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National Library of Australia Cataloguing-in- Publication Data

Autho r: l\auma n, Adrian E. ( Adrian Ernest), a utho r.
Title: Evaluatio n ·m a nut.she.II: a practical g u ide lo the evalu ation o f h ealth promo tio n progra ms/Adria n Ba uman &
Don N utbeam.
Edi(1o n: 2 n d ed itio n
ISBN : 9780071016209 (paperbod<)
Notes: Includes b ·1 b1'1ogra p hical referen ces a nd ind ex.
Su b jects: Health p romo fion.
I lealth planning.
O th er Autho rs/
Co n tr'1buto r:-: N utbeam, Don, au th o r.
Dewey Numbe r: 613

Publish ed in Austra l'1a by

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Prin ted in C hina o n 90 gsm matt art by RR Donnelley
 List of tables and figures VI

About the authors IX

Preface XI

Introduction Xlll

Planning for evaluation 1

1.1 Problem definition: starting at the end 3
1.2 Planning a solution 3
1.3 Creating the right conditions for the successful
implementation of programs 5
1.4 Planning for the implementation of health promotion
projects and progTams 6
1.5 Health promotion actions and outcomes 7
1.6 Evaluation 11
1.7 Summary 13
References 16
Further reading 16

Research and evaluation in h ealth promotion:

key stages, methods and types 17

2.1 Evaluation methods and types 17

2.2 Balancing scientific design with practical need 19
2.3 Stages of evaluation 22
2.4 Quantitative and qualitative methods in program
evaluation 32
2.5 Fom,ative, process and outcome evaluations 35
2.6 Sununary 36
References 37
iV CONTENTS

Formative evaluation 38
3.1 Formative evaluation: testing methods and materials befo.re
starting a project or program of work 38
3.2 Formative evaluation for different types of health promotion
intervention 47
3.3 Summary 48
References 48

Process evaluation 51
4.1 Assessing the.implementation of health promotion
projects and programs 51
4.2 Methods for conducting process evaluation 54
4.3 Summary 61
References 61

Evaluation methods for health promotion projects

[interventions] 64
5.1 Evaluation designs for health promotion projects 65
5.2 Selection bias and sampling 74
5.3 Statistical significance and data analysis 77
5.4 Health promotion measure.ment 79
5.5 Summary 87
References 87

Complex program evaluation 89

6.1 Background to complex program evaluation (CPE) 89
6.2 Complex public health interventions 90
6.3 Formative and process evaluation for CPE 92
6.4 Evaluation designs for complex programs 95
6.5 Challenges in conducting CPEs 97
6.6 Summary 102
References 102
 CONTENT S V

..
Evaluation methods for program replication,
dissemination and institutionalisation 104
7.1 Stages in assessing the sjgnificance of programs 105
7.2 Replication (intervention demonstration) 107
7.3 Dissemination 111
7 .4 Institutionalisation 114
7.5 Summa1y 116
References 11 7

Evidence, practice, policy and the critical practitioner 119

8.1 Getting evidence into pr actice 119
8.2 Getting evidence into policy 123
8.3 Critical appraisal of research and evaluation evidence 124
8.4 Concluding comments: evaluation- art and science 128
References 129

Appendices 130
Glossaiy 141
Index 149
Chapter 1
Table 1.1 Hypothetical logic model: planning a health
promotion program to improve healthy food
in school canteens 15

Chapter 2
Table 2.1 The differences and similarities between
practitioner and scientific perspectives of health
promotion programs 21
Table 2.2 Case studies of research illustrating the stages in
the model using different health promotion
interventions 30

Chapter 3
Table 3.1 Examples of the uses of formative evaluation in health
promotion 43

Chapter4
Table 4.1 Practical tasks in carrying out process evaluation tasks 55
Table4.2 Examples of process evaluation (PE) 57

Chapter 5
Table 5.1 Examples of research design 72
Table 5.2 Sampling methods used in the evaluation of health
promotion interventions 76
Table 5.3 Measurement at ruffe1·ent stages of program evaluation 85
 LI ST OF TABLE S A ND FIGURE S Vii

Chapter 6
Table 6.1 Published e."<amples of CPEs showing 'complexity' in
formative, process and in1pact evaluation 100

Chapter?
Table 7.1 Replication and d issemination examples 110

Chapters
Table 8.1 Examples of systematic reviews of health
promotion evidence 126

Appendices
Table A2.1 Examples of statistical techniques and analysis in a
hypothetical (and effective) weight-loss intervention 131
Table A3.1 Some examples of techniques and methods used to
assess measure:me:nt reliability and validity 133

Chapter 1
Figure 1.1 The planning and evaluation cycle 2
Figure 1.2 Health promotion actions and outcomes 8
Figure 1.3 Theoretical distrib ution over time of outcomes
from health promotion inte1ventioos 12

Chapter 2
Figure 2.1 Building evidence: for public health programs:
stages of research and evaluation 24

Chapter 3
Figure 3.1 Stages showing formative, process and impact/
outcome evaluations 39
Viii LI ST OF TABLE S AND FIGURES

Chapter4
Figure 4.1 Advanced statistical modelling in process evaluation:
understanding bow interventions work through
mediator and moderator analyses 60

Chapter 5
Figure 5.1 The evaluation process 66
Figure 5.2 Quantitative evaluati on designs for individual
progran1s (stage 3 of Figure 2.1), ranked from
'most scientific' experimental designs to less scientific
'pre-experimental' designs 74
Figure 5.3 Reliability (reproducibility) and responsiveness of
measurement 83

Chapter 6
Figure 6.1 Complex interventions: planning and
evaluation stages 92

Chapter 7
Figure 7.1 Stages in scaling up interventions to achieve
population health 106
Figure 7.2 Conceptual framework for research replication and
dissemination 107

Chapter B
Figure 8.1 Variation in the use of evidence in health promotion:
planned, responsive and reactive practice 120
Adria n Bauman is Sesquicentenary Professor of Public Health and Health
Promotion at the University of Sydney, Australia. He directs the WHO
Collaborating Centre on Physical Activity, Nutrition and Obesity, which
has a major interest in chronic disease prevention. He has taught health
promotion research methods and program evaluation to public health
students for 30 years, and has applied these principles in his population
health research program. His recen t research interests are in research
translation and in evaluating scaled-up health promotion inteIVentions at
the population level.

