Well-valuation: Ripple Effects Mapping as a Method for Wellness Program Evaluation


Wellness professionals are increasingly required to demonstrate program impacts. Evaluation of these impacts can be elusive because they are contingent upon dynamic social processes of change that may not be fully understood, controllable, or predictable. In these situations, qualitative evaluation methods like Ripple Effects Mapping are well-suited for constructing holistic information about wellness program outcomes. This post describes how to implement the five phases of the REM evaluation process.

Ripple Effects Mapping

Ripple effect mapping (REM) is a participatory method of qualitative data collection that seeks to identify intended and unintended effects (positive and negative) of a program using Appreciative Inquiry (AI). It is useful in situations where the results of programs occur over time within complex settings and can be used to explore outcomes at both the individual and organizational levels. In REM, participants are asked to consider the social, emotional, physical, intellectual, occupational, and spiritual dimensions of their life as they share their experiences in, and after, the program.

Synergies with Wellness

Wellness is defined by the National Wellness Institute as an active process through which people become aware of, and make choices toward, a more successful existence. It is a process in which the social, spiritual, occupational, intellectual, emotional, and physical dimensions of individuals and groups function in harmony. Wellness promotion is a humanistic practice that leverages methods grounded in salutogenensis, self-determination, authentic relationship, inter-professional collaboration, and an inter-disciplinary knowledge base to cultivate wellness. Like wellness, Ripple Effects Mapping is a holistic, context-responsive, and person-centered evaluation method that can help understand how a program impacts the wellness journey. The Appreciative Inquiry style questioning used in REM is similar in nature to wellness coaching in that it is non-directive, strengths-based, and growth-oriented. Instead of focusing on solving problems, AI seeks to generate new ways of thinking, identify opportunities, and catalyze new patterns of behavior by cultivating “more good” instead of “less bad”. Therefore, the use of REM in evaluation is particularly congruent with the aims of wellness promotion.

Implementing REM and Building a Grounded Theory of Change

There are two phases to the REM process: interactive interviewing and group mind mapping. In a third phase, the evaluation team uses a grounded theory style analysis to construct a theory of change to explain the origins the intended and unintended outcomes that emerge. This approach to REM works best when conducted with a sequence of stakeholder groups consisting of up to 10 individuals each. The sampling strategy may entail seeking out extreme or deviant cases, typical cases, maximum variation, critical cases, politically sensitive cases, or convenience sampling at each phase. Once the first group of participants has been selected, the REM sessions can begin.

Phase I: Peer-to-Peer Interviews

In phase I of REM, session participants begin by interviewing each other using a semi-structured, pre-determined appreciative inquiry protocol. Participants share stories in pairs about their peak experience in the program, what they value about the program, and what they wish for the program in the future. Opening the REM session with peer-to-peer sharing allows participants to become comfortable in the environment and recall their past experiences. Participants are instructed to think holistically about their experiences and describe these to their partner. This phase may last approximately 10-15 minutes.

Phase II: Group Mind Mapping

In the second phase of the REM process, the group comes together to create a mind map. A mind map is a diagram that concentrically organizes information to show relationships among elements of a system over time. This phase should be audio-recorded so the evaluation team can return to the transcripts for rich details. The facilitator begins the initial round of questions from an interview guide and each participant responds by relating their experience orally. After communicating orally, the facilitator invites the participant to write a brief statement about this experience within a set of concentric circles.These concentric circles can be interpreted as changes over time, with the inner ripple representing changes occurring at a time more proximal to program participation and the outer ripple representing changes occurring at a time more distal to program participation.

Questions in the initial round may include but are not limited to:

  1. What is a highlight, achievement, or success you experienced as a direct result of your involvement with the program?
  2. What unexpected things (positive or negative) have happened as a result of your involvement with the program? And,
  3. What connections with others—new and/or deepened—have you made as a result of the program? The facilitator may probe participants to expand upon their answers as needed.


Once the facilitator has completed the first ripple of questioning and probing for the transactional (ripple 1) changes, the facilitator draws another circle concentrically around participants’ initial responses and moves to protocol questions that elicit experiences for the transitional (ripple 2) and transformational (ripple 3) ripples. The protocol continues with questions such as:

  1. How did you benefit from [experience participant wrote in previous circle]?
  2. What happened because of [experience participant wrote in previous circle]?
  3. As a result of [experience participant wrote in previous circle], how has your attitude or behavior changed? and,
  4. How are these changes benefiting others or changing what others do?

As before, participants will orally communicate their experience and write a brief note about it in the new circle. This time, they will connect the new experience to its generating experience with a line. This sequence can be repeated multiple times to gather as many transitional (ripple 2) and transformational (ripple 3) outcomes as participants are willing to share and lasts approximately 1-1.5 hours.

3 level


At the end of each mind-mapping session, participants are asked to provide their interpretation of the experiences shared by the group and to identify the most valuable outcome they experienced as a result of their participation in the program. These responses can be elicited using questions like:

  1. What relationships do you see between different aspects of the map?
  2. What do you think is the most significant change on the map? Why?
  3. How valuable are these changes? Why? and
  4. What from this map that will be helpful in improving the program for the future?

This final round of questioning contributes to the ability of an evaluator to fulfill their role in making informed judgement about the merit, worth, and significance of the program. It also aids evaluators in constructing a parsimonious theory of change that, as Weiss (1995) recommends, concentrates on key aspects of the program identified as most valuable or significant by program stakeholders.

Phase III: Interviewing Other Stakeholