©Wellington-Dufferin-Guelph Public Health 2018

For more information, please contact: Louise Brooks, Health Promotion Specialist

Family Health Promotion
Wellington-Dufferin-Guelph Public Health
160 Chancellors Way
Guelph, ON  N1G 0E1

T:  519-822-2715 or 1-800-265-7293

info@wdgpublichealth.ca
www.wdgpublichealth.ca

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Citation

Wellington-Dufferin-Guelph Public Health (2018). The Impact of Bridges Out of Poverty Workshops Guelph, Ontario.

Table of Contents

Introduction 

Purpose

Goal

Overview of Research Design

Objectives

Research Questions

Ethics

Methods

Key Informant Interviews

Key Findings

Awareness of Barriers

Understanding

Access 

Power

Vocabulary

Workforce Practices

Steps to Reduce Barriers

Organizational Change

Impact

Evaluation Changes

Training

Intersecting

Narrative Format

Videos

Consulting

Audience

Discussion

Recommendations

Conclusion

References

Appendices

Appendix A Evaluation Matrix

Appendix B Information Package

Appendix C Field Notes Template

Introduction

Wellington-Dufferin-Guelph Public Health (WDGPH) is a member of the Guelph and Wellington Task Force to Eliminate Poverty (PTF). The PTF is committed to working collaboratively to take local action and advocate for system and policy change to address the root causes of poverty. In 2012, to support the work of the PTF, WDGPH and the County of Wellington formed the Circles Guelph Wellington initiative to increase understanding of poverty with a specific emphasis on identifying and reducing barriers to services and supports for individuals and families with low resources.  

Influencing the way individuals think about poverty was key to creating positive change in the community.  To support this, and as part of the initiative, WDGPH adopted a strategy made popular in the Sarnia region of Ontario for mobilizing community change, the Bridges Out of Poverty framework (Payne, DeVol & Smith, 2005). The objective of the framework is to look at poverty through an economic lens, while exploring other circumstances that contribute to poverty that an individual has no control over. The framework is built on the proven concept that everyone in the community has a role to play in poverty reduction.

In 2013 Bridges Out of Poverty was successfully implemented in the Wellington, Dufferin and Guelph area. Since then, WDGPH has provided training to more than 40 organizations from various community sectors with approximately 4500 individuals attending information sessions and 4582 participating in training workshops throughout Wellington, Dufferin and Guelph.

The request for workshops continues to grow. WDGPH wants to ensure that Bridges Out of Poverty continues to be an effective training for organizations by monitoring its progress, impact and to learn from these efforts.

Bridges Out of Poverty is promoted for its potential to mobilize change at the individual, organization and community level, and understanding how it accelerates change is significant to informing the future direction of the workshops.
 

Purpose

The overall purpose of the evaluation is to understand the impact of the Bridges Out of Poverty training workshops in participating workplaces in Wellington, Dufferin and Guelph that received Bridges out of Poverty training between 2014 to 2017.

Goal

The goal of the evaluation is to provide information that will guide decisions on the future direction of Bridges Out of Poverty training workshops in Guelph, and Wellington and Dufferin counties. 

Overview of Research Design

An evaluation matrix was developed to look at indicators, data sources, data collection methods and required resources. Research questions were developed based on the objectives of the evaluation. (Appendix A).

Research questions

1. Did Bridges out of Poverty training workshops contribute to increased awareness and knowledge of organization process, policies and procedures that create barriers for clients with low resources?
2. Did Bridges out of Poverty training workshops influence workplace practices that reduce barriers when working with clients with low resources?
3. Did Bridges Out of Poverty training workshops contribute to or accelerate organizational change to reduce barriers for clients with low resources?

Ethics

This evaluation received ethics approval from the WDGPH research ethics committee.

Methods

Bridges Out of Poverty is an approach to support the development of organizations and their staff to work with individuals who live in poverty.  Learning is aimed at ensuring agencies and organizations do not, through their own in-built assumptions, create barriers for the individuals they work with. Assessing the impact of full day workshops provides an indication of the extent to which the training influenced organizational change.

Key informant (KI) interviews were conducted with local organizations that received Bridges out of Poverty training between 2014-2017 to gain a broader perspective of the impact of the Bridges Out of Poverty training.

Ten agencies and organizations were initially contacted from January to March 31 2018 by email and telephone. A script was developed to provide a consistent message for recruitment. An information package was sent to the individuals who agreed to participate. The package consisted of a letter and consent form. The information letter outlined the purpose of the evaluation, the criteria needed to participate and the length of time requested for a key informant interview. Consent forms requested permission to digitally record the interview. Consent forms were signed by the participant and returned to the evaluator prior to the interview.  A ten dollar gift card and a lunch valued at 17 dollars was offered as incentives. A letter thanking participants was distributed with the gift card. In total 8 organizations participated in the evaluation.  (Appendix B).

Key Informant Interviews

Semi-structured qualitative interviews were scheduled over a 3 month period from March 1 to May 31 2018.  Interview questions (9) were developed and administered during the interviews (See Appendix C).

Participants were asked questions about their learning experience from the Bridges Out of Poverty workshops. Questions were designed to understand:

• an increased awareness of barriers faced by individuals in poverty
• the steps to reduce identified barriers
• a shift or change in workplace practices or policies to reduce barriers

Participants were provided with an outline of the training modules before the interview to support the discussion. Interviews were digitally recorded and later transcribed in a field note template (Appendix C).

Participants represented a broad variety of community sectors including faith based, social services, non-profit and post-secondary education. In total 8 individuals in a variety of leadership roles from various organizations participated in the interviews (See Table 1). 

TABLE 1: Breakdown of participants by sector and role

Key Findings

Background

A pre-question in the key-informant (KI) interview was to ask participants why their organization requested to have a Bridges workshop or training. Responses to this question provide insight into whether or not the outcomes of the training matched the intent. From the eight organizations that participated in the KI interviews, the rationale for the training was as follows:

• increasing awareness and understanding of  individuals living in poverty
• increasing awareness of personal bias
• understanding stigma and to move learning forward
• understanding how to effectively work with low resourced families
• understanding the impact of poverty and child development

Information gathered from all the questions asked during key informant interviews was analyzed for patterns and common themes and arranged in a table.  A pattern of common themes emerged from the interviews that repeatedly demonstrated the existing challenges of organizations working with low resourced individuals. The breakdown of themes and corresponding details are displayed in Table 2.

TABLE 2: Themes and details

Section 1: Awareness of Barriers

Evaluation question 2 contributed to our understanding of barriers. Specifically, evaluation question 2 asked: Did Bridges out of Poverty workshops contribute to increased awareness of organization’s process, policies and procedures that create barriers for clients with low resources? This section summarizes the responses to questions 2-3 in the interview guide.

Graph 1: Impact of Bridges Training on increasing organizational awareness of barriers faced by clients with low resources.

The graph above shows 8 respondents indicated yes, Bridges training increased awareness of barriers. No respondents indicated that Bridges training did not increase awareness of barriers.

For those organizations that indicated that Bridges Out of Poverty training increased awareness of the barriers faced by clients with low resources, the following is a description of these identified barriers. 

“We expect the absolute most from those who have the absolute least” - a participant’s response when asked about barriers faced by low resourced individuals

Eight participants reported an increased awareness of bias (judgement) as a barrier to working effectively with low resourced individuals. The workshop highlighted the ‘us versus them’ thinking that is often unknowingly embedded in discussions surrounding poverty and how stigma and discrimination further limit opportunities for low resourced individuals. One participant reported the training was brilliant as ‘there was a shift in thinking’ about low-resourced individuals purchasing habits. Poor food choices are not reflective of an individual’s understanding of what constitutes a healthy food. Income and an individual’s situation determines food choice stating “they know eating low fat meat is better for them but they just can’t afford it.” Two participants reported how the training provided insight into how low resourced individuals may not have access to normal banking services such as a bank account due to their credit rating. This 

forces individuals to choose alternative financial services that charge higher than normal interest rates or service charges to provide the same service forcing individuals to spend additional money. Four participants reported bias around low resourced individuals purchasing high priced items such as IPhones and large screened televisions when there is a need to buy food or pay the rent. The training provided information about the importance of entertainment and how television provides relief from the daily stressors of living in poverty. Cell phones are a client’s only connection to their support networks and this information helped participants to look at their client’s situation from a different perspective.  One participant reported they assumed all low-resourced individuals are happy to access agency services. The participant stated the training offered insight into the importance of relationships and why low resourced individuals may accept advice from a friend regarding treatment rather than the frontline worker. 

Understanding

Eight participants reported the workshops promoted a greater understanding of the bahaviours associated with generational poverty. More specifically, how the cyclical patterns of behavior can negatively impact an individual’s decision making process. This emphasized the challenges individuals face when working towards attaining positive goals. Three participants reported that training helped them to understand that low resourced individuals approach services or treatment in different ways adding “flexibility is needed for different types of families.” Two participants reported that understanding societal experience plays a major role in an individual’s decision making process helped them to realize that “not all clients are ready willing or able” to participate in what is being requested of them. Of the two participants, one participant stated “it is not good or bad it just is” and to recognize this factor when working with low resourced individuals.  Four participants reported the training emphasized the importance of meeting low resourced individuals where they are at and how the approach can help individuals to reach their goals.

“Its personal development and personal understanding of the people in your neighbourhood and society from those who are different than you.” - a participant’s response when asked about barriers faced by low resourced individuals
 

Equity

Training was often referred to during interviews as professional development. Workshops provide support for organizations wanting to stress the importance of inclusivity and equitable services. Four participants stressed the importance of training future service providers and volunteers who have never worked with low resourced individuals.  Four participants reported the workshops offer a broader vision and capacity to understand individual situations and the necessary tools needed to respond. One participant reported the training was a “powerful tool” as it showed inherited expectations around common elements that are very different between middle class and low resourced individuals. Two participants suggested the training supports a message of equity stating the requirement to show “proof of ‘being in need” is undignified adding, “When was the last time you had to show your paystub to get a service?” 

Access

Five participants reported the training provided them with the necessary information to identify the accessibility barriers that exist within their organization. One participant reported the need for identification and to “provide paper” often delayed the process of when an individual receives support. One participant reported limitations on the number of times an individual can access support as “debilitating”.  One participant reported the hours of operation are not compatible with the individuals who access the service. Two participants reported the language used on administrative forms was not clear nor was it at a reading level that many low resourced individuals could understand or interpret without assistance.

"After the Bridges training we considered a multitude of barriers and what might be affecting participation." - a participant's response when asked about reducing barriers for low-resourced individuals

Power

Three participants discussed how agencies or organizations have institutional power that can intimidate clients and one participant described that information as a moment of clarity during training. Low resourced individuals may feel reluctant to challenge agency suggestions or requests and feel intimidated to negotiate for what they really require. Agency power can lead to an individual’s reluctance to access services. The information from the workshop reinforced the importance of creating a participatory relationship with individuals to encourage and support the use of services. One participant reported the training mobilized the organization to look at the “barrier of intimidation” and how they can provide further 

support to low resourced individuals by building relationships and trust. Another participant described how the training supported a review of a termination of service policy, a policy initially used when a client does not respond to appointments or phone calls. The review resulted in supporting a research study to review accessibility and why clients disengage.  One participant reported telephone scripts used when calling and scheduling clients were reviewed and revised to be non-judgmental and more relationship based.

Vocabulary

Vocabulary was identified as a barrier to communicating effectively with individuals from generational poverty. Individuals raised in poverty have a limited vocabulary. Although this is not new information, eight participants reported that the individuals use of profanity as an adjective, a verb, or a noun is a new concept. The narratives used as examples during training provided an increased understanding that the use of profanity in daily conversation is not derived from aggression, but rather an individual’s inability to express their message in any other form. One participant said “If you don’t have the language or the skills to use language effectively, how can you tell your story other than use the F-bomb?”

Section 2: Workforce Practices (Planning)

Evaluation question 2 contributed to our understanding of workforce practices. Specifically, evaluation question 2 asked: Did Bridges out of Poverty workshops influence workplace practices that reduce barriers when working with clients with low resources?  This section summarizes the responses to questions 4-5 in the interview guide.

Graph 2: Impact of Bridges Training on Plans to Reduce Barriers  

Number of responses in above graph:

• Planning to review or current reviewing policies and procedures: 4
• Planning to revisit barriers and potential interventions: 2
• Planning to use the framework to inform work: 3
• Training accelerated review of policies: 5

*Organizations were able to identify more than one barrier

Steps to Reduce Barriers

The steps to reduce barriers varied in organizations from planning to review policies to using key strategies from the training as a guide for future planning.   Four participants reported their organizations have either reviewed policies or are currently reviewing policies to address barriers associated with accessing services. Two participants reported their organizations are planning to revisit barriers associated with inclusivity. Three participants reported their organization is planning to implement the Bridges Out of Poverty framework as a guide to inform their work. Of the three participants, one participant reported the Bridges Out of Poverty framework is currently used as a tool in annual planning sessions. Five participants reported that the training modules that discussed language, hidden rules and mental models mobilized the review of policies. One participant said, “We are trying to use more plain language and we are very conscious of it as well as accessibility on our website”.

Section 3: Organizational Change

Evaluation question 3 contributed to our understanding of the impact of Bridges Out of Poverty on organizational change. Specifically evaluation question 3 asked: Did Bridges Out of Poverty workshops contribute to or accelerate organizational changes to reduce barriers for clients with low resources?  This section summarizes the responses to questions 6 and 7 in the interview guide.

Graph 3: Organizational Change as a result of Bridges Out of Poverty Training

Graph above shows responses:

• Changes to existing policies: 5
• Changes to practice or process: 2
• Influenced program change: 5
• Annual staff training: 5
• Benefited from training: 8

*Organizations were able to identify more than one change

Impact

A key element in the Bridges Out of Poverty framework is how it impacts organization practices or processes. Five participants reported change in their organizations policies as a result of training.  Of the five organizations, one organization extended the hours of operation to increase access to services and two organizations updated administrative forms to be more user friendly for clients. One organization applied the training to support the removal of a termination of services policy stating the policy did not help to understand why clients did not attend scheduled appointments and instead mobilized a research project looking into client readiness. One organization revised a policy to increase the number of times an individual can access a service on a monthly basis.

Two organizations implemented specific strategies from the training to support working more effectively with low resourced clients.  One organization hired an additional staff person with a direct focus on the intake process. Another organization streamlined their process to ensure low-resourced individuals have increased support to access community services.

The training mobilized five organizations to modify programs or develop new programs. Two organizations implemented a more dignified application process to ensure ease and privacy when requesting access to a program and two organizations ensured program access is no longer delayed due to the challenge of required documents to prove need. One participant said, “Not only did the training accelerate change but it continues to support the work we do.”

One of the five organizations made a profound impact in the community. The organization implemented a new financial loan program to support low-resourced individuals unable to access financial loans in the more traditional manner. The model is a collaborative effort between the organization and a local credit union and is the first microfinance program of its type in the Wellington-Dufferin and Guelph area. 

Five organizations implemented Bridges Out of Poverty workshop as annual staff training to provide a solid understanding of poverty and low-resourced individuals. Two organizations have staff who mentor other staff if they are unable to attend the workshop. One of the five organizations offers an annual training session to their Board members to support advocacy work. One organization implemented Bridges Out of Poverty session as part of the curriculum to provide future service providers 

with a snapshot of how to work with low resourced individuals in the community.  All eight organizations say they benefited from the training. 

Evaluation of Changes

Of the eight organizations that implemented change as a result of Bridges Out of Poverty training, five put in place practices to evaluate and monitor the changes. Two organizations monitor changes by informally collecting feedback from community partners. Two organizations reported distributing client satisfaction surveys to understand if the services or programs are effective and to understand the experience of the client. One organization uses the Bridges Out of Poverty framework as a tool to support measuring outcomes to improve services. Three organizations constantly refer to the Bridges Out of Poverty strategies when working with clients. Since implementing the changes, the three organizations received positive feedback in the areas of client interaction, improved understanding of low resourced clients and providing services or programs that reflect the needs of the client. One participant said, “It’s all intertwined with the Bridges framework, if we are measuring the success of our programs, the Bridges messages will be threaded throughout.”

Training

This section answers question 8 in the interview guide and provides feedback about ways to support or improve future training. Specifically evaluation question 8 asked:  Is there anything your organization would have liked to have seen covered during the Bridges Out of Poverty workshop or training session that was not addressed?” This section summarized the responses to question 8 and 9.

Intersecting

Six participants reported the workshop content combined with the strength of the facilitator made for an excellent learning opportunity.  Eight participants reported learning new and relevant information from attending the workshops. Three participants expressed a strong desire to continue further training by either attending additional training workshops or hosting a workshop at their organization.  To enhance further learning, two participants expressed interest in workshops that explored the link between poverty and mental health and between race and poverty and both participants believed the training could have additional impact under the umbrella of health equity.

Narrative format

Eight participants spoke at length about the use of narratives as resonating the most from the training.  Narratives that incorporate real life examples is the recommended format for the delivery of the workshop by Aha Process! training in the United States. A combination of personal stories and those provided by Bridges Out of Poverty facilitator training strengthen the understanding of the content of the workshop. One participant said, “The storytelling helped to make it kind of come alive. You could imagine working with families in similar situations.”  Another participant stated, “The stories and the facts are particularly compelling."

The training expands the paradigm of thinking about poverty, whatever matrix you are in, there is very significant change that happens and that doesn’t happen often. It’s quite remarkable. I know if I say go to this training it’s guaranteed to be great.

-a participant's response when asked for comments about attending Bridges Out of Poverty training.

Interaction

Two participants reported that more time for discussions would allow for increased learning. Full day training provides ample opportunity to arrange strategic interactive group discussions.  Of the two participants, one participant said, “More interaction would be great and would provide an opportunity to have it geared to one or more specific program or agencies.”

Videos

One participants suggested training sessions could be improved by adding text to the videos for those who are hearing impaired.

Consulting

“Because of training, much more attention has been paid to developing ways to obtain feedback from those who receive services.”

-A participant’s response when asked about monitoring changes to services to reduce barriers

Three participants reported a consult with the facilitator post training would provide an opportunity to move the strategies forward.  All eight participants expressed gratitude to WDGPH for the provision of the workshops that promote a discussion about poverty in the community.

Audience

Two participants discussed the importance of the make-up of workshop attendees stating managers and those who can effect change need to participate in more than one training to accelerate any form of sustainable change.

Discussion

The Bridges Out of Poverty training workshops are highly valued by the eight organizations that participated in the KI interviews.  The evaluation findings confirm the positive contribution the workshops make to an organization’s understanding of poverty and the barriers faced by low resourced individuals.

The extent to which the workshop improved understanding of identifying and reducing barriers for low resourced individuals is apparent in the changes to workplace practice. The eight participants indicated that training influenced the knowledge needed to implement change in workplace practices to reduce barriers and referenced particular sections of training where their understanding had been enhanced. The mental models of economic class, the hidden rules of poverty, language and the importance of relationships were specifically noted as attributing to the modifications. Training was attributed to enabling the eight participants to reflect upon preconceived bias and behaviors that contributed to identifying barriers for clients with low resources that translated to changes in their workplace practice at an organizational level.

The training influenced and accelerated policy change to reduce barriers for low resourced individuals. Policy change at the organizational level did not result from one training session but rather as a result of influencing factors including the role of the decision maker attending the training, the number of training sessions attended and the ability to apply the key strategies in different contexts. Eight participants attended at least three training sessions and were in management roles within their organizations. Participants made reference to policies affecting barriers of access and language as the most frequent areas policy change.

Recommendations

To support the key findings and the future direction of Bridges Out of Poverty, it is recommended to:

1. Build capacity with community partners to broaden the reach of training across all community sectors.
   • Train individuals from championing organizations to deliver information sessions up to two hours in length. Increasing capacity will broaden the reach of training and support stronger relationships with partners. Trainer certification is not required for any session under two hours.
   • Increase the number of certified trainers to provide full day training workshops to ensure the sustainability of the program in Wellington, Dufferin and Guelph.
   • Online training options are available from Aha! Process that eliminate the need to attend training in the United States.
2. Provide pre and post training consultations in combination with full day training sessions to help support the implementation of changes in organizations.
   • ​​Provide consultations to increase an organization’s understanding and ability to implement key strategies to reduce barriers for low resourced individuals.
   • Provide additional templates and a presentation specific to implementing change.   
3. Support organizations monitoring or evaluating organizational changes as a result of the Bridges Out of Poverty training. Provide templates for monitoring or evaluating change to help support organizations that have implemented change.
4. Revise videos to ensure they are AODA compatible.

Add text to videos used during the workshop to ensure they are AODA compatible. The capacity to implement the changes may require external support.

Conclusion

The evaluation sought to understand the impact of Bridges Out of Poverty training in an organization’s understanding of reducing barriers for low-resourced individuals.  The findings in this report provide WDG Public Health, in particular the Family Health Promotion program, with information to understand the depth of change the Bridges Out of Poverty workshops can attain in the community.

A predominate theme emerged from the responses suggested that the Bridges Out of Poverty training contributed to increasing awareness and knowledge of the process and procedures that create barriers for low resourced individuals. The extent to which the workshops influenced change is of particular interest. Participants reported their capacity to understand bias, agency power, communication and vocabulary resulted in changes in understanding knowledge and skills. The increased awareness and understanding became the motivation to change work place practices and policies.

The degree to which organization change occurred is dependent on numerous factors. Responses indicate real change occurs as the result of attending more than one workshop. Successful implementation of the training framework is dependent on the leadership role of the individual attending the training and their ability to apply the key strategies in their organization. Organizations would benefit from individual consultation sessions pre and post training to clarify training goals and to develop application skills of key training strategies.  

