National Child Nutrition Program Cluster Evaluation: Preliminary Findings Evaluation team Colin Bell Jan Garrard Dionne Holland Boyd Swinburn

Deakin University 2003 Background: National Child Nutrition Program A community grants program established in 1999 by Commonwealth Department of Health and Ageing Aimed at improving nutrition among children aged 0 to 12 years and pregnant women Focus on priority communities: Rural and remote communities Aboriginal and Torres Strait Islander communities Lower socio-economic communities 110 community-based projects funded nationally 18 projects in Victoria - $2,190,300 over three year period

Deakin University 2003 Evaluation: Background Evaluation not built into overall program planning No specific evaluation budget Importance of evaluation recognised by Victorian office of Dept of Health & Ageing 9 projects committed $3,000 each to fund a ‘cluster’ evaluation Additional $60,000 from Dept of Health & Ageing Deakin University contracted to conduct the evaluation

Deakin University 2003 Evaluation: Preview A ‘retrofitted’ evaluation strategy Optimum balance of common measures while acknowledging the uniqueness of projects, populations and settings Evidence base for effective community-based child nutrition programs is poor – good practice often not documented, disseminated and acknowledged A practical, feasible evaluation strategy designed to meet the needs of funding body, project management agencies and practitioners

Deakin University 2003 Evaluation: Objectives To assess intended and unintended impacts of individual projects To gain an understanding of key implementation issues impacting on project success To draw upon collective learnings from the 9 projects to guide future efforts in community-based child nutrition

Deakin University 2003 Evaluation: Design & Methods Multiple case study design (9 ‘cases’) Process measures (ie. what have they done?) and Impact measures (ie. what have they achieved?) At individual project level - evaluation team assisted each project to conduct process and impact evaluation Across projects, evaluation team conducted a total of 53 key informant interviews – combination of core questions and project-specific questions Enabled ‘detection’ (but not quantitative measurement) of impacts – useful for unintended impacts Provided data on important how? and why? questions

Deakin University 2003 Evaluation: Lessons Learned Build evaluation planning into project planning Provide adequate resources for evaluation (approx 10-15% of project budget) Recognise that responsive, needs-based, individually tailored community-based projects will rarely meet the requirements for rigorous quantitative assessment Such projects rarely find their way into conventional evidence-based reviews.

Deakin University 2003 Lessons Learned (cont) Focus instead on what can be achieved (measured impacts) in what settings with what population groups under what conditions – recognise this will vary in different priority settings Distil common achievements and learnings if possible Provide a mechanism for sharing experiences via a ‘community-based projects’ evidence-base.

Deakin University 2003 Cluster Evaluation Projects ‘High Five’ School project – Warrnambool ‘Eat Well, Grow Well’ – Hamilton, Southern Grampians Shire H 2 O for Moonee Valley Kids – North Melbourne ‘Breast is Best’ – Brimbank, West Melbourne ‘Healthy Eating for Country Kids’ – Swan Hill ‘Who’s Eating Gilbert Grape and Vicki Vegetable’ – Murray Valley Aboriginal Cooperative, Robinvale ‘A healthy family is built on a good diet of nutritious food’ - Robinvale ‘Child nutrition in the West’ – West Melbourne ‘Food Facts for preschoolers’ - KPV

Deakin University 2003 Aim: To increase the fruit and vegetable intake in order to improve the overall nutrition of prep to year 4 children in the South West of Victoria ↑largest in yr 2&3 Also ↑ in serves Vegetable intake was very low (~5%) & only increased at one of the schools Supporting curriculum changes and parent involvement South West Health Care

Deakin University 2003 Aim:To increase the proportion and duration of breastfed babies in the City of Brimbank, particularly in low SES and CALD communities Distributed BF promotion kits to GPs & MCHNs Prenatal BF promotion checklist adopted by Sunshine Hospital Breastfeeding guide for new mothers (Vietnamese) Specific support and promotion of BF in Vietnamese community 66 BF-friendly venues Adoption of Lactation policy by ISIS 01/0275%69%51%34% ISIS Primary Care

Deakin University 2003 Murray Valley Aboriginal Co-Op Murray Valley River Quest PAN messages at ‘stops’ on route Reached 516 children Teachers said it was easy to implement and raised awareness In 2003 hours have ↑ Murray Valley Aboriginal Cooperative 48 towns53 towns100 towns Aim: Improve nutritional knowledge and healthy eating patterns of pregnant women, young mothers/caregivers of children aged 0-12 years and children within local Aboriginal and Torres Strait Islanders

Deakin University 2003 Western District Health Service Education sessions effective in improving knowledge of participants Supermarket tours and visits to new mums also beneficial ↑awareness of conditions which may require dietetic referral among WDHS staff Eat Well – Grow Well Aim: To improve the nutritional health of children aged 0-5 years in the Southern Grampians Shire

Deakin University 2003 Swan Hill District Hospital ↑access to nutrition education for pregnant/new mums Good readership of newsletter and newspaper column These were helpful for making healthy food choices Aim: To improve the eating habits of all children and pregnant women in Swan Hill and surrounding district, providing GPs with nutrition information kit

Deakin University 2003 Doutta Galla Community Health Service ‘H 2 O for Moonee Valley Kids’ Drink water rather than sweet drinks ‘Food and Families’ 4 week course on nutrition information and parents skills Somali women Breastfeeding, bottle, solids, vitamin D Aim: To improve the healthy food intake of infants and children aged 0-12 years with Kensington, Flemington, North Melbourne and Ascot Vale

