What is the program development and evaluation planning cycle?

The program development cycle is a continuous cycle or spiral of planning which includes identifying, analysing, prioritising, implementing and evaluating. That is, we need to define the issue, work out what to do about it, act, and then evaluate what impact this has had. There are many useful resources to help health workers in the planning and evaluation cycle (See EVOLVE website for some examples). The steps in program development and evaluation are:

1. Identifying a specific issue, community and focus for a program

The needs assessment — identifying and analysing the health issue:

conducting consultations

gathering information about the issue

examining characteristics of the community

analysing the information and making a judgment.

2. Designing the program

Specifying the broad purpose of the program:

the program aim.

Converting the analysis of the issue into a draft plan:

identifying the program objectives

stating the expected outcomes.

Developing roles with key people.

Reviewing available resources.

Ensuring the program is realistic and achievable.

3. Developing an action plan

Planning for the organisation of tasks:

selecting and sequencing activities.

Selecting the program strategies.

Preparing materials, resources, activities.

Training staff.

4. Implementing the program

5. Evaluability assessment

6. Evaluating the program

Process evaluation.

Impact evaluation.

Outcome evaluation.

This chapter deals with step 1, identifying a specific issue, step 5, evaluability assessment, and step 6, evaluating the program from the cycle. Designing the program, developing an action plan and implementing the program will be dealt with in other chapters according to the activities the community decides upon. The steps in program-planning and evaluation are best thought of as a continuing cycle (as illustrated in Figure 6.1) rather than as a linear sequence of events. The cyclical process indicates that the process is never ‘finished’; when one round of interventions is complete, one reflects on the evaluation findings and plans relevant new interventions.

FIGURE 6.1 Program-planning and evaluation cycle

Research in Primary Health Care

Conducting a community needs assessment is a form of research and should be conducted with all of the considerations and safeguards expected of other forms of research. The research process has an important role to play as an ongoing, integrated part of practice. When participatory research is integral to practice, practice is strengthened in a number of ways. Firstly, health promotion practice will be built around the needs of the people for whom it is designed. It will be responsive to those needs and based on recognition that needs are dynamic rather than static and therefore change over time. Secondly, with grounding in community needs, health workers are less likely to implement programs that do not meet these needs, thus preventing expensive mistakes. Thirdly, when research is integral to practice, health promotion and other activities of health workers are routinely evaluated and the findings used to improve the quality of health promotion work.

The inextricable relationship between research and practice means that the additional resources required to carry out research may not be as great as expected. When research is an integral part of practice, it is as much a state of mind and an approach to working as anything else. Certainly there are times, for example, when a major community assessment may be required and this may necessitate an additional commitment of time and resources and the active involvement of people with expertise in community assessment. However, not researching and improving practice may result in wasting the limited resources that are being allocated to health promotion.

Ethical considerations in program development and evaluation

There are international and national rules governing how research is conducted. It is not proposed that we deal comprehensively with ethical issues here. (See Owen & Rogers 1999 Ch 8 for a comprehensive overview of guidelines for ethical practice in community-based evaluation research.) In Australia, the Australian Health Ethics Committee (http://www.nhmrc.gov.au/health_ethics/ahec/index.htm) advises the National Health and Medical Research Council (NH&MRC) on ethical issues relating to health and the development of guidelines for the conduct of medical research involving humans. Human Research Ethics Committees (HRECs) oversee research on behalf of this organisation. These committees are found in large organisations such as universities, education departments, health departments and large hospitals. The Centre for Disease Control has excellent resources for ethics principles and standards from various countries (http://www.cdc.gov/eval/resources.htm

There is some debate about whether HREC approval is needed for community-based needs assessments and evaluations. HRECs are charged with supervising research with publication of the results in mind (Posavac & Carey 2003: 110). Some believe that much can be gained by seeking approval in any circumstance, others believe that if the community is involved in identifying their own needs, planning the implementation of the program designed to address the need, and evaluating the program, then seeking approval from an outside HREC is unnecessary. Further, reflective practice is a form of evaluation and that does not need HREC approval. Awareness of power relationships is probably the most important consideration in gathering information. Power imbalances may emerge in the research procedures in needs assessments and evaluation.