The training shed light on the importance of organizations continuously monitoring the identified barriers experienced by low resourced individuals.  WDG Public Health is in a prime position to provide support (templates, consultations) to organizations to monitor change. Providing support will help continue to reduce the social stereotypes and judgement associated with low resourced individuals.

A sustainable model to ensure long term results in organizations and the community is key to the future of the Bridges Out of Poverty training.  Increasing the number of individuals providing training and partnering with community champions to provide information sessions would build capacity and leverage resources across all community sectors.

The evaluation findings suggest Bridges Out of Poverty training impacts an organizations understanding of the barriers faced by low resourced individuals and the steps needed to reduce the barriers. Issues concerning a sustainable training model and the ability to apply key strategies in organizations were considered important factors that influence change. Evidence indicates that Bridges Out of Poverty is an enabler of change in organizations and in the community. Expanding the training across all community sectors will increase the impact of the training and continue to mobilize and effect positive change in the community.

References:

Payne, R. K., DeVol, P. E., & Smith, T. D. (2006). Bridges out of poverty: Strategies for professionals and communities.

Appendix A: Evaluation Matrix

Bridges out of Poverty Evaluation Matrix

Objectives of the evaluation:

• To understand the impact of Bridges out of Poverty training /workshops in participating workplaces (organizations, agencies) in Wellington, Dufferin and Guelph (WDG)

Outcome Evaluation

Question 1:  Did Bridges out of Poverty (half and full day) workshops contribute to Increased awareness and knowledge of organization process, policies and procedures that create barriers for clients with low resources?

Question 2. Did Bridges out of Poverty (half and full day) workshops influence workplace practices that reduce barriers when working with clients with low resources?

Question 3: Did Bridges workshops contribute to or accelerate organizational changes to reduce barriers for clients with low resources?

Additional Questions to consider:

For those organizations that have made changes, have the measured or evaluated the impact of those changes?
For those organizations that have not made changes—why not?

Evaluation Activities

Key Informant Interviews

Current/past participants
Managers and staff from participating agencies /organizations

Appendix B:  Recruitment and Information Package

Script

Subject: Evaluation of Bridges Out of Poverty Participation Request

The Impact of Bridges Out of Poverty Training and or Workshops in Agencies and Organizations in Wellington, Dufferin and Guelph (WDG).

Hi ______________________;

My name is Louise Brooks, I’m a Health Promotion Specialist at WDG Public Health. I’m emailing you today because we (WDG Public Health) are conducting an evaluation of our Bridges Out of Poverty workshop and training sessions.  We are asking individuals (staff or managers) from agencies and organizations that arranged a Bridges Out of Poverty (workshop or training session) in 2014 to 2017 if they are interested in participating in the evaluation by volunteering for a key informant interview.

The purpose of the evaluation is to learn more about the impact of half-day and full-day Bridges Out of Poverty workshops and training sessions specific to agencies and organizations in WDG.
 

If you agree to volunteer and participate in a key informant interview, it would take approximately 60 minutes answering questions about the Bridges Out of Poverty workshop, its concepts and strategies presented at the workshop or training session you attended and to understand your workplace practices and polices faced by individuals with low resources .   The interview can be scheduled at a time that is most convenient for you. As a thank you for participating in a key informant interview for our evaluation, Public Health will provide you with lunch ($17 value) and a $10.00 grocery store gift card.

The results from the key informant interviews will be used by WDG Public Health to:

• make decisions around understanding the impact  Bridges Out of Poverty workshop and training sessions in agencies and organizations  in WDG.
• share evaluation findings with the community ( partners, agencies, organizations)
• publish a final report that will be available on the WDGPH website (www.wdgpublichealth.ca).

It is entirely your choice to participate in the evaluation, there is no physical risk and your employer will not be informed of your decision as to whether or not you participate. Participation will not affect any current or future service or partnerships with WDGPH. You can withdraw from the interview at any time and you can skip any question you do not want to answer.  After you complete the interview, you can withdraw your information up to the time prior to the drafting of the report by contacting Louise Brooks, 519-822-2715 ext. 4358 or louise.brooks@wdgpublichealth.ca .  Your organization, your name or job title will not be identified in the final report. 

The benefits to participating in the evaluation will provide us (WDG Public Health) with information to identify whether or not the Bridges Out of Poverty workshops and training sessions;

• Increased awareness of the barriers faced by individuals with low resources by agencies and organization in the community
• Mobilized or accelerated change in workplace practice
• Reduced identified barriers faced by low resourced individuals in WDG.

The evaluation will also help guide the direction and future of the Bridges Out of Poverty workshops and training sessions in WDG.

I’m attaching an information package that contains further information about the evaluation and a consent form that you can review and sign prior to the start of the key informant interview.  I will follow-up within 1 week by email to arrange a specific date and time that works for you for the key informant interview.

I would also like to add that we (WDG Public Health) are committed to providing help to people with disabilities in the interview process. If you require any help, please let me know and I will work with you to meet your needs.

Please connect with me, Louise Brooks at 519-822-2715 ext. 4358 if you have any concerns or if there is additional information you require, or questions you would like to ask.

Thank you,

Louise Brooks,

Health Promotion Specialist

WDG Public Health

Appendix B: Recruitment and Information Package Information Letter and Consent Form

LETTER OF INFORMATION

Evaluation Project Title:

The Impact of Bridges Out of Poverty Workshop and Training Sessions in Agencies and Organizations in Wellington, Dufferin and Guelph in (WDG).

Who is conducting this evaluation?

This evaluation is being conducted by Wellington-Dufferin-Guelph Public Health.   If you have any questions or concerns about the evaluation, please feel free to contact Liz Robson Manager, Family Health Promotion, 1-800-265-7293, ext. 4214 (email liz.robson@wdgpublichealth.ca).

This evaluation s sponsored by Family Health Promotions, Wellington-Dufferin-Guelph Public Health (WDGPH).

What is the purpose of the evaluation?

The purpose of the evaluation is to learn more about the impact of half-day and full-day Bridges Out of Poverty workshops and training sessions specific to agencies and organizations in Wellington and Dufferin counties and the City of Guelph.  The evaluation aims to understand changes to workplace practices and organization policies related to the barriers faced by individuals with low resources.

What is the purpose of the key informant interview?

The purpose of the key informant interview is to obtain feedback from agencies and organizations who participated in half-day or full-day Bridges Out of Poverty workshop or training and or workshops and to examine the impact on workplace practice and /or organization change in policies as they relate to the barriers faced by individuals with low resources.

Who can participate?

The evaluator hopes to conduct key informant interviews with staff from each of the agencies and or organizations that attended half-day or full-day Bridges out of Poverty training/workshop sessions in 2016.

Wellington-Dufferin-Guelph Public Health (WDG Public Health) is committed to providing help to people with disabilities in the interview process. If you require any help, please advise the interviewer, and we will work with you to meet your needs.

How long will this take?

If you volunteer to participate in a key informant interview, we would ask you spend 60 minutes answering questions about the Bridges Out of Poverty concepts and strategies.  The interview can be scheduled at a time that is most convenient for you.

Will I be paid?

As a thank you for participating in a key informant interview for our evaluation, Public Health will provide you with lunch ($17 value) and a $10.00 grocery store gift card.

How will my results be used?

The results from the key informant interviews will be used by Wellington-Dufferin-Guelph Public Health to:

• make decisions around future  Bridges Out of Poverty workshop and training sessions in WDG.
• share research findings with the public health community,
• publish a final report that will be available on the WDGPH website (www.wdgpublichealth.ca).

