Examples of Population Health Intervention Research

A number of CIHR Institutes and partners have supported population health intervention research (PHIR) through a variety of creative funding mechanisms.

Northern Healthy Foods

Evaluating the Northern Healthy Food Initiative: What is the impact on food security on Aboriginal and non-Aboriginal communities in Northern Manitoba?
Dr. Shirley J. Thompson and Dr. Jeff A. Gordon

Context for the Research

For many years now, people in Northern Manitoba have lived with food insecurity and shortages. Even when including country foods, 75% of people in communities in Northern Manitoba reported being food insecure, according to this research. Northern Manitoba residents are very much dependent on winter roads (which are only available for a month or two and are increasingly unreliable due to climate change) or purchasing food in bulk during the few months where access to roads is guaranteed. Otherwise, food and other important survival materials have to be flown in, which is an expensive option. As a result, much of the food available in these communities is "junk food" because it keeps and travels well. Island Lake communities demanded programs and assistance to ensure more self-sufficiency in their own communities one year when the winter roads did not freeze over.

While working on another project with Northern Manitoba communities, the nominated principal investigator, Dr. Shirley Thompson, was approached by a collaboration of NGOs working in these communities to conduct research and help evaluate self-sustainability options for each community. Dr. Thompson wrote the proposal in collaboration with the provincial government and NGOs/communities. This research involved these collaborators from the beginning; their knowledge guided the proposal, the collaborators all wrote letters of support for the research and collectively determined which communities would be investigated. These researchers were the first to consider food security in Manitoba's First Nations including country foods in their investigation of food security in First Nations communities, combining this research with an evaluation of different options for self-sustainability.

Main Findings of Research

The published results provided information on effective aspects of community development projects centered on food and self-sustainability and food insecurity rates. Some of the successful projects included local gardening, building greenhouses, poultry and freezer loan projects, etc. The research examined the delivery of these community programs and factors associated with the effectiveness of each program (taking the local community context into account). Some of the factors associated with success were whether NGOs were community-based, the level of health or school engagement in food programming, whether the programs were run by paid staff or volunteers and whether programming considered country foods and local knowledge. The research demonstrated that some of these projects were quite successful at increasing access to healthy foods (e.g. through building green houses, teaching people how to maintain a chicken coop, making community freezers easily accessible, teaching people to make homemade preserves, etc.) in the communities studied but also highlighted that programming unsupported by the Northern Healthy Foods Initiative on country foods is highly effective at reducing food insecurity (e.g., Nelson House Country Food Program). It also highlighted a need for sustained support to ensure that infrastructure and capacity building are continued as otherwise the future of the projects is in question. For example, because of the remoteness, location and high rates of poverty in these communities, support is needed to provide greenhouses and/or gardening tools which will help ensure sustained access to healthy foods.

Outcomes (Actual and Planned)

The most significant outcomes to date have centered on the dissemination and use of the research results. Aside from helping study the implementation and reporting on the success of many self-sustaining projects in Northern Manitoba, Dr. Thompson also presented research findings to policy-makers in several different departments including Manitoba Healthy Living, Youth and Seniors; Manitoba Agriculture, Food, and Rural Initiatives; Manitoba Conservation; Manitoba Aboriginal & Northern Affairs, Regional Health Authorities and Agriculture and Agri-Food Canada. This work has contributed to increased awareness that food security is an extensive problem in Northern Manitoba and that a scaled-up and diversified approach is needed to address this problem. Dr. Thompson found that "Northern communities are using our research video and report to find answers and ask for change to the unacceptable situation of 75% food insecurity in Northern Manitoba". The work has also been presented to the Public Health Agency of Canada and at annual public health conferences in Canada. In terms of dissemination of knowledge amongst collaborators, Dr. Thompson reports that through this research and knowledge translation activities the communities were able to share best practices amongst themselves through focus groups, conferences, workshops, posters and community participatory video sessions. Dr. Thompson reported that although the research findings have been disseminated, it may take longer still to reach some long term outcomes.

This research has also been quoted in press releases from Northern Manitoba NGOs who are now using its results to advocate for better policies. The provincial government has officially accepted the report and is currently developing recommendations based on its results. Frontier School Division regularly receives requests for presentations of the results of this research. For example, researchers produced a video that describes the results of their research. Between 30 and 50 copies of this video have been distributed for viewing by pupils. Other researchers have now endeavored to plan, implement and evaluate food security projects in 16 additional communities. This new team of researchers has consulted with Dr. Thompson and they have used this study's findings as well as adapted its methodology for their research.

