Pick one of the following health issues identified as salient in Bowe Countys most recent community health assessment: vaccination, adolescent pregnancy, gunshot wounds, or type 2 diabete

L. Michele Issel, PhD, RN Professor of PhD Program

University of North Carolina at Charlotte College of Health and Human Services

Charlotte, North Carolina

Rebecca Wells, PhD, MHSA Professor

The University of Texas School of Public Health

Houston, Texas

Health Program Planning and Evaluation A Practical, Systematic Approach for Community Health

FOURTH EDITION

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Cover Design: Scott Moden Director of Rights & Media: Joanna Gallant Rights & Media Specialist: Merideth Tumasz Media Development Editor: Shannon Sheehan Cover Image: © Lynne Nicholson/Shutterstock Printing and Binding: Edwards Brothers Malloy Cover Printing: Edwards Brothers Malloy

Library of Congress Cataloging-in-Publication Data Names: Issel, L. Michele, author. | Wells, Rebecca, 1966- author. Title: Health program planning and evaluation: a practical, systematic approach for community health/L. Michele Issel and Rebecca Wells. Description: Fourth edition. | Burlington, MA: Jones & Bartlett Learning, [2018] | Includes bibliographical references and index. Identifiers: LCCN 2017010386 | ISBN 9781284112115 (pbk.) Subjects: | MESH: Community Health Services—organization & administration | Program Development—methods | Health Planning—methods | Program Evaluation—methods | United States Classification: LCC RA394.9 | NLM WA 546 AA1 | DDC 362.12068—dc23 LC record available at https://lccn.loc.gov/2017010386

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iii

© Lynne Nicholson/Shutterstock

Contents List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

List of Exhibits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xvii

Preface to the Fourth Edition . . . . . . . . . . . . . . . . . . xix

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv

List of Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . .xxvii

SECTION I The Context of Health Program Development 1

Chapter 1 Context of Health Program Development and Evaluation . . . . . . . . . . . . . . . 3

History and Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Concept of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Health Programs, Projects, and Services . . . . . . 4

History of Health Program Planning and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Evaluation as a Profession . . . . . . . . . . . . . . . . . . . . . . . . . 8

Who Does Planning and Evaluations? . . . . . . .10

Roles of Evaluators . . . . . . . . . . . . . . . . . . . . . . . . . .10

Planning and Evaluation Cycle . . . . . . . . . . . . . . . . . . .11

Interdependent and Cyclic Nature of Planning and Evaluation . . . . . . . . . . . . . . .11

Using Evaluation Results as the Cyclical Link . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Program Life Cycle . . . . . . . . . . . . . . . . . . . . . . . . . .13

The Fuzzy Aspects of Planning . . . . . . . . . . . . . . . . . . .14

Paradoxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Uncertainty, Ambiguity, Risk, and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Introduction to the Types of Evaluation . . . . . . . . . .19

Mandated and Voluntary Evaluations . . . . . . .20

When Not to Evaluate . . . . . . . . . . . . . . . . . . . . . .21

The Public Health Pyramid . . . . . . . . . . . . . . . . . . . . . . .21

Use of the Public Health Pyramid in Program Planning and Evaluation . . . . . . . .23

The Public Health Pyramid as an Ecological Model . . . . . . . . . . . . . . . . . . . . .23

The Town of Layetteville in Bowe County . . . . . . . . .25

Across the Pyramid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Discussion Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Internet Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Chapter 2 Relevance of Diversity and Disparities to Health Programs . . . . . . . . . . . . . . . . . . 29

Health Disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Diversity and Health Disparities . . . . . . . . . . . . .32

Diversity and Health Programs . . . . . . . . . . . . . .33

Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

Influences of Sociocultural Diversity on Interventions . . . . . . . . . . . . . . . . . . . . . . . . .38

Influences of Biological Diversity on Interventions . . . . . . . . . . . . . . . . . . . . . . . . .39

Approaches to Developing Programs . . . . . . .39

Profession and Provider Diversity . . . . . . . . . . . .40

The Three Health Provider Sectors . . . . . . . . . .43

Diversity Within Healthcare Organizations and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

Organizational Culture . . . . . . . . . . . . . . . . . . . . . .44

Cultural Competency Continuum . . . . . . . . . . .44

Enhancing Cultural Competency . . . . . . . . . . .48

iv Contents

Types of Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

Organizational Assessment . . . . . . . . . . . . . . . . .75

Marketing Assessment . . . . . . . . . . . . . . . . . . . . . .76

Needs Assessment . . . . . . . . . . . . . . . . . . . . . . . . .76

Community Health Assessment . . . . . . . . . . . . .77

Workforce Assessment . . . . . . . . . . . . . . . . . . . . . .77

Steps in Planning and Conducting the Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77

