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Am J Public Health. 2007 April; 97(4): 648–654.
PMCID: PMC1829337

Integrating Public Health Policy, Practice, Evaluation, Surveillance, and Research: The School Health Action Planning and Evaluation System

Abstract

The Canadian Cancer Society and the National Cancer Institute of Canada have charged their Centre for Behavioral Research and Program Evaluation with contributing to the development of the country’s systemic capacity to link research, policy, and practice related to population-level interventions. Local data collection and feedback systems are integral to this capacity. Canada’s School Health Action Planning and Evaluation System (SHAPES) allows data to be collected from all of a school’s students, and these data are used to produce computer-generated school “health profiles.”

SHAPES is being used for intervention planning, evaluation, surveillance, and research across Canada. Strong demand and multipartner investment suggest that SHAPES is adding value in all of these domains. Such systems can contribute substantially to evidence-informed public health practice, public engagement, participatory action research, and relevant, timely population intervention research.

WE ENVISION A FUTURE IN which a comprehensive, coherent macrolevel system (integrated across national, provincial or state, and local levels) will enable communities to take evidenced informed action to improve the health of citizens at the population level. This system will enable communities to pinpoint intervention opportunities with the highest potential impact, identify the most optimal intervention approaches, access intervention resources, and use local data collection and feedback resources to continuously guide, evaluate, refine, and learn from their work.

The elements of such a system are taking shape. For instance, the capacity to synthesize and disseminate intervention research data is being built internationally.1,2 In Canada, the country’s Public Health Agency3 and the Canadian Tobacco Control Research Initiative4 are using a model to review interventions that take into account not only evidence, but also plausibility and practicality.5

A local data collection and feedback system is an integral component of the macrosystem we have envisioned. The School Health Action Planning and Evaluation System (SHAPES), initiated in 2000, was designed to support the collection and use of local data for planning, evaluation, and field research and to help align and integrate these activities with policy and practice. As described subsequently, we have discovered that SHAPES is also useful for surveillance. Our goal here is to stimulate interest and collaboration in the development and use of local data collection and feedback systems to improve public health.

ORIGINS AND PURPOSES OF SHAPES

In 1993, the Canadian Cancer Society and the National Cancer Institute of Canada (which is funded by the Canadian Cancer Society) created the Centre for Behavioral Research and Program Evaluation (CBRPE), now located at the University of Waterloo; CBRPE’s mission was to build capacity for and conduct social and behavioral studies that contribute to improved cancer prevention and care at the population level. To advance this mission, the CBRPE is creating infrastructure, similar to a clinical trials network, to support both population-level intervention research and application of the evidence produced.

The CBRPE builds infrastructure in support of its mission vision within the broad framework provided by the macrosystem. SHAPES was developed in this context, and members of the Population Health Research Group at the University of Waterloo have been integral to the SHAPES work from the beginning.

SHAPES enables rapid and relatively inexpensive collection of health-related data from all students at a given school and promptly reports the results gathered from these data. The system consists of the following components: (1) a scannable questionnaire, (2) a quality-controlled scanning protocol to ensure accurate data files, and (3) a computer-generated report that is delivered back to the school or community, usually within 2 to 6 weeks (Figure 1 [triangle]).

FIGURE 1
Sample page from a SHAPES feedback report.

The most important aspect of SHAPES is not the content of the questionnaire but the underlying information technology system, which can be used to collect data in any substantive area. SHAPES uses scannable questionnaires, rather than an Internet-based system to enable collection and documentation of the high-quality data required for research and surveillance.

SHAPES was designed to serve 3 core purposes. First, SHAPES was created to support evidence-informed public health planning. The need for such planning was made clear to us when we discovered, during a randomized controlled trial, that smoking prevention programs focusing on social influences—the types of programs that have been recommended as best practice by the US surgeon general6—are not effective in most schools. Our results revealed an interaction between school characteristics and intervention effects: the curriculum assessed had a large effect in high-risk schools (where high smoking rates were prevalent among 12th-grade students) but had no effect in other schools.7

The findings of our study suggested that optimal population-level effects might be achieved most economically if interventions selectively targeted high-risk schools (about 30% of the schools in our study population). A tool designed to assess school risk and to guide the targeting of interventions would enable communities to achieve the greatest possible population-level effects with the resources available to them.

Second, SHAPES was designed to support public health field research. Both researchers and practitioners now recognize that public health intervention effects in general are influenced by context.8,9 That is, the same intervention may produce different outcomes in different settings. Our aforementioned study is a case in point. If population-level intervention science is to advance further, the capacity to characterize populations within study settings must be in place. SHAPES provides a means for doing so.

