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The Heart Health Sustainability Model



The HHRC Sustainability Model



This article was prepared by Anne Lessio who is the Training Manager at the Heart Health Resource Centre. She is responsible for administering the center's training workshops and consultation service. Previously Anne was the Project Manager of the "A Change of Heart" heart health demonstration site and learned first hand the complexity of and time required for successful sustainability efforts.



A. INTRODUCTION



The Ontario Heart Health Program (OHHP), funded by Ontario's Ministry of Health and Long Term Care, is a five-year program with the goal of reducing the prevalence of three modifiable risk factors (smoking, physical inactivity, unhealthy eating) associated with cardiovascular disease. In the 1999-2000 fiscal year, the OHHP funded 36 community-based projects throughout Ontario, which collectively offered 727 local programs and activities.



The OHHP builds upon the accomplishments and learnings of the heart health demonstration phase, which occurred between 1990 - 1997. One of the learnings from the demonstration projects is that sustainability is a complex process, requiring much time and planning. The OHHP incorporated this learning by requiring that the current local heart health projects complete a sustainability plan in year 3 of the five-year funding period.



The Heart Health Resource Centre (HHRC) has assumed a lead role in providing comprehensive support to the local heart health community projects in the area of sustainability. This article describes the four components of the HHRC Sustainability Model along with their respective definitions, key concepts, projected outcomes and factors. The information in this article is a summary of the HHRC "Sustainability Workbook for Action" which is available (see section H below for contact information). Also available is the workbook's executive summary (in the form of a newsletter). The Factors for each of the four components of the HHRC Sustainability Model are listed in both the workbook and newsletter, plus they are available in worksheet format.

B. THE CONCEPT OF SUSTAINABILITY AND THE HHRC SUSTAINABILITY MODEL



i. The General Concept of Sustainability



The concept of sustainability, and more specifically its implementation in health promotion, although not new, is still in the formative stages. Sustainability has been interpreted in many ways by many authors. Within the OHHP, sustainability has come to be understood as a broad term referring to continuation. Most of the research about sustainability has focused on program maintenance and has been associated with concepts such as "institutionalization", "incorporation", and "integration". This is a process by which a local host organization gradually assumes the entire responsibility for a program as the originating agency retreats and disengages from the decision-making process and from financial and managerial control of the program. With the HHRC Sustainability Model, this is referred to as "community integration".



ii. The Four Components of the HHRC Sustainability Model



Although program continuation is a crucial component of sustainability, the HHRC Sustainability Model is broader than just the maintenance of programs. Sustainability is considered to consist of four different components, each of which requires some level of continuation for a successful sustainability outcome.



As noted above, one of the crucial components is to sustain the PROGRAMS that communities plan, implement and evaluate. Another component related to continuation is sustaining the ISSUE of heart health on the agenda of stakeholders such as the public, decision-makers and community partners. A third component of sustainability is sustaining the BEHAVIOUR CHANGES of individuals and communities that occur during the OHHP. The fourth and final component of the HHRC Sustainability Model is to sustain the PARTNERSHIP that will support the activities to be continued.



Each of these four components of sustainability (the ISSUE, the PROGRAMS, the BEHAVIOUR CHANGES, and the PARTNERSHIP) is outlined in more detail below. But first the three transferable concepts common to each of the four components are described.



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C. TRANSFERABLE CONCEPTS BETWEEN ALL FOUR COMPONENTS OF THE HHRC

SUSTAINABILITY MODEL



While each of the four components of sustainability have distinct key concepts, three key concepts are common among all components: Diffusion, Leadership and Resource Considerations.



i. Diffusion



Diffusion is the general process of spreading an innovation from one setting or individual to another. This can include spreading new ideas, techniques or resources. According to the "Diffusion of Innovation Theory" developed by Everett Rogers, a new idea is adopted in stages across a particular audience. The essence of the diffusion process is the human interaction through which one person communicates a new idea to another person. The first people to adopt a new idea or behavior, known as the "innovators", represent about 2.5% of the population. Next come the "early adopters", about 13.5% of people, who are fast followers and tend to be opinion leaders. Then the early and late majority, comprising 68% of the population, adopt the new behavior. Followed by the laggards, who represent 16% of people.



Diffusion is a slow process. Full completion of diffusion strategies within the heart health funding period, such that all laggards are "converted", is unlikely. Thus, the challenge is to identify strategies that will maximize diffusion efforts during the funding phase of the period and will require minimal maintenance after the funding period.