Finally, this funding and the opportunity to do this research had an influence on Dr. Thompson and graduate students at University of Manitoba. Because of the high need in this area, it has become the main focus of Dr. Thompson's research. Further, because of experience gained in doing this type of research and/or the wide media attention, the results received, more graduate students at University of Manitoba are choosing to focus on food security issues and solutions in Northern Manitoba.

Healthy Living as a Core Function of Public Health

Evaluation of Healthy Living as a Core Function in Public Health
Dr. Joan Wharf Higgins and Dr. Karen Strange

Context for the Research

In response to CIHR-IPPH's (2003) publication titled The future of public health in Canada: Developing a Public Health System for the 21st century, the British Columbia Ministry of Health introduced A Framework for Core Functions in Public Health which defined and described a total of 21 key public health functions, including the Healthy Living Core Program. This encompasses strategies to improve knowledge, skills and health-related behaviors in the areas of tobacco reduction/cessation, healthy eating and physical activity. One of the key aspects of this framework is its focus on evidence-informed public health guided by local context.

Dr. Joan Wharf Higgins, the nominated principal investigator (NPI) is a Canada Research Chair in Health and Society, a professor at the School of Physical Education and Scientific Advisor to the BC and Yukon Health and Learning Knowledge Centre. As part of this role, she was involved with a larger team of CIHR- and Michael Smith Health Research Foundation-funded researchers and public health staff who were working together to develop and implement the framework across public health authorities. Before implementation of the framework in two health authorities — Vancouver Coastal Health (VCH) and Vancouver Island (VIHA) — the NPI was approached by these authorities to document the implementation experience including challenges and successes. The research examined implementation, impacts, how geographic and organizational contexts affected implementation, as well as definition, use and application of evidence in public health practice. This project was completed in March 2010. An important factor in the success of this project was the ability of the NPI to apply for funding within a short time frame and the fact that the funding was flexible enough to allow the researcher to adapt the research methodology and topics to suit the needs of collaborators and end-users.

Main Findings of Research

One of the key findings of this research is a better understanding of how best practices/evidence gets utilized by public health practitioners. Researchers found that organizations need to provide support that allows public health practitioners time to gather and reflect on evidence (which comes in many shapes). Research also suggested that it is challenging for practitioners to access and interpret evaluations of previous initiatives while also tailoring evaluated programs and outcomes to their own communities (especially for rural communities or sub-groups of minority populations such as the economically disadvantaged).This finding resulted in clear recommendations, including core competencies for public health practitioners.

The research also demonstrated how pivotal the community development and networking aspects of public health practitioners' work is and emphasized the importance of using a population health approach to incorporate social determinants of health in effective public health programming.

Finally, the research produced an environmental scan and improved the understanding of the relationships between regional, provincial and national bodies involved in the delivery of healthy living initiatives. This allowed collaborating health authorities to get a better sense of what other healthy living services were offered in their communities and gave a sense of how much (if any) overlap there was between those services and those offered by other groups. In some cases, it was evident there was a fair amount of overlap. The study also highlighted some gaps.

Outcomes (Actual and Planned)

There is already some evidence that knowledge translation of research outcomes is occurring with the partnering organizations. The NPI has written and submitted two official reports to the partnering organizations (health authorities) and a stakeholder at one of the partner organizations stated that the results of this research would be used to guide policy (e.g. determining core competencies for public health practitioners). The NPI has been invited twice to speak with management and knowledge users in the collaborating organization to describe the results of this research and these presentations were well-received. Further, by clearly explaining these results and their relevance to decision makers, it is more likely that they will be integrated into strategies and future planning. In fact, part of the presentations included facilitation by the NPI to assist the stakeholders in coming up with recommendations. Finally, the report has been shared with all research participants, as well as other individuals referred to the NPI by the partnering organizations (e.g., other researchers working on similar healthy living initiatives).

When asked to describe the most significant outcome of this research, one stakeholder stated: "for sure, the partnership with [the NPI] and her research group, a lot of success has come out of that collaboration." This partnership success is partly attributed to the NPI's openness to tailoring methods and goals of the research to reflect the needs of the collaborators. As one stakeholder stated, "reports do not always get read," but this will not be the case here. The NPI created a true collaboration to ensure she collected useful information that could be used by collaborators and she was willing to present findings in accessible terms to knowledge users.