Third, SHAPES was intended to strengthen public health evaluation. Communities can move faster than researchers and often develop and implement untested interventions, sometimes with spectacular results. For instance, Florida used an innovative approach, driven largely by students, and reduced youth smoking rates statewide by 18% to 40% over 2 years.10 However, the results of smaller-scale, and more common, community intervention innovations are often unknown because these efforts are not adequately evaluated. SHAPES was designed to facilitate and enhance evaluations of novel community-led interventions that targeted school-aged children and youth, enabling those spearheading such interventions and those in the field at large to learn from the “natural experiments” that their innovative policies and programs create.

DEVELOPMENT OF SHAPES

Tobacco was the focus during the initial development of SHAPES. The SHAPES tobacco module (previously known as the school smoking profile) was created primarily to serve community stakeholders (e.g., schools). Before developing the tobacco module, we surveyed all 37 public health units in Ontario, Canada—Canada’s largest province—to gauge their interest. These public health units are responsible for community health, and they lead and support youth tobacco control programs. Public health professionals were resoundingly enthusiastic about the SHAPES concept. They recommended beginning with a tobacco module and then developing physical activity and eating behavior modules to align SHAPES with students’ activities and behavior.

An advisory group of stakeholders from the public health, education, health charities, and research sectors was created to ensure that SHAPES would be practical for each sector to use and would add value to their work. These individuals brought national, provincial, and, especially, local perspectives to the SHAPES development process.

SHAPES was designed for easy implementation and widespread use.11 SHAPES requires no skill or training to use, it was low in cost (in terms of both time and money), it was compatible with school routines (the number of questions was usually limited so that data can be collected within a single school period), it was “testable” (i.e., it is easy to discontinue its use if the initial experience is not satisfactory), and it was a more effective option than, for example, do-it-yourself local surveys requiring expensive staff time for development, analysis, and reporting. Local public health staff, teachers, students, or other community members can join forces to collect the data, greatly reducing costs. In addition, such hands-on work can help stimulate community engagement and enhance a sense of local ownership.

The feedback reports generated by SHAPES allow students, teachers, public health staff, and other stakeholders (e.g., those responsible for provincial or state-level planning or evaluation) to gain understanding, inform their planning efforts, and take stock of progress easily. Modules we designed included standard items so that comparisons across settings could be made. There was also space for custom items of special interest to users. For instance, standard items included in the tobacco module make it possible to compare a school’s smoking rate with the rates of other schools (aggregated) and with provincial (state) and national norms. Communities can add custom items for specific purposes (e.g., they might want data on where students are obtaining tobacco products so that they can evaluate and refine their approach to enforcing restrictions on sales to minors). SHAPES reports included suggestions about actions to consider in light of the data that emerge.

When the tobacco module had been completed, we assessed its reliability and validity. This process included a study designed to ascertain whether data collected by individual communities would underestimate school-level smoking rates as determined through the use of a “research grade” data collection protocol (e.g., with preannounced breath samples). We found that community data collection does not underestimate school-level prevalence rates.

There were many challenges in developing SHAPES, including (1) developing protocols that enabled community participants to collect data while meeting research ethical requirements, (2) creating procedures for ensuring data quality during scanning, and (3) developing software to automate reports (to speed up feedback and reduce costs). Other challenges remain; for example, a major current challenge is to stimulate more regular, robust community action in response to feedback reports.

DEMAND FOR SHAPES

Community demand for the SHAPES tobacco module was rapid and strong. At the same time that we performed validity testing and continued developmental research on the module, we had requests from schools, boards of education, public health departments, and provincial tobacco control staff to use the module. Without us having actively promoted the module, it had already been implemented and completed by more than 160000 students in more than 600 schools in projects funded by research grants, national and provincial (state) governments, and community public health departments.

Recently, Health Canada used SHAPES for the 2004–2005 national Youth Smoking Survey of Canadian students in grades 5 through 9. The rationale for switching from a traditional survey organization to SHAPES was faster reporting of surveillance results and added value (with no added cost) to schools from the provision of feedback reports, which encouraged increases in school-level participation and enabled the best possible surveillance data to be gathered. 30 766 students in 288 schools participated. The results of this initial trial were positive, and Health Canada decided to use SHAPES in the 2006–2007 Youth Smoking Survey as well.

We are at a critical juncture. The developmental research on the tobacco module is complete, and there is strong demand; even though this is the situation we had hoped for, it creates a challenge. We need to shift from conducting research on to supporting applications for SHAPES. Independent researchers working in traditional research settings might not even attempt to make this transition; it would go beyond their mandate and tax their resources. It would have been impossible for us to even contemplate attempting to move our research into the application phase had it not been for our organizational mission and infrastructure, which compelled and enabled us to make the product we have developed available for use.

Indeed, without CBRPE’s unusual mission and infrastructure, we simply could not have developed SHAPES. Such mission-referenced infrastructure funding is rare, in Canada at least, and it has been invaluable. In the quest to improve the flow of research into application, it is critical to design and build organizational structures that enable this transition. Our experience suggests that such structural support is vital but generally unavailable to most research groups.