For example, a potential diffusion strategy that can be used to sustain one of the components of sustainability, the ISSUE, is to select one or more opinion leaders from the community who resemble the intended audience as spokespersons for the media part of a communication campaign.



ii. Leadership



There is an element of leadership involved in each of the four components of sustainability. Leaders can be animators, facilitators or champions and can be formal, informal or volunteer leaders. Within specific programs, leaders can be role models or peer leaders; or they can be program champions.



iii. Resource Considerations



A resource is any source of aid or support than enhances a person's ability to deal with a problem or situation. Resources can take the form of human, financial or material. In working towards sustainability, the heart health projects will need to address the resource implications of continuing programs and activities. Lower maintenance programs, those that require fewer resources and have low administrative overhead, will likely be easier to finance. Lower maintenance programs tend to appeal to potential future funders or adopting organizations.



Two main strategies exist for a community to employ to generate sufficient resources to sustain the issue, program, behavior changes and partnership. A community can either solicit SUPPORT or it can solicit FUNDS. Rather than being mutually exclusive, these two strategies can be complementary.



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D. COMPONENT OF SUSTAINABILITY -- THE ISSUE



i. Definition



An issue is a 'point or matter', the decision of which is of special or public importance. Craig Levebre says that, "the goal of sustaining the issue is to convince people and institutions to make long-term commitments to heart health". To address heart disease, many years of programming will be required. If continued work is to be sustained, the issue of heart disease needs to be kept alive and important to: the public; the decision-makers; and to community partners.



ii. Key Concepts



Three key concepts ensure that heart health is kept on the agenda of the different stakeholders. 1. Health communication campaigns, where the campaigns have two primary purposes. First, to change levels of general awareness about heart health and second to advocate for initiatives geared towards healthy social policy change.

2. Diffusion

3. Leadership



iii. Suggested Projected Results



The aim of keeping heart health on the stakeholder agenda is to increase the likelihood that:

* The PUBLIC will ...take the next step towards lifestyle changes and be supportive of community/ system heart health policy shifts.

* The DECISION-MAKERS will.... be open and willing to shifts in practices and policies that create supportive environments for heart health which in turn help sustain the work of the local project and support the local project as a champion for others.

* the LOCAL PARTNERS will... be open to a proposal of integrating a program or initiative to address heart health and stay involved, in order to continue collective and individual efforts too address the issue.



iv. Factors



Factors are specific actions that when in place, increase the likelihood of sustainability. There are 18 factors in total for sustaining the ISSUE. Below is a sampling of these.

1. Dissemination of the "stimuli" (messages, information, and presentations) to intended audiences occurs frequently and consistently, over a sustained period.

2. No or low cost media advocacy strategies are in place to affect decision-makers and partners.

3. Credibility as a resource on the issue has been established by providing accurate, relevant, and timely information.

4. Partners are prepared to include the promotion of the issue in their work, ideally by using consistent messaging.

5. Opinion leaders are in place who are prepared to act as spokespersons for the issue.



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E. COMPONENT OF SUSTAINABILITY -- THE PROGRAMS



i. Definition



A program is one individual activity within the overall local community heart health project. A program may stand alone (e.g., school breakfast program), or be part of a larger initiative (e.g., comprehensive heart health school program). Program sustainability means working towards the continuation of programs within the community. Programs usually progress through 4 stages: initiation, implementation, evaluation and integration. Sustaining the program will require different strategies depending on its stage of development.



ii. Key Concepts



There are four key concepts in sustaining a program:

1. Commuity Integration: a program is integrated when one or more organizations assume responsibility for it, as the initiating agency retreats and disengages from the decision-making process and from financial and managerial control of the program.

2. Best Practices: it is more likely that a program will be sustained if it has been based on a best practice.

3. Diffusion: more people are reached with a program when it is widely disseminated. Increased uptake, and therefore impact, can occur in new settings/ channels or in a new geographic area.

4. Leadership: effective program leadership is important. As well, in working towards program integration, program champions are key.



iii. Suggested Projected Results



The goal of sustaining a program is for it to continue in the community after the OHHP. This is achieved by integrating the program into the community through one, or a combination, of the following models:

* Independent model: an host organization / agency / individual takes full responsibility for a program, usually through an integration process

* Cooperative Model: a single agency administers the program while other organizations cooperate, as needed, in the delivery of the program

* Coordinated Model: joint planning of program occurs but individual partners implement various pieces

* Collaborative Model: the current or adapted partnership continues to work together on the program with common goals and shared responsibilities



iv. Factors



Depending on the stage of program development, there are specific factors to consider in order to identify the appropriate actions to increase the probability of sustaining the PROGRAMS. The following is a sampling of these:

1. The program is grounded in sound theory or is based on "best practices".

2. There is more than one partner involved in the program development.

3. The program can be implemented in absence of paid staff. This makes it four times more likely to be sustained.

4. The program helps partners, especially lead partners, to achieve their individual mandates.

5. Evaluation results indicate that program participants are very positive about the program, its implementation and its effect.

6. The program data being collected is useful in convincing potential lead agencies to adopt the program and / or provide evidence of continued support from a funder.