The principles of Primary Health Care provide a solid foundation for conducting needs assessments and evaluation within the program-planning cycle. However, research procedures form the basis of these processes and therefore further discussion is needed concerning some of the ethical issues that health workers need to consider, whether they seek HREC approval or not.

Five categories of ethical issues have been identified:

The PRECEDE planning model

The aim of the PRECEDE planning model is to assist health workers to design and evaluate programs based on evidence. The planning model was formally known as the PRECEDE–PROCEED model, and ‘grew out of … combined and cumulative experience in practice, research, teaching, consultation and government service, all guided and enriched by significant teachers, colleagues and students’ (Green & Kreuter 1999: xxix) and is acknowledged as a theoretically robust model. One of the hallmarks of this model is its flexibility and scalability (Green & Kreuter 2005). The principles are the same whether the program is large or small. It is an ecological approach to health planning in that it takes into account the multiple factors that determine health. It helps planners arrive at a highly focused subset of factors for intervention. In this section we provide an overview of the model before expanding on the steps of program development and evaluation.

There are eight phases in the combined PRECEDE–PROCEED model for program development and evaluation. The information gathered is often referred to as primary and secondary data. Phases one to four (PRECEDE) are addressed in this chapter. This model is constantly evolving and so for a detailed discussion on the model refer to Green and Kreuter (2005); to http://www.lgreen.net/precede.htm or to the EVOLVE website where links to useful websites are provided and where you can find articles, chapters and books in which the PRECEDE–PROCEED model has been applied, examined or extended.

The first phase is social assessment, which refers to the needs that are defined by a community in terms of the dimensions of their quality of life. This means asking the community to identify and discuss their needs and aspirations (Green & Kreuter 2005). This phase assists planners to assess the uniqueness of a community. The kinds of social problems a community experiences are a practical and accurate barometer of its quality of life and include such things as discrimination, poverty, isolation, self-esteem or poor nutrition. A range of methods can be used to undertake community assessments, some of which are described in more detail later in this chapter.

The second phase is the epidemiological assessment. These needs are defined by health professionals in terms of morbidity and mortality. This assessment and data gathering builds on the social assessment, although it can be, and often is, done in isolation. The task of the second phase is to identify the specific health issues that may contribute to, or interact with, the social issues identified in phase one. It consists of identifying the specific health-related genetic, behavioural and environmental factors that could be linked to the health issues identified so far. Because they are the risk factors that the intervention should be tailored to effect, they must be specifically identified and carefully ranked. Prioritising is necessary because there will always be too many issues to deal with (Green & Kreuter 2005). Our knowledge of genetic predispositions is increasing. Environmental factors are those external to the individual, often beyond his or her control, that can be modified to support or protect the behaviour; health or quality of life of that person or the community through organisational or administrative action. Being aware of these factors reminds health workers of the limitations of health promotion programs consisting of health education directed only at personal behaviour, and of the multidimensional nature of health issues and of the frequent need for multi-sectoral approaches (Green & Kreuter 2005).

Phase three is the educational and ecological assessment. This phase consists of sorting and categorising the factors that seem to have direct impact on the behaviour or the environment. Interventions that are planned within these categories will depend on their relative importance and the resources available. The PRECEDE model groups them according to the educational and organisational strategies likely to be employed in a health promotion program to bring about environmental and behavioural change. Refer back to the iceberg model of disease presented in Chapter 1 and notice how the PRECEDE model can be used to assess needs at all levels in the iceberg.

Once the data are combined and needs are identified, those involved in a program must prioritise actions. The three broad categories for strategies, predisposing, enabling and reinforcing factors, are described by Green & Kreuter (2005) as:

In phase four the assessment of organisational capabilities and resources for the development and implementation of a program is conducted. Limitations of resources, policies and abilities and time constraints are assessed. Some of these limitations and constraints can be offset by cooperative arrangements with other local agencies or larger organisations at state or national levels or through the development of alliances at the local level. All that remains is the selection of the right combination of strategies.

