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CONTENTS
Preface xiii
Acknowledgments xv
Incorporate Theory 60
Goals and Objectives 64
The Initiative’s Activities 71
Use Existing Evidence-Based Programs 75
The Program’s Theory of Change 77
The Logic Model Depicting the Theory of Change 77
Criteria for Successful Initiatives 81
Stakeholders’ Participation in Planning and Developing Initiatives 82
Summary 82
Discussion Questions and Activities 83
Key Terms 84
Summary 268
Discussion Questions and Activities 269
Key Terms 269
REFERENCES 367
INDEX 373
PREFACE
You may not know what the term evaluation means, and, like me all those years ago and
many of my students now, you are probably still a little wary of the term and wondering
where this is all leading. No matter where you are in your understanding of program and
policy evaluation, my hope is that whether you are a practitioner, a student, or both, you
will find this book helpful on your journey and on your path to understanding. Just as I did
many years ago, you probably evaluate what you do all the time without giving it a name.
Evaluation is often an unconscious activity that is carried out before choosing among one
or many options, both informally and formally. Informal evaluations range from selecting
a restaurant for dinner to selecting a course of dishes off the menu. All the decisions you
make along the way have implications for the success or failure of the outing. At the end
of the evening, you go over the steps you took and decide whether the trip was worth it.
If it wasn’t, you may decide never to go to that restaurant again. So it is with program
evaluation. We assess the resources and activities that went into a program, and then we
determine whether the program or policy achieved what was intended, was worth it to those
who experienced it and to those who funded it.
Evaluation activities occur in a range of work-related settings including community-
based organizations, coalitions and partnerships, government-funded entities, the phar-
maceutical industry, and the media. Program evaluations assess how an event or activity
was conducted, how well it was conducted, and whether it achieved its goal. Evaluation
determines the merit of a program or policy, and it forms the basis for evidence-based
decision-making.
Evaluation is the cornerstone of program improvement and must be carefully planned
and executed to be effective. It helps make the task of assessing the appropriateness
of a public health intervention or the success of a program or policy explicit by using
appropriate research methods. In evaluation, a plan is developed to assess the achievement
of program objectives. The plan states the standards against which the intervention will
be assessed, the scope of the evaluation, and appropriate tools and approaches for data
collection and analysis.
There are many opportunities to conduct an evaluation during the life of an interven-
tion, and the approaches to conducting the evaluation in each case will differ. The methods
and tools for an evaluation that is conducted during the first few months of a program are
different from those used when the program or participation in the program ends and the
effectiveness of the program or policy is being assessed. In addition, during the life of
the program, evaluation tools and approaches can be used to record program and policy
participation and progress.
This book presents a model for evaluation and describes the approaches and methods
for evaluating community health program and policy interventions. It is aimed at public
xiv Preface
health and community health students as well as practitioners who are new to program
and policy evaluation. This book makes no assumptions of prior knowledge about evalua-
tion. The approach to evaluation that is presented allows for the development of simple or
complex evaluation plans while focusing on practical approaches. It encourages a critical
thinking and reflective approach with the full involvement of multiple stakeholders through-
out the evaluation process. This book provides learners with a systematic, step-by-step
approach to program evaluation.
The book is organized into 13 chapters. It discusses the community assessment and the
development of the public health initiative as the precursors to the four-step participatory
model for evaluation with stakeholders at the center of each component. It frames pro-
gram evaluation in the context of community-based participatory research. This edition also
includes a chapter on process evaluation. Two case studies help the reader experience virtual
evaluations, and mini-case studies and opportunities to “Think About It” allow the reader
to reflect on the material and improve critical thinking skills. Valuable Takeaways provide
simple reminders of important concepts covered in the chapter. An appendix provides some
additional resources for evaluation.
ACKNOWLEDGMENTS
This edition is dedicated to the memory of my father, Dr. Evelyn C. Cummings. My sincere
appreciation for all their support over the years also goes to my mother and all members of
my family in the diaspora. To all the friends who have been a part of my amazing journey and
have inspired me to explore the world and follow my passion, thank you. I have had the plea-
sure of working and teaching in Liberia, Sierra Leone, South Africa, the United Kingdom,
the United States, and most recently, in Ghana as a Fulbright Scholar, from where I draw
much of my inspiration. I would, however, be remiss if I did not also remember the person
who gave me the opportunity to write this book. Sadly, he passed away just as we started
working on this edition. Dad, Andy Pasternak, and all the departed, continue to rest in
perfect peace.