Diffusion Process of Action Schools! BC

Evaluating the Diffusion Process of Action Schools! BC: Characteristics of Schools, Teachers and Innovation that Impact Level of Uptake and Sustainability
Dr. Louise C. Mâsse, Dr. Heather Anne McKay and Dr. Patti-Jean Naylor

Context of the Research

The mandate of Action Schools! BC is to contribute to the health of children by integrating physical activity and healthy eating messages into the fabric of the school community. In pursuit of its goal of providing children with a foundation for life-long healthy living, the initiative provides a framework for schools to create local action plans to provide more opportunities for children to make healthy choices more often during their school day. Action Schools! BC was identified by the BC provincial government as a positive solution to address the decrease in physical activity among children. After successful pilots, the Physical Activity component of Action Schools! BC was rolled out in 2004.

In fiscal year 2007-08, a team of researchers from University of British Columbia, University of Victoria, the BC Ministry of Healthy Living and Sport and the BC Ministry of Education evaluated the dissemination of Action Schools! BC. The research assessed factors contributing to the adoption of the model by teachers and sustainability of its implementation across the province. These findings were to be used to alter the program as needed. The research received support from both the Health and Education sectors (e.g. school districts, principals, etc.).

There was support for the research project from the program implementer, the two ministries involved, schools districts and principals. In addition, the research was conducted at a time when significant changes were occurring in the school context (i.e., the provincial government was mandating Daily Physical Activity in the school setting and 30 minutes of physical activity per day in elementary schools). The success of the model reflects the positive political will and the support of the provincial government that continues to be highly supportive of sustaining the model in schools.

A contributing factor to the successful implementation of this research is the long history of collaboration between researchers, the Ministries, the extended school community and program implementers who are partners in Action Schools! BC. Another contributing factor was that the research team took time upfront to design, plan and implement the initiative in full collaboration with community and government partners. They also ensured that the main education stakeholders, the two ministries and the implementers of Action Schools! BC had input in the research. For instance, the research team presented survey instruments to partners and stakeholders for validation, corrections and clarifications and involved stakeholders in the analysis and reporting of findings. This collaboration helped with data interpretation and contributed to academic language being translated into prose that resonated with politicians and users of the initiative.

Main Findings of Research

The research found that users of Action Schools! BC undertook more physical activity than non-users. For instance, the number of minutes of physical activity offered outside of physical education (PE) was significantly linked with the uptake of Action Schools! BC. For instance, 73% of teachers in registered schools reported being Users of the Physical Activity component of Action Schools! BC. Importantly, 96% of principals and 66% of teachers indicated that they were using or planning to use Action Schools! BC to meet the government-mandated 30 minutes of daily physical activity.

Characteristics of the innovation, teachers and schools significantly influenced uptake of Action Schools! BC. Teachers who thought the Action Schools! BC model was compatible with their teaching values, easy to try and able to yield health benefits were more likely to adopt the model. Teachers who attended an Action Schools! BC workshop and felt confident in their ability to implement the initiative were also more likely to use the model. Finally, changing policies within the school setting to accommodate the Action Schools! BC initiative was instrumental in promoting its uptake and implementation.

In 2008, BC introduced a policy that mandates schools to provide 30 minutes of daily physical activity (DPA) for students. This new policy was perceived to reinforce adoption of the "Action Schools! BC" model. Findings also indicated that DPA requirements were important contributing factors to creating a context for action in BC schools.

Outcomes (Actual and Planned)

Some areas for further research were identified as a result of the project. For instance, some stakeholders thought the linkage between Action Schools! BC and the new DPA policy merits further study. In addition, "fidelity" to the model, or to what extent the model is being implemented among registered schools across the province, would also yield valuable information. Another area targeted for further research is the Healthy Eating component of Action Schools! BC, as it was implemented later than the physical activity component.

Research outcomes reinforced the importance of Action Schools! BC to teachers and school administrators and validated the need for continued resources and refresher training for teachers — the end-users of Action Schools! BC tools. Refresher courses offered on an ongoing basis are viewed as a critical component to keep teachers engaged and committed to providing more opportunities for their students to be physically active.

The research results could potentially influence adoption of the Action Schools! BC model by other provincial and territorial governments that have already demonstrated their interest in the model. The rigour of the evaluation provides further assurance to other interested parties that the model works for teachers and school administrators.