The institutional legitimacy provided by the Canadian Cancer Society and the National Cancer Institute of Canada also has been invaluable. These 2 organizations support the CBRPE as a means of contributing to the development of the macrosystem to support evidence-informed action by those implementing policies and programs. Hence, scientists associated with the CBRPE can work as partners with those who are developing Canada’s public health infrastructure. A current challenge is to develop closer ties between CBRPE and the educational system.

VALUE ADDED BY SHAPES

Because the SHAPES tools can be customized to suit users’ needs, the system is broadly applicable. This versatility provides the scope necessary to add value to many substantive areas (not just tobacco, physical activity, and diet) through several different types of applications. First, SHAPES enables policy or program leaders to target and evaluate school- or community-level interventions intended to benefit young people. These are the core purposes for which the system was originally designed.

Second, SHAPES can strengthen intervention evaluations by allowing quasi-experimental designs that involve multiple settings and communities to be superimposed on local evaluations. If communities use standard measures and take advantage of a central scanning facility, a national SHAPES database can be developed. (We are currently planning such a database.) This type of database will make it possible to determine, year to year, the schools or communities that are most successful in changing youth smoking rates, or other outcomes of interest, and thus to identify and disseminate—or further study—promising approaches to resolving the problem specified. This infrastructure would complement randomized trials by helping to generate practice-based evidence.12 Quasi-experimental evaluations, with comparisons across settings and over time, would add rigor to assessments of other interventions highly relevant to communities dealing with comparable problems.13,14

The value of such capacity is not trivial. Traditional randomized studies are expensive and require years to complete. Generalization of trial results over time is risky because, for example, youth culture evolves. Moreover, formal trials rarely take advantage of community creativity and ingenuity in designing and implementing interventions. SHAPES makes it possible for community members to lead the intervention process and to conduct natural experiments in partnership with researchers to discover what works, with whom, and in what context. Such community-driven research can complement more rigorous but sometimes less relevant and timely clinical trial research.15

Third, we anticipate that a SHAPES national database will facilitate and strengthen randomized trials. For instance, it will become possible for researchers planning formal trials to identify eligible (e.g., high-risk) schools, to match schools using SHAPES data, and to obtain prebaseline (slope) data on study schools. Also, because SHAPES spans jurisdictions, a national database would permit research on interactions between interventions assessed in randomized controlled trials and external macro (i.e., national, provincial or state, community) interventions.

Fourth, SHAPES makes it more feasible to seize time-limited opportunities to study natural experiments. For instance, Fong et al.16 assessed the effects of the new Canadian tobacco warning labels on youth smoking rates by collecting longitudinal data, starting with a prelabel baseline, in Canada and the United States in a quasi-experimental design. SHAPES helped these researchers obtain baseline data on 12 000 young people quickly and economically. This was crucial: there was not enough time to secure a grant, which would have been necessary to collect baseline data using standard methods. With baseline data in hand to support a credible proposal, Fong et al. obtained funding from the National Institutes of Health to conduct the full study.

SHAPES can support evaluations of these types of critical natural experiments through “automatic” data collections if there is a central database, some degree of standardization of measures, and the ability to aggregate data at the level of the intervention (i.e., school, community, province or state, country). The warning label study illustrates the potential value of international collaboration in building a database that spans national boundaries; such an infrastructure would greatly facilitate assessments of national-level natural experiments by enabling cross-country comparisons.

Fifth, the availability of local data can trigger media attention and help ensure that relevant issues are included on the public agenda. Local media already have built stories around SHAPES data, such as for youth smoking in the province of Prince Edward Island. SHAPES data can also be used to add a local angle to a national story by providing local statistics, and there may be considerable potential to boost such activity. For instance, the editor of a newspaper in a provincial capital suggested that if we could obtain data from all of the schools (or representative schools) in his city, he could envision an annual front-page update on the health of the city’s young people.

Finally, SHAPES data can be used to develop benchmarks and to stimulate school and community motivation. Schools or communities can compare their progress to national and provincial norms. Such comparisons may enhance commitment to becoming or remaining frontrunners in the quest to improve youth health profiles.

FUTURE OF THE SHAPES SYSTEM

The CBRPE is working with policy and program leaders to enhance SHAPES beyond tobacco. Nearing completion is the SHAPES physical activity module, which enables schools to monitor the activity patterns of their students and evaluate how program or policy changes, such as the removal of intramural sports programs, affect these patterns. We now have validity, reliability, and utility data available for this module, which went through the same development process used with the tobacco module.17 A third module focusing on eating behaviors is currently being developed.