Don Nutbeam is Vice-Chancellor of the University of Southampton, UK, and

a Professor of Public Health. He was formerly Head of Public Health in the
UK Department of Health.

Acknowledgments
Several people have contributed to the development of Evaluation in a
Nutshell. We would like to acknowledge the contribution of Bill Bellew and
Lesley King for their constructive comments and advice on early drafts of this
edition of the book.
 his book is for students of health promotion and for health promotion
T practitioners. Evaluation in a Nutshell is intended to equip the reader
with the ability to understand, interpret and assess the quality of published
research, and to excite interest in evaluation and promote further study
that will lead to the development of core skills in evaluation. It provides
foundation knowledge and recommended further reading.
In writing this book, we have drawn on many years of expe1ience in
conducting evaluations of health promotion programs, working with health
promotion practitioners and teaching public health students. From this
experience we recognise the need for students and practitioners to understand
the basic principles of evaluation and the application of these principles in
evaluation design, whether for the: purpose of conducting an evaluation or for
assessing the work of others.
Any review of published research will reveal that not all health promotion
programs are equally successful in achieving their goals and objectives.
Experience tells us that programs are most likely to be successful when the
determinants of a health problem are well understood; when the needs and
motivations of the target population are addressed; and when the context in
which the program is being implemented is taken into account. That is, the
intervention 'fits' the problem.
Similarly, in developing an evaluation design for a health promotion
program, the evaluation design needs to fit the circumstances of the program.
Programs can be evaluated in a ran ge of ways, may demand differing levels of
resources and may use various evaluation designs. This book illustrates how
evaluation questions change as a program evolves, and shows how programs that
are truly innovative need dose scrutiny and highly structured and comprehensive
evaluation. On the other hand, programs that have previously been shown to
work in a variety of circumstances, and are Low-cost and Low-risk, v.rill require
more modest monitoring for the purposes of accountability and quality
control. The evaluation of projects ""ith tightly defined objectives in a controlled
environment will be different to that of multi-component, long-term programs.
Evaluations must be tailored to suit the activity and circumstances of
individual programs: no single method or design will be 'right' for all
programs.
Xii PREFACE

Evaluation in a Nutshell introduces the strategic and technical issues in

evaluation and discusses some of the practical and scientific challenges related
to the evaluation of health promotion programs. The book takes a real-life
public health perspective. Even for experienced researchers and practitioners,
the book provides a useful prompt on key issues, as well as guidance on how
to organise and conduct evaluation studies.
 intnoducsitiom
valuation is the formal process ofjudging the 'value' ofsomethlng. In health
E promotion, an evaluation will detem1ine the extent to which a program
has achieved its desired health outcomes and will assess the contribution of
the different processes that were applied to achieve these outcomes. Scientists,
health practitioners, politicians an d the wider community all have different
views on what represents 'value' from a health promotion program, how
success should be defined and what should be measured. For example:
• Policy-makers and budget managers need to judge the likely
success of programs in order to make decisions about how to
allocate resources and to be accountable for these decisions.
Success is often defined by the relationship between financial
investment and the achievement of health outcomes in the
short term.
• Health practitioners need to judge the likely and actual success of
a program in achieving its defined health outcomes in 'real-life'
situations, so that they know that their work is effective and
understand what needs to be done to ensure successful
implementation. Success may be defined in tem1s of the
effectiveness of the program in achieving health outcomes, the
practicality of implement ation, program sustainability and the
maintenance of health gains in the longer term.
• The community that is to benefit from health promotion action
may place great value on the processes through which a program
is conducted, particularly on whether the program is pa1ticipato1y
and addresses priorities that the community itself has identified.
Success may be defined in terms of relevance to perceived needs
and providing opportunities for community participation.
• Acaden1ic researchers need to judge a program's success ( or
failure) in order to contri bute to the science of health promotion
and improve health promotion practice. Success may be defined
in tem1s of the effects identified through rigorous study designs
and measured through quantifiable and validated outcomes, and
where the expected effects are theoretically based.
xiv I NT RODU CT I ON

These perspectives are distinct but not mutually exclusive. In each

perspective, success is judged through improved health outcomes, yet each
differs greatly in the emphasis given to the cost, practicality and processes
involved in achieving these outcomes. Correspondingly, there is a vast
spectrum of approaches used to evaluate health promotion programs. These
range from highly structured, methodology-driven evaluations that focus
strongly on the measurement of outcomes through to much less rigid, highly
participatory fom1s of evaluation.
As practitioners, we need to be accountable for what we do and we
need to make explicit what we expect to achieve through the investments
that are made in health promotion interventions. All programs can benefit
from some form of evaluation, but not all require the same intensity of
evaluation nor use the same crite1ia for success. Innovative programs using
a costly or controversial intervention for the first time need close scrutiny
with comprehensive evaluation. Programs that have been proven to work,
and are low-cost and uncontroversial, require monitoring for the purposes of
accountability.
This book aims to:
• provide an overview and a simple classification systen1 for the
evaluation of a health promotion program;
• distinguish between fom1ative, process, impact and outcome
evaluation;
• cons ider the relative strengths of qualitative and quantitative
research methods;
• provide practical guidance on when and how to evaluate programs,
and the range of evaluation designs and research methods that can
be used to evaluate different project and program types;
• consider how best to 'measure' health promotion activity and
outcomes;
• provide a practical glossa1y of terms used in health promotion
program evaluation;
• refer the reader to sources of fu1ther infom1ation.
Updates to the e,'(amples and tables in this book will be made available
at v.rww.mhhe.com/ au/ bauman2e.
Planning for evaluation

This chapter introduces the purposes and functions of evaluation and describes the
stages in planning and implementing a health promotion program or intervention.
These range from defining the problem and developing solutions to planning and
implementing programs. Each stage is linked to the evaluation methods described in
this book.

Evaluation should be included during the planning stage as an integral part

of the development of a project or program. It is far more difficult to 'add' the
evaluation in at later stages, after the critical decisions on program design and
execution have been made.
Successful evaluation of a program is more likely if:
• a thorough analysis of a h ealth problem and its distribution
in a population is conducted (thls will indicate the scope for
intervention);
• there are clearly defined, logical and feasible program goals and
objectives related to the initial analysis;
• formative assessment is used to develop an intervention, giving
sufficient attention to the materials, resources and human capacity
required for successful implementation;
• the intervention is implemented as planned;
• the project or program is of sufficient size, duration and
sophistication to be proven effective or ineffective in relation to
its goals and objectives;
• there is dear direction on how the evaluation is to be conducted
and what is to be measured;
• the evaluation provides sufficient relevant information to those
deciding the program's value.
Achieving these conditions for successful evaluation is challenging, but more
likely if a structured approach to planning is adopted.
Planning models are commonly used in the development and
management of contemporary health promotion. Such models support
evidence-led practice and provid e a foundation for systematic evaluation
2 EVA LU A TIO N I N A NUT S H ELL

by specialist evaluators, when this is feasible and funded. Some models of

planning use population, and individual enablers, facilitators and barriers, to
identify the best approach to project planning ( Green & Kreuter 2005); others
use planning models to specify the intervention components to be delivered.
Using a model enables those planning a project or program to
structure the various sources of infom1ation that have guided the
development of the intervention, and to consider in a logical sequence
the likelihood of achieving the program goals and objectives through
each step and strategy planned for the program. A model provides
a structured description of how the impacts of, and outcomes from, a
health promotion inte1vention develop over time and also provides a
sound foundation for the evaluation of an intervention (see Chapter 5).
Figure 1.1 presents the health promotion planning and evaluation 'cycle'
used in the companion volume to thfa book, Theory in a Nutshell: A Practical
Guide to Health Promotion Theories (Nutbeam et al. 2010). This describes the
various stages in the planning, implementation and evaluation of a health

Theory helps identify what are

Theory helps 10
targets for intervention
clarify how and
when change can
be achieved in !
1 ,.
targets for
Problem definition \
intervention
( redefinrtion)

~ 2
Solution
generation

6
Intermediate
3 outcome
Resource

5
Impact
4
Theory indicates
how to achieve
organisation change
measurements
and raise community
for use in
awareness Theory provides a benchmark
eva luation
against which actual can be
com pa red with ideal program

Figure 1.1 The planning and evaluation cycle

 CHAPTER 1 P L ANN IN G FOR EVA LU A TI ON 3

promotion program, in the form of a cycle. In this chapter, we consider each

of these stages in tum.

1.1 Problem definition: starting at the end

A wide range of information can be used to define a health problem and
generate potentially effective solutions. This may include routinely collected
epidemiological, demographic and behavioural and social information, but
may be enhanced by focused local community needs assessments. At this
information-gathering stage, it is important to consider:
• what is the overall magni tude of the problem- how many people
in the target population are likely to have the problem or be
affected by it?
• how prevalent is the problem in various subgroups (for example,
older adults, adolescents and people from socially disadvantaged or
culturally diverse populations)?
• what is the public health impact of the problem- how serious
are the consequences of the problem for the individuals affected
and the population as a whole (for example, does it contribute to
disability, reduced quality of life or reduced mental health, and
does it increase health service usage and costs or contribute to
premature death)?
• does it have any impact outside health (on the environment,
economic effects or effect s on other sectors)?
• what is the potential for intervention- can some factors or
conditions be changed that will have an impact on the problem
(these may be behavioural, social or environmental, or relate to
improved health services)?
• what evidence is there that, if there is potential to intervene
to change risks or conditions, this may produce the desired
in1provements in public h ealth?
• what evidence is there that the community recognises the problem
and gives priority to addressing it?

1.2 Planning a solution

The second stage in the cycle prompts analysis of potential solutions, leading
to the development of a program plan and/or individual project component
plans that specify the interventions to be employed, as well as the sequence
of activity. Planning for a program will inevitably be more complex and
4 EVA L UA TIO N I N A N U TS H E LL

multifaceted than planning for a more limited individual project, because

it involves clearer sequencing and the use of a wider range of measures
for success. The differences between projects and program evaluation are
discussed in greater detail in Chapters 3 and 4.
This stage in the planning process indicates how and when change
might be achieved in the target variable (population, organisation or
policy). The processes of change in the program are identified, leading to
the selection of effective interventions to achieve change and to the timing
and sequencing of interventions designed to achieve maximum effect. This
stage in the planning process can be supported by the use of techniques such
as intervention mapping (IM) and logic models. These techniques describe
how the project or program elements are expected to work, involving the
structured, systematic description of the intervention and the changes
that a project or program is intended to bring about, and defining what
will happen during a program, in what order and with what anticipated
effects. These planning processes and techniques are also part of formative
evaluation (the steps required before a program is launched), described in
Chapter 3.
A theoretical framework or model often underpins the planning of
health promotion programs, guiding the project or program's content. These
theories can be considered using a socio-ecological framework and may
include strategies to influence a range of people, from individuals and small
groups to communities, environments and policies. Further infom1ation on
theories and models in health promotion practice can be found in Nutbeam,
Harris & Wise (2010). A review of health promotion programs shows that a
wide range of potential intervention methods can be used. A discrete project
based on the use of a single method (such as education) in a well-defined
setting (such as a school) may make detailed use of individual behaviour
change theo1y, and the tasks of evaluation will usually be clear. In a more
comprehensive program that uses different intervention strategies in different
settings and that is directed at different target populations, the task of
evaluation is generally more complex and contentious. The interdependence
of the various health promotion actions makes it difficult to assess their
individual contributions and poses real problems in the choice of evaluation
methods and the analysis of results. These challenges in evaluation design
and the differences in evaluating projects and programs are considered more
fully in Chapters 5 and 6.
Decisions about what represents the best sta1ting point and how to
combine the different interventions will be guided by established health
promotion theory, evidence from past programs and the experience of
 CHAPTER 1 P L ANN IN G FOR EVA LU A TI ON 5

