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Designing Effective Healthy Lifestyle Programs

Consumer Health Foundation

Healthy Lifestyles Collaborative

Session I

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Four Steps for Program Design

• 1. Specify your target outcomes

• 2. Specify your theory of change

• 3. Develop your program design

• 4. Capture your program design in a logic model

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1. Plan with outcomes in mind

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What do we mean by outcomes?

• Outcomes are changes in the people, organizations, or systems that we aim to serve

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What do we mean by outcomes?

• Changes in people– Knowledge– Attitudes & beliefs– Skills– Behavior– Health status

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What do we mean by outcomes?

• Changes in organizations– Vision– Mission– Strategies– Capacity– Capabilities– External Relationships– Internal Culture

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What do we mean by outcomes?

• Changes in systems– System capacity– System cost– System organization– System coordination– System quality– System accessibility

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What does it mean to “plan with outcomes in mind?”

• Begin by specifying what outcomes we want to achieve for people, organizations, or systems

• Make sure we are operating under sound theory of change

• Work backward to design a program that could achieve these outcomes

• Capture the essentials in a logic model

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2. Specify your theory of change

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What is “theory of change?”

• Theory of change, sometimes called program theory, is the set of theoretical assumptions about why your program will benefit particular service population.

• In other words:– What makes you so sure this will work?

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Why is theory of change important?

Every behavioral change program in the world has a theory of change– Some are more explicit than others– Some are more sound than others– Flawed theory of change is one of four basic reasons

why programs fail:• Flawed theory of change• Flawed program design• Flawed program implementation• Flawed program evaluation

– If your theory of change is seriously flawed your program is bound to fail

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Examples of theory of change

• Discuss whether the following statements are sound or unsound– If you immunize a child against MMR, then that

child will avoid MMR– If you educate adolescents about the risks of

tobacco, they will avoid smoking– If you provide a family with Medicaid, they will take

their children in for EPSDT visits– If you teach a family how to make better food

choices, their children will better control their weight

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An integrated theory of change for healthy lifestyles programs

• A theory of change to help you answer seven questions:– Who is your service population?– What outcomes do you want to help them achieve?– Which stage of behavioral change are they in?– What are the pros and cons of change for the service

population?– What change processes will help them move toward

change?– What influences can help them change?– What interventions will your program provide?

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Service Population / Desired Changes or Outcomes

Maintenance

Working to prevent relapse

Action

Making specific changes

Preparation

Intending to take action in next month

Contemplation

Intending to take action in next six month

Pre-contemplation

No intention to take action

An integrated view

Five Stages of Individual Behavior Change

Pros of ChangeCons of Change Decisional Balance

Behavioral

Reengineering * Support * Counter conditioning * Rewarding * Committing

Experiential

Increasing awareness *

Emotional arousal* Social reappraisal * Environmental opportunities * Self reappraisal

Change Processes

Messaging * Education * Counseling * Physical Activity * Skill Training * Organizational Change * Community Change * Policy Change

Change Interventions

Interpersonal * Organizational * Community * Public Policy

Environmental Influences

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Who is your service population?

• By:– Age– Race– Ethnicity– Sex– Geography– Health status– Economic status– Environmental status

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What specific outcomes do you want to help them achieve?

• Changes in:– Eating– Exercise– Substance use– Other

• The knowledge, attitudes, skills required to achieve the above

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What stage of change are they in?

• Pre-contemplation– No intention to quit smoking

• Contemplation– Contemplating quitting within six months

• Preparation– Preparing to quit within one month

• Action– Taking action to quit

• Maintenance– Maintaining non-smoking and preventing relapse

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What is their “decisional balance”?

• What are the pros of change for this population?

• What are the cons of change for this population?

• How do we affirm the pros and overcome the cons so that people move toward action and maintenance and stay there?

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What change processes could help?

• Experiential Processes (Knowledge, Attitudes)– Increased awareness

• Smoking can hurt me

– Emotional arousal• Smoking scares me

– Social reappraisal• My smoking could hurt my family if I get sick

– Environmental opportunities• I see most public places disallow or limit smoking

– Self re-appraisal• I am disappointed in myself for smoking

• Most helpful in pre- contemplation, contemplation, preparation

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What change processes could help?

• Behavioral Processes (Skills, Behaviors)– Stimulus control

• I avoid situations that trigger a craving to smoke

– Helping relationship• I talk with someone who listens when I need to talk about my

smoking

– Counter conditioning• I do something else with my hands as a substitute for smoking

– Rewarding• I treat myself when I go without smoking

– Commitment• I make an explicit commitment not to smoke

• Most helpful in preparation, action, maintenance

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What environmental influences could help?

• Social-ecological model of change• Personal behavior can be affected by:

– Interpersonal influences• Family, friends, social networks

– Organizational influences• School, work, faith community, health care organization,

supermarkets, restaurants, public agencies

– Community influences• Relationships between organizations, cultural environment,

built community

– Public policy influences• Local, state, federal

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What interventions?

