Health Program Development - Jones & Bartlett Learning

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Section 3

Health Program Development

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CHAPTER 6

Program Theory and

Interventions Revealed

After developing statements about health problems that have been ranked

as a high priority, the next steps in health program planning involve a more

intellectual and creative effort to articulate an explanation of what caused the

problem. This is a critical step toward identifying which intervention or group

of interventions will be most effective in addressing the health problem. Wild

guesses, past experience, and personal preferences might be used as the basis

for decision making, but a more rational approach is to identify existing scientific knowledge and theories that can be used to develop a program theory.

A theory is a description of how something works. It is a set of statements

or hypotheses about what will happen and, therefore, contains statements

about the relationships among the variables. We use working theories in everyday life, usually in the form of working hypotheses, such as ¡°If I ask the children to clean their rooms, they are not likely to do it.¡± We also use theories

based in science. For example, based on theories of thermodynamics and heat

conduction, we can predict how long the turkey needs to roast.

With regard to planning a health program, a primary consideration is to

specify what is to be explained or predicted with a theory. The health problem

is what needs to be explained, from a programmatic perspective. To explain

how to change or affect the health problem, a theory must contain relevant variables, or factors, and must indicate the direction of the interactions among those

variables related to the health problem. Identifying the relevant antecedent, contributing, and determinant factors of the health problem gives planners the

foundation for developing a working theory of how the programmatic interventions will lead to the desired health outcome. A difficult part of this task is

to identify where a health programmatic intervention can have an effect on

those factors. As more details and more factors are included in the explanation of the health problem and beliefs about how the programmatic interventions will work, the theory becomes increasingly more complex.

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CHAPTER 6 PROGRAM THEORY AND INTERVENTIONS REVEALED

The theory development phase of program planning requires thinking

rather than doing, so it often receives less attention than is needed to fully

develop an effective health program. However, using a systematic approach to

develop a program theory and to engage stakeholders in the development of

the theory has big and long-term payoffs that outweigh any delay or costs associated with developing the theory.

PROGRAM THEORY

A sound basis for developing the health program and for guiding the program evaluation is the use of a program theory. Rossi, Freeman, and Lipsey

(1999) acknowledged that the need for a program theory has long been recognized by evaluators in the social sciences. Only recently, however, has a

program theory been advocated for as useful in public health program development (Potvin, Gendron, Bilodeau, & Chabot, 2005). Program theory is a conceptual plan, with some details about what the program is and how it is

expected to work. The comprehensive overview of how the program is to

work has various names; other names include logic model, causal model, outcome line, program model, and action theory. These names all refer to a conceptional plan of how the program will work. Whether one is developing a new

health program or designing an evaluation for an existing health program,

understanding and articulating the program theory is essential.

There are two main components of program theory, as shown in the top

half of Figure 6.1. The theory about resources and actions is called the process

theory, and the theory about interventions and outcomes is called the effect

theory. The concept of program theory is used throughout this textbook rather

than the more widely used term ¡°logic model,¡± as discussed in Chapter 8. The

key difference is that a full program theory, as compared to a logic model, contains a far more explicit explanation of the relationship of the factors related

to the health problem with the interventions. These relationships are the effect

theory. Similarly, the process theory offers a more explicit and detailed

description of the resources used than is normally found in a logic model. The

major similarity is that both a logic model and the program theory provide

road maps to creating a successful program. The development of a program

theory and its components leads to a stronger program and a more convincing

argument for the program¡¯s existence.

Process Theory

The process theory includes three components: the organizational plan, the

service utilization plan, and specifications of their outputs (Rossi et al., 1999).

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Program Theory

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Figure 6.1 Model of Program Theory

Program theory

Planning and

thinking

foundation

Process theory

Program

delivery

and

implementation

reality

Effect theory

Organizational

plan

(inputs, capacity)

Service utilization plan

(activities, interventions)

Outputs

(products)

Outputs

(products)

Initial health

effects

(outcomes)

Longer-term

health effects

(impact)

Source: Adapted from Rossi, Freeman, and Lipsey, 1999.

Process theory can be integrated with the current public health language of

inputs, which are part of the organizational plan; activities, which are part of

the service utilization plan; and outputs, which are by-products of the organizational and service utilization plans.

The organizational plan, according to Rossi et al. (1999), encompasses the

nature of the resources needed to implement and sustain the program. As

such, it includes specifications about personnel, the organization of resources

to be used in the program, and elements of capacity, such as infrastructure,

information technology, fiscal resources, and personnel. It covers all the

¡°behind the scenes¡± work needed to provide a program. The organizational

plan implicitly contains ¡°if¨Cthen¡± statements. For example, if program staff are

adequately supported with regard to supplies and managerial support, then

program staff will deliver the interventions as planned. These ¡°if¨Cthen¡± statements are useful not only for checking the logic behind requesting specific

resources, but also for guiding the portion of the evaluation plan that focuses

on the processes behind the delivery of the health program.

The service utilization plan, according to Rossi et al. (1999), specifies how

to reach the target audience and deliver the programmatic interventions and

services to that audience. It constitutes the nuts and bolts of providing the program and of implementing the program plan. The service utilization plan

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