The overall impact of this research is not known as it has not yet been published in a scientific journal. However, members of the research team have previously published about the effectiveness of the Action Schools! BC initiative on children's health. Current results on the dissemination of the model were presented at two conferences including the International Conference on Physical Activity in Toronto, and the team made two presentations to the Ministry of Healthy Living. A summary of research findings was disseminated to schools and school districts that participated in the study.

The Grade 10 Community Physical Activity Pass

The Grade 10 Community Physical Activity Pass
Dr. Lucie Lévesque

Context of the Research

The main objective of the Community Physical Activity Pass is to raise physical activity levels of children by increasing their access to and participation in community recreation facilities' programming. The initiative was implemented by Kingston Gets Active (KGA) — a partnership between municipal, education, health, social and recreation sectors in the Kingston area. Originally designed for Grade 5 students, the Pass was given to Grade 10 students to encourage them to be physically active since Ontario children no longer have mandatory Physical Education (PE) in their curriculum after Grade 9. Providing passes for free access to designated recreation activities and facilities eliminated one potential financial barrier to recreation and physical activity participation.

The primary researcher was involved in the coalition of stakeholders and offered to conduct this research, which aimed to assess the effectiveness of the Activity Pass for Grade 10 students.

Main Findings from the Research

The research team analyzed data from the CIHR-funded Grade 10 Pass for 2007-2008 and found that that several factors predicted pass use. For instance, pass use is more likely if students attend a school in close proximity to a recreation facility (transportation being a key barrier to use), are already active and have used the recreation facilities for unstructured activities in the past. The research also found that students who rated their health as poor or fair were much more likely to use their pass.

Collaboration and Partnerships

The research team presents research results to KGA coalition members on a yearly basis. The meetings also serve to discuss issues emerging from the research findings and to brainstorm new ideas. The participatory process and ongoing collaboration between the research team and community stakeholders promotes ownership and commitment by all involved to find solutions to barriers and identify ways to enhance the program. This in turn promotes sustainability.

This research could not have been conducted in the funding timeframe if the relationship and trust between the university and the regional steering committee for Kingston Gets Active had not been established a priori.

A lesson learned is that the replacement of a single key decision-maker at the school board level can have a significant impact on a research project conducted as a natural experiment. As noted, the research was initiated on the basis of obtaining passive consent from students and active consent became necessary at a later stage, reducing the response rate significantly. This is an important point to note for researchers wishing to undertake research in schools, particularly at higher grades.

Outcomes and Impacts

The research findings suggested the need for reinforcement at the classroom level for the promotion and use of the pass. Partners involved with the implementation of the program in schools (i.e., public health and school stakeholders) thought that earlier exposure to the pass would enhance pass uptake, As Grade 9 students still receive mandatory physical education classes, it seemed a logical place to start promoting the passes, the rationale being that PE teachers could easily encourage students to use the free pass. It also seemed that this encouragement could come from classroom ambassadors who could act as champions for the free pass and remind their fellow students to use it. Thus, it was decided that Grade 9 students would be given a pass the following school year and that Grade 10 students would receive the free pass for one additional year before phasing it out for that grade. Given the costs associated with the free passes for the city's recreational facilities, it was decided to focus on Grade 9 students in subsequent years with the hope that they would continue using the facilities after Grade 9 with fewer incentives.

The research team obtained additional funding to work with the KGA — in particular the school health team from the public health unit — to implement and evaluate the Grade 9 passes. As promotion was identified as a likely leverage point for increasing use of the Activity Pass, the research will focus on developing and assessing promotional strategies. For instance, it will include one day of training for the classroom ambassadors. The training is based on an existing training program for KGA physical activity ambassadors, which will be adapted for the students. There is a plan to consult the youth ambassadors on various methods to better reach their peers and promote the use of the PA passes. The research team also intends to engage the youth ambassadors in future research. For instance, it is hoped that they can promote participation of their peers in the research in which they will be the primary participants. The researchers also intend to include control schools to test the role of the classroom ambassadors in the promotion and use of the PA pass.

It is somewhat premature to observe impacts from the research on the Grade 10 free passes at an academic level or a public policy perspective, as it has not been published in academic journals. However, research results were presented in at least four Canadian and two international conferences. From a public policy perspective, the research and its follow-up study on the implementation of the Grade 9 Physical Activity (PA) pass could serve as a model for implementation in other jurisdictions as the Grade 5 Activity passes did.

For example, the success of the KGA Grade 5 PA Pass program prompted the Public Health Agency of Canada to fund a National Grade 5 Community PA Pass program, titled "Canada Gets Active," in the fall of 2009. Should the Grade 9 free pass experiment in Kingston succeed, it could lead to uptake from other communities across Canada, as did the Grade 5 Active Pass.

