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Finds Mixed Results Care And Satisfaction

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Program evaluation for health care programs holds much importance when it comes to understanding the utility and outcome of these programs against the set objectives. For understanding whether the healthcare program has been able to meet its aim or not, it is pivotal to evaluate the program rigorously against a set of guidelines outlined by a public healthcare body. Through evaluation, concerned stakeholders and policymakers are able to extract information about the program based on which the performance and operation of the same can be judged. Different formats are present that support a wide array of tools and aids to be used for program evaluation. The ‘Realist Evaluation’ approach was outlined by researchers Pawson and Tilley who proposed the idea of evaluating health care programs by understanding what works for whom in what circumstances and in what respects and how[1]. The present discussion compares the Realist Evaluation approach and the model of evaluation put forward by Michelle Issel. It is a critical analysis that highlights the similarities and points of difference between the two.

The public health concerns at the contemporary era reflect the need of developing health care programs that are tailored for individuals, populations and service delivery systems across the globe. Practical application of healthcare programs would be successful when the evaluation and successive dissemination of findings are stable enough so that based on such data further modifications can be done. The two most debatable evaluation methods at present are the Realist Evaluation model and the model outlined by Michelle Issel. Though both the models are theory-driven evaluation tools, the Realist Evaluation model is set apart as it has explicit and overt philosophical underpinnings unlike the other model being discussed here[2].


The common element between the Realist Evaluation model and the model outlined by Michelle Issel is that both use the well-established program theory as the basis of their evaluation. The theory is a conceptual model that aims to justify how the selected intervention, in the form of a project, program, strategy or policy, contributes to the results produced by the actual or intended impacts. It includes both negative and positive impacts and highlights other factors contributing to impacts[3]. Both the Realist Evaluation model and Michelle Issel’s model have the objective of assessing whether the program is designed in a manner so that the intended outcomes can be achieved. The theory becomes the backbone of the programs, and it lays out a clear, logical description of the reasons behind the activities leading to results of benefits. Both the evaluation approaches clarify the agreement about how the program being evaluated works and identifies the gaps in the evidence.

The first realist evaluation approach was developed by Pawson and Tilley who argued that in order to understand what the actual outcomes of a health program are; the decision makers must identify the effectiveness of the program keeping in mind the population it addresses and the circumstances under which it has been implemented. The main focus of this type of evaluation is to examine what elements of the chosen program have been successful in bringing about the outcomes given the corresponding circumstances and who have been affected by the program[4]. In contrast, the evaluation approach of Issel had been focusing on the sole understanding of whether the program has worked or not. While Pawson and Tilley have attempted to justify the fact that a program might be successful under certain circumstances and not be successful under other, Issel has not considered this aspect of program evaluation in his model. Realist evaluation model keeps into consideration the contexts in which the program might have given different results, assuming that program outcomes are a variable aspect. The aim of Issel, on the other hand, had been only to answer the question of whether the program has worked or not, notwithstanding the fact that a program might give different results under different settings and with different set of population[5].


Scientific realism is the underlying notion of the realist philosophy and argues that an intervention works, or does not work since the actors take up or do not take up certain decisions against the program. The realism model further argues that the ‘reasoning’ of the actors as a response to the opportunities and resources provided by the selected program leads to the outcomes. The approach of Issel do not consider this concept and undermines the role played by the actors in program outcomes. While realist evaluators identify the generative mechanisms are explaining how the outcomes have been achieved, followers of Issel’s model do not take this step[6]. As per the realist model, the intervention, that is the program, and the actors are entrenched in the social reality while this reality in the community context exerts an influence on the implementation of the program and the degree to which the actors would respond to it. The context-mechanism-outcome (CMO) configuration is considered as the primary framework for realist analysis. Since the realist evaluation holds up the idea that generative causality is applicable to program effectiveness, the claims made by the realists are modest. Their statements have the underlying principle that a program evaluation can never give rise to findings that are universally applicable. Such notion is not mentioned in the evaluation approach of Issel, whose approach towards generalizability of findings different.

From the above discussion, it can be stated that program evaluation is the systematic method used for collection, analysis and interpreting the information from programs that answer questions about the same program related to the efficiency and effectiveness. The evaluation process is a  relatively evolving phenomena as novice tools are emerging with more distinct features. The Realist Evaluation approach of Pawson and Tilley, and the model outlined by Issel are both based on the program theory; however, they are distinct from each other. While the former is embedded in philosophical concepts, the latter is not. The prime difference between the realist theory and that of Issel is that the former one specifies the mechanisms generating the outcomes. Understanding the implications of both the models would justify the application of each under different circumstances against the chosen program objectives.