EVALUATING PUBLIC
AND COMMUNITY
HEALTH PROGRAMS
CHAPTER
1
AN INTRODUCTION TO
PUBLIC AND COMMUNITY
HEALTH EVALUATION
LEARNING OBJECTIVES
■ Identify the uses and approaches of evaluation.
■ Describe preassessment evaluation.
■ List the principles of participatory evaluation.
■ Describe the links among community assessment, program implementation, and
program evaluation.
■ Explain the ethical and cultural issues in evaluation.
■ Describe the value and role of stakeholders in evaluation.
2 An Introduction to Public and Community Health Evaluation
Public health may be assessed by the impact it has on improving the quality of life of
people and communities through the elimination or the reduction in the incidence, preva-
lence, and rates of disease and disability. An additional aspect of public health is to create
social and physical environments that promote good health for all. The Healthy People 2020
goal describes health as being produced at multiple levels: households, neighborhoods and
communities. In addition, it describes the importance of social and economic resources
for health with a new focus on the social determinants of health. Its overarching goals
are as follows:
1. Attain high quality, longer lives free of preventable disease, disability, injury, and
premature death.
2. Achieve health equity, eliminate disparities, and improve the health of all groups.
3. Create social and physical environments that promote good health for all.
4. Promote quality of life, healthy development, and healthy behaviors across all life
stages. (http://www.healthypeople.gov/2020/About-Healthy-People)
Public health, therefore, has an obligation to improve conditions and access to appro-
priate and adequate resources for healthy living for all people, and it includes education,
nutrition, exercise, and social environments. Public health programs and policies may be
instituted at the local, state, national, or international level.
The Committee for the Study of the Future of Public Health defines the mission of
public health as “fulfilling society’s interest in assuring conditions in which people can be
healthy” (Institute of Medicine, 2001, p. 7). Public and community health programs and
initiatives exist in order to “do good” and to address social problems or to improve social
conditions (Rossi, Lipsey, & Freeman, 2004, p. 17). Public health interventions address
social problems or conditions by taking into consideration the underlying factors and core
causes of the problem. Within this context, program evaluation determines whether public
health program and policy initiatives improve health and quality of life.
Evaluation is often referred to as applied research. Using the word applied in the def-
inition lends it certain characteristics that allow it to differ from traditional research in
significant ways.
■ Evaluation is about a particular initiative. It is generally carried out for the purposes
of assessing the initiative, and the results are not generalizable. However, with the
scaling up of programs to reach increasingly large segments of the population, and with
common outcome expectations and common measures, evaluations can increase their
generalizability. Research traditionally aims to produce results that are generalizable
to a whole population, place, or setting in a single experiment.
■ Evaluations are designed to improve an initiative and to provide information for
decision-making at the program or policy level; research aims to prove whether there
is a cause-and-effect relationship between two entities in a controlled situation.
■ Evaluation questions are generally related to understanding why and how well an inter-
vention worked, as well as to determining whether it worked. Research is much more
Overview of Evaluation 3
focused on the end point, on whether an intervention worked and much less on the
process for achieving the end result.
■ Evaluation questions are identified by the stakeholders in collaboration with the eval-
uators; research questions are usually dictated by the researcher’s agenda.
Some approaches to evaluation, such as those that rely on determining whether goals
and objectives are achieved, assess the effects of a program; the judicial approach asks for
arguments for and against the program, and program accreditations seek ratings of programs
based on a professional judgment of their quality and are usually preceded by a self-study.
Consumer-oriented approaches are responsive to stakeholders and encourage their partic-
ipation. This book focuses on the evaluation of public health programs primarily at the
community and program level.
OVERVIEW OF EVALUATION
Rossi et al. (2004) describe evaluation as “the use of social research methods to systemati-
cally investigate the effectiveness of social intervention programs in ways that are adapted
to their political and organizational environments and are designed to inform social action to
inform social conditions” (p. 16). In addition, these authors caution that evaluation provides
the best information possible under conditions that involve a political process of balancing
interests and reaching decisions (p. 419).
Evaluation is the cornerstone for improving public health programs and is conducted
for the purpose of making a judgment of a program’s worth or value. Evaluation incor-
porates steps that specify and describe the activities and the process of evaluation; the
initiative and why it is being evaluated; the measures needed to assess the inputs, outputs,
and outcomes; and the methodology for collecting the information (data). In addition, an
evaluation analyzes data and disseminates results in ways that ensure that the evaluation
is useful.