The program is then implemented and evaluated. We will be discussing evaluation later in the chapter; however, listing evaluation last is misleading. Evaluation is an integral and continuous part of working with the entire model from the beginning.

Community assessments

Community assessment can be defined as a process that results in:

This definition highlights several issues that are central to meaningful community assessment.

Need — what is it?

While comprehensive community assessment examines both the resources and needs of a community, it is true that the notion of needs has a central place in community assessment. This is especially so when there is a focus on social justice and working to achieve equity for those who are disadvantaged. Arguably, any examination of community needs assessment should start, therefore, with an examination of just what need is and a review of some of the issues surrounding the definition of something as a need (Robinson & Elkan 1996). Need has been defined as ‘the condition marked by the lack of something requisite’ (Macquarie Dictionary 2001). This definition highlights the fact that the very concept of need itself is value-based and socially constructed. Whether something is identified as a need will depend on the perspectives and values of those involved. In addition, it is through the way in which issues are defined at a social and political level that individuals, groups and societies come to decide which issues are of concern to them and which things they need. Given the value-laden nature of need, it is important to be clear about which values should be driving the needs-identification process in the Primary Health Care approach.

There are several different ways in which needs can be classified, according to the perspective used to identify need (Robinson & Elkan 1996). Bradshaw (1972) identified four types of need: felt need, expressed need, normative need and comparative need. Which issues are constructed as needs depends on the particular values in place in the society or group (Carver et al 2008).The categories of felt and expressed need include need determined by people themselves, while the category of normative need represents need determined by experts, and comparative need represents need determined by past responses to similar problems. These needs are expressed in the PRECEDE model in steps one to three. With an emphasis on equal partnership between professionals and community members in a Primary Health Care approach to health promotion, all these types of need have something useful to contribute to an assessment of need.

Felt need

Felt need is most easily described as what people say they need. For example, if a local community is surveyed regarding its highest priorities for health promotion action, people may say that they want more intensive-care beds, safer streets in which their children can play or less youth unemployment in the local area. This is closest to the social assessment in the PRECEDE model or the predisposing and reinforcing factors of phase three.

Felt need is important because it involves asking people themselves what their needs are. However, on its own it may not give a complete picture of need for a number of reasons. Firstly, people may limit what they tell you they need to what they think they can have (Robinson & Elkan 1996). If they believe that meeting some of their needs is beyond their reach, they may not ask for them.

Secondly, people may only voice needs that they believe you are interested in. For example, if a health worker asks someone about their health needs, that person may interpret the question as referring to his or her illness problems alone and may not think of health in its broad context.

Thirdly, powerful groups in the community can have a strong influence in determining how people see their needs. Community members’ beliefs about what they need can, in fact, be socially constructed by interest groups, opinion leaders and the mass media. Groups and communities may ‘adopt’ certain needs as their own because these have been sold to them through the mass media. In many instances it is not the need alone but also one potential response to the need that is presented as the ‘solution’.

Fourthly, the perspective of a small group of community members may not reflect the perspective of the whole community. Careful consideration needs to be made of whom a group of community informants represent — a section of the community, a small subsection or only themselves (Hawe et al 1990; McKenzie et al 2005; Robinson & Elkan 1996).

If we are to take the principles of Primary Health Care seriously, we need to work to promote health based on people’s own assessment of their need — that is, felt need must be among the types of need represented in the assessment. However, because of the all-pervading forces that influence people’s felt need, most particularly through the media, people may not have had a real opportunity to decide for themselves. In health promotion, as in any other area of health, workers need to ensure that people are able to make informed decisions and that they have access to the information they need to make those decisions (Naidoo & Wills 2000; Robinson & Elkan 1996; Hawe et al 1990). Of course, this process may require more than giving people information; it may require them to examine the forces that influence their decisions. That is, this process of helping people clarify their felt need may well involve the process of conscientisation. This concept was discussed in more detail earlier in this chapter.

The presence of felt or expressed need alone, without the presence also of normative or comparative need, raises some questions. What if a group or community wants something but there is no evidence to demonstrate the need for it? In such a situation more information may be needed. Does the group or community know that it is comparatively well off in the area concerned? This may change the priorities that the group sets. Conversely, is it the case that there is a lack of formal evidence in this area because of the shortcomings of information collection, rather than that there is no objective need? (Robinson & Elkan 1996)

An important point to note is that the felt need may be expressed in the form of a solution. This can be very limiting. It is always worth digging deeper. It is worth asking what is the issue or problem rather than what the solution to a problem is. There may be many creative solutions to identified issues.

Furthermore, health promotion funding is currently made available for specific projects, often aimed at particular diseases or risk factors. Frequently, funding may be granted and the project begun without any prior systematic assessment of the community’s felt needs. The particular project being funded may be a long way down the community’s list of priorities, and people may not be motivated to participate in the project. It is then imposed on the community, at ‘best’ with the community being educated about why they should want it. This approach to funding presents some very real dangers, as it encourages health workers and bureaucrats to ignore communities’ own assessments of their needs or regard them as a simple ‘add on’ rather than an integral part of the project (SACHRU [South Australian Community Health Research Unit] 1991).

Expressed need

Expressed need is need that is demonstrated by people’s use of services or demand for new or more services. That is, expressed need can be described as ‘felt need turned into action’ (Bradshaw 1972 in Robinson & Elkan 1996: 20–2). Examples of expressed need include waiting lists for services such as child care, housing or public dental services. In PRECEDE this could be the epidemiological assessment in phase two, or the enabling factors of phase three (McKenzie et al 2005).

Of course, this expressed need has even more limitations on it than felt need, as people can only add their names to waiting lists for services that already exist or are about to come into existence. Indeed, waiting lists are limited to issues of service provision: it is not possible to join a waiting list for a new public policy, for example, although the number of letters written to a politician on a particular issue may be regarded as another form of expressed need.

The constraints on people’s choices here are even greater than in felt need, since the specific service they are demanding must already be there. Moreover, expressed need can easily be misinterpreted. For example, a waiting list at the local dentist might be interpreted as the need for more dental treatment services, when in fact it could reflect inadequate oral health promotion or lack of awareness of school dental therapy services. Another problem with expressed need is that in many situations people may add their names to all available waiting lists for a particular service, although in reality they would accept only one place (e.g. a nursing home placement). In such a situation adding up the numbers of names on waiting lists is likely to give an inaccurate impression. In other situations people may refrain from placing their names on waiting lists if they believe the waiting lists are already long and their chances of success low. In addition, people’s beliefs about whether they have a right to particular services, or deserve to have access to them, will influence whether they act to formally express a need.

Normative need

Normative need is need determined by ‘experts’ on the basis of research and professional opinion. Examples of normative need include safe levels of water pollution, recommended daily allowances of different food groups and the need to avoid unsafe levels of lead ingestion. The epidemiological assessment, or the enabling factors described in the PRECEDE model, would form part of this assessment. Normatively determined need is often regarded as objective and unbiased because it has been determined by experts. It often carries the assumption that it is value-free and beyond reproach, but this assumption needs to be called into question (Carver et al 2008). In addition, professional opinion often changes over time, leaving the public confused (Bradshaw 1972: 641). Normative need may reflect some level of paternalism and it certainly can provide conflicting information, depending on the values of the experts themselves (Bradshaw 1972: 641; Owen & Rogers 1999; Robinson & Elkan 1996).

One crucial issue that influences normative need and that requires examination is the fact that many professional groups act, often unconsciously, as gatekeepers in society. They may be unable or unwilling to acknowledge publicly that something is occurring at an unsafe level if their judgment in this case has political implications. This then represents another possible limitation of normatively determined need. Finally, an over-reliance on epidemiological data to provide evidence of normative need is increasingly being called into question, as the limitations of only relying on one type of data are recognised.