We are also developing tools to document programs, policies, and facilities related to tobacco use18 and physical activity.19 These tools, combined with SHAPES student-level data, will enable richer assessments of natural experiments and multilevel analyses.2024 In addition, as a means of focusing and triggering action by the community, we are working with users to develop mechanisms and processes that will engage communities in planning data collection and responding to SHAPES feedback reports. Stimulating action remains a significant challenge.

It is particularly exciting to contemplate the possibility of using SHAPES (or similar systems) to expand and support collaborations internationally, with a goal of developing a more nuanced understanding of the combinations of policies and programs (at the national, provincial or state, and local levels, including the school level) that would achieve the most beneficial population-level effects. This type of research is critical in dealing with global problems that require national-level interventions (e.g., addressing tobacco use in support of the World Health Organization’s Framework Convention for Tobacco Control).

INTEGRATING POLICY, PRACTICE, RESEARCH, AND SURVEILLANCE

The concept of local-level data collection and feedback systems is more important than the specific example of SHAPES. The most powerful aspect of such systems is their ability to transform public health practice, applied research, evaluation, and surveillance into creative interventions that can be effectively evaluated. Systems such as SHAPES can support rigorous participatory action research, making it feasible for communities to work as equal partners with researchers and for researchers to secure funding and publish their findings. There is a strong foundation for joint work and mutual learning across practice and research sectors.5,2527

Those conducting surveillance or research using systems such as SHAPES can approach community partners with a service and not simply ask for access to data. Many institutions, such as schools, receive more requests from researchers than they can accommodate. These institutions are more likely to grant access for data collection if they receive “value-added” benefits, such as feedback and follow-up reports, and if data collection serves multiple functions, such as planning, evaluation, and surveillance, thus reducing the number of requests schools receive for data collection.28

SHAPES is just 1 component of the larger macrosystem we envision that integrates research with policy and practice. The system also would include (1) tools to track existing community programs and policies, (2) dissemination mechanisms enabling decisionmakers to quickly access resources on interventions that work as well as on implementation techniques,3 and (3) a component supporting data collection and feedback, such as SHAPES, in key community settings—not only schools but also worksites, clinics, and so forth.

Such a comprehensive macrosystem would enable community decisionmakers to systematically target, plan, and evaluate interventions on the basis of pertinent information; would enable continuous learning about what interventions work, with whom, and under what conditions; and would allow an overview of the extent to which best practice interventions are in place and have an impact. With this overview, senior-level decisionmakers could make data-driven judgments about priorities and resource allocations.

This macrosystem would facilitate an environment29 in which researchers and communities are able to work together to develop, test, and use best practice interventions by following the orchestrated, goal-directed paths provided by the system. The system would enable users to set realistic goals, monitor their progress toward those goals, and develop a sense of collective agency and efficacy.3032 It would also provide an evidence base to support reflective practice33 within “communities of practice,” where those involved in policy, programs, research, evaluation, and surveillance are brought together and work jointly toward a common goal.34

Can our vision for integrating research, policy, and practice at a macrolevel become a reality? The vision is ambitious, but under the leadership of major Canadian government and non-government stakeholders,35 progress has been made. SHAPES is illustrative of this progress and represents a critical national asset that could not have been created by any organization alone. SHAPES is an initial, necessary component of the larger macrosystem, and its successful implementation adds to the existing impetus and bolsters the confidence required to build other elements for the macrosystem.

International collaborations would enhance the value and impact of data systems such as SHAPES and would allow assessments of a richer array of natural experiments. These collaborations also would help build a foundation for implementing an emerging vision of collective international efforts to better integrate the research, policy, practice, and community sectors in supporting population-level interventions.36

Acknowledgments

Development of SHAPES was supported by the Social Sciences and Humanities Research Council of Canada (grant 828-1999-1019) and the Centre for Behavioral Research and Program Evaluation, Canadian Cancer Society/National Cancer Institute of Canada.

Staff of the Population Health Research Group supported the development and application of SHAPES. We thank Rashid Ahmed, Matthew Gray, Jason Lindo, Matthew VanderMeer, and Tammy Cumming. We also thank Dexter Harvey and Bill Morrison for their support in early field testing, Suzy Wong and Scott Leatherdale for major contributions to developing the Physical Activity Module, and to colleagues in public health and education across Canada for their input in developing the system and their investment in testing and refining it.

Notes

Peer Reviewed

Contributors
R. Cameron, S. Manske, and K. S. Brown originated the idea of the School Health Action Planning and Evaluation System (SHAPES) and initiated its development. S. Manske is the scientific leader of the SHAPES program. M. A. Jolin is a number of the team that is creating SHAPES; she also oversees the technical development and automation of the system, and builds partnerships. D. Murnaghan and C. Lovato were involved in the development, testing, and refinement of the SHAPES tobacco module. R. Cameron and S. Manske led the preparation of this article; all other authors made substantive contributions to the article as it evolved.

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