Ownership by Local Stakeholders to Support Healthy Living for Youth in Schools

L'appropriation par les acteurs locaux de la stratégie globale de mise en oeuvre de l'approche École en santé comme condition favorable au développement de saines habitudes de vie chez les jeunes
Dr. Yves Couturier and Marthe Deschênes

Context of the Research

"L'Approche École en Santé" (AÉeS) is a comprehensive and concerted health promotion strategy of the Ministry of Education, Recreation and Sports and the Ministry of Health and Social Services. The AÉeS proposes a model to carry out preventive actions at the school level by mobilizing staff (teaching and non-teaching personnel), students and their parents, and by connecting these actions to an "educational plan" and the school's "plan for success." A school needs or situational assessment is a key element of the approach. Schools participate on a voluntary basis. About one third of Quebec schools have adopted the approach.

The AÉeS was designed and implemented by the Quebec Institute of Public Health, a government-funded organization founded in 1998 to improve the coordination, development and use of expertise in public health. Some of the key tools in the approach focus on how to conduct a situational or needs analysis at the school level for developing a physical activity strategy and the other is a decision-making process tool. The Quebec Institute of Public Health is the primary user of the research findings.

The research aimed to better understand conditions for the successful implementation and sustainability of the AÉeS as it is being deployed across Quebec. It also sought to identify local adaptations to the model and gaps to improve the approach and its adoption. A research team from the l'Université de Sherbrooke, Université de Montréal and Université du Québec à Montreal (UQAM) undertook this research in partnership with the Ministry of Education, Recreation and Sport and the Ministry of Health and Social Services. The study took place in eight schools in three regions of Quebec.

Main Findings

The study found that there was good understanding of the principles underpinning the model, particularly at the school direction level and among physical education teachers who were often its champions. It found that underlying concepts were less well understood among the general teacher population, students, parents and the community. This represented the main challenge for the sustainability of the approach. It also found certain local adaptations to the approach. Some were positive (e.g. enhancing the efficiency of decision-making by using tools from another approach promoted in schools "Agir Autrement"); some less positive (e.g. ad hoc decision-making or simply using already existing activities rather than conducting a needs assessment to determine which activities best met local needs). The research identified significant gaps in terms of the support provided by regional promoters. The research also found that, while the principles were generally well understood by the schools, schools found the tools to conduct needs assessment and decision-making too complicated and exhaustive.

Collaboration and Partnerships

Given the timelines required to get approval from school boards and ethics committees, this type of research would not be possible without this pre-existing relationship between the researchers and implementers. This close association also facilitated bringing corrective action to the approach for a second phase of implementation. However, it was also noted that given the school timelines and getting through the ethics committee at the university, it was not possible to implement the research in the CIHR timeframe of 12 months. In fact, the research team needed almost 24 months and are grateful that CIHR agreed to an extension.

Outcomes and Impacts

At one level, the research provided validation for the government's policy and course of action regarding the approach Écoles en Santé. More immediately, it paved the way for a second wave of implementation, as researchers made a number of recommendations for corrective action in the approach and supporting tools. The research team has worked closely with the INSPQ's team to remedy some of the gaps identified through the research, notably in the area of support and training to the schools seeking to implement the approach. They will give greater consideration to schools' context and will make tools more user-friendly. To do so, they are also undertaking a participatory research project with users to ensure that the redesigned tools meet their needs.

As noted above, the principal user of the research is the Institute of Public Health. The Institute considers the development and deployment of the AÉas to be an iterative process and viewed this research project as timely and concrete in assisting to identify implementation gaps preventing greater adoption of the approach and solutions to improve uptake.

It is somewhat premature to observe impacts from the research at an academic level, as it has not been published in an academic journal. However, the researchers presented the results to participating schools and to key decision-makers in all regions of Quebec, as well as their immediate research partners. The research was presented at three national and international congresses. The Institute of Public Health also disseminated the research findings to all health and school districts across Quebec. Potentially, all Quebec schools received information on the research's findings.

From a public policy perspective, the research has encouraged dialogue between researchers and decision-makers. The research team also made linkages with two complementary initiatives implemented in Quebec: "Réussir Ensemble en français" and "Agir Autrement." These have been developed with the same premise of creating collaborations between schools, families and communities to support academic success. Potentially, the linkages developed between AEeS and these other programs will allow for greater sharing of research findings in the future and possibly greater synergy between the various approaches that schools are encouraged to adopt and which often face similar implementation issues.

