Relations (a non-profit charitable organization that works with the community, public and private sectors to provide educational programs and research addressing racism in society) identified six of the more common cultural groups in each of the three previously mentioned neighborhoods. Community organizations that have regular parent groups were contacted for the purpose of recruiting community members who were from the six cultural groups and had young children to participate in focus group sessions. The purpose of the sessions was to obtain general impressions of the MSAPAP. Participants were given a $25 honorarium and the contacted organizations were given $150 to provide child-care and refreshments for participants at their sites. Consultants were hired to ensure that the moderator’s guide and supplementary handouts were in plain language and translated when necessary. For each cultural group, the consultants obtained background information, identified the preferred language, determined the typical literacy level, examined how the culture may influence participation in the consultation, and identified what physical activity may mean to them. Also, an artist was commissioned to draw pictures of various physical activities to make it easier for participants with low literacy to understand the concepts covered by the facilitators. Strategies such as requesting possible TPH staff contacts and distributing flyers to community organizations were used to recruit potential facilitators who were bilingual in English and the language of their cultural group. Those who were interviewed and subsequently hired received 8 h of focus group training. A member of the Physical Activity Workgroup attended the training sessions to provide background information about the MSAPAP. For each of the six 2-h sessions with members of the parent groups, two trained people were involved as either a facilitator or a note-taker. The sessions were conducted in the language of the participants. Participants were asked about: barriers and facilitators to their and their children’s participation in physical activity; their views about the proposed goals, target groups and strategies of the MSAPAP; and factors that might make it challenging for them and their children to participate in the MSAPAP. The sessions were audio-taped. The workgroup incorporated the feedback from all of the stakeholder consultation into the final diagrammatic depiction of the MSAPAP.
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RESULTS AND DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODOLOGYRESULTS AND DISCUSSIONCONCLUSIONREFERENCES |
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Literature review
Based on the review, the workgroup concluded that: (i) there was support to focus on school-based interventions to increase physical activity among young children; (ii) there was support for implementing early childhood interventions to increase the likelihood of participants becoming physically active in later years; (iii) physical activity interventions should be implemented both in school and outside of school; (iv) the beliefs and values of the diverse cultures represented in a community need to be integrated into physical activity interventions to foster family and community empowerment and ownership; and (v) physical activity interventions should be based on sound theory, including a multi-strategy approach. These ideas were subsequently integrated into the planning of the MSAPAP.
Community needs assessment
A manuscript that provides detailed results of the needs assessment is currently in preparation and will be submitted for publication at a later date. Thus, only a few key findings are highlighted here, for the purpose of illustrating how key informants’ input was incorporated into the logic model. Key informants provided the following suggestions to address various gaps in the provision of physical activity programs in Toronto: (i) the MSAPAP should include stronger community partnerships; (ii) a variety of activities should be implemented to increase awareness of the benefits of participating in physical activity and awareness of available physical activity programs; (iii) strategies to overcome cultural barriers to participating in physical activity should be utilized; (iv) schools should be a central site in the MSAPAP because children and their parents/ caregivers have greater familiarity and access to schools; (v) the MSAPAP should emphasize fun and inclusive participation in physical activity, rather than competition; and (vi) the MSAPAP should be tailored to accommodate differences in individual communities in Toronto.
Stakeholder consultation
School boards, community organizations and lay home visitors
The school boards, community organizations and lay home visitors from TPH represent mainstream community organizations and therefore the data were analyzed collectively. The school board participants felt that they should be a key partner in the MSAPAP because, given the amount of time that children spend in school, the school is a hub for providing opportunities to participate in physical activity. However, they did not want to take on the responsibility of being the lead organization for the MSAPAP. Therefore, the Physical Activity Workgroup subsequently proposed that a Community Action Group, with ethno-racial representation and participation of key community stakeholders, be established.
As a group, the stakeholders provided some suggestions. They supported the proposed goals of the MSAPAP and expressed an interest in participating in it. They suggested that improved academic performance should be added as a goal. They felt that some decision-makers would think more favorably of the MSAPAP if a positive relationship between physical activity and academic performance was highlighted. However, the Physical Activity Workgroup did not incorporate this suggested revision into the logic model because the MSAPAP, which is based on a single health-risk factor approach, is probably not comprehensive enough to have such a high-level impact. Participants supported the proposed target groups, but felt that the MSAPAP should target children beyond 3–8 years of age. They suggested a more inclusive target group that also, for example, included older children (particularly female teenagers) and family members.