Form and Develop the Team . . . . . . . . . . . . . . . .78

Create a Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79

Involve Community Members . . . . . . . . . . . . . .79

Define the Population . . . . . . . . . . . . . . . . . . . . . .80

Define the Problem to Be Assessed . . . . . . . . .81

Investigate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

Prioritize . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82

Make a Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . .82

Implement and Continue . . . . . . . . . . . . . . . . . . .83

Anticipate Data-Related and Methodological Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83

Across the Pyramid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85

Discussion Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . .85

Internet Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87

Chapter 4 Characterizing and Defining the Health Problem . . . . . . . . . . . . . . . . . . . 91

Collecting Data From Multiple Sources . . . . . . . . . . .91

Public Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91

Primary Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92

Observational Data . . . . . . . . . . . . . . . . . . . . . . . . .92

Archival Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93

Proprietary Data . . . . . . . . . . . . . . . . . . . . . . . . . . . .93

Published Literature . . . . . . . . . . . . . . . . . . . . . . . .93

Data Beyond Street Lamp . . . . . . . . . . . . . . . . . . .93

Collecting Descriptive Data . . . . . . . . . . . . . . . . . . . . . .94

Magnitude of the Problem . . . . . . . . . . . . . . . . . .94

Dynamics Leading to the Problem . . . . . . . . . .94

Population Characteristics . . . . . . . . . . . . . . . . . .96

Attitudes and Behaviors . . . . . . . . . . . . . . . . . . . .96

Years of Life and Quality of Life . . . . . . . . . . . . . .96

Stakeholders and Coalitions . . . . . . . . . . . . . . . . . . . . .50

Across the Pyramid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

Discussion Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

Internet Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

SECTION II Defining the Health Problem 57

Chapter 3 Community Health Assessment for Program Planning . . . . . . . . 59

Defining Community . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

Community as Context and Intended Recipient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

Defining Terms: Based, Focused, and Driven . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

Types of Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

Types of Strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

Approaches to Planning . . . . . . . . . . . . . . . . . . . . . . . . .64

Incremental Approach . . . . . . . . . . . . . . . . . . . . . .64

Apolitical Approach . . . . . . . . . . . . . . . . . . . . . . . .66

Advocacy Approach . . . . . . . . . . . . . . . . . . . . . . . .66

Communication Action Approach . . . . . . . . . .67

Comprehensive Rational Approach . . . . . . . . .67

Strategic Planning Approach . . . . . . . . . . . . . . .68

Summary of Approaches . . . . . . . . . . . . . . . . . . .69

Models for Planning Public Health Programs . . . . .69

Mobilizing for Action through Planning and Partnership (MAPP) . . . . . . . . . . . . . . . . . .70

Community Health Improvement Process (CHIP) . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

Protocol for Assessing Community Excellence in Environmental Health (PACE-EH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

In Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

Perspectives on Assessment . . . . . . . . . . . . . . . . . . . . .71

Epidemiological Perspective . . . . . . . . . . . . . . . .72

Public Health Perspective . . . . . . . . . . . . . . . . . . .74

Social Perspective . . . . . . . . . . . . . . . . . . . . . . . . . .74

Asset Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . .74

Rapid Perspective . . . . . . . . . . . . . . . . . . . . . . . . . .75

v Contents

Path to Program Outcomes and Impacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

Components of the Effect Theory . . . . . . . . . 135

Matching Levels: Audience, Cause, Intervention, and Effects . . . . . . . . . . . . . . . 137

Generating the Effect Theory . . . . . . . . . . . . . . . . . . 138

Involve Key Stakeholders . . . . . . . . . . . . . . . . . 138

Draw Upon the Scientific Literature . . . . . . . 138

Diagram the Causal Chain of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

Check Against Assumptions . . . . . . . . . . . . . . 141

Functions of Program Theory . . . . . . . . . . . . . . . . . . 141

Provide Guidance . . . . . . . . . . . . . . . . . . . . . . . . . 141

Enable Explanations . . . . . . . . . . . . . . . . . . . . . . 142

Form a Basis for Communication . . . . . . . . . . 142

Make a Scientific Contribution . . . . . . . . . . . . 143

Across the Pyramid . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Discussion Questions and Activities . . . . . . . . . . . . 144

Internet Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Chapter 6 Program Objectives and Setting Targets . . . . . . . . 147

Program Goals and Objectives . . . . . . . . . . . . . . . . . 147

Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Foci of Objectives . . . . . . . . . . . . . . . . . . . . . . . . . 148

Objectives and Indicators . . . . . . . . . . . . . . . . . 151

Good Goals and Objectives . . . . . . . . . . . . . . . 154

Using Data to Set Target Values . . . . . . . . . . . . . . . . 156

Decisional Framework for Setting Target Values . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Stratification and Object Target Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

Use of Logic Statements to Develop Targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160

Options for Calculating Target Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160