others, and knowledge of the local context in which the program will be
implemented.
The development of program strategies that incorporate the right
combination of actions in the right sequence completes the planning stage of
the program and should link clearly and logically to the project or program
outcomes that were identified in the first stage of planning. Some modification
of the objectives may be required at this stage, together with refinements
to the measures used to evaluate the short-term impact of a program. The
measurement of impact and outcome is addressed in more detail in Chapter 5.
It is essential to define clearly the planned optimal structure and
sequencing of the intervention in the second step of the planning process.
This definition provides a point of reference for evaluating the process of
implementation that has led to progress (or lack of progress) in achieving
program goals and objectives. This is desuibed in more detail in Chapter 3
and is a compulsory element of any program evaluation. This process
provides key information that will be very useful to practitioners in refining
and reproducing future interventions.

1.3 Creating the right conditions for the successful

implementation of programs
This stage (stage 3 in Figure 1.1) is not only concerned with obtaining the
resources (such as money, staff and materials) required for the successful
implementation of a project or program. lt is also concerned with the need to
build capacity in a community or organisation to enable an intervention to
be introduced and sustained, an d to generate and maintain the community
and political support necessary for successful implementation. It will usually
involve different types of formative evaluation, testing and piloting of
interventions to be used as a part of the program. Formative evaluation is
desuibed in more detail in Chapter 3.
In some circumstances, either the resource assessment or fom1ative
evaluation of methods and materials may show that the available resources or
community response do not match what is needed. It will then be necessary
to refomrnlate the program objectives to better fit available resources and/or
to clarify the types of action required to secure the level of community and
political support necessary to generate essential resources and opportunities
for action. This planning stage is important whether the inte1vention is a
simple, time-limited project or a more complex, long-tem1 program with
multiple components.
6 EVA L UA TIO N I N A NUT S H EL L

Insufficient attention to this phase in the development

ofa program, including the pre-testing of methods and materials,
is a common reason for program failure. This is especially true
when program delivery may involve working through partners,
such as schools, work sites and different government agencies.

1.4 Planning for the implementation of health

promotion projects and programs
The next stage is planning for implementation (stage 4 in Figure 1.1). At
this planning stage., the primaiy aim is to ensure that a program is likely to
be implemented as closely as possible to the original plan, recognising that
implementation in ' real-life' conditions will often require adaptation. Good
record-keeping to assess the process of implementation is the key evaluation
task at this stage. This will enable subsequent examination of program fidelity
(the extent to which a program was implemented as planned) and the
relationship between program implementation and subsequent observed
outcomes. Further information on process evaluation is described in Chapter 4.
There may be pressure to implement projects with insufficient resources,
within time frames that are too short or in communities that are not ready
for the inte1vention. Such projects may happen, but such pressure often leads
to incomplete project implen1entation and tends to produce incomplete
evidence on the program's effectiveness.
As we have seen, the implementation of a project or program may involve
one or multiple strategies or components to achieve the program objectives
and goals that were identified through the initial analysis of the problem
and its determinants. Traditionally, health promotion interventions have
relied heavily on methods designed to promote individual behaviour change
through public education or mass communication aimed at improving
knowledge and changing attitudes. Increasingly, however, health promotion
programs involve other forms of intervention designed to influence the
social, environmental and economic factors that detem1ine health. This
requires working through professional groups and directly with communities
in different ways to mobilise social action, as well as advocating for political
and organisational change. Combining the delivery of different interventions
and securing the necessa1y partnership s to achieve desired healtl1 promotion
outcomes are among the major challenges for practitioners.
 CHAPTER 1 P L ANN IN G FOR EVA LU A TI ON 7

1.5 Health promotion actions and outcomes

It is important to identify and define a range of measurable outcomes that form
the basis for a program plan. These outcomes range from the direct ' impact' of
health promotion interventions in the short tem1 to health outcomes in the
longer tem1. These levels of program effects are shown in Figure 1.1 as stages
5-7. They provide an oveiview of the relationship between the ' processes' of
health promotion and the different types of impact and outcome that such
interventions might produce.
A comprehensive health promotion program (see Chapter 6) might
consist of multiple interventions targeted at achieving different types of
outcome in the shorter and longer term. A shorter term health promotion
project might focus on achieving a smaller subset of health promotion
outcomes. Figure 1.2 shows a typology that characterises these different
health promotion actions and the subsequent measures that can be used to
assess their impact and outcomes.
Working from the end-points on the right-hand side of the model in
Figure 1.2, health and social outcomes reflect the end-points of health and
preventive interventions. Thus, ou tcomes such as quality of life, functional
independence and equity have the highest value in the model. Some health
outcomes are also more narrowly defined in terms of disease and physical
and mental health status. For example, for an HIV-prevention program the
primary health outcome would be to reduce HIV infection and AIDS-related
mortality rates.
Inte rmediate health outcomes represent the determinants (immediate
antecedents) of health and social outcomes. These include personal behaviours
that provide protection from disease or injmy (such as physical activity) or
increase risk of ill health (such as tobacco use) and are represented as healthy
lifestyles in the model. The physical environment can limit people's access to
facilities or represent a direct hazard to their physical safety, and economic and
social conditions can enhance or li mit people's ability to adopt recommended
behaviours. These detem1inants are represented as healthy environments.
Access to, and appropriate use of, preventive services are acknowledged as
an important determinant of health status and are represented as effective
preventive health services.
Thus, for example, a multi-component program designed to reduce HIV
infection rates in the long term might have a project component targeted at
a sex worker population. In this case, the project might be directed towards:
• achieving preventive behaviours (safe sex) among the target
population;
• delivering services that p rovide access to HIV testing and affordable
HIV treatment for the target population.

Health promotion Health promotion
actions outcomes
(outcomes of the process
of intervention)
Education Health literacy
Examples include Measures include
pa1ien1 educa1ion, heal1h-related knowledge,
school e duca1ion and anitude, motivation,
broad cast media behavioural imentions,
communication persona I skills and
self-efficacy
Social mobilisation
Socio/ action and influence
Examples include Measures include
community communi1y participation,
developmen1,
community empowerment,
group facilitation and
so cia I norms and
te chnica I advice
public opinion
Ad..acacy Healthy public policy and
Examples include organisational practices
lobbying, poli1ical Measures include policy
orga ni sat ion and statements, legislation,
ac1ivism, and regulation and re source
allo cation organisational
overcoming
bureaucratic inertia practices
Figure 1.2 Health promotion actions and outcomes
(X)
rn
<
lnte rmed iate Social health )>
r
health outcomes outcomes c
)>
(program impact, or (long·term outcomes) ....
short-term outcomes) 0
z
z
Healthy lifestyles )>
Measures include z
c
tobacco use, ....
(/1
physical activi1y, ::c
rn
Food choices and r
Social outcomes r
alcohol and illicit drug use
Measures include
quali1y of life,
tffecrive prevenrive functional independence,
health services social capital and equity
Measures include
access to and provision of
relevant and preventive
services
Health outcomes
Healthy environments
Measures include
Measures include
reduced morbidity,
safe physical environment,
reduced disability and
supponive economic and
avoidable mortali1y
soda I conditions, good
food supply and res1ri cted
access to 1obacco/ alcohol
 CHAPTER 1 P L ANN IN G FOR EVA LU A TI ON 9

At the previous stage, health promoticm outcomes (shown in Figure 1.2) refer
to modifiable personal, social and environmental factors that lead to the
detem1inants of health (intermediate health outcomes). These may represent
the immediate results of planned health promotion activities. Thus, they
include measures of the cognitive and social skills that determine the ability
of individuals to gain access to, understand and use health information
(health literacy in the model). Examples of health promotion outcomes
would include improved health knowledge and an understanding of where
to go and what to do to gain access to health seivices and other support.
Social action and influence includes organised effo1ts to promote or enhance
the actions and control of social groups over the detemunants of health.
This includes the mobilisation of human and material resources in social
action to overcome suuctural barriers to health, enhance social support and
reinforce social norms conducive to health. Examples of outcomes range from
improved social 'connectedness' a nd social support to improved community
empowem1ent.
Healthy environments are largely detem1ined by healthy public policy and
organisational practices. Policy-determined legislation, funding, regulations
and incentives significantly influence organisational practices. Thus, e,'(amples
of health promotion outcomes here might be changes to health and social
policies that lead to improvements in services, social benefits, the built
environment and housing. These would influence organisational practices
and redirect resource allocation to suppo1t environments conducive to health.
Using the HIV-prevention project as an e,'(ample, health promotion
outcomes could include:
• in1proving health literacy by raising levels of accurate knowledge
about HIV prevention and improving skills and confidence
to put into practice recommended behaviours in challenging
circumstances among the target population;
• facilitating a more supportive environment through social action,
to improve commitment to safe sex practices in commercial sex
establishments, and to support access to condoms and other
preventive behaviours;
• improving health policy and services by providing more facilities
for, and better access to, HIV testing and regular health checks
among the target population.
Figure 1.2 also indicates three health promotion actions- what to do, as
distinct from what outcomes are achieved. Education consists primarily of
the creation of opportunities for learning that are intended to raise levels of
personal health literacy and thereby increase the capacity of individuals and
communities to act to improve and protect their health. Social mobilisation
10 EVA L UA TIO N I N A N U TS H E LL

is action taken in partnership with individuals or social groups to mobilise

social and material resources for health. Advocacy is action taken on behalf
of individuals and/ or communities to overcome structural barriers to the
achievement of health.
In the example of HfV prevention, these health promotion actions would
include, for example, the direct education of sex workers; advocacy on their
behalf with operators of commercial sex establishments; and training of
health professionals to advocate for and provide HfV testing and treatment
servJCes.
Another example of this hierarchy of actions and outcomes can be
considered for smoking-prevention programs among teenagers. Social and
health outcomes include reduced tobacco-related morbidity and mortality,
but these outcomes may come decades after the original health promotion
program. Intem1ediate outcomes include reduced smoking rates and higher
quit rates among adolescents. Health promotion outcomes would include
measures of intention to not smoke, changes to social and peer norms
around smoking, and policies restricting cigarette advertising or restricting
purchases ( as in proof of age requir ements). In the far left-hand column
of Figure 1.2, health promotion actions in this example would comprise the
education of young people concerning the negative consequences of smoking;
the social mobilisation of parents and other social role models to make
smoking less socially attractive and acceptable to young people; and advocacy
for legislative action to reduce access to tobacco and exposure to tobacco
advertising.
Figure 1.2 can be used to illustrate not only the linkages between the
different levels of outcomes but also those within levels. For example, among
the intem1ediate outcomes, action to create healthy environments may be a direct
determinant of social and health outcomes ( for example, by producing a safe
working and living environment or improving equity in access to resources),
and also separately influence healthy lifestyles, for example, by improving
access to healthy food or restricting access to tobacco products. There is a
dynamic relationship between these different outcomes and the three health
promotion actions; it is not the static, linear relationship that the model in
Figure 1.2 might suggest.
By starting in this way, the beginning of the planning process is firmly
focused on the end-point outcomes and the shorter term measures that are
logically related to their achievement. Sta1ting planning with the end-points
prompts a thorough and logical analysis of the linkages between intervention
and outcome. This phase ensures that there is a clear definition of who or
what is the target of the intervention (sub-population group, environmental
or organisational element) and what outcomes will be sought. The early
 CHAPTER 1 P L ANN IN G FOR EVA LU A TI ON 11

definition of these outcomes and consideration of how they might be measured

form the important fust stage of the evaluation process. The principles of
measurements, and selection methods, are described further in Chapter 5.

