Evaluation Challenges for Community Health Programs

There is no one-size-fits-all approach for evaluating rural programs and interventions. Even a well-designed evaluation strategy may encounter challenges. One of the best ways to identify specific issues with evaluations is to confer with other communities that implemented similar programs about specific challenges they encountered. Some challenges associated with evaluating rural programs, and their possible solutions, are discussed below.

• Measuring outcomes – It may be difficult to determine whether certain outcomes, such as changes in individual behaviors, can be attributed to a particular intervention or program. Some outcomes are much more difficult to measure, such as long-term changes in community norms. Some evaluations of policy, system, and environmental changes instead focus on tracking short-term or intermediate outcomes given time needed to achieve and measure long-term outcomes. Community health programs that address long-term behavior change may also seek to measure short-term outcomes.
• Measuring prevention and showing that a negative outcome “did not happen” – The ultimate goal of many health programs is prevention. Evaluating such programs is challenging because the ultimate outcome is not easily measurable. While it may not be possible to directly evaluate if prevention is happening, communities can measure prevention activities and processes or policies to prevent certain unhealthy behaviors or health outcomes.
• The multifactorial nature of health issues – Any given community health issue may have multiple contributing factors: biological/genetic influences, environmental determinants, social and economic drivers (for example, educational and employment opportunities), the strength of families and social networks, and community safety, among others. These factors and their interrelationship must be considered when conducting program evaluations. The potential influences of these contextual factors are important to consider when developing an evaluation plan.
• The diversity of sectors and stakeholders involved in program efforts – Community health programs are developed and implemented by a range of different stakeholders, including policymakers, public health practitioners, clinicians, and community leaders. Each person has a different perspective and may view a public health issue differently. This diversity, coupled with any problems regarding coordination or collaboration, can make program evaluation challenging.
• Determining the effectiveness of individual strategies – Many health programs address a combination of policy, system, environmental, and individual changes, which makes it challenging to pinpoint the effectiveness of a single strategy.
• Access challenges specific to rural communities – Rural communities face access-related barriers to care that may affect evaluation. Remote geography, long distances to health care providers, and lack of transportation may keep individuals in rural communities from participating in health programs. To reduce attrition, participants may receive payment for travel expenses to participate in program and evaluation activities.
• Protected populations – Rural health programs involving protected populations — children, pregnant women, and people who are incarcerated — must consider how to minimize risk and address other federal requirements for protecting these populations in research. For example, programs working with children under the age of 18 will need to secure permission from a parent or guardian. The program should be explicit about the data that will be collected from, or the service that will be provided to, children so that guardians can assess potential risks. Securing permission from parents early in program implementation will help facilitate the evaluation process.
• Lack of evaluation measures designed for use in rural settings – Evaluation measures are often not designed for programs in rural settings, which require rural communities to adapt measures to accomplish their evaluation goals.