A systematic review of school health policy measurement tools: implementation determinants and outcomes

A Semantic Approach to Describe Social and Economic Characteristics That Impact Health Outcomes (Social Determinants of Health): Ontology Development Study

BACKGROUND

Social determinants of health (SDoH) have been described by the World Health Organization as the conditions in which individuals are born, live, work, and age. These conditions can be grouped into 3 interrelated levels known as macrolevel (societal), mesolevel (community), and microlevel (individual) determinants. The scope of SDoH expands beyond the biomedical level, and there remains a need to connect other areas such as economics, public policy, and social factors.

OBJECTIVE

Providing a computable artifact that can link health data to concepts involving the different levels of determinants may improve our understanding of the impact SDoH have on human populations. Modeling SDoH may help to reduce existing gaps in the literature through explicit links between the determinants and biological factors. This in turn can allow researchers and clinicians to make better sense of data and discover new knowledge through the use of semantic links.

METHODS

An experimental ontology was developed to represent knowledge of the social and economic characteristics of SDoH. Information from 27 literature sources was analyzed to gather concepts and encoded using Web Ontology Language, version 2 (OWL2) and Protégé. Four evaluators independently reviewed the ontology axioms using natural language translation. The analyses from the evaluations and selected terminologies from the Basic Formal Ontology were used to create a revised ontology with a broad spectrum of knowledge concepts ranging from the macrolevel to the microlevel determinants.

RESULTS

The literature search identified several topics of discussion for each determinant level. Publications for the macrolevel determinants centered around health policy, income inequality, welfare, and the environment. Articles relating to the mesolevel determinants discussed work, work conditions, psychosocial factors, socioeconomic position, outcomes, food, poverty, housing, and crime. Finally, sources found for the microlevel determinants examined gender, ethnicity, race, and behavior. Concepts were gathered from the literature and used to produce an ontology consisting of 383 classes, 109 object properties, and 748 logical axioms. A reasoning test revealed no inconsistent axioms.

CONCLUSIONS

This ontology models heterogeneous social and economic concepts to represent aspects of SDoH. The scope of SDoH is expansive, and although the ontology is broad, it is still in its early stages. To our current understanding, this ontology represents the first attempt to concentrate on knowledge concepts that are currently not covered by existing ontologies. Future direction will include further expanding the ontology to link with other biomedical ontologies, including alignment for granular semantics.

School Health Services in India: Status, Challenges and the Way Forward

Schools provide a crucial platform for health and well-being interventions targeting children and adolescents. Early promotive and preventive initiatives are vital for enabling children and adolescents to reach their optimal potential, thereby adding to the country's social return-on-investment, creating a favourable demographic dividend. This review analyses the evolution of school health initiatives in India, including the current curriculum proposed under the Ayushman Bharat program. The manuscript highlights the challenges, and gaps in implementation of the current school health programs and proposes potential pathways for bridging these gaps for promotion of adolescent well-being. The review also discusses the concept of Health Promoting Schools and suggests adaptations and key recommendations to Indian context regarding 'how' to translate it into on-field reality based on the appraisal of successful case studies from other countries. Though India started school health services more than 100 y ago, the school health programmes in most Indian states are weak and fragmented, with piecemeal health screening with minimal focus on health promotion and well-being. The recently launched School Health and Wellness initiative under the Ayushman Bharat program has lots of promise. However, it needs to be translated into effective implementation to prevent it from meeting the fate of its forerunner programs. The school health program needs to move beyond the screening centric approach and be aspirational and holistic in nature focusing upon the overall well-being of the adolescents. Concerted efforts through intersectoral convergence are needed to optimally utilise the platforms of schools for promotion of adolescent well-being.

Applying hybrid effectiveness-implementation studies in equity-centered policy implementation science

Policy implementation science (IS) is complex, dynamic, and fraught with unique study challenges that set it apart from biomedical or clinical research. One important consideration is the ways in which policy interacts with local contexts, such as power and social disadvantage (e.g., based on ability, race, class, sexual identity, geography). The complex nature of policy IS and the need for more intentional integration of equity principles into study approaches calls for creative adaptations to existing implementation science knowledge and guidance. Effectiveness-implementation hybrid studies were developed to enhance translation of clinical research by addressing research questions around the effectiveness of an intervention and its implementation in the same study. The original work on hybrid designs mainly focused on clinical experimental trials; however, over the last decade, researchers have applied it to a wide range of initiatives and contexts, including more widespread application in community-based studies. This perspectives article demonstrates how effectiveness-implementation hybrid studies can be adapted for and applied to equity-centered policy IS research. We draw upon principles of targeted universalism and Equity in Implementation Research frameworks to guide adaptations to hybrid study typologies, and suggest research and engagement activities to enhance equity considerations; for example, in the design and testing of implementing strategies. We also provide examples of equity-centered policy IS studies. As the field of policy IS rapidly evolves, these adapted hybrid type studies are offered to researchers as a starting guide.