Are there any risks or discomforts if I participate in this study?

• It is your choice if you want to participate in this research study.  Public Health will not inform your employer of your decision to participate.
• There are no physical risks to participate in this study.

Are there any benefits for participating in this study?

• The research will identify whether or not Bridges Out of Poverty workshops/training;
  • Increase awareness of the barriers faced by individuals with low resources by agencies and organization in the community
  • Mobilized or accelerated change in workplace practice
  • Reduced identified barriers faced by low resourced individuals in Wellington Dufferin and Guelph (WDG).
  • The evaluation will help guide the direction and future of the Bridges out of Poverty framework in WDG.

What should I know about confidentiality?

• All the information you share will be kept confidential.  If a voice recorder is used, after the interview, the data will be transferred to an encrypted and password protected laptop computer at which time the interview will be deleted permanently from the recorder. The information will be stored in a file on a protected agency drive at a Public Health office.
• Public Health will not use your name, organization, or job title on any transcriptions, field notes or reports unless written permission has been given to do so. 

Can I stop my participation in the interview?

You can stop the interview at any time without consequences.   You can skip any questions you do not want to answer.  If you decide after the interview that you would like to withdraw your information from the evaluation, please contact the assigned Health Promotion Specialist, Louise Brooks, by phone or email. You can withdraw your information any time prior to the drafting of the evaluation report.

How will I learn about the study results?

 If you would like to be emailed a copy of the final report, on the consent form, please provide your email address and consent to this contact on the attached consent form.  If you do not consent to receiving the final report by email and you change your mind, you can contact the assigned Health Promotion Specialist, Louise Brooks, louise.brooks@wdgpublichealth.ca  519-822-2715 ext. 4358.

Who can I contact for questions?

If you have questions regarding your rights and welfare as a research participant in this study, please contact: Liz Robson, Program Manager, Wellington-Dufferin-Guelph Public Health; LizRobson@wdgpublichealth.ca or 1-800-265-7293 ext. 4214. 

CONSENT FORM

Project Title:   The Impact of Bridges Out of Poverty Workshop and Training Sessions in Agencies and Organizations in Wellington, Dufferin and Guelph. (WDG)

Principal Investigator:  Andrea Roberts, MA, Director, Family Health and Health Analytics, Wellington-Dufferin-Guelph Public Health (WDGPH).

Signature of participant

I have read and understood the letter of information. My questions have been answered to my satisfaction, I understand that my participation will not affect any service I receive from WDGPH nor my relationship with WDGPH and I agree to participate in this.

 ð  Yes             ð  No

I give permission to Public Health to use direct quotes from my responses as long as my name, and job title are not identified.

ð  Yes              ð  No

I give permission for Public Health to use a digital recorder to record my full responses.
ð  Yes              ð  No

I give permission for Public Health to email me a copy of the final report when it is available. 

ð  Yes              ð  No

Email Address: ­­­_______________________________

Your name (please print): ­­­­­­­­­­_____________________________________
Signature: _________________________________

Date:       ____ / ____ /_________

The information on this form is collected under the authority of the Health Protection and Promotion Act in accordance with the Municipal Freedom of Information and Protection of Privacy Act and the Personal Health Information Protection Act. This information will be used for the delivery of public health programs and services; the administration of the agency; and the maintenance of health-care databases, registries and related research, in compliance with legal and regulatory requirements. Any questions about the collection of this information should be addressed to the Chief Privacy Officer at 1-800-265-7293 ext 2975

Appendix B: Recruitment and Information Package Letter of Thank You

Date: INSERT DATE mm/dd/yyyy

Dear:  INSERT NAME

We would like to take this opportunity to thank you for your help in supporting the Bridges Out of Poverty evaluation project and for participating in a key informant interview.  In appreciation, please accept this $10.00 gift card.

The evaluation objective of the study is to determine what impact if any has the Bridges Out of Poverty workshops and training has made for agencies and organizations in the Wellington Dufferin and Guelph area.

The secondary objectives of the evaluation include:

Increased awareness of the barriers facing individuals of low resources
Changes to workplace practice and policies to reduce barriers working with clients or individuals, families with low resources
Evaluating the effectiveness of the Bridges Out of Poverty workshops as an accelerator for change in the communities of Wellington-Dufferin and Guelph (WDG)

Thanks you for your time and effort in our evaluation. Upon request you will be emailed a copy of the final report when it is ready.

If you have any questions please contact Liz Robson, Program Manager, Public Health: 1-800-265-7293 ext. 4218; liz.robson@wdgpublichealth.ca

Best regards,

Liz Robson

Program Manager

Family Health

Executive Summary

National, provincial and local data on the LGBTQ population is limited for many reasons including:

• The Census and the Canadian Community Health Survey (CCHS) only began collecting data on the LGBTQ population in 2001 and 2003, respectively. The questions asked do not pertain to sexual behaviour or gender identity.
• Underreporting of LGBTQ status occurs frequently, due to fear of disclosure.
• Many individuals with same-sex attraction or individuals that engage in same-sex behaviours do not identify as gay or bisexual.
• Data often excludes many subpopulations of people that might identify as LGBTQ

Improved Local LGBTQ Data Collection

Increased Visibility of LGBTQ Individuals in Health Promotion Strategies

Agency-Wide Positive Space Training

Acquire and Utilize Additional LGBTQ Resources

Cannabis is No Ordinary Commodity: Public health considerations for municipalities on cannabis retail outlets

Research Topic

Preconception health is defined as the health of all individuals during their reproductive years, regardless of gender identity, gender expression or sexual orientation. It is an approach that promotes healthy fertility and focuses on actions that individuals can take to reduce risks, promote healthy lifestyles and increase readiness for pregnancy, whether or not they plan to have children one day [1]. 

Why Preconception Health?

Globally there are challenges from an individual to a systematic level at recognizing preconception health (PCH) risk factors and their impact on reproductive, maternal and child health. About 50% of all pregnancies are unplanned [2]. Waiting until pregnancy may be too late to prevent exposure to risk factors, since the first few weeks are the most critical for a developing fetus. Therefore, it is important that a woman’s body is ready for an unexpected pregnancy to support both maternal and fetal health. There are several PCH risk factors that may lead to poor birth outcomes, including genetics, poor nutrition, obesity/underweight, poor oral health, tobacco/alcohol/drug use, chronic diseases, infections, mental health, stress, and environmental toxins. If we shift our attention to PCH and help manage and/or reduce these risk factors, then we have a better chance of improving birth outcomes by reducing the rates of preterm birth, low birth weight, and congenital anomalies, all of which can lead to lifelong medical and developmental concerns or infant mortality [1].

Background

Wellington-Dufferin-Guelph Public Health (WDGPH) is mandated by the Ministry of Health and LongTerm Care’s Ontario Public Health Standards to address PCH [3]; however, there is no standardized programming. To address this challenge, WDGPH conducted a literature review, environmental scan and community survey from 2013 to 2014 in search for a local evidence-based strategy. The concept of PCH care visits within primary care emerged as a promising strategy in the literature. A need for more research and use of innovative strategies was also highlighted. The community survey added further support for this strategy. The majority of respondents reported that their top source of PCH information was their physician/primary care provider (PCP). Furthermore, the majority of respondents indicated that if their physician/PCP initiated a PCH conversation, they were more likely to follow the advice given.To support this strategy, the Canadian Community Health Survey (2014) identifies that the majority of women in Ontario have a regular medical doctor (94%) and that they have had contact in the last 12 months (86%) [4]. With this information, WDGPH developed and studied an innovative technology-based strategy within the primary care setting. 

Description of Research

Introduction & Research Goals

This strategy involved the development of an innovative patient-driven electronic PCH risk assessment (RA) tool using tablet technology called My Health eSnapshot. My Health eSnapshot is a comprehensive PCH RA tool designed to identify risks related to reproductive and sexual health, genetics, nutrition, weight, physical activity, oral health, chronic diseases, infections, immunizations, substance use, environmental toxins, mental health, stress, and more. It also includes a patient handout with evidence-based PCH messages based on risk factors identified by the RA tool. In partnership with Boston Medical Centre, My Health eSnapshot was adapted from The Gabby Preconception Care System for use in the Canadian physician/PCP setting. The Gabby System is a patient-driven RA tool that uses health information technology to deliver preconception care to women in their home through a virtual nurse Gabby. The system also creates a customized patient handout to share with their physician/PCP [5]. WDGPH used a health information technology platform called Ocean, created by a Toronto-based company CognisantMD, to program and implement My Health eSnapshot. This innovative tool also complements the Preconception Health Care Tool, a Canadian evidence-based resource created by the Centre for Effective Practice [6].

To understand the impact of My Health eSnapshot, WDGPH conducted a research study. 

Research Methods

My Health eSnapshot was a cohort study that used a mixed method approach. It was studied across seven primary care sites in the WDGPH area from February to June 2016. Research sites were each asked to recruit 120 participants. Eligible participants were: female, between ages 15 and 49, not pregnant, with no hysterectomy, able to read and write English, comfortable using a tablet, active email address and residents of the WDG area. Participants were offered a $10 grocery gift card incentive. 

My Health eSnapshot was implemented using a three part model, which involved participants:

1. completing the tool in their physician/PCP office with results automatically integrated into their electronic medical record (EMR);
2. discussing results with their physician/PCP during their scheduled appointment; and
3. receiving a customized patient handout, summarizing their results with key health messages, that is generated and printed from the EMR as a take-home resource 

WDGPH collected data from participants through the RA tool and a series of evaluation tools. The RA data was collected through Ocean Studies, a research and survey module on the Ocean platform. One-week and two-month online follow-up surveys were emailed to participants using FluidSurveys. These surveys evaluated the RA tool and the patient handout, asked participants about their experience discussing their results with their physician/ PCP, and evaluated participants’ knowledge and behaviour change related to the identified PCH risk factors. Key informant interviews were also conducted with primary care staff to identify the benefits, challenges and sustainability of implementing My Health eSnapshot. 

Key Findings

Introduction

The following is an overview of the My Health eSnapshot research findings. To ensure participant confidentiality, data analysis involved linking results from the RA and two online follow-up surveys using a private code that was created by the patient and used throughout the study. 

Risk Assessment

A total of 300 participants completed the PCH RA prior to their physician/PCP visit.The majority of participants were between the ages of 20 and 34 years (56%); the majority had either a college diploma or university degree (59%); there was an equal representation of urban and rural residents (43% and 41% respectively); the majority reported that they may want to become pregnant someday (63%), and of those, 50% reported that they would like to become pregnant between the ages of 25 and 30.

All participants were screened for 34 PCH risks. The number of risks identified ranged from 4 to 24 risks across all participants. On average, each participant had 15 risks. The most prevalent risks identified were: Canada’s Food Guide not followed (99%), consumed unsafe foods (e.g. fish high in mercury, raw/undercooked foods) or caffeinated beverages (98%), experienced stress in the last 12 months (92%), consumed an alcoholic beverage in the last 12 months (89%), and immunizations not up-to-date (87%). 

One-Week Online Survey

Of the 300 participants who completed the RA, a total of 188 (63%) completed the one-week survey. The majority of participants reported having a positive experience using the RA, including that it was clear and easy to understand (99%), they enjoyed using a tablet (97%), they felt comfortable answering the questions (89%), they were motivated to make positive changes to their health (56%), and that they would recommend the experience to a friend (72%). Of the 188 participants, 86 (46%) had a discussion with their physician/PCP. 

The majority reported that completing the RA before their appointment made it easier to have a conversation with their physician/PCP (65%). The majority were also motivated to make positive changes to their health after having a conversation about their results with their physician/PCP (59%). Of the 188 participants, 130 (69%) received and read the patient handout. The majority found it clear (98%),helpful (85%),and liked receiving the handout (82%). More than half also learned something new about their health (57%) and were motivated to make positive changes to their health (59%). 

Two-Month Online Survey

Of the 300 participants who completed the RA, a total of 144 (48%) completed the two-month survey. The majority of participants learned the importance of talking to their physician/PCP about life-long health needs (72%), and how their health now affects their own future health and the health of their future children (51%). Over half of participants were motivated by the study to learn more about their health or to make positive change to their health (63%). Some participants also reported learning about new health concerns that they did not know they had before (36%). 

72% of WOMEN IN THE STUDY Would recommend My Health eSnapshot to a friend 

Key Informant Interviews

Key informant interviews were conducted with seven primary care staff at four of the six research sites. Most key informants reported benefits to the clinic and to patients from participating in this study, including: being introduced to the Ocean technology, connecting the tablet to the EMR system, having the results welldisplayed and easy to find in the EMR, having the ability to generate a customized patient handout, gaining new and easy opportunities to learn more about patients and their risk factors, having a new opportunity to provide health teaching, and increasing the profile of PCH within the clinic. Key informants also provided valuable feedback about the challenges they experienced with study implementation, including: time, length of the RA tool and patient handout, participant recruitment, and some technological issues (e.g., internet connectivity and printing of the patient handout).The main suggestions for changes to the study model included: shortening the RA tool and patient handout, offering My Health eSnapshot at specific appointment types (e.g., physicals, sexual health, and family planning), scheduling adequate time during the PCP appointment and continuing to collaborate with primary care for future implementation. All of the key informants had very positive feedback about the Ocean platform and reported that they would consider using My Health eSnapshot in the future, if their suggested changes were made to the intervention model. 

Limitations

Limitations included: target sample size not reached, participant attrition, high non-response rates to some questions, recall bias on 2 month survey, some questions not specific enough to measure PCH risk, unknown number of participating physician/PCPs at each research site,inconsistent model implementation across research sites, and internet/technology issues. 

Conclusions & Recommendations

The My Health eSnapshot research study findings are promising. The data analysis demonstrates that the majority of participants reported having a positive experience using My Health eSnapshot (RA and patient handout). Primary care staff also reported many benefits to using the My Health eSnapshot model of care. While the primary research question relating to PCH knowledge and behavior change could not be answered due to data limitations, the study did contribute to answering secondary research questions. These included identifying the most prevalent PCH risk factors, and evaluating the process and user-friendliness of My Health eSnapshot. At the conclusion of the study, WDGPH created an advisory committee to review the research findings and make recommendations to improve the RA, patient handout, and delivery model. Next steps will include validating the My Health eSnapshot RA tool, improving the delivery model, and leading further research, evaluation, and promotion. My Health eSnapshot is the first of its kind in Ontario. This research is contributing to the growing momentum around PCH in Canada and internationally. 

REFERENCES:

1. Ontario Public Health Association. (2014). Shift - Enhancing the health of Ontarians: A call to action for preconception health promotion and care. Toronto, ON.
2. Filner LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011 Jul 28;84(5):478-485.
3. Ontario Ministry of Health and Long-Term Care. Ontario Public Health Standards 2008 [standard online]. c2008 [revised 2014 May 1; cited 2014 Jul 25]. Available from http://www.health.gov.on.ca/en/pro/programs/ publichealth/oph_standards/docs/ophs_2008.pdf
4. Statistics Canada. (2016-04-21). CANSIM Table 105-0501 Health indicator profile, annual estimates, by age group and sex, Canada, provinces, territories, health regions (2013 boundaries) and peer groups, occasional [Data File]. Retrieved on October 26, 2016, from http://www5.statcan. gc.ca/cansim/a05?lang=eng&id=1050501
5. Jack B, Bickmore T, Hempstead M, Yinusa-Nyahkoon L, Sadikova E, Mitchell S, Gardiner P, Adigun F, Penti B, Schulman D, Damus K. Reducing preconception risks among African American women with conversational agent technology. The Journal of the American Board of Family Medicine. 2015 Jul 1;28(4):441-51.
6. Centre for Effective Practice (2015). Preconception Health Care Tool. Retrieved on March 28, 2017 from https://thewellhealth.ca/preconception 

Research Topic

Preconception health is defined as the health of all individuals during their reproductive years, regardless of gender identity, gender expression or sexual orientation. It is an approach that promotes healthy fertility and focuses on actions that individuals can take to reduce risks, promote healthy lifestyles and increase readiness for pregnancy, whether or not they plan to have children one day [1]. 

Why Preconception Health?

Globally there are challenges from an individual to a systematic level at recognizing preconception health (PCH) risk factors and their impact on reproductive, maternal and child health. About 50% of all pregnancies are unplanned [2]. Waiting until pregnancy may be too late to prevent exposure to risk factors, since the first few weeks are the most critical for a developing fetus. Therefore, it is important that a woman’s body is ready for an unexpected pregnancy to support both maternal and fetal health. There are several PCH risk factors that may lead to poor birth outcomes, including genetics, poor nutrition, obesity/underweight, poor oral health, tobacco/alcohol/drug use, chronic diseases, infections, mental health, stress, and environmental toxins. If we shift our attention to PCH and help manage and/or reduce these risk factors, then we have a better chance of improving birth outcomes by reducing the rates of preterm birth, low birth weight, and congenital anomalies, all of which can lead to lifelong medical and developmental concerns or infant mortality [1].

Background

Wellington-Dufferin-Guelph Public Health (WDGPH) is mandated by the Ministry of Health and LongTerm Care’s Ontario Public Health Standards to address PCH [3]; however, there is no standardized programming. To address this challenge, WDGPH conducted a literature review, environmental scan and community survey from 2013 to 2014 in search for a local evidence-based strategy. The concept of PCH care visits within primary care emerged as a promising strategy in the literature. A need for more research and use of innovative strategies was also highlighted. The community survey added further support for this strategy. The majority of respondents reported that their top source of PCH information was their physician/primary care provider (PCP). Furthermore, the majority of respondents indicated that if their physician/PCP initiated a PCH conversation, they were more likely to follow the advice given.To support this strategy, the Canadian Community Health Survey (2014) identifies that the majority of women in Ontario have a regular medical doctor (94%) and that they have had contact in the last 12 months (86%) [4]. With this information, WDGPH developed and studied an innovative technology-based strategy within the primary care setting. 

Description of Research

Introduction & Research Goals

This strategy involved the development of an innovative patient-driven electronic PCH risk assessment (RA) tool using tablet technology called My Health eSnapshot. My Health eSnapshot is a comprehensive PCH RA tool designed to identify risks related to reproductive and sexual health, genetics, nutrition, weight, physical activity, oral health, chronic diseases, infections, immunizations, substance use, environmental toxins, mental health, stress, and more. It also includes a patient handout with evidence-based PCH messages based on risk factors identified by the RA tool. In partnership with Boston Medical Centre, My Health eSnapshot was adapted from The Gabby Preconception Care System for use in the Canadian physician/PCP setting. The Gabby System is a patient-driven RA tool that uses health information technology to deliver preconception care to women in their home through a virtual nurse Gabby. The system also creates a customized patient handout to share with their physician/PCP [5]. WDGPH used a health information technology platform called Ocean, created by a Toronto-based company CognisantMD, to program and implement My Health eSnapshot. This innovative tool also complements the Preconception Health Care Tool, a Canadian evidence-based resource created by the Centre for Effective Practice [6].

To understand the impact of My Health eSnapshot, WDGPH conducted a research study. 

Research Methods

My Health eSnapshot was a cohort study that used a mixed method approach. It was studied across seven primary care sites in the WDGPH area from February to June 2016. Research sites were each asked to recruit 120 participants. Eligible participants were: female, between ages 15 and 49, not pregnant, with no hysterectomy, able to read and write English, comfortable using a tablet, active email address and residents of the WDG area. Participants were offered a $10 grocery gift card incentive. 

My Health eSnapshot was implemented using a three part model, which involved participants:

1. completing the tool in their physician/PCP office with results automatically integrated into their electronic medical record (EMR);
2. discussing results with their physician/PCP during their scheduled appointment; and
3. receiving a customized patient handout, summarizing their results with key health messages, that is generated and printed from the EMR as a take-home resource 

WDGPH collected data from participants through the RA tool and a series of evaluation tools. The RA data was collected through Ocean Studies, a research and survey module on the Ocean platform. One-week and two-month online follow-up surveys were emailed to participants using FluidSurveys. These surveys evaluated the RA tool and the patient handout, asked participants about their experience discussing their results with their physician/ PCP, and evaluated participants’ knowledge and behaviour change related to the identified PCH risk factors. Key informant interviews were also conducted with primary care staff to identify the benefits, challenges and sustainability of implementing My Health eSnapshot. 

Key Findings

Introduction

The following is an overview of the My Health eSnapshot research findings. To ensure participant confidentiality, data analysis involved linking results from the RA and two online follow-up surveys using a private code that was created by the patient and used throughout the study. 

Risk Assessment

A total of 300 participants completed the PCH RA prior to their physician/PCP visit.The majority of participants were between the ages of 20 and 34 years (56%); the majority had either a college diploma or university degree (59%); there was an equal representation of urban and rural residents (43% and 41% respectively); the majority reported that they may want to become pregnant someday (63%), and of those, 50% reported that they would like to become pregnant between the ages of 25 and 30.

All participants were screened for 34 PCH risks. The number of risks identified ranged from 4 to 24 risks across all participants. On average, each participant had 15 risks. The most prevalent risks identified were: Canada’s Food Guide not followed (99%), consumed unsafe foods (e.g. fish high in mercury, raw/undercooked foods) or caffeinated beverages (98%), experienced stress in the last 12 months (92%), consumed an alcoholic beverage in the last 12 months (89%), and immunizations not up-to-date (87%). 

One-Week Online Survey

Of the 300 participants who completed the RA, a total of 188 (63%) completed the one-week survey. The majority of participants reported having a positive experience using the RA, including that it was clear and easy to understand (99%), they enjoyed using a tablet (97%), they felt comfortable answering the questions (89%), they were motivated to make positive changes to their health (56%), and that they would recommend the experience to a friend (72%). Of the 188 participants, 86 (46%) had a discussion with their physician/PCP. 