Participants expressed concern that the list of program activities in the logic model represents prescribed program activities that the community must do. Their concern was addressed by informing them that the list of program activities helps define the MSAPAP and that the community can select from a menu of program activities and can adapt program activities. Participants emphasized that it is important that the community be able to tailor the MSAPAP to address their unique needs.
Participants agreed with the proposed idea that the MSAPAP include a half-time community facilitator who would provide time and expertise in supporting the community’s implementation of the MSAPAP. They felt that this support person would be a key part of the MSAPAP given that the community will need to work with existing resources rather than augmented resources (with the exception of a community facilitator being available) to maximize physical activity. It was suggested that community members need to be integrally involved in the MSAPAP to facilitate community ownership, implementation and sustainability.
Participants mentioned various factors that may present challenges to the implementation of the MSAPAP. They posited that identifying and overcoming barriers to physical activity should be an integral part of the MSAPAP. For example, they noted that some physical activity programs in the community have been cancelled because program fees were initiated or increased. They also noted barriers regarding culture, gender, lack of transportation and safety for children playing outdoors. They expressed concern that the current school curriculum does not mandate daily physical activity and that many elementary teachers who don’t have training and qualifications in physical education are providing physical education in schools. They also pointed out that many low-income people focus on meeting basic needs and, therefore, physical activity is not a priority for them.
Participants suggested several factors that might facilitate implementation of the MSAPAP: (i) education about ways to be physically active without requiring facilities and equipment; (ii) reduced user fees for physical activity programs; (iii) stronger partnerships between schools and other community organizations; (iv) greater coordination of services in the community; (v) more provision of programs (including after-school programs); (vi) child-care arrangements for parents; and (vii) opportunities for teachers and parents to receive training in how to provide physical activity programs. They did feel, however, that it would be challenging to provide training on how to lead physical activity programs to generalist teachers due to the constraints of time and workload.
Parent groups
Participants supported the proposed goals of the MSAPAP and expressed an interest in participating in it. They emphasized that it is important to involve community members in the MSAPAP. They agreed that the main target group should be children, but suggested that it include children both younger and older than 3 and 8 years, respectively.
Participants commented that children would be more physically active if outdoor play areas were safer. They said that children should be able to participate in physical activity programs before, during and after school. They noted that more facilities are needed to increase children’s opportunities to be physically active. Some participants suggested that religious groups should offer physical activity programs and make their religious centers available for space to engage in physical activity programs. However, other participants posited that religious facilities are available exclusively for praying and that it is inappropriate to provide physical activity programs in churches.
Participants felt that it is important for boys and girls to participate equally in physical activity. However, cultural factors sometimes make this difficult. For example, Somalian and Sri Lankan participants said that their cultures don’t support wearing revealing clothes in public, which may prevent them from participating in some physical activities such as swimming. Somalian participants also noted that, traditionally, girls are less likely than boys to participate in certain sports such as soccer. Thus, the MSAPAP needs to include programs that are inclusive of different cultures.
Participants suggested that children would be more physically active if parents participated in physical activity with their children. They noted the importance of educating parents about the benefits of physical activity and the availability of physical activity programs in the community. They suggested that communication channels such as television, radio, newspaper, posters, flyers and schools should be used. They commented that the information should be provided in the various languages spoken in the community.
Participants made several suggestions to facilitate implementation of the MSAPAP. In terms of accessibility, they suggested: (i) increasing the availability of a variety of physical activity programs suitable for children from different cultures; (b) offering programs with no or minimum user fees; and (iii) providing more programs at community centers close to home. Also, they expressed that parents in the community would be interested in taking a leadership role in providing programs if training is provided, if child care is available, and if they can supervise physical activity programs in clothing that is acceptable to their culture.
Final logic model
The Physical Activity Workgroup revised the logic model based on the findings from the stakeholder consultation. Figure 1 shows the final logic model for the MSAPAP. The main target group is children aged 3–8 years, but the program is open to children beyond this age group. Intermediate target groups that influence the children are leaders from community organizations, teachers, child program workers, parents/caregivers, and other community stakeholders. The broad goals are to ensure access and equity for children to be physically active, to maximize their physical activity and to improve their health.