The Built Environment

The Built Environment
Dr. Lawrence Frank, Dr. Michael Bauer (A moving study)
Dr. Jason Gilliland (Identifying causal effects of the built environment on physicalDr. Jason Gilliland (Identifying causal effects of the built environment on physical activity, diet and obesity among children)
Dr. Sara Kirk (Tools, Information, Motivation, Environment)

Context of the Research

Neighbourhoods that are designed to encourage physical activity can literally be a lifesaver. Being physically active 150 minutes a week, in bouts of 10 minutes or more, can dramatically lower a person's risk of heart disease and stroke. Regular activity also helps prevent and control risk factors for heart disease and stroke such as high blood pressure, high cholesterol, and obesity. Yet only 15% of Canadian adults accumulate 150 minutes of moderate- to vigorous-intensity physical activity each week. It's a daunting reality and one that some Canadian research teams hope to change.

Three such teams received funding in June 2011 under the Built Environment: Population Health Intervention Research strategic initiative. This initiative aims to:

  • support intervention research that examines programs, events and/or policy changes related to the built environment (outcome of community planning, design and implementation) and has the potential to address health problems at the population level
  • build population health research capacity in Canada to study the built environment and its impacts on obesity and other health issues
  • encourage "horizontal" networks and collaboration among the different sectors such as urban planners, researchers from various disciplines (including trainees and new investigators), communities, government, industry, and non-profit organizations
  • develop knowledge transfer and exchange (knowledge translation) opportunities between researchers and knowledge users

This initiative was funded by the Heart and Stroke Foundation, in collaboration with the CIHR Institute of Circulatory and Respiratory Health; Institute of Human Development, Child and Youth Health; Institute of Musculoskeletal Health and Arthritis; Institute of Nutrition, Metabolism and Diabetes; and Institute of Population and Public Health.

The Research

A moving study: Physical activity as diet before and after residential relocation
Dr. Lawrence Frank and Dr. Michael Brauer

This Metro Vancouver study is investigating how different neighbourhood design attributes influence health over time. Researchers are comparing built environment features and health of people before and after they move to a new neighbourhood. They will focus on diet, physical activity levels, body weight and exposure to air and noise pollution. They will test how relationships vary across different age groups, ethnicities and income levels. Findings will advance the science and our understanding of how neighbourhood layout and design influence health outcomes across different populations.

Identifying causal effects of the built environment on physical activity, diet and obesity among children
Dr. Jason Gilliland

Research suggests that the built environment in which we live, play, shop, work and go to school influences obesity levels by making it hard or easy to be physically active and eat healthy foods. This study is assessing how the built environment impacts physical activity and eating behaviours among elementary-school children in Southwestern Ontario. The research team is mapping all the environmental features that are believed to be barriers or enablers for physical activity and healthy diets (such as parks and fast food restaurants). Researchers will also use an innovative combination of observational tools including portable GPS, physical activity monitors, and diaries to investigate how the mapped environments are actually experienced and used by different groups of children, and if they have an effect on obesity levels. The researchers will also develop a free software program that can be used by planners, developers, and policy makers for studying existing and proposed developments. The ultimate goal is to provide information to guide policymakers and planners in making health-promoting changes in the built environment.

TIME (Tools, Information, Motivation, Environment) for Health: A multi-level intervention to promote healthy eating in children and their families
Dr. Sara Kirk

Families are often under so much time pressure around scheduled physical activity that they may not have the time to make healthy food choices at home. Yet, there are a number of settings where food availability is not consistent with current recommendations for healthy eating, including recreational facilities. While these facilities promote health in the form of physical activity, by contrast, the nutrition environment within them is often neglected in favour of energy-dense fast and processed foods that are quick to prepare, cheap to provide and profitable.

This study will design, implement and evaluate a multi-level intervention aimed at improving family nutrition habits and incorporating a change in the built environment to increase healthy food availability in recreational facilities. At the facility level, researchers will focus on evaluating the impact of existing work aimed at changing the food environment, such as increasing the availability of healthy food choices or encouraging families to purchase healthier food options. For the family-level intervention, parents of children aged five-12 years will be given a GPS-enabled smart phone that will provide information about availability of healthy food options and motivation such as personalized health messages, meal ideas and shopping hints and tips. Researchers will also develop a toolkit for facility directors.

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