1.6 Evaluation
Different types of evaluation tasks occur at each stage of the cycle shown in
Figure 1.1. These start with formative evaluation, a set of activities designed to
develop and pre-test program materials and methods (see Chapter 3); and
process evaluation, a set of activities directed towards assessing progress in
program implementation (see Chapter 4).
Health promotion interventions have different types of impact and
different outcomes over time. Change in the different types of outcome will
occur according to different timescales, depending on the nature of the
intervention and the type of social or health problen1 being addressed. As a
consequence, different evaluation methods are used to measure impact and
outcome at different stages in the life of a program.
Impa ct evaluation measures t he short-term effects that are predicted and
defined during the planning stage of the program. These impact measures
are termed health promotion outcomes in Figure 1.2. These health promotion
outcomes are intended to lead to subsequent change in intermediate health
outcomes, for example, in behaviours and environments, in ways that will
ultimately improve health and social outcomes in the model. Outcome
assessment involves the measurement of individual behaviour or changes
to the social, economic and en vironmental conditions that determine
health. Figure 1.2 provides e,'Camples of these intermediate outcomes. The
assessment of social and health outcomes is the end-point assessment of
health promotion.
Figure 1.3 illustrates how a comprehensive set of health promotion
interventions might produce different outcomes over time. This model was
originally developed to illustrate likely progress over a five-year period in a
comprehensive, community-base<l heart disease- prevention program. Thus
the 'units of time' are years and the model shows how, after one year, the
program impact could be measured mainly in terms of increased community
awareness and participation in intervention components. By the third year,
good progress in achieving short-term program impacts (health promotion
outcomes) should be measurable, alongside peak-level community awareness
and participation. Early progress in achieving intem1ediate outcomes (such as
behavioural risks) should also be measurable. After five years, major progress
in these intem1ediate outcomes should be obseivable and early impact
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 THE COUNSELLOR’S CUP.

Rub a quarter of a pound of sugar upon the rinds of two fine China
oranges, put it into an enamelled stewpan, and pour on it a pint of
water; let these boil gently for two or three minutes, then pour in half
a pint of China orange-juice mixed with that of one lemon, and
previously strained through muslin; the moment this begins to boil,
pour it into a hot jug, and stir to it half a pint of the best Cognac
brandy. Serve it immediately. When preferred cold, prepare the syrup
with the juice of the fruit, cover it down in the jug, set it into ice, or
into a very cool place, and add the spirit only just before the cup is
wanted for table. Should the fruit be very acid, increase the
proportion of sugar. A few slight strips of the rind of a Seville orange
cut very thin, would to many tastes be an agreeable addition to the
beverage; which should be made always with fresh sound fruit.
Sugar, 4 oz. (6 if needed); rasped rinds of China oranges, 2; water,
1 pint: 3 minutes. Strained juice of China oranges mixed with that of
1 large lemon, 1/2 pint; best Cognac brandy, 1/2 pint.
Obs.—For a large cup these proportions must be doubled. Sherry
or Madeira substituted for the brandy, will make a pleasant cool cup
of this kind; and equal parts of well made lemonade, and of any good
light white wine, thoroughly cooled down, will give another agreeable
beverage for warm weather; but a much smaller proportion of wine
would better adapt it to many tastes.
 CHAPTER XXX.

Coffee, Chocolate, &c.

 COFFEE.

There is no beverage which is held in more universal esteem than

good coffee, and none in this country at least, which is obtained with
greater difficulty (unless indeed it be pure wine). We hear constant
and well-founded complaints both from foreigners and English
people, of the wretched compounds so commonly served up here
under its name, especially in many lodging houses, hotels, and
railway refreshment rooms;[182] yet nothing can well be easier than
to prepare it properly. Some elaborate and various fanciful modes of
making it have been suggested at different times by writers fond of
novelty, but they have in general nothing to recommend them
beyond the more simple processes which follow, and of which we
believe the result will seldom prove unsatisfactory to our readers,
unless it be to such of them as may have been accustomed to the
spiced or other peculiar Oriental preparations of the fragrant berry, or
simply to the exquisite quality of it, which would appear to be
obtainable only in the East; or which, at all events, is beyond the
reach of the mass of English consumers, and of their near
Continental neighbours.
182. At some of the principal stations on lines connected with the coast, by which
an immense number of strangers pass and repass, the coffee is so bad, that
great as the refreshment of it would be to them, particularly in night travelling,
in very cold weather, they reject it as too nauseous to be swallowed. A little
national pride ought surely to prevent this, if no higher principle interfered to
do so; for to exact the full price of a good commodity, and habitually to supply
only trash for it, is a commercial disgrace.
 TO ROAST COFFEE.

