EVALUATING COMPLEX COMMUNITY-BASED HEALTH PROMOTION: ADDRESSING THE CHALLENGES

Author: Gwyneth Margaret Jolley

Jolley, Gwyneth Margaret, 2013 EVALUATING COMPLEX COMMUNITY-BASED HEALTH PROMOTION: ADDRESSING THE CHALLENGES, Flinders University, School of Medicine

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Abstract

This thesis by published work investigates evaluation of community-based health promotion initiatives which use structural or policy approaches rather than focussing on individuals. Empirical research providing evidence of the effectiveness of community-based health promotion is limited. The thesis consists of a literature review, five papers from my research, and lessons drawn from reflection on my experience as an evaluator of community-based programs. Three of the five papers report on evaluations, including a meta-evaluation of sustainability in a Healthy Cities project. One paper is a review of (mostly) practitioner-actioned evaluations of community health services programs and the other paper reports on arising research leading to the development of evaluation resources. The research questions are: i) What was the health promotion and evaluation context for my publications and how did this influence my evaluation work? ii) How do my publications reflect evaluation developments prior to 2008, including the role of the evaluator in relation to community-based health promotion initiatives? iii) What are the contemporary challenges in conducting community-based health promotion evaluations? iv) What are the overall lessons from the evaluation practice presented in my publications and how do they inform new approaches to evaluation of community-based health promotion initiatives? The thesis argues that contested understandings of health promotion and the dominance of a positivist research paradigm present challenges to effective evaluation of community-based health promotion initiatives. Although evaluation theory has evolved to include interpretive approaches, mainstream evaluation practice still has to contend with demands for a linear, objective scientific approach that does not sit well with community-based health promotion. My evaluation work and the arising publications illustrate the tensions and compromises in taking a more interpretive approach. This thesis contends that, as evaluation has come to be accepted as a more values-based enterprise, health promotion evaluation should reflect principles of participation, empowerment and equity. Community-based health promotion initiatives are often complex interventions in complex settings and this presents evaluation challenges. These include flexible goals, diverse settings and participants, interaction between stakeholders and dynamic, non-linear programs. The developmental nature of many health promotion programs means that evaluations are context-contingent and this limits transferability of findings. The thesis concludes that mainstream approaches to evaluation are not able to cope well with the complexity of community-based health promotion and that complexity theory shows promise in addressing evaluation challenges. I classify my studies into complicated or complex domains by examining the extent and diversity of components, stakeholders and interactions and consider how the evaluations might have benefited from use of complexity theory. Building on insights from my publications, complexity and developmental evaluation, I present a conceptual model of my thinking about planning and evaluation processes. This model brings together program theory and developmental evaluation and may assist evaluation of complex interventions by supporting reflexive practice that can accommodate the adaptive and interactive nature of community interventions. The thesis argues that ideas from complexity can help to build cumulative evidence in order to identify the foundation principles of effectiveness that can be transferred to a new situation.

Keywords: evaluation,health promotion,complexity,developmental evaluation
Subject: Health Sciences thesis, Public Health thesis

Thesis type: Doctor of Philosophy
Completed: 2013
School: School of Medicine
Supervisor: Professor Fran Baum