Deakin University 2003 Western Region Health Centre ‘Eating altogether-5 times better’ Fruit, vegetable & water promotion at 2 primary schools Bilingual child education program In 1 year, 700 people from LD communities participated in 75 nutrition education sessions Western Region Health Centre Aim: Increase nutritional knowledge and capacity of pregnant women, parents and children ages 0-12 with CALD and recently arrived communities, to enhance healthy eating patterns

Deakin University 2003 Robinvale District Health Service Parent cooking classes Multi-cultural food day Attended by people Nutrition education sessions Large Polynesian population Breakfast program at schools Linked with MVAC Aim: Improve nutritional knowledge and healthy eating patterns of parents and children in Robinvale

Deakin University 2003 Kindergarten Parents Victoria Staff training sessions 9 locations throughout Victoria with over 170 participants ↑ knowledge of Aust. Dietary Guidelines for children, role of nutrition policy, value of partnerships b/w parents and early childhood staff Parent workshops At sessional preschools, long day care, other services ↑ understanding of childhood nutrition Resources Staff training sessions, ‘parent workshop’ package, Food Safety Information Sheet, nutrition built into existing KPV resources (eg Preschool Matters’ Aim: To increase the capacity of early childhood services to deliver consistent, relevant and current nutrition information to preschool children and their parents

Deakin University 2003 Cluster Evaluation 53 semi-structured key informant interviews completed 11 project officer interviews 39 key informant interviews (single and focus groups) 2 Steering Committee member interviews Combination of core and project specific questions Presenting preliminary findings today Report available early 2004

Deakin University 2003 Reported Impacts Increased collaborative links Human servicesNGOsGovt Depts Community Health Centres PCPs Royal Children’s Hospital Breast Feeding Association Ecumenical Migration Centre Dept. of Health and Ageing LGAs City West Water

Deakin University 2003 Reported Impacts (cont) Diffusion of nutrition messages Reached target groups Children, parents, carers, pre-schools, kindergartens, primary schools And beyond….. Program participants ‘spread the message’ Fathers read brochures on breastfeeding aimed at mothers Program participants ‘modelled’ healthy eating behaviours

Deakin University 2003 Reported Impacts (cont) Spin-offs Children Increased concentration in class Likely reduction in dental carries Families Budget savings (eg. not purchasing soft drink) Bilingual workers Future work Empowerment

Deakin University 2003 Capacity Building Framework Organisational Development Workforce development Resource allocation Partnerships Leadership Context Build Capacity Infrastructure Program sustainability Problem solving Source: Hawe 1999

Deakin University 2003 Organisational Development Management support Projects more effective when management understood the complexity of community work and supported it Recognition of work Projects better supported within the organisation when encouraged to showcase their achievements Additional support from co-workers Policy development

Deakin University 2003 Workforce Development Project officer training and previous experience in community work Needed a sound knowledge of community work and how it differs from clinical work Generally, new graduates who lacked field experience struggled unless provided with additional support within the workplace Projects easier to implement when working in a team environment Important to share learnings with co-workers to gain support and increase organisational capacity to carry out community work

Deakin University 2003 Resource Allocation Control of project resources (incl budget) Advice on how to get the ‘best bang for your buck’ Project officers need to be aware existing resources ‘Cost-effectiveness’ of different strategies Continual planning towards obtaining additional resources, especially into the future

Deakin University 2003 Partnerships Can be extremely effective Working towards a common goal, but from varied view points Provided additional ‘sponsorship’ Often opened up opportunities for shared access to experts and resources Enhanced opportunities for sustainability as multiple organisations/individuals were able to share the role lessening the burden (time and money) on one person Often enabled strategic responses across multiple settings

Deakin University 2003 Leadership Essential Creative problem solving skills Needs to be able to take on the view points and the needs of the local community and develop and re- develop strategies where needed Continuity Leadership role best held by the same person throughout the project Empowerment of others

Deakin University 2003 Context Physical, economic, political, organisational and cultural environments of the project Currently high profile of nutrition Organisations with community-based and population focus

Deakin University 2003 What does the literature say about success factors for community-based interventions? Limited literature around community- based child nutrition programs Community-based smoking programs have been at it a lot longer! Systematic review of 32 studies covering 30 years of community-based interventions to reduce smoking (Secker- Walker et al. 2003)

Deakin University 2003 Lessons for child nutrition promotion (Adapted from Secker-Walker et al. 2003) Child nutrition needs to be recognised by the community as an important issue Community organisation, assessment of community capacity, and the identification of individuals and organisations interested in supporting nutrition interventions are important during project development. Community members and staff need skills in working with diverse groups and in health education Coalitions need several months to form, and a year or more to become effective change agents in their community

Deakin University 2003 Interventions to improve child nutrition need to continue for several years Resources for promoting good nutrition and support for healthy eating should be readily available throughout the community It is important to involve, train, and provide referral services and resources for health professionals The use of mass media (print, radio, television) is especially useful for modelling behaviour change, and for changing community norms about nutrition Lessons for child nutrition promotion (cont)

Deakin University 2003 Conclusion Projects have had some good impacts at the local level Contributed to the knowledge base about effective implementation Important to disseminate these findings