Persons who drink coffee habitually, and who are very particular
about its flavour and quality, should purchase the best kind in a raw
state, keep it for two or three years if they are not certain that it has
been so long harvested—as when new it is greatly inferior to that
which has been kept—and have it roasted at home. This can be
cheaply done in small quantities by means of the inexpensive
apparatus shown above; the cost of it not exceeding seven or eight
shillings, and the supply of charcoal needed for it being very trifling
indeed; or, with that inserted below, which is larger and about double
the price. The cylinder which contains the coffee should be only half
filled, and it should be turned rather slowly over the fire, which
should never be fierce, until a strong aromatic smell is emitted; the
movement should then be quickened, as the grain is in that case
quite heated, and it will become too highly coloured before it is
roasted through, if slowly finished. When it is of a fine, light, equal
brown, which must be ascertained, until some little experience has
been acquired, by sliding back the door of the cylinder, and looking
at it occasionally towards the end of the process, spread it quickly
upon a large dish, and throw a thickly folded cloth over it. Let it
remain thus until it is quite cold; then put it immediately into canisters
or bottles, and exclude the air carefully from it.

Patent Percolator, with Spirit Lamp.

 A FEW GENERAL DIRECTIONS FOR MAKING COFFEE.

When good coffee is desired, let it be procured if possible of a

first-rate London house[183] which can be depended on; and we
would recommend that it should be of the finest quality that can be
obtained; for there is no real economy in using that which is
nominally cheaper, as a larger quantity will be required to give the
same amount of strength, and the flavour will be very inferior. It
should always be freshly roasted; but when a constant and large
demand for it exists, it will be easy to have it so. When it has been
stored for any length of time it will be much freshened and improved
by being gently heated through, either in the oven or in a stewpan
held high above the fire. It should be often turned while it is warming,
and ground as soon as it is cold again. Never purchase it ready
ground unless compelled to do so. When no proper mill for it is fitted
up in the house, a small portable one, which may be had at a trifling
expense, will answer tolerably well for grinding it, though it cannot be
used with quite the same facility as those which are fastened firmly
to a wall; but whatever form of mill may be used it should be
arranged so as to reduce the berries to a moderately fine powder; for
if it be too coarse the essence will be only partially extracted from it
by filtering; and if it be extremely fine the water will not percolate
through it, and it will not be clear.
183. We could indicate several houses where unadulterated coffee may be
procured, but it is not always to be had from them so choice in quality as it
might be; and it is in general too highly roasted. By far the finest we have
ever tasted we had on two occasions, some years since, from Mr. Cobbett, of
Pall Mall. The fragrance of it was too remarkable to be easily forgotten, and
the flavour was exquisite; but it was apparently an accidental sample which
he had met with in the market, for though very good, that with which we were
supplied afterwards never equalled it.
Messrs. Staniforth and Co., 138, Oxford-street, are deservedly noted for the
excellence of their coffee. It is always ground at the instant of serving it to a
customer; and they have the complaisance of roasting even so small a
quantity as two pounds, to suit the taste of the purchaser: it may therefore be
procured of them as pale-dried as it can be wished.
 The house of Messrs. Decastro and Peach, next door to Hatchett’s Hotel,
Piccadilly, may likewise, we think, be quite depended on for supplying
genuine coffee to the public; and they have an immense demand for it.
We say nothing about mingling chicory with it. Our directions are
for making pure coffee; which, when not taken in excess, is, we
believe, a wholesome as well as a most agreeable beverage. The
effect of chicory is, we believe, to impart a slight bitter flavour to the
infusion, and to deepen its colour so much as to make it appear
much stronger than it really is. True connoisseurs, however, do not
attach any importance to the dark hue of coffee, the very choicest
that can be tasted being sometimes of quite a pale tint.
Always serve hot milk or cream, or hot milk and cold cream, if
preferred, with breakfast coffee. In the evening, when milk is served
at all with it, it should likewise be boiling.
Do not, in any way, make use of the residue of one day’s coffee in
preparing that of the next; you would but injure the purity of its
flavour by doing so, and effect next to nothing in the matter of
economy.[184]
184. When the coffee has been filtered in a proper manner, water poured
afterwards on the “grounds” as they are termed, will have scarcely any taste
or colour; this is not the case when it has been boiled.
 EXCELLENT BREAKFAST COFFEE.

A simple, well-made English filter, or percolator, as it is called, will

answer perfectly for making coffee; but from amongst the many of
more recent invention which are on sale, the reader who prefers one
of ornamental appearance, and of novel construction, will easily be
suited. The size of the filter must be adapted to the number of
persons for whom the coffee is to be prepared; for if a large quantity
of the powder be heaped into an insufficient space for it, there will
not be room for it to swell, and the water will not pass through. Put
three ounces of coffee into one which will contain in the lower
compartment two pints and a half; shake the powder quite level and
press it closely down; remove the presser, put on the top strainer,
and pour round and round, so as to wet the coffee equally, about the
third part of a measured pint of fast boiling water. Let this drain quite
through before more is added; then pour in—still quite boiling—in the
same manner as much more water, and when it has passed through,
add the remainder; let it drain entirely through, then remove the top
of the filter, put the cover on the part which contains the coffee, and
serve it immediately. It will be very strong, and perfectly clear. Fill the
breakfast cups two parts full of new boiling milk, and add as much of
the infusion as will give it the degree of strength which is agreeable
to those for whom it is prepared. When it is liked extremely strong,
the proportion of milk must be diminished, or less water be poured to
the coffee.
If nearly an additional half pint of water be added before the top of
the percolator is taken off, it will still be very good, provided that the
coffee used be really of first-rate quality.
To make cheaper breakfast coffee to be served in the usual
English mode, the same process should be followed, but the
proportion of water must be considerably increased: it should
always, however, be added by slow degrees.
Good breakfast coffee (for three persons). Best Mocha, in
moderately fine powder, ground at the instant of using it, 3 oz.;
boiling water added by degrees, 1 pint; (more at pleasure). Boiling
milk served with it, 1-1/2 pint to 1 quart. Common English coffee:
coffee-powder, 3 oz.; water, 1 quart, to be slowly filtered; hot milk,
half to whole pint. Cream in addition to either of the above, at choice.
 TO BOIL COFFEE.

To boil coffee and refine it, put the necessary quantity of water into
a pot which it will not fill by some inches; when it boils stir in the
coffee; for unless this be at once moistened, it will remain on the top
and be liable to fly over. Give it one or two strong boils, then raise it
from the fire, and simmer it for ten minutes only; pour out a large
cupful twice, hold it high over the coffee pot and pour it in again, then
set it on the stove where it will keep hot without simmering or moving
in the least, for ten minutes longer. It will be perfectly clear, unless
mismanaged, without any other fining. Should more, however, be
deemed necessary, a very small pinch of isinglass, or a clean egg-
shell, with a little of the white adhering to it, is the best that can be
used. Never use mustard to fine coffee with. It is a barbarous custom
of which we have heard foreigners who have been in England
vehemently complain.
Coffee, 2 oz.; water, 1 pint to 1 quart, according to the strength
required. Boiled 10 minutes; left to clear 10 minutes.
Remark.—Filtering is, we should say, a far more economical, and
in every way a superior mode of making coffee to boiling it; but as
some persons still prefer the old method, we insert the receipt for it.
 CAFÉ NOIR.

This is the very essence of coffee, and is served in nearly all

French families, as well in those of many other countries,
immediately after the rice-crust. About two-thirds of a small cupful—
not more—sweetened almost to syrup with highly refined sugar in
lumps, is usually taken by each person; in families of moderate rank,
generally before they leave the table; in more refined life, it is served
in the drawing-room the instant dinner is ended; commonly with
liqueurs after it, but not invariably. To make it, proceed exactly as for
the breakfast-coffee, but add only so much water as is required to
make the strongest possible infusion. White sugar-candy in powder
may be served with it in addition to the sugar in lumps.
 BURNT COFFEE, OR COFFEE À LA MILITAIRE.

(In France vulgarly called Gloria.)

Make some coffee as strong and as clear as possible, sweeten it
in the cup with white sugar almost to syrup, then pour the brandy on
the top gently over a spoon, set fire to it with a lighted paper, and
when the spirit is in part consumed, blow out the flame, and drink the
gloria quite hot.
 TO MAKE CHOCOLATE.

An ounce of chocolate, if
good, will be sufficient for one
person. Rasp, and then boil it
from five to ten minutes with
about four tablespoonsful of
water; when it is extremely
smooth add nearly a pint of new
milk, give it another boil, stir it
well, or mill it, and serve it
directly. For water-chocolate use
three-quarters of a pint of water
instead of the milk, and send
rich hot cream to table with it.
The taste must decide whether it
shall be made thicker or thinner.
Chocolate, 2 oz.; water,
quarter-pint, or rather more; milk, 1-3/4: 1/2 minute.
Obs.—The general reader will understand the use of the
chocolate-mill shown in the engraving with the pot; but to the
uninitiated it may be as well to observe, that it is worked quickly
round between both hands to give a fine froth to the chocolate. It
also serves in lieu of a whisk for working creams, or jellies, to a froth
or whip.
 A SPANISH RECIPE FOR MAKING AND SERVING CHOCOLATE.

Take of the best chocolate an ounce for each person, and half a
pint of cold water; rasp or break it small in a mortar, set it over a slow
fire, and stir or mill it gently until it has become quite smooth like
custard; pour it immediately into deep cups, and serve it with a glass
of sugar and water, or with iced water only[185] to each cup; and
with plates of very delicate dried toast cut in narrow strips, or with the
cakes called “ladies’ fingers.” Should the chocolate appear too thick,
a little water must be added. Milk is sometimes substituted for it
altogether.
185. Sometimes with a water ice, which should be of an appropriate character.
 TO MAKE COCOA.

Directions for making it are usually sold with the prepared, or best
quality of cocoa, which is merely mixed with boiling water in the
proportions indicated on the packets. That which is prepared from
the nibs requires several hours’ boiling, and should be left until it is
quite cold, that the oil which will be found on the surface may be
cleared from it before it is again heated for table: this is particularly
needful when it is to be served to persons in delicate health.
CHAPTER XXXI.

Bread.
 REMARKS ON HOME-MADE BREAD.

It is surely a singular fact that the one article of our daily food on
which health depends more than on any other, is precisely that which
is obtained in England with the greatest difficulty—good, light, and
pure bread—yet nothing can be more simple and easy than the
process of making it, either in large quantities or in small. From
constant failure, it is nevertheless considered so difficult in many
families, that recourse is had to the nearest baker, both in town and
country, as a means of escape from the heavy, or bitter, or ill-baked
masses of dough which appear at table under the name of
household or home-made bread; and which are well calculated to
create the distaste which they often excite for everything which bears
its name. Without wishing in the slightest degree to disparage the
skill and labour of bread-makers by trade, truth compels us to assert
our conviction of the superior wholesomeness of bread made in our
own homes. When a miller can be depended on to supply flour of
good quality, and the other ingredients used in preparing it are also
fresh and good, and mingled with it in due proportions, and the
kneading, fermentation, and baking, are conducted with care and
intelligence, the result will uniformly be excellent bread. Every cook,
therefore,—and we might almost say every female servant—ought to
be perfectly acquainted with the proper mode of making it; and skill
in preparing a variety of dishes, is poor compensation for ignorance
on this one essential point.[186] Moreover, it presents no more real
difficulty than boiling a dish of potatoes, or making a rice pudding;
and the neglect with which it is treated is therefore the less to be
comprehended or excused.
186. Only those persons who live habitually on good home-made bread, can form
an idea of the extent to which health is affected by their being deprived of it.
We have been appealed to on several occasions for household loaves—
which we have sent to a considerable distance—by friends who complained
of being rendered really ill by the bread which they were compelled to eat in
the sea-side towns and in other places of fashionable resort; and in London
we have heard incessant complaints both from foreigners and habitual
residents, of the impossibility of obtaining really wholesome bread.