Chosen health care program

‘Healthy Start’ is a well-reputed preventive health education project based in Australia that works with the refugees arriving in the country and aims at increasing health literacy within the community. The program started in the year 2012 by a group of volunteers of comprising of medical students at ‘Hope for Health’. The program receives its funding from the Brisbane South Health Network (BSPHN) and runs in collaboration with Multicultural Development Association (MDA) Ltd in Brisbane. MDA Ltd is a chief settlement agency working for new humanitarian refugee arriving in Brisbane[7]

The mission of Healthy ‘Start’ is to engage the refugees settled in Australia in health activities for achieving better health outcomes and equip them with the necessary skills required to maintain a healthy lifestyle. Since the process of taking refugee in Australia is a tiring and traumatic one, refuges suffer poor health outcomes after their struggle for existence. The program helps this population with the adequate information required to take care of their health in the Australian context. The vision is to present the refuges with the chance to secure a healthy future. The aims of the program are multifold. The primary aim is to educate the refugees on health topics such as medications, nutrition, general health, pregnancy, emergency health conditions and adolescent health. The second aim is to encourage efficient and prompt interaction with the healthcare system of Australia. Further, the next aim is to address negative typecasts in relation to service delivery. Lastly, it aims to permit an environment of interaction between the refuges and the locals. Health knowledge imparted to the population aids in increasing their confidence and morale so that there are no restrictions in accessing health care services or maintaining own health and hygiene. Integration of refuges in the Australian context is of prime importance; hence the program fosters a foundation for efficacious settlement of the population in the country[8]


Evaluation report of the healthcare program 

The evaluation of the Healthy Start program was undertaken in the year 2016 whose elaboration and analysis would be presented in here. The Brisbane South Primary Health Network (BSPHN) thought it significant to conduct a thorough evaluation of the impact of the program in relation to behaviour change and long-term knowledge. The Mater/UQ Centre for Primary Health Care Innovation (MUQCPHCI) at Mater Health Services (MHS) were considered for undertaking this evaluation. Two consultant professionals from G8 and a Coordinator engaged in the evaluation. The Healthy Start Team and MDA Ltd were contacted for gaining insight into the program. Information was given to them by the delivery of two Healthy Start Programs- one each for the Eritrean and Somali community. As the program proceeded, cancellation of the Eritrean group was necessary as a result of date clash with the Orthodox religious day. The evaluation as done only for the Somali group.

The purpose of the evaluation of the program was multi-faceted. The first aim was to assess whether the program objectives and goal were achieved. The evaluation also aimed to assess the degree to which the program had contributed towards increasing the health literacy and bringing about behaviour change among the refugee community. After that, the evaluation attempted to document critical factors of success and barriers to implementing the program. Lastly, evaluation was done to come up with an overview of the value of the program to the funding body.

The evaluation process considered utilising a Post-Workshop Questionnaire for understanding the immediate learning after the workshops and conducting a six-week Post Workshop phone interview with participants for understanding the influence on behaviour change. The participants of the program were guided on the day on the workshop to fill up the requisite forms. Recommendations and observations were gained by the evaluators about the participants when the workshop ended. The bicultural worker from MUQCPHCI was responsible for conducting a telephonic interview with 9 participants six weeks after the workshop was completed. The measures for the evaluation tool pertained to the health topics included in the workshop.  The evaluation concluded that the program had been successful in fostering a positive change among the targeted population. The report indicated that the Healthy Start Program had the potential to be continued in future. It showed benefits for enhanced health literacy levels of refugee communities[9]


Assessment of the evaluation’s relative strengths and weaknesses  

A strong and rational health care program evaluation is of prime importance when it comes to understanding the effectiveness of the program. It is the evaluation phase that determines whether the program has been apt and helps in outlining the future recommendations for the betterment of such program. Reviewing program evaluation gives the opportunity to identify the gaps in the evaluation process, based on which more stable evaluation process can be determined. While conducting an evaluation, it is pivotal to collect data in an accurate manner and work on them[10].

The aims of a program determine the manner in which the evaluation is to be carried out at its best. The aims of the evaluation are to be so set that the focus is on the assessment of the degree to which the objectives have been met adequately. Secondary aims might be there based on the assessment of the increase of enforcement and acceptability of the program for the stakeholders[11]. The Healthy Start Program had the aim of increasing the health knowledge of the refugees and the changes in health behaviour showcased by them. The evalution focused on assessing the degree to which the program contributed towards increased health literacy and changes in refugee health behaviour. In addition, there were some secondary aims of the evaluation as it assessed the facilitators and barriers for implementation of the program.

Program evaluation can be of different forms and appropriateness of these depends on the aims of the program to be evaluated. The common forms are processed evaluation and impact evaluation. Impact evaluation is carried out after the completion of the program , and it aims to assess the extent to which the program has met the ultimate goals. The usefulness of impact evaluation lies in the fact that such evaluation provides empirical evidence for application in funding decisions and policy-making[12]. The Healthy Start Program evaluation had been an impact evaluation with the goal of examining the wider influence of the program on the target population and coming up with a true value of the program to the funding body. Impact evaluation can be done through different study designs, one of which is before-and-after study design. The The Healthy Start Program evaluation considered this before-and-after design that assessed the levels of health literacy and nature of health behaviour before and after the program. The before-and-after design offers a substantial amount of evidence about intervention effectiveness than the other non-experimental designs. The design is most suitable for representing the instantaneous influences of programs carried out for short time frame. The study without a control group is simple to be carried out as the only requirements are sampling frame and a team of researchers to collect data[13].

