Public Health Evaluation and the Social Determinants of Health

Allyson Kelley

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000071719
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Compelling evidence shows health disparities are the result of inequalities in income, education, limited access to medical care, substandard social environments, and poor economic conditions. This book introduces these social determinants of health (SDOH), discusses how they relate to public health programs, and explains how to design and evaluate interventions bearing them in mind.

Arguing that many public health programs fail to be as effective as they could be, because they ignore the underlying causes of health disparities, this important reference gives concrete examples of how evaluations focusing on the social determinants of health can alleviate health inequalities, as well as step-by-step guidance to undertaking them.

This resource blends current research, existing data, and participatory evaluation methods. It is designed for teachers, students, practitioners, and policymakers interested in public health programming and evaluation.

A Choice Recommended Title

1 An overview of public health evaluation and the social determinants of health

Learning objectives

After reading this chapter, you should be able to:

• Define evaluation, program evaluation, and the types of evaluation used in public health

• Define the social determinants of health (SDOH) and provide examples

• Summarize the history of SDOH and key events leading up to advocacy for health as a fundamental human right

• List organizations involved in SDOH efforts

• Understand why SDOH focused evaluations are needed

In 1854, John Snow, a British physician, traced the source of a cholera outbreak in Soho, London, to a water pump handle. Snow had the water pump handle removed and cases of cholera immediately decreased (British Broadcasting Corporation, 2014). Some of you probably recognize his name and contributions as the beginning of modern epidemiology. Snow talked with residents of London and identified the source of the outbreak as a public water pump. Because Snow connected place and people, he was able to decrease mortality from the outbreak. Snow’s early life was anything but privileged. He likely did not have economic stability, access to quality health care, acceptance by his community or peers, access to reliable transportation, or access to safe drinking water, clean air, or toxin free environments. Snow lived until the age of 45, and this was considerably longer than the average life expectancy for males born in 1813, estimated at 35 years (Office for National Statistics, 2015).

You might be wondering what John Snow’s life has to do with public health program evaluation (PHE) and the social determinants of health … and the answer is everything. Public health seeks to improve the quality of life in individuals, families, and communities through the creation of social and physical environments that promote health for all people (Harris, 2016).

Evaluation as process is about finding value, through the systematic collection of information about activities, characteristics, and outcomes that allow us to make judgments about a program. Judgments help improve a program’s effectiveness and inform decisions about how the program continues and develops (Centers for Disease Control and Prevention [CDC], 2011). Evaluation also helps determine value based on acceptable standards. An example of acceptable standards might be a target population health status and rates of morbidity and mortality within a community compared with state, national, or global average rates or norms. Evaluation occurs in a variety of contexts, but for the purposes of this text we will focus on PHE. In the United States, the Government Accountability Office defined program evaluation as a systematic study using research methods to assess how well a program works and why it works. Evaluation results assess effectiveness and identify how to improve programs or inform resource allocation and future efforts. PHE may be focused on a specific problem, initiative, or policy, or on an entire program.

Evaluation may be informal or formal. Informal evaluation might occur spontaneously when changes are needed to improve a program immediately—for example, changing program times, adding sessions, or revising how data is collected. Formal evaluations are systematic and well planned. Formal evaluations are characterized by planned activities, prescribed procedures and protocols, objective scores of measurement, controlled settings, narrowed scope, and strong inferences (McKenzie, Neiger, & Smeltzer, 2005).

Evaluation approaches are often identified by the terms process, outcome or impact, or formative and summative evaluations. Cost–benefit and cost-effectiveness evaluations are additional types of program evaluations frequently used in public health programming (Longest, 2014).

Process evaluations are used to determine if a program or part of a program is working as planned. Data collection for process evaluation may include information about services available, kinds of services provided, the extent to which these were delivered as planned, the social and demographic characteristics of individuals involved in programming, information about the community(ies) involved in a program, and the number and types of organizations involved in a given program. Results from process evaluations are used to identify needs, make changes, and redirect programming or service delivery. Process evaluations occur during program implementation. Sometimes process evaluation is called formative or implementation evaluation—for this text we will use the term process evaluation.

Outcome evaluations assess whether a program, policy, or initiative goal was met and if a program (or activity/component being evaluated) impacted a desired variable or outcome. Outcome evaluations often use a comparison group and compare results across a sample or population to determine the effect; and they occur after a program has been implemented or when there are outcomes available to compare. Sometimes outcome evaluation is called impact or summative evaluation. In this text we will use the term outcome evaluation.

Cost–benefit evaluation is used to determine the costs of operating a program in relation to the benefits of that program to an individual or society.

Cost-effectiveness evaluation is used to compare costs of operating a program to reach program goals and objectives.

Evaluation may be carried out internally by a program manager or staff member, or externally by an independent evaluator, expert, or funding agency. Evaluation standards may vary by program and context, but the Centers for Disease Control and Prevention (2017) developed 30 standards that guide program evaluation. Here are four categories used to organize standards: Utility ensures that an evaluation will serve the needs of the users or audience for which it is intended; Feasibility ensures that evaluations are realistic, prudent, diplomatic, and frugal; Propriety ensures that evaluations are legal, ethical, and consider those affected by evaluation results and involved in the program; and Accuracy ensures that evaluations communicate adequate information to help determine the worth or merit of a program (CDC, 2017).