The majority reported that completing the RA before their appointment made it easier to have a conversation with their physician/PCP (65%). The majority were also motivated to make positive changes to their health after having a conversation about their results with their physician/PCP (59%). Of the 188 participants, 130 (69%) received and read the patient handout. The majority found it clear (98%),helpful (85%),and liked receiving the handout (82%). More than half also learned something new about their health (57%) and were motivated to make positive changes to their health (59%). 

Two-Month Online Survey

Of the 300 participants who completed the RA, a total of 144 (48%) completed the two-month survey. The majority of participants learned the importance of talking to their physician/PCP about life-long health needs (72%), and how their health now affects their own future health and the health of their future children (51%). Over half of participants were motivated by the study to learn more about their health or to make positive change to their health (63%). Some participants also reported learning about new health concerns that they did not know they had before (36%). 

72% of WOMEN IN THE STUDY Would recommend My Health eSnapshot to a friend 

Key Informant Interviews

Key informant interviews were conducted with seven primary care staff at four of the six research sites. Most key informants reported benefits to the clinic and to patients from participating in this study, including: being introduced to the Ocean technology, connecting the tablet to the EMR system, having the results welldisplayed and easy to find in the EMR, having the ability to generate a customized patient handout, gaining new and easy opportunities to learn more about patients and their risk factors, having a new opportunity to provide health teaching, and increasing the profile of PCH within the clinic. Key informants also provided valuable feedback about the challenges they experienced with study implementation, including: time, length of the RA tool and patient handout, participant recruitment, and some technological issues (e.g., internet connectivity and printing of the patient handout).The main suggestions for changes to the study model included: shortening the RA tool and patient handout, offering My Health eSnapshot at specific appointment types (e.g., physicals, sexual health, and family planning), scheduling adequate time during the PCP appointment and continuing to collaborate with primary care for future implementation. All of the key informants had very positive feedback about the Ocean platform and reported that they would consider using My Health eSnapshot in the future, if their suggested changes were made to the intervention model. 

Limitations

Limitations included: target sample size not reached, participant attrition, high non-response rates to some questions, recall bias on 2 month survey, some questions not specific enough to measure PCH risk, unknown number of participating physician/PCPs at each research site,inconsistent model implementation across research sites, and internet/technology issues. 

Conclusions & Recommendations

The My Health eSnapshot research study findings are promising. The data analysis demonstrates that the majority of participants reported having a positive experience using My Health eSnapshot (RA and patient handout). Primary care staff also reported many benefits to using the My Health eSnapshot model of care. While the primary research question relating to PCH knowledge and behavior change could not be answered due to data limitations, the study did contribute to answering secondary research questions. These included identifying the most prevalent PCH risk factors, and evaluating the process and user-friendliness of My Health eSnapshot. At the conclusion of the study, WDGPH created an advisory committee to review the research findings and make recommendations to improve the RA, patient handout, and delivery model. Next steps will include validating the My Health eSnapshot RA tool, improving the delivery model, and leading further research, evaluation, and promotion. My Health eSnapshot is the first of its kind in Ontario. This research is contributing to the growing momentum around PCH in Canada and internationally. 

REFERENCES:

1. Ontario Public Health Association. (2014). Shift - Enhancing the health of Ontarians: A call to action for preconception health promotion and care. Toronto, ON.
2. Filner LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011 Jul 28;84(5):478-485.
3. Ontario Ministry of Health and Long-Term Care. Ontario Public Health Standards 2008 [standard online]. c2008 [revised 2014 May 1; cited 2014 Jul 25]. Available from http://www.health.gov.on.ca/en/pro/programs/ publichealth/oph_standards/docs/ophs_2008.pdf
4. Statistics Canada. (2016-04-21). CANSIM Table 105-0501 Health indicator profile, annual estimates, by age group and sex, Canada, provinces, territories, health regions (2013 boundaries) and peer groups, occasional [Data File]. Retrieved on October 26, 2016, from http://www5.statcan. gc.ca/cansim/a05?lang=eng&id=1050501
5. Jack B, Bickmore T, Hempstead M, Yinusa-Nyahkoon L, Sadikova E, Mitchell S, Gardiner P, Adigun F, Penti B, Schulman D, Damus K. Reducing preconception risks among African American women with conversational agent technology. The Journal of the American Board of Family Medicine. 2015 Jul 1;28(4):441-51.
6. Centre for Effective Practice (2015). Preconception Health Care Tool. Retrieved on March 28, 2017 from https://thewellhealth.ca/preconception 

Executive Summary

• Most participants (85%) were unaware of Canada’s Low-Risk Alcohol Drinking Guidelines.
• Most participants demonstrated some knowledge about the health effects of alcohol.
• There was a low-level of knowledge among participants about alcohol’s effect on breast cancer, stroke, and heart disease.
• Drinking during pregnancy was not socially accepted among most participants, and the large majority were aware of the harms of drinking during pregnancy and breastfeeding.
• The most commonly reported alcohol-related community issues reported by participants were drinking and driving; alcohol-related violence; and over-serving at bars, pubs and restaurants. Public drunkenness was also a top issue for Guelph respondents.
• The majority of respondents supported these policy options:
  • Banning the sale of energy drinks that are premixed with alcohol (71%)
  • Making bars pay for city clean-up costs associated with the late-night bar scene (69%)
  • Requiring alcohol to be sold with a warning label, like cigarettes (55%)
  • Increasing the minimum price of alcohol yearly to be consistent with inflation (58%)
  • Pricing alcoholic drinks based on alcohol content so that drinks with lower alcohol content are cheaper and drinks with higher alcohol content are more expensive (51%)
• Over half of residents also (56%) disagreed with the policy option of allowing alcohol to be sold in convenience stores.

Executive Summary

Drinking behaviour of WDG residents:

• 81% of WDG residents report drinking alcohol in the last 12 months. A higher proportion of WDG residents drink compared to all Ontario (72%)
• On average, WDG residents drink between 4 and 5 drinks per week
• 49% of WDG residents reported drinking in excess of at least one of Canada’s Low Risk Alcohol Drinking Guidelines (LRADGs)1. A higher proportion of WDG residents reported exceeding the LRADGs compared to Ontario (41%)
• Men are more likely to exceed both LRADGs but there has been a 10% increase between 2007-2013 in the proportion of women who report exceeding the special occasion limit

Drinking behaviour of special populations:

• 22% of grade 7 students and 66% of grade 10 students reported drinking in the last 12 months
• Grade 10 males are more likely to report heavy drinking than females and grade 10 youth in Dufferin are more likely to report heavy drinking than grade 10 students in Wellington and Guelph
• A higher proportion of grade 7 and 10 youth who drink more frequently are at risk of depression compared to youth who drink less frequently

University Students

• 89% of students at the University of Guelph reported drinking within the last 12 months
• 31.1% of students classify as light-infrequent drinkers and 27.5% of students classify as heavy-frequent drinkers

• Of women of childbearing age (15-44 years old), 86% reported drinking within the last 12 months and 62% reported exceeding the LRADGs in 2013.1 Canada’s national Low Risk Alcohol Drinking guidelines were created to give Canadians information on how to drink on a low-risk way.  
• ​Of the women included in a WDGPH Prebirth Clinic study, 18% reported consuming alcohol during their pregnancy and on 2% of the total sample continued to use alcohol after they became aware of their pregnancy.

1.0 INTRODUCTION

1.1 Background

Executive Summary

Introduction

Key Messages from the 2015 Oral Health Status Report