The Healthy Start Program evaluation process emphasises on understanding the changes in health behaviour of the participants and the increment in the level of health knowledge. The evaluation looked at immediate learning following the workshop using a Post-Workshop Questionnaire and longer-term impact on behaviour change with a six-week Post Workshop phone interview with volunteer participants who had attended the workshop. Health literacy is known to incorporate health-related knowledge, motivation, attitudes, behavioural intentions, confidence and personal skills related to lifestyles, along with the knowledge of accession of health care services[14]. Against this concept, the approach of the evaluation of the program can be stated as justified.

Another point of strength of the evaluation was the centre that was involved in the process. The centre was well placed for the purpose of the evaluation as it hosted the Greater Brisbane Refugee Health Advisory Group (G8), a group helping the refugee community improve and foster the level of health literacy and assisting them to understand adequately their health needs.

Though the Healthy Start Program evaluation has some key strengths, there are certain points of weakness as well embedded in the process. Firstly, the evaluation was done with the help of a questionnaire that had close-ended questions, and there are a number of limitations of such questions. Misinterpretation of a question usually goes unnoticed. Discrepancies between answers of respondents might be blurred. Marking the incorrect response is probable. Further, the questions had to be responded in the form of ‘strongly agree’, ‘agree’, ‘neutral’, ‘disagree’,’strongly disagree’. It might have been difficult for the participants to understand the differences between  “Strongly Agree’ and ‘Agree’ and thus all responses received might not have been true to its value. It is confusing for the participants to come up with an answer[15].

The second yet the much significant element of weakness was the fact that only the Somali refugee group was considered for the evaluation and as the Eritrean group could not be included. In order to understand the effectiveness of the program to its true sense, it was important to include to include both the groups in the evaluation process. For generalizability of a study outcome, it is necessary to select a respondent sample from diverse backgrounds and levels.[16] While the Somali respondents indicated a positive impact of the program, the Eritrean respondents might have highlighted some flaws of the Healthy Start Program. Any additional information would have crucial for gaining insights into the impact of the program.

From the above discussion it is concluded that though the Healthy Start Program evaluation had certain remarkable points of strengths, the weaknesses of the evaluation process are not to be neglected. For conducting a flawless and impeccable program evaluation, a number of factors are to be adjudged prior to the commencement of the process of evaluation. 



Berkman, N., S. Sheridan, and K. Donahue. "Health literacy interventions and outcomes: an updated systematic review. 2011." Rockville, MD: Agency for Healthcare Research and Quality(2016)

Dalkin, Sonia Michelle, et al. "13 What works, for whom and in which circumstances when implementing the namaste advanced dementia care programme in the home setting?." (2017): A351-A352.

Duckett, Stephen, and Sharon Willcox. The Australian health care system. No. Ed. 5. Oxford University Press, 2015.

Fink, Arlene. Evaluation Fundamentals: Insights into the Outcomes, Effectiveness, and Quality of Health Programs: Insights Into the Outcomes, Effectiveness, and Quality of Health Programs. Sage, 2005.

Funderburk, Jennifer S., and Robyn L. Shepardson. "Real-world program evaluation of integrated behavioral health care: Improving scientific rigor." Families, Systems, & Health 35.2 (2017): 114.

Grembowski, David. The practice of health program evaluation. Sage Publications, 2015.

Healthy Start. N.p., 2017. Web. 30 Sept. 2017.

Holloway, Immy, and Kathleen Galvin. Qualitative research in nursing and healthcare. John Wiley & Sons, 2016.

Issel, L. Michele, and Rebecca Wells. Health program planning and evaluation. Jones & Bartlett Learning, 2017.

Kruk, Margaret E., et al. "Evaluation of a maternal health program in Uganda and Zambia finds mixed results on quality of care and satisfaction." Health Affairs 35.3 (2016): 510-519.

McKenzie, James F., Brad L. Neiger, and Rosemary Thackeray. Planning, implementing & evaluating health promotion programs: A primer. Pearson, 2016.

Pawson, R., and N. Tilley. "Realist evaluation. 2004." (2015).

Porter, Sam. "Realist evaluation: an immanent critique." Nursing Philosophy 16.4 (2015): 239-251.

Posavac, Emil. Program evaluation: Methods and case studies. Routledge, 2015.

The ‘Healthy Start Program’ Evaluation Report. 2016. Web. 30 Sept. 2017.


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