Grøn Sisse, Loblay Victoria, Conte Kathleen P, Green Amanda, Innes-Hughes Christine, Milat Andrew, Mitchell Jo, Persson Lina, Thackway Sarah, Williams Mandy, Hawe Penelope
DTU - Technical University of Denmark, Engineering Systems Design, Akademivej, Building 358, 2800 Kgs. Lyngby, Denmark.
School of Public Health, University of Sydney, Edward Ford Building, A27 Fisher Road, University of Sydney, NSW 2006, Australia.
Health Promot Int. 2020 Dec 1;35(6):1415-1426. doi: 10.1093/heapro/daaa001.
Implementing programs at scale has become a vital part of the government response to the continuing childhood obesity epidemic. We are studying the largest ever scale-up of school and child care obesity prevention programs in Australia. Health promotion teams support primary schools and early childhood services in their area to achieve a number of specified, evidence-based practices aimed at organizational changes to improve healthy eating and physical activity. Key performance indicators (KPIs) were devised to track program uptake across different areas-measuring both the proportion of schools and early childhood services reached and the proportion of practices achieved in each setting (i.e. the proportion of sites implementing programs as planned). Using a 'tight-loose-tight' model, all local health districts receive funding and are held accountable to reaching KPI implementation targets. However, local teams have independent discretion over how to best use funds to reach targets. Based on 12 months of ethnographic fieldwork and interviews across all districts, this study examines variations in the decision making and strategizing processes of the health promotion teams. We identified three distinct styles of practice: KPI-driven practice (strategic, focussed on targets); relationship-driven practice (focussed on long-term goals); and equity-driven practice (directing resources to sites most in need). In adapting to KPIs, teams make trade-offs and choices. Some teams struggled to balance a moral imperative to attend to equity issues, with a practical need to meet implementation targets. We discuss how models of program scale-up and tracking could possibly evolve to recognize this complexity.
大规模实施相关项目已成为政府应对持续的儿童肥胖流行问题的重要组成部分。我们正在研究澳大利亚有史以来规模最大的学校和儿童保育肥胖预防项目的推广情况。健康促进团队支持其所在地区的小学和幼儿服务机构，以实现一系列特定的、基于证据的做法，这些做法旨在推动组织变革，以改善健康饮食和体育活动。制定了关键绩效指标（KPI）来跟踪不同地区的项目实施情况，既衡量覆盖的学校和幼儿服务机构的比例，也衡量每个机构实现的做法的比例（即按计划实施项目的机构比例）。采用“松紧紧”模式，所有地方卫生区都获得资金，并需对达到KPI实施目标负责。然而，地方团队在如何最佳使用资金以实现目标方面有独立的决定权。基于对所有地区进行的为期12个月的人种志实地调查和访谈，本研究考察了健康促进团队决策和制定策略过程中的差异。我们确定了三种不同的实践风格：KPI驱动型实践（战略性的，侧重于目标）；关系驱动型实践（侧重于长期目标）；以及公平驱动型实践（将资源导向最需要的机构）。在适应KPI的过程中，各团队进行权衡和选择。一些团队难以在关注公平问题的道德要求与实现实施目标的实际需求之间取得平衡。我们讨论了项目推广和跟踪模式可能如何演变以认识到这种复杂性。