Comparative need

Comparative need is determined by comparing the services available in one geographical area with those available in other geographical areas. Therefore, it may be argued that a particular area requires a certain service because other areas with similar demographic characteristics have one. In PRECEDE this could be the result of a social assessment, but it could also be part of phase four, the administrative assessment. Comparative need can be useful in highlighting relative deficiencies in some communities. However, it can also be problematic because it is based on the assumption that the service provided in the place of comparison was the most appropriate response to the problem (Bradshaw 1972 in Robinson & Elkan 1996: 20–2), and that the needs of the two areas are in fact the same.

All of these needs tell us different things. A combination of social, epidemiological, environmental, behavioural and administrative assessments provide us with a comprehensive base from which to plan programs.

In preparing to assess the needs of any individual, group or community, it is vital to know why the particular assessment needs to be done. What needs to be known, and to what end (Robinson & Elkan 1996)? This will help determine how the assessment should be conducted. Adequate resources need to be available. As discussed above, uncovering needs, creating the expectation that something will be done about them, then not acting, is unlikely to develop confidence in those whose time has been wasted. Box 6.1 outlines the principles that underpin a Primary Health Care approach to community assessments and Box 6.2 outlines the steps.

BOX 6.1 Principles of community assessment

1. Community assessment should be an integral part of health promotion work.

2. Community assessment should reflect the social view of health, which is so much a part of health promotion and Primary Health Care.

3. Community assessment should involve both formal and informal assessment of needs and resources or assets.

4. Community assessment should recognise the partnership between people themselves and health workers in determining their needs and resources, planning action and evaluating any outcomes. Part of this process may involve negotiation between community members and health workers.

5. Needs assessment should involve a combination of felt, expressed, normative and comparative need.

BOX 6.2 The steps in community assessment

1. Identify the purpose of the community assessment.

2. Identify available resources.

3. Establish a project team and steering committee.

4. Develop a research plan and time frame.

5. Collect and analyse available information.

6. Complete community research.

7. Analyse results.

8. Report back to community.

9. Set priorities.

10. Determine responses to the needs identified.

(Source: South Australian Community Health Research Unit (SACHRU) 1991 Planning Healthy Communities: a Guide to Doing Community Needs Assessment. SACHRU, Adelaide)

Community needs assessment is a process of determining both the needs and the resources of a community. While considerable attention tends to be focused on the needs of communities, and these certainly are important, a focus on needs alone tends to paint a ‘deficit’ picture of communities (McKenzie et al 2005).

One theory that purports to challenge the traditional approaches to community development is the asset-based community development theory. Rather than identifying problems in communities, Kretzmann & McKnight (1995) have demonstrated that assessing community assets such as community members’ skills, also need to be identified in community development (see also O’Hara & Weber 2006 and the EVOLVE website for useful resources).This approach does not imply that communities do not need additional resources from the outside. Rather, that outside resources will be much more effectively used if the local community is itself fully mobilised and engaged and if it can define the agendas for which additional resources must be obtained.

The primary reason for incorporating this approach is that there is considerable evidence to suggest that community development is successful when local communities are committed to investing in themselves and this includes identifying and developing their own assets (McKnight & Kretzmann 2005: 158). The assets fall into three main categories: primary building blocks which comprise assets and capacities of the neighbourhood, largely under neighbourhood control; secondary building blocks which are assets in the community but controlled by outsiders; and potential building blocks which are resources outside the neighbourhood controlled by outsiders (McKnight & Kretzmann 2005). This capacity is mapped alongside identifying the needs of the community.

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. Concepts and values in health promotion
2. Screening, risk assessment, immunisation and surveillance
3. Social marketing approaches to health promotion
4. Health promotion in context: Primary Health Care and the New Public Health movement

Stay updated, free articles. Join our Telegram channel

Join