Caveats to the Goal-Oriented Approach . . . . . . . 170

Across the Pyramid . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Discussion Questions and Activities . . . . . . . . . . . . 171

Internet Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

Statistics for Describing Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99

Descriptive Statistics . . . . . . . . . . . . . . . . . . . . . . 100

Geographic Information Systems: Mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Small Numbers and Small Areas . . . . . . . . . . 101

Epidemiology Rates . . . . . . . . . . . . . . . . . . . . . . 102

Stating the Health Problem . . . . . . . . . . . . . . . . . . . . 102

Diagramming the Health Problem . . . . . . . . 102

Writing a Causal Theory of the Health Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Prioritizing Health Problems . . . . . . . . . . . . . . . . . . . 110

Nominal Group Technique . . . . . . . . . . . . . . . . 111

Basic Priority Rating System . . . . . . . . . . . . . . . 111

Propriety, Economics, Acceptability, Resources, and Legality (PEARL) Component . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Prioritizing Based on Importance and Changeability . . . . . . . . . . . . . . . . . . . . . 114

Across the Pyramid . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Discussion Questions and Activities . . . . . . . . . . . . 117

Internet Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

SECTION III Health Program Development and Planning 121

Chapter 5 Program Theory and Interventions Revealed . . . . . . . . . . . . . . . . . . 123

Program Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Process Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Effect Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

Finding and Identifying Interventions . . . . . 126

Types of Interventions . . . . . . . . . . . . . . . . . . . . 127

Specifying Intervention Administration and Dosage . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

Interventions and Program Components . . . . 130

Characteristics of Good Interventions . . . . . 131

vi Contents

Budgeting as Part of Planning . . . . . . . . . . . . . . . . . . 204

Monetize and Compute Program Costs . . . . . 204

Budget for Start-Up and Evaluation Costs . . . 205

Break-Even Analysis . . . . . . . . . . . . . . . . . . . . . . . 205

Budget Justification . . . . . . . . . . . . . . . . . . . . . . 207

Budget as a Monitoring Tool . . . . . . . . . . . . . . . . . . . 209

Budget Variance . . . . . . . . . . . . . . . . . . . . . . . . . . 209

Types of Cost Analyses . . . . . . . . . . . . . . . . . . . . 209

Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Health Informatics Terminology . . . . . . . . . . . 214

Information Systems Considerations . . . . . . 214

Across the Pyramid . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216

Discussion Questions and Activities . . . . . . . . . . . . 217

Internet Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

Chapter 9 Implementation Evaluation: Measuring Inputs and Outputs . . . . . . . . . . . . . . . 219

Assessing the Implementation . . . . . . . . . . . . . . . . . 219

Implementation Documentation . . . . . . . . . 220

Implementation Assessment . . . . . . . . . . . . . 221

Implementation Evaluation . . . . . . . . . . . . . . . 221

Efficacy, Effectiveness, and Efficiency . . . . . . . . . . . 222

Data Collection Methods . . . . . . . . . . . . . . . . . . . . . . 223

Quantifying Inputs to the Organizational Plan . . . . . . . . . . . . . . . . . . . 223

Human Resources . . . . . . . . . . . . . . . . . . . . . . . . 228

Physical Resources . . . . . . . . . . . . . . . . . . . . . . . . 229

Quantifying Outputs of the Organizational Plan . . . . . . . . . . . . . . . . . . . 230

Information Systems . . . . . . . . . . . . . . . . . . . . . . 230

Monetary Resources . . . . . . . . . . . . . . . . . . . . . . 230

Quantifying Inputs to the Services Utilization Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

Participants and Recipients . . . . . . . . . . . . . . . 230

Intervention Delivery and Fidelity . . . . . . . . . 231

Quantifying Outputs of the Services Utilization Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

Coverage as Program Reach . . . . . . . . . . . . . . 234

Participant-Related Issues . . . . . . . . . . . . . . . . . 238

Program Logistics . . . . . . . . . . . . . . . . . . . . . . . . . 240

SECTION IV Implementing and Monitoring the Health Program 173

Chapter 7 Process Theory for Program Implementation . . . . . . . . . . . 175

Organizational Plan Inputs . . . . . . . . . . . . . . . . . . . . . 175

Human Resources . . . . . . . . . . . . . . . . . . . . . . . . 177

Physical Resources . . . . . . . . . . . . . . . . . . . . . . . . 179

Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

Informational Resources . . . . . . . . . . . . . . . . . . 180

Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

Managerial Resources . . . . . . . . . . . . . . . . . . . . 180

Fiscal Resources . . . . . . . . . . . . . . . . . . . . . . . . . . 182

Organizational Plan Outputs . . . . . . . . . . . . . . . . . . . 182

Time Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

Operations Manual . . . . . . . . . . . . . . . . . . . . . . . 182

Organizational Chart . . . . . . . . . . . . . . .

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