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The MSAPAP is conceptualized as six strategies. Each strategy is comprised of program activities, as illustrated below.
Community engagement involves mobilizing community stakeholders, developing a Community Action Group, and exploring ways for organizations to work together to coordinate their physical activity programs. The assumption is that these activities will achieve shorter-term outcomes such as better quality partnerships among community organizations, greater sharing of resources among organizations, and increased parental involvement in implementing physical activity programs.
Community assessment entails identifying barriers to physical activity participation in the community, developing an inventory of physical activity programs available in the community, and assessing the level of inter-organizational collaboration in physical activity programming. Expected shorter-term outcomes for these activities include increased awareness of available physical activity programs and increased awareness of community needs related to physical activity promotion.
Accessibility involves identifying barriers to physical activity participation, and developing and implementing programs to address these barriers. Identifying the barriers to address enables the expected shorter-term outcomes to be established. Possible outcomes are more available sites where children can engage in physical activity, and reduced user fees for physical activity programs.
Promotion entails using various communication channels to promote existing and new physical activity programs in the community. Some expected shorter-term outcomes related to this strategy are increased awareness of available physical activity programs and increased utilization of physical activity resources among teachers and child program workers.
Education and skill development involves providing support to intermediate target groups regarding how to utilize physical activity resources and implement physical activity programs. It is assumed that these activities will achieve shorter-term outcomes such as increased knowledge and skills to provide physical activity programs and to be physically active with children.
Inclusive programming entails offering before-, during- and after-school physical activity programs that are suitable for children from different cultures. An expected shorter-term outcome is increased opportunities for children of diverse ethno-cultural backgrounds to be physically active.
Another assumption is that achievement of the shorter-term outcomes will lead to two further outcomes: (i) a decrease in access barriers to physical activity opportunities for children; and (ii) an increase in the availability and use of inclusive child physical activity programs. In turn, it is assumed that reaching these two outcomes will contribute to the achievement of the longer-term outcomes for children, namely: (i) increased intrinsic motivation for physical activity; (ii) an increased proportion of children who are physically active (as defined by at least 30 min of accumulated physical activity at least 4 days per week); (iii) increased self-esteem; and (iv) increased fitness.
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CONCLUSION |
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TOPSUMMARYINTRODUCTIONMETHODOLOGYRESULTS AND DISCUSSIONCONCLUSIONREFERENCES |
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A review of the literature regarding physical activity interventions for children, key informant interviews to assess community needs pertaining to physical activity promotion, and extensive stakeholder consultation were done to plan a community-based approach to maximize children’s physical activity in the community. A variety of stakeholders, such as school boards that provide both curricular and co-curricular physical activity programs, organizations that provide physical activity programs in the community, lay home visitors who are employed by a public health unit, and parent groups from different cultures, were consulted to obtain input in the planning of multiple strategies to increase physical activity among children. This consultation provided key stakeholders with the opportunity to shape a comprehensive approach to promoting physical activity at all levels and through multiple channels in the community. In turn, the process increased the likelihood that the multi-strategy approach is feasible to implement in the community and well accepted among stakeholders. For example, with the support of some of these stakeholders, several of the authors are currently conducting research related to some specific program activities in the logic model that address desired outcomes such as schools meeting curriculum requirements for physical activity. This area of investigation raises issues that have been contentious within the education system. The shared commitment to the common objective of increased physical activity among children, which was solidified through the consultation process, established an inter-sectorial trust that enabled the exploration of sensitive issues in policy and practice. Thus, the evaluability assessment facilitated both the development of strategies to promote physical activity, and the subsequent implementation and evaluation of program activities within those strategies.
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ACKNOWLEDGEMENTS |
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We wish to thank Jennifer Yessis, Adam Spencer and Barb van Maris from Smaller World Communications for providing support for the implementation of the community needs assessment and stakeholder consultation, and in the ensuing development of the logic model. We also appreciate the contribution of the facilitators and note-takers in the focus group sessions. The evaluability assessment was supported by funding from the Children and Youth Action Committee in Toronto.
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