7. Participants who have completed the program are engaged in the diffusion process.

8. An intentional process of gradual turnover of project responsibility to a local person, committee, or organization has occurred or is occurring.



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F. COMPONENT OF SUSTAINABILITY - BEHAVIOUR CHANGES



i. Definition



The Stages of Change model describes 5 progressive stages of behaviour change an individual passes through in pursuit of new behaviours:

Precontemplation, Contemplation, Preparation, Action and Maintenance.

People attempting to change their behaviours will usually access both self-help strategies and community programs, thus both Individual and Community Strategies will be necessary in the sustainability phase to sustain the behaviour changes.



ii. Key Concepts



Both Population supports (such as healthy public policies) and Individual supports (such as social support strategies) are key concepts to supporting behaviour changes. These, along with Leadership and Diffusion Strategies, are necessary to prevent individuals from relapsing into their previous behaviours.



iii. Suggested Projected Results



To ensure that the behavior changes in the individual and in the community are sustained after the funding period, local communities will need to establish up to four kinds of outputs:

* Healthy public policies and practices, both formal and informal, addressing all three risk factors for heart disease.

* Physical structures, supporting heart healthy behaviors, e.g., bike paths, are in place

* Individual Programs and Supports are Available and Accessible for people who want to maintain heart healthy behaviour changes e.g., professional help lines, health professional support services and self-help groups

* Strategies that support an individual's behaviour changes, e.g., processes of change, are included in future resources and programs as they are delivered.



iv. Factors



Factors are either population-based or individual-based. The following factors are samples of those supporting the Population-based strategies:

1. Healthy public policies and environmentally supportive outcomes are included in all appropriate programs.

2. Broad based community participation in the development of healthy public policies and environmental supports.

3. Local government shows commitment to publicly affirming the importance of heart healthy communities and their resolution to be one.



While the following factors are samples of those supporting the Individual-based strategies

1. Behaviour maintenance resources, e.g., self-help information, are developed for ongoing use of program participants.

2. Peer support models are developed during the program initiation phase.

3. Peer leaders are recruited from previously held behaviour change programs.



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G. COMPONENT OF SUSTAINABILITY - THE PARTNERSHIP



i. Definition



Ontario community heart health partnerships are known by many names - coalitions, networks, coordinating committees and work groups to name a few. They are referred to here, generically, as partnerships and, imply a group working towards a set of shared outcomes.



In discussing the continuation of a partnership, it is assumed that there is a slate of programs, either planned or underway, on which the partners will continue to focus their efforts. Therefore, it is unlikely that significant efforts will be made to sustain a community heart health partnership unless there is some direction set for the continuation of programs.



ii. Key Concepts



The key concepts specific to sustaining the PARTNERSHIP are:

1. Membership / Involvement: this relates to getting and keeping people involved (citizens, professionals, politicians etc.)

2. Community capacity: the ability of individuals and the community to get the job done.

3. Infrastructure of the partnership: to sustain an infrastructure, those aspects that have worked well can be combined with the needs of the future so a sustainable structure emerges.

4. Ways of work: how the partners operate together in planning and implementing project activities.

5. Diffusion: building on social networks by engaging "influencers" will be important to sustaining both the partnership and the heart health issue.

Influencers are people whose opinions are respected, whose insights are valued and whose support is almost always needed to make any big change.

6. Leadership: Effective leadership instills confidence in the group and results in a greater quantity and quality of outcome. This makes it more likely that current partners will stay involved for the next phase.



iii. Suggested Projected Results



Form follows function -- the structure and infrastructure for the Partnership selected by each community must support the activities the community has decided to pursue during the sustainability phase. This may be different from the structure and infrastructure of the Partnership that supported the project during the OHHP. Nine possible Partnership structures are described in the HHRC Sustainability workbook.



iv. Factors



A total of 37 factors are listed in the HHRC Sustainability workbook for consideration as a community addresses the continuation of their

PARTNERSHIP. These factors are grouped under the headings of:

Membership/Involvement factors; Community Capacity factors; Infrastructure factors and Ways of Work factors.

H. FOR MORE INFORMATION



The HHRC has developed a workbook, executive summary (in a newsletter format), and workshops based on the HHRC Sustainability Model. Research articles supporting this information are also available at the HHRC. Finally, all the factors for each of the four components are listed in a worksheet format facilitating a community's ability to implement the Sustainability Model. If you would like more information, you may contact Anne Lessio, of the Heart Health Resource Centre, at [email protected].



Since the mandate of the HHRC is specifically to support the OHHP, and the applicability of the HHRC Sustainability Model is far greater than heart health, the HHRC has entered discussions with the Ministry of Health and Long Term Care and with other generic resource centers to ensure that the sustainability model itself will be sustained.