The SDOH are focused on policies, programs, places, and people at the local, state, nation, or global level. PHE can help guide SDOH programming to document how efforts interact to create health or the absence of health (Krech, 2012). Combined, PHE and the SDOH have the potential to change the landscape of health in our lives and in our world. Throughout this text we will learn about the SDOH by exploring programs, policies, initiatives, and people. We will focus on how PHE can change the narrative about what determines health and how programs are addressing the underlying causes of health inequalities. Let’s begin with exploring the history of SDOH.

Health as a universal right

The Universal Declaration of Human Rights (www.un.org/en/universal-declaration-human-rights/) affirms the equal and universal rights to health for all people, irrespective of economic class, gender, race, ethnicity, caste, sexual orientation, disability, age, or location. The right to health has been a topic of interest since the beginning of time. Without health, we die. With health, we live. But one of the challenges of public health is to find out why some people are healthy and live long lives, while others are not and do not. John Snow’s efforts in the 1850s improved how people lived by ensuring residents of Soho, London, had safe drinking water, effective sewage disposal, food safety, housing, and safe work environments (Scriven & Garman, 2007). How do we know that Snow’s work led to improved health? Using concepts and methods from PHE and efforts like Snow’s we can provide evidence needed to advocate for policy changes that improve population health.

SDOH and history

There are some key events that led to a focus on SDOH as the primary driver of health equality and inequality—let’s explore these now.

The constitution of the World Health Organization (WHO) was first drafted in 1946. This constitution was developed to address the social roots of health problems globally, and to address challenges related to medical care delivery. Their goal was that all people would attain the highest possible level of mental, physical, and social well-being.

Increasing costs of health care and “diseases of comfort” in the 1970s prompted new efforts to promote public health while addressing determinants of health. Public health in the United Kingdom (UK) and Canada changed radically with the release of the Lalonde Report (Lalonde, 1974). This was the first government document to recognize the importance of upstream policy agendas. Lalonde (1974) stated that improvements in health would come from improving the environment, moderating risk-taking behaviors, and increasing knowledge about human biology. A shortcoming of this report is that it resulted in an emphasis on lifestyle factors, on people taking responsibility for their own health, and a failure to address the socioeconomic and environmental factors that determine health.

The Alma Ata Declaration in 1978 proceeded from the Lalonde report. It was developed at the National Conference on Primary Health Care in Alma Ata, USSR (now called Almaty, Kazakhstan). This gathering of world health leaders, including WHO, was the first of its kind because it linked primary health care as a major factor in attaining the highest possible level of health for all people. This declaration also outlined steps to reduce health inequalities between countries and the role of governments in ensuring health as a fundamental human right.

The Black Report, published by the UK Department of Health and Social Security, documented inequalities in health and identified social factors—income, education, housing, diet, employment, and conditions of work—as the leading cause (Gray, 1982).

WHO’s 1985 Health for All approach paved the way for health policy reform and a new focus on addressing population health through the socioeconomic determinants of health (WHO, 1986).

The 1986 International Conference on Health Promotion in Ottawa, Canada, followed the Alma Ata Declaration and resulted in the Ottawa Charter (WHO, 1986). The Ottawa Charter was designed to advocate for social justice and access to health, and to reduce health inequalities.

England attempted to follow health strategy reform with the Health of the Nation (HOTN) strategy published in 1992 (Department of Health, 1992). This strategy was lauded for being the first of its kind to promote health in a broad sense. But it was criticized because it failed to address the socioeconomic determinants of health and utilized a disease-based model of health, focusing on factors that contributed to diseases as opposed to the conditions that created them in the first place (Holland & Stewart, 1998).

President Clinton’s 1998 health initiative targeted ethnic health disparities and called for health officials to address disparities. As a result of this initiative, Healthy People 2010 goals focused on research and policy interventions (Gehlert, Sohmer, Sacks, et al., 2008).

The Minority Health and Health Disparities Research and Education Act of 2000 prompted the creation of the Center for Minority Health and Health Disparities (US Department of Health and Human Services [USDHHS], 2000). This Center was, and is, charged with the development of the National Institutes of Health (NIH) Strategic Plan to address health dispa...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of figures
• List of tables
• Preface
• 1 An overview of public health evaluation and the social determinants of health
• 2 A condition of place, people, communities, and justice
• 3 Planning a social determinants of health focused evaluation
• 4 Collecting and analyzing SDOH data
• 5 SDOH program examples
• 6 SDOH evaluation examples
• 7 Case studies of a SDOH evaluation
• 8 Bringing it all together
• Appendix A: SDOH evaluation report outline
• Appendix B: Theory of change and logic model examples
• Appendix C: Health impact assessment guidelines
• Appendix D: Matrix to document structural inequalities, SDOH pathways, and impact
• Index