ENRI Week: Evaluation of Upstream Public Health Initiatives Often Continues to be Reduced to Downstream Health Outcomes, Giving Little Importance to Critical Metrics of Social Change by Jennifer Latham

My name is Jennifer Latham and I am the Evaluator for Rhode Island’s Health Equity Zone (HEZ) Initiative and a graduate student at Brown University. Working with the HEZ, I have gained a mindset for evaluation that aligns with a community-led, place-based vision of health equity. I truly enjoy the evaluative challenge of my role and am honored to be part of ENRI and the RIDOH the team supporting health equity in my home state.

In practice, evaluation efforts in service of health equity have focused on measuring disparities and improvement in existing disparities as an evaluative tool. However, when seeking evaluation aligned with community-based models this deficit-based approach remains inadequate. Assessing factors that contribute to advancing health equity, and not only leveling the “symptoms” of inequity, is critical to demonstrating whether we have achieved improvement. Yet, we continue to align upstream systems-level work with direct intervention measures for reporting, diluting the value of this work into supportive programmatic activities with specified programmatic outcomes. This approach binds evaluation strategies and reporting to outcomes measured through the impact on downstream health outcomes (the “symptoms” of the problem), rather than measurable factors in the community that directly represent key indicators of change.

To meet the dual need to evaluate the impact of community-based initiatives on the upstream problem and the resulting impact on the downstream “symptoms” of inequities in health outcomes, I developed and use an evaluative approach derived from several foundational evaluation and data analysis theories to create a framework that is based on the collaboration of systems evaluation, contribution analysis, and equitable evaluation practices. Through an intensive exploration of the factors and pathways that contribute to health equity in Rhode Island’s place-based Health Equity Zone (HEZ) Initiative using causal diagramming alongside equity-centered approaches to lift the narratives of people with lived experience in the communities, we were able to identify what we see as the key indicators (the building blocks if you will) of health equity within the HEZ initiative, or any place-based initiative.

Not surprisingly, through this approach, the evaluation highlighted critical transformative factors toward defining success in achieving health equity that included community capacity, empowerment, trust, engagement, social connectedness, transformative learning, relationship-building, and collaboration.??Specifically, the capacity of the community to identify and address the unique social and environmental root causes of inequity, and the empowerment of the community to enact change were revealed as the two primary key leading indicators of success. Measures of these and other transformative factors need additional exploration and understanding to be used as indicators of change and accepted as valid reporting measures to demonstrate the true impact of place-based initiatives on systems level change, while also demonstrating improved health outcomes.

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The American Evaluation Association is hosting Evaluation Network of Rhode Island (ENRI) Week. The contributions all this week to AEA365 come from ENRI Affiliate members. Do you have questions, concerns, kudos, or content to extend this AEA365 contribution? Please add them in the comments section for this post on the AEA365 webpage so that we may enrich our community of practice. Would you like to submit an AEA365 Tip? Please send a note of interest to AEA365@eval.org. AEA365 is sponsored by the American Evaluation Association and provides a Tip-a-Day by and for evaluators. The views and opinions expressed on the AEA365 blog are solely those of the original authors and other contributors. These views and opinions do not necessarily represent those of the American Evaluation Association, and/or any/all contributors to this site.

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