This definition of evaluation as adopted by the social sciences and public health
reflects a long tradition of evaluation that takes different approaches to evaluation and are
applied across a wide field of study. Each has its own criteria, and the evaluator chooses
the approach that best suits their field, their inclination, or the purpose for which the
evaluation is being conducted.
The next section provides a brief overview of the most widely used approaches. These
evaluation approaches include the consumer-based, decision-based, goal-free, participa-
tory, expertise-oriented, and objectives-based.
Consumer-Based Approach
In the consumer-based evaluation approach, the needs of the consumer are the primary
focus and the role of the evaluator is to develop or select criteria against which the initiative
or product is judged for its worth. The focus of this evaluation is on the cost, durability, and
performance of the initiative or product being evaluated.
4 An Introduction to Public and Community Health Evaluation
Decision-Based Approach
This approach adopts a framework for conducting evaluation that includes the context,
inputs, process, and product. It is also referred to as the context, input, process, and product
(CIPP) approach. In including the context in the evaluation, this approach considers both
the problem that is being addressed and the intervention that addresses it. In the context of
public health, adopting this model requires understanding the public health problem being
addressed and the program or policy intended to address it. The community or needs assess-
ment forms the basis for developing the intervention. The input components of the evaluation
assess the relationship between the resources available for the program and the activities
identified to address the problem. Process evaluation, which is the third component of
this model, asks the question, “Is the program being implemented as planned?” The last
component, the product, assesses the extent to which goals and objectives have been met.
Goal-Free Approach
A goal-free approach to evaluation is just that. The evaluation does not start out with any
predefined goals or objectives related to the initiative being evaluated. It is expected that
the initiative will have many outcomes that are not necessarily related to the objectives that
may have been crafted when the initiative was initially conceived and started. Therefore,
not having defined objectives allows the evaluator to explore a wide range of options for
evaluation.
Participatory Approach
The participatory approach to evaluation adopts an approach that values and integrates
stakeholders into the process. Stakeholders in this process are the beneficiaries of the ini-
tiative’s interventions. In this case, the evaluator serves as technical advisor allowing the
stakeholders to take responsibility for most aspects of the evaluation process. The aim of
this approach is to transfer skills in a co-learning setting and to empower stakeholders to
become evaluators of their own initiatives.
Expertise-Oriented Approach
The expertise-oriented approach expects the evaluator to be a content expert who draws on
his life experience to judge a program’s worth. It may or not be accompanied by specified
clearly defined and explicit criteria. This approach is often used in judging competitions
and in public health and other fields in accreditation. However, in accreditation, such as the
accreditation of schools of public health, although the institution provides the self-study
narrative based on predefined criteria, the judgment of the program’s merits and the decision
to grant accreditation is made by the accrediting body.
Objectives-Based Approach
The objectives-based evaluation is the most commonly used in public health practice espe-
cially recently as responses to calls for proposals for funding now invariably require the
applicant to include objectives. The objectives for an initiative are developed following the
community assessment, and form the bases on which the initiative is developed focusing
on risk or protective factors that would have an impact on the problem being addressed.
Levels of Evaluation 5
Additional objectives that may address concerns of the evaluator or the implementing team
may be written as necessary to guide the evaluation and for the framework upon which the
evaluation questions and the evaluation are designed.
LEVELS OF EVALUATION
Evaluation at the Project and Program Level
Evaluation may be conducted at the project or program level. Public health organizations
and agencies may achieve the overall mission of the organization through a number of
stand-alone projects that together make up a program. For example, a local service organi-
zation of an agency may have activities that address many of the determinants of health—for
example, low literacy, access to health insurance, low levels of physical activity and poor
nutrition. Addressing each of these determinants of health may occur in a department of
health promotion, yet each may have an independent set of activities to achieve an overall
goal to improve the health of minority, low-income populations within a jurisdiction. At the
project level, process evaluation may be concerned with how the set of activities is being
implemented and the extent to which each is being implemented according to a previously
established plan. The link between literacy, lack of insurance, healthy nutrition, and phys-
ical activity is fairly well understood, so that, in combination, it is assumed that sets of
activities at the project level will, over a specified time, address common objectives, such
as reduce the percentage of individuals who are diagnosed with heart disease or increase
the number of individuals with diabetes who achieve HbA1c levels of less than 7%. This
evaluation takes place in the context of a carefully selected set of activities based on theo-
retically sound community assessment, which provides the framework for an intervention
designed to achieve a stated set of goals and objectives.
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