Introduction
As the burden of chronic diseases in the United States continues to increase, greater
efforts are being made to identify and implement interventions that successfully reduce
disease risk, improve access to high-quality health care, and create sustainable health-promotion
programs that ultimately improve health status and quality of life (1). Identifying
effective primary and secondary prevention strategies through tailored program evaluation
efforts has become an essential public health function in clinical and public health
settings (2). Articles in this issue of Preventing Chronic Disease (PCD) address various
aspects of program evaluation, such as planning, methods, approaches, stakeholder
involvement, and the use of program evaluation findings to guide the direction of
future programs.
The articles presented in this issue have three primary goals: 1) to provide the reader
with practical examples of program evaluation that can be immediately applied in other
settings; 2) to carefully discuss the way program missions and objectives, stakeholder
interests, evaluation theory, and evaluation methods are considered when conducting,
analyzing, and reporting the status of program outcomes; and 3) to candidly explore
the use of evaluation frameworks, logic models, and organizational strategic planning
to increase capacity for routinely monitoring program outcomes at the national, state,
and community levels.
Chronic Diseases in the United States
Chronic diseases such as diabetes, cardiovascular diseases (particularly heart disease
and stroke), and cancer are among the most prevalent and costly of all health problems
(3-6). More than 90 million Americans live with chronic diseases (3), and chronic
diseases account for three fourths of the nation's $1.4 trillion in medical care costs
and one third of the years of potential life lost before age 65 (3). Individual, family,
health system, community, and societal factors are all believed to have contributed
to the rise in chronic disease rates in the United States (7). Factors postulated
to explain this phenomenon range from increased prevalence of individual risk factors
(8), a lack of health care resources for the poor and underserved (9), and environmental
conditions that do not support the adoption and sustainability of healthy eating and
physical activity behavior (10). Collectively, these factors may express themselves
differently from one sociogeographical context to another. As a result, a combination
of tailored, multifaceted, and multidisciplinary clinical and public health approaches
is needed to systematically intervene.
More recent public health discussions about the role of social determinants and health
disparities among women and racial and ethnic minorities in the United States help
illustrate the complex and dynamic aspects of chronic diseases. The discussions also
emphasize the dynamic interactions between individuals and their social and physical
environments (11). Addressing the reciprocal relationship between the individual and
the environment requires complementary clinical and public health approaches as well
as the unique contributions of numerous partners (2). Clearly, reducing the burden
of chronic diseases requires amassing and coordinating efforts from various traditional
public health partners as well as other untapped resources that share an interest
in preventing chronic diseases and improving the quality of life of people with chronic
diseases.
The Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention (CDC) is dedicated to helping Americans
live long, healthy, and satisfying lives (12). The organization's missions include
preventing death and disability from chronic diseases; promoting maternal, infant,
and adolescent health; and promoting healthy personal behaviors. To accomplish these
missions, the CDC relies on the strengths and contributions of a diverse group of
committed partners such as state and local health departments, international and national
organizations, academic institutions, philanthropic foundations, industry and labor
groups, professional associations, and volunteer and community organizations (12).
Through its relationship with collaborating partners, the CDC is able to provide national
leadership in health promotion and disease prevention by 1) conducting public health
surveillance, epidemiologic studies, and behavioral interventions; 2) disseminating
guidelines and recommendations for public health interventions; and 3) helping state
health departments build their capacity to prevent chronic diseases (12). The CDC
is committed to applying research findings to chronic disease prevention and control
to improve the health of the people in the United States. To accomplish this goal,
the CDC is developing, implementing, and evaluating national, regional, state, and
community programs. During this process, the CDC considers the distribution of risk
factors among vulnerable populations, social determinants of health, and characteristics
of the social and physical environments.
Program Evaluation: Demand for Accountability and Results
Evaluation of national, regional, state, and community programs remains a priority
of the CDC, which uses various tailored program evaluation activities designed to
meet their stakeholders’ needs and capacities. In addition, demand is increasing for
1) a formal evaluation infrastructure for regularly assessing the effectiveness of
public health programs (13); 2) the creation and maintenance of evaluation monitoring
systems to collect, analyze, and interpret public health intervention findings (13,14);
3) the capacity to monitor progress toward improving the health of vulnerable populations
(15,16); and 4) evidence that findings about changes in health outcomes (whether positive
or negative) are used to make changes in programs (17,18). Using program evaluation
activities that incorporate all four of these important factors will better position
the CDC and its partners to make critical decisions about program performance and
the use of federal funds in a way that demonstrates sound stewardship of taxpayer
money.