Protocol for a scoping review of health equity frameworks and models applied in empirical studies of chronic disease prevention and control

BACKGROUND

Chronic diseases, such as cancers and cardiovascular diseases, present the greatest burden of morbidity and mortality worldwide. This burden disproportionately affects historically marginalized populations. Health equity is rapidly gaining increased attention in public health, health services, and implementation research, though many health inequities persist. Health equity frameworks and models (FM) have been called upon to guide equity-focused chronic disease and implementation research. However, there is no clear synthesis of the health equity FM used in chronic disease research or how these are applied in empirical studies. This scoping review seeks to fill this gap by identifying and characterizing health equity FM applied in empirical studies along the chronic disease prevention and control continuum, describing how these FM are used, and exploring potential applications to the field of implementation science.

METHODS

We follow established guidance for conducting scoping reviews, which includes six stages: (1) identify the research question; (2) identify relevant studies; (3) select studies for inclusion; (4) data extraction; (5) collating, summarizing, and reporting the results; and (6) consultation. This protocol presents the iterative, collaborative approach taken to conceptualize this study and develop the search strategy. We describe the criteria for inclusion in this review, methods for conducting two phases of screening (title and abstract, full text), data extraction procedures, and quality assurance approaches taken throughout the project.

DISCUSSION

The findings from this review will inform health-equity focused chronic disease prevention and control research. FM identified through this review will be added to an existing website summarizing dissemination and implementation science frameworks, and we will offer case examples and recommendations for utilizing a health equity FM in empirical studies. Our search strategy and review methodology may serve as an example for scholars seeking to conduct reviews of health equity FM in other health disciplines.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework Registration https://doi.org/10.17605/OSF.IO/SFVE6.

A Scoping Review on Quality Physical Education Programmes and Their Outcomes on Primary-Level Pupils

A scoping review was carried out on the literature relating to the evaluation of the implementation of quality physical education (QPE) programmes and related outcomes on final-stage primary-level pupils' attitudes towards physical education (ATPE), physical activity behaviour (PAB), mental wellbeing (MWB) and academic achievement (AA). The scoping review included studies published between 2000 and 2020 in the PubMed, Elsevier, SCOPUS and CINAHL databases and was completed in accordance with the PRISMA extension for scoping reviews' guidelines. Based on the inclusion criteria, 15 out of 2869 studies were included in the review. A thematic analysis was used to inductively and deductively analyse the studies for common themes of features of QPE programmes in primary schools, arising from nine different countries, considering the four outcome dimensions (ATPE, PAB, MWB and AA). The common themes identified as features of QPE across all four dimensions were as follows: (1) government leadership; (2) PE curriculum; (3) school principal and leaders; (4) organisational management from leadership in school; (5) teachers; (6) parental involvement; and (7) community partnerships. Based on these findings, recommendations were made for an evaluation framework on QPE in primary education.

Investigating implementation of school health policies through a health equity lens: A measures development study protocol

Background

School-based policies that ensure provision of nutrition, physical activity, and other health-promoting resources and opportunities are essential in mitigating health disparities among underserved populations. Measuring the implementation of such policies is imperative to bridge the gap between policy and practice. Unfortunately, limited practical, psychometrically strong measures of school policy implementation exist. Few available explicitly focus on the issues of equity and social justice as a key component of implementation, which may result in underassessment of the equity implications of policy implementation. The purpose of this study is to develop equity-focused measures in collaboration with practitioners, researchers, and other key implementation partners that will facilitate evaluation of policy implementation determinants (i.e., barriers and facilitators), processes, and outcomes.

Methods

We will actively seek engagement from practitioners, researchers, and advocacy partners (i.e., stakeholders) who have expertise in school health policy throughout each phase of this project. We propose a multi-phase, 1-year project comprising the following steps: (1) selection of relevant constructs from guiding frameworks related to health equity and implementation science; (2) initial measure development, including expert feedback on draft items; (3) pilot cognitive testing with representatives from key target populations (i.e., school administrators, teachers, food service staff, and students and parents/guardians); and (4) measure refinement based on testing and assessment of pragmatic properties. These steps will allow us to establish initial face and content validity of a set of instruments that can undergo psychometric testing in future studies to assess their reliability and validity.

Discussion

Completion of this project will result in several school policy implementation measurement tools which can be readily used by practitioners and researchers to evaluate policy implementation through a health equity lens. This will provide opportunities for better assessment and accountability of policies that aim to advance health equity among school-aged children and their families.

Trial registration

Open Science Framework Registration doi: 10.17605/OSF.IO/736ZU.