• Given your answers to the first six questions:– Will you work directly with the service

population, with influencers, or both?– What interventions will your program provide

to:• Move the service population to action and

maintenance• Keep the service population in action and

maintenance

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What interventions?

• Some common interventions:– Messaging– Education– Counseling– Physical activity– Skill training– Organizational change– Community change– Policy change

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3. Develop your program design

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Elements of Program Design

• Service Population

• Theory of Change

• Outcomes

• Outputs

• Activities

• Inputs

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4. Construct a logic model

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What is a logic model?

• In its simplest conception, it is simply a graphic or tabular description of your program.

• Looking deeper, the best logic models illustrate the underlying theory of the program, or "theory of change." 

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Acme Child Health Enrollment Program

Theory of Change

Inputs Activities Outputs Outcomes

Theoretical assumptions about why a program will work

The resources needed to deliver the program

Key actions of program staff and clients

Products of the program

Changes in the target population

Uninsured children who are eligible but not enrolled will become enrolled if

their parents/ caregivers:•Know they are eligible•Value coverage•Know how to enroll•Have assistance with enrollment process•Complete enrollment process

•10 CBOs•20 outreach workers•2 training experts•Client families with children•$5,000 mini-grant to each organization

Train CBO staff

CBO staff:•Interview parents/ caregivers about child health insurance status•Educate about Medicaid-S-CHIP•Offer assistance with application•Guide through application process•Monitor enrollment

•Parents/ caregivers of 500 children interviewed•100 educated and offered assistance•70 accept application & assistance•50 are enrolled

Families have peace of mind

Children have access to needed health services

Children have better health status

Target Population: Uninsured children eligible for Medicaid or S-CHIP in Anytown, USA

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Acme Child Health Enrollment Program

Theory of ChangeUninsured children who are eligible but not enrolled will become enrolled iftheir parents/ caregivers:•Know they are eligible•Value coverage•Know how to enroll•Have assistance with enrollment process•Complete enrollment process

10 CBOs with total of 20 outreach workers

2 training experts

Inputs

$5,000 mini-grant to each organization

Client families with children

Target PopulationUninsured children eligible for Medicaid or S-CHIP

Interview parents/ caregivers

Educate eligible parents/

caregivers

Activities

Train outreach workers

Provide application assistance

500 interviewed

100 educated

Outputs

50 enrolled

70 accept assistance

Families have peace of mind

Children have access to needed services

Outcomes

Children have better health status

20 trained

Monitor enrollment

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Why are funders so interested?

• Logic models promote program improvement– The process of constructing a logic model forces the funded

organization to develop more theoretically sound programs

• Logic models are efficient – When properly constructed, a logic model can convey the

basic blueprint of a program in one or two pages. 

• Logic models promote understanding and communication– Once funding organizations adopt the terminology of logic

models -- terms like assumptions, inputs, activities, outputs, outcomes -- it gives them a common for understanding and discussing the relative strengths and weaknesses of diverse programs. 

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Why are funders so interested?

• Logic models provide the basis for practical program evaluation – A properly constructed logic model helps the funder identify

the most important focal points for process evaluation and outcome evaluation. 

• Logic models promote organizational learning– As funders review and compare logic models, they learn

valuable information about the theory and practice of health and human service programming. 

– This helps the funder make better decisions and become a more valuable partner in their ongoing relationship with community health and human service programs.

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Why are grantees so interested?

• Because funders are interested!– Programs with a well constructed logic model may

give themselves a competitive advantage in fundraising. 

• Because logic models improve program planning– The process of constructing a logic model forces

programs to ask themselves a number of questions about their target population, assumptions, desired outcomes, etc.  To the extent that these questions are raised and answered during the planning phase, the chances of successful implementation are increased. 

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Why are grantees so interested?

• Because logic models support program implementation.  – Many organizations that develop logic models for funders also

find that periodic review of the logic model in staff or board meetings can help the organization stay focused on its mission assure that its resources are being directed toward the most important outcomes. 

• Because logic models support practical program evaluation– By using the logic model as the basis for evaluation objectives,

both the funder and the funded organization can assure themselves that the evaluation is focused on the most essential aspects of the program.

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If you can answer these questions..

– Who is your service population?  – What outcomes, or personal changes do you want to

help this population achieve? – What level of output do you hope to achieve, in terms

of people served, products produced, etc.  – What activities will be required to produce these

outputs?  – And what inputs, or resources, will be required to

complete the necessary activities?  – What is the theory of change or theory of change that

leads you to believe that people exposed to this program will achieve the desired outcomes? 

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..you can construct a logic model!

• A logic model is simply a way of illustrating what you should already know about your program or plan

• The most important purpose of the logic model is program improvement.– If, in the course of constructing a logic model,

you identify gaps in your knowledge or planning, you simply problem-solve until you can fill those gaps as best you can

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Constructing your own logic models