The demand for accountability is not new to the CDC. In 2002, Milstein et al explained:
With demands for accountability and results at a high level, the CDC faced the problem
that many of its programs involved collaborative, multifaceted initiatives with communities
across the nation and around the world. Engaging these community partners required
complex approaches melding policy, structural, and individual change that were 1)
implemented differently in different contexts and 2) hard to measure feasibly and
consistently. Furthermore, the ultimate outcomes of interest, such as reductions in
hypertension, HIV infection, obesity, or violence, were ones that might take years
to materialize. The CDC remained committed to showing that its efforts as an agency
were worthwhile. Yet understanding the precise effects of a single program under these
circumstances proved to be an extraordinary challenge. (13)
Fortunately, considerable development in program evaluation approaches in the last
century has made it possible to embrace the complexities of public health (19). For
example, decision and accountability, utilizations focused, client centered and responsive,
case study, and outcomes monitoring and value added are a few of the evaluation approaches
that have met the high program evaluation standards of usability, feasibility, propriety,
and accuracy (19). Because of the need for multifaceted, multidisciplinary, and multidimensional
approaches to address real-world factors that influence chronic diseases, the use
of one or more evaluation approaches to ascertain program effectiveness is imperative.
Program Evaluation and Chronic Diseases
Gathering evidence to demonstrate accountability for program outcomes is a priority
for the CDC. Evaluation is one of the 10 essential public health services and is considered
a critical function of public health agencies (2). The articles in this program evaluation
issue of PCD include Original Research, Community Case Studies, Essays, Step-by-Step,
Tools & Techniques, and Book Reviews. Through these various types of articles, we
hope to expose readers to the value of stakeholder participation at all levels of
program design; share a rich discussion of how program evaluation findings can and
should be used to make improvements in the implementation and evaluation of existing
and future chronic disease programs; promote the identification of program evaluation
areas that need additional attention and improvements; and explore examples of evaluation
methods and approaches.
Original Research
In Mukhtar et al's original research article on Healthy People 2010 diabetes objectives
(20), evaluators describe the way the CDC's Division of Diabetes Translation (DDT)
adopted and monitored progress toward selected Healthy People 2010 objectives. These
objectives included improving the rates of preventive care service, such as hemoglobin
A1c tests and annual foot and eye examinations, among people with diabetes. Data from
the Behavioral Risk Factor Surveillance System (BRFSS) diabetes module were used to
evaluate progress toward achieving Healthy People 2010 targets. Evaluators compared
2003 data with Healthy People 2010 targets and 2000 baseline rates. The degree to
which the DDT and its partners achieved the Healthy People 2010 targets is discussed,
as are challenges and important factors to consider when selecting and monitoring
these national objectives. Areas for future research and evaluation are also discussed.
In their original research article, Besculides et al describe an evaluation approach
that identifies best practices in implementing lifestyle interventions for women in
the WISEWOMAN program (21). The authors report using qualitative and quantitative
methods, or a mixed-method approach, in this evaluation effort. Specifically, they
use quantitative program performance data to identify high- and low-performance WISEWOMAN
sites and use qualitative interviews, observations, and focus groups to understand
underlying strategies for implementing the interventions. The authors conclude with
a discussion about the relevance of using a mixed-method approach to conduct evaluation
of community-based interventions.
Hypertension is the leading cause of stroke, coronary artery disease, heart attacks,
and heart and kidney failure in the United States (22). Programs that provide free
or low-cost blood pressure medications and preventive treatment protocols based on
authoritative guidelines may not only improve health among patients with hypertension
but also result in substantial cost savings. Rein et al found that the state-funded
education and direct service program in Georgia resulted in better health outcomes
than two other scenarios — no preventive treatment for high blood pressure and the
average U.S. private sector preventive treatment (23). Evaluators conclude with a
discussion about the need for more evidence-based and cost-effective programs to prevent
heart disease and stroke.
Community Case Studies
In Houston et al's community case study, the authors share with readers the evaluation
of South Carolina's Diabetes Prevention and Control Program and the Diabetes Today
Advisory Council's effort to conduct a 1-day conference for people with diabetes.
The conference offered educational sessions on improving diabetes self-management
practices (24). Authors describe the evaluation efforts since the conference's inception
and report results from data gathered using qualitative and quantitative evaluation
methods. Of importance is a discussion of the evolution of the evaluation planning
and methodology as the conference became more sophisticated and far-reaching over
a period of years. Using focus groups, a general participant questionnaire, and a
Diabetes-Related Understanding Scale, evaluators were able to determine that participants
were motivated to adopt diabetes self-management behavioral changes and were pleased
with the conference overall. The evaluation also demonstrated that the conference
effectively improved diabetes management skills among attendees. Evaluators concluded
that the conference could help supplement and reinforce formal diabetes education.
Ideally, program evaluation should be considered at the inception of any public health
program. Balamurugan et al explain that the effectiveness of programs in underserved
rural areas of Arkansas was impeded because of the lack of advance evaluation planning
(25). The authors report that the state health department was successful in establishing
12 diabetes self-management education (DSME) programs in underserved counties that
had a disproportionately high prevalence of diabetes. Although some of the barriers
faced by the programs were anticipated (e.g., staffing and reimbursement issues),
the authors discuss the reasons only some of those barriers could be addressed effectively.
Unanticipated barriers were encountered as well, such as inconsistent data collection
procedures, a suboptimal data collection capacity, participant retention issues, and
the lack of an adopted and implemented evaluation plan among DSME program sites. The
authors offer strategies to overcome barriers and use what they learned to plan the
new wave of DSME sites that will soon be initiated in similar geographical regions
of Arkansas.
Step-by-Step
In 1999, the CDC published the Framework for Program Evaluation in Public Health (26).
Martin and Heath use this framework to discuss a hypothetical case study of a physical
activity program to prevent diabetes. In their article, the authors discuss each of
the six steps: 1) engage stakeholders, 2) describe the program, 3) focus the evaluation
design, 4) gather credible evidence, 5) justify conclusions, and 6) ensure use and
share lessons learned (27). The authors describe stakeholders and present a logic
model with possible short-term, intermediate, and long-term objectives. They briefly
discuss quantitative and qualitative data gathering and analysis and conclude with
a brief discussion about the ways to share program evaluation findings with the community.
Essays
An essay by Martin and Thomas addresses Office of Management and Budget (OMB) clearance
(28). Federally funded program evaluations usually require collecting data from the
public. The data are used to measure processes, impact, and outcomes resulting from
health promotion programming. Although collecting these data is important, so is considering
the burden of paperwork on the public. Martin and Thomas discuss the process for attaining
approval from the OMB for federally sponsored data collection. They also describe
how important it is for program evaluators and their collaborators and partners working
with the federal government to plan early and consider OMB clearance requirements.
Tools & Techniques
The Steps to a HealthierUS Cooperative Agreement Program (i.e., the Steps Program)
focuses on chronic disease prevention and health promotion efforts to reduce the burden
of diabetes, obesity, asthma, and related risk factors. In their article, MacDonald
et al describe the need for the Steps Program to coordinate national and community
evaluation efforts (29). The authors discuss the importance of providing national
leadership for evaluation among all Steps Program sites while also allowing flexibility
for site-specific evaluation efforts that would allow movement toward well-designed
and complementary evaluation plans at national and community levels.
Mukhtar et al (30) describe their experience in developing the Diabetes Indicators
and Data Sources Internet Tool (DIDIT). This user-friendly Web-based tool contains
information on 38 diabetes indicators and their associated data sources. The DIDIT
was developed in collaboration with multiple stakeholders, including state representatives,
the CDC, and contractors. The authors highlight the elements that were essential for
the tool's development. Expertise in diabetes surveillance and software development
as well as stakeholder enthusiasm and dedication were important components. These
components were complemented by the project leader's strong leadership skills and
sense of vision, clear communication and collaboration among all team members, and
commitment from the management of the Division of Diabetes Translation.
In their article, Tucker et al begin with a brief history of the Racial and Ethnic
Approaches to Community Health (REACH 2010) initiative (31). Authors discuss the way
40 REACH 2010 communities (African American, Alaska Native, American Indian, Asian
American, Hispanic, and Pacific Islander communities) use community-based participatory
approaches to reduce risk factors for and the prevalence of chronic diseases. Using
a logic model, the authors describe the way program activities are related to program
theory as well as short- and long-term program outcomes. The article emphasizes the
need to conduct local, site-specific evaluations as well as a national evaluation
that takes into consideration cross-site assessment of successful partnerships. The
authors discuss the way using qualitative data collected from REACH 2010 projects
with a management information system called the REACH Information Network will help
users understand how program components influence system changes. The authors also
describe the way quantitative data are systematically collected using the REACH Risk
Factor Survey to establish estimates of program effects. Local, site-specific, and
national evaluations using qualitative and quantitative evaluation methods will help
determine whether local interventions decrease health disparities.
Book Review
This issue includes Lavinghouze's book review (32) of Practical Program Evaluation
Assessing and Improving Planning, Implementation, and Effectiveness by Huey-Tsyh Chen
(33). Lavinghouze describes Chen's efforts to provide a program evaluation taxonomy
that would be particularly useful to individuals new to the field of program evaluation
as well as to more seasoned evaluators who want to encourage stakeholder understanding
of evaluation. She describes Chen's ability to provide a thorough overview and review
of the theory-driven approach to evaluation and apply it to the taxonomy he presents.
She points out that although terms and definitions used in the book are inconsistent
with those found in current literature, Chen encourages the readers to broaden their
perspectives so that they can embrace this new terminology. According to Lavinghouze,
Chen's book emphasizes acknowledging the stakeholder throughout the evaluation process.
She concludes that Chen's taxonomy is a major step in the overall conceptualization
of the evaluation process and that the taxonomy enhances evaluators' attempts to understand
and appropriately apply evaluation designs at a practical program level.
Conclusion
The diverse nature of evaluation efforts undertaken by the CDC and its many partners
highlights the interest and commitment to designing, implementing, and evaluating
high-quality chronic disease prevention and control activities that are responsive
to target audience and stakeholder needs. The use of evaluation is being integrated
into the accountability movement and is embedded in a consumer-oriented public health
ideology (34). It is becoming an increasingly important accountability tool in the
current environment and is considered a necessary component of decision making about
the use of federal funds to support successful programs. According to Segerholm, "Against
this background, it is high time to start critically examining evaluation itself as
a phenomenon and practice" (34). We hope the articles in this issue not only emphasize
the importance of program evaluation but also provide our readers with examples to
incorporate into evaluation approaches, stakeholder engagement strategies, and their
own public health efforts.