Quantitative measures used in empirical evaluations of mental health policy implementation: A systematic review

Background

Mental health is a critical component of wellness. Public policies present an opportunity for large-scale mental health impact, but policy implementation is complex and can vary significantly across contexts, making it crucial to evaluate implementation. The objective of this study was to (1) identify quantitative measurement tools used to evaluate the implementation of public mental health policies; (2) describe implementation determinants and outcomes assessed in the measures; and (3) assess the pragmatic and psychometric quality of identified measures.

Method

Guided by the Consolidated Framework for Implementation Research, Policy Implementation Determinants Framework, and Implementation Outcomes Framework, we conducted a systematic review of peer-reviewed journal articles published in 1995-2020. Data extracted included study characteristics, measure development and testing, implementation determinants and outcomes, and measure quality using the Psychometric and Pragmatic Evidence Rating Scale.

Results

We identified 34 tools from 25 articles, which were designed for mental health policies or used to evaluate constructs that impact implementation. Many measures lacked information regarding measurement development and testing. The most assessed implementation determinants were readiness for implementation, which encompassed training (n  =  20, 57%) and other resources (n  =  12, 34%), actor relationships/networks (n  =  15, 43%), and organizational culture and climate (n  =  11, 31%). Fidelity was the most prevalent implementation outcome (n  =  9, 26%), followed by penetration (n  =  8, 23%) and acceptability (n  =  7, 20%). Apart from internal consistency and sample norms, psychometric properties were frequently unreported. Most measures were accessible and brief, though minimal information was provided regarding interpreting scores, handling missing data, or training needed to administer tools.

Conclusions

This work contributes to the nascent field of policy-focused implementation science by providing an overview of existing measurement tools used to evaluate mental health policy implementation and recommendations for measure development and refinement. To advance this field, more valid, reliable, and pragmatic measures are needed to evaluate policy implementation and close the policy-to-practice gap.

Plain Language Summary

Mental health is a critical component of wellness, and public policies present an opportunity to improve mental health on a large scale. Policy implementation is complex because it involves action by multiple entities at several levels of society. Policy implementation is also challenging because it can be impacted by many factors, such as political will, stakeholder relationships, and resources available for implementation. Because of these factors, implementation can vary between locations, such as states or countries. It is crucial to evaluate policy implementation, thus we conducted a systematic review to identify and evaluate the quality of measurement tools used in mental health policy implementation studies. Our search and screening procedures resulted in 34 measurement tools. We rated their quality to determine if these tools were practical to use and would yield consistent (i.e., reliable) and accurate (i.e., valid) data. These tools most frequently assessed whether implementing organizations complied with policy mandates and whether organizations had the training and other resources required to implement a policy. Though many were relatively brief and available at little-to-no cost, these findings highlight that more reliable, valid, and practical measurement tools are needed to assess and inform mental health policy implementation. Findings from this review can guide future efforts to select or develop policy implementation measures.

Adaptation and Validation of the Program Sustainability Assessment Tool (PSAT) for Use in the Elementary School Setting

There is a lack of valid and reliable measures of determinants of sustainability specific to public health interventions in the elementary school setting. This study aimed to adapt and evaluate the Program Sustainability Assessment Tool (PSAT) for use in this setting. An expert reference group adapted the PSAT to ensure face validity. Elementary school teachers participating in a multi-component implementation intervention to increase their scheduling of physical activity completed the adapted PSAT. Structural validity was assessed via confirmatory factor analysis. Convergent validity was assessed using linear mixed regression evaluating the associations between scheduling of physical activity and adapted PSAT scores. Cronbach's alpha was used to evaluate internal consistency and intracluster correlation coefficients for interrater reliability. Floor and ceiling effects were also evaluated. Following adaptation and psychometric evaluation, the final measure contained 26 items. Domain Cronbach's alpha ranged from 0.77 to 0.92. Only one domain illustrated acceptable interrater reliability. Evidence for structural validity was mixed and was lacking for convergent validity. There were no floor and ceiling effects. Efforts to adapt and validate the PSAT for the elementary school setting were mixed. Future work to develop and improve measures specific to public health program sustainment that are relevant and psychometrically robust for elementary school settings are needed.

The psychometric and pragmatic evidence rating scale (PAPERS) for measure development and evaluation

To rigorously measure the implementation of evidence-based interventions, implementation science requires measures that have evidence of reliability and validity across different contexts and populations. Measures that can detect change over time and impact on outcomes of interest are most useful to implementers. Moreover, measures that fit the practical needs of implementers could be used to guide implementation outside of the research context. To address this need, our team developed a rating scale for implementation science measures that considers their psychometric and pragmatic properties and the evidence available. The Psychometric and Pragmatic Evidence Rating Scale (PAPERS) can be used in systematic reviews of measures, in measure development, and to select measures. PAPERS may move the field toward measures that inform robust research evaluations and practical implementation efforts.