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Title V Technical Assistance Meeting

 How Will We Know If Anyone Is Better Off?

Life Course Interventions Require Innovative Evaluation

By Caroline Stampfel, MPH
Director of Programs
AMCHP 

As the maternal and child health (MCH) field continues to move from theory to practice, we need to find out if our interventions based on a life course approach are truly having an impact. How will we know?

Through careful evaluation. Simple, but not easy. Life course interventions represent innovation in practice – what's needed to move the field forward is innovation in evaluation and accountability methods as well

The premise of life course approaches is that a person's current health affects the health of future generations. We know that genetics play a role, but we recognize that there's no need to be deterministic – biology ≠ destiny. As public health practitioners, we in the MCH field have the power to improve the health and well-being of women, children, and families to improve the health of future generations. We do this by taking on a multitude of issues beyond health care access and quality, and not just by providing public health programming to address immediate needs.

Rather, a life course approach means we design programs around opportunities to intervene that can change the trajectory of a person's health and that of their children, and their children's children. We do this by aiming to close gaps in health outcomes and other factors for people who have been marginalized and discriminated against. A life course approach to improving health emphasizes equity.

Lofty stuff! But people are doing it.

The Best Babies Zone project is a set of interventions that illustrate how the life course approach is coming alive in cities around the country, with efforts that are focused at the neighborhood level, prioritized around community will, and centered on making that place the best place to be born. In order to understand whether this and other life course interventions make a difference, we need to zero in on measurement: that is, put parameters around improved health across the life course and define what we are trying to achieve. This raises a lot of questions: What do we measure? How long do we have to wait to see improvement? What are the best methods?

In a chapter I co-authored with Lauren Shiman, "Assessment and Evaluation," in the book Moving Life Course Theory Into Action: Making Change Happen, we unpack several measurement challenges for life course interventions. Arguably the biggest challenge is attribution, or being able to say that any observed changes in our measured results can be attributed to our intervention vs. any other things that are happening in that area at the time. The second main challenge is complexity, or needing to make course corrections on short and mid-term outcomes because waiting a generation for full outcomes is not feasible.

Attribution is the idea that any observed improvement in outcomes for a population can be traced back to something you did as part of your intervention. The best way to do this is through a randomized controlled trial. But for a lot of reasons, most of our public health interventions are not suited to this kind of experimental design, so we need to find other ways to get at the question, "Does it work?" Choosing comparison groups, collecting initial, baseline data, and using mixed-methods evaluations are strategies to deal with the challenge of attribution.

The challenge of complexity is that life course interventions have long-term outcomes as their overall goal; in some cases we might not know for 10 to 15 years if an intervention will result in a positive change for the next generation. Complex interventions require real-time learning. Methods such as participatory evaluation and developmental evaluation help us deal with these complexities.

The fact is, however, that there is no perfect evaluation design for life course interventions. That should not stop us from trying and from being innovators – not just to demonstrate impact on health outcomes, but to demonstrate our progress on other important measures. We have seen public health, particularly as funded from federal and state governments, shift toward increased accountability; that is, toward measuring and demonstrating outcomes that result from the money, time, and effort invested in the program approach. We hear terms like "results-driven," "value-based," and "pay for performance" used in public health, showing how the field is doubling down on measuring outcomes.

Almost simultaneously, we have seen a widening of the space for authentic engagement of the person and population being served. In life course-based interventions, we need to hear voices that have been stifled or underrepresented for generations. In doing so, we also need to make space within accountability frameworks to measure what matters. Outcomes matter – we want people to be healthier – but so does the ability of our programs to help right historic wrongs. Life course interventions give the public health field a chance to partner with a community in order to implement changes not just because they work, not just for the promised return on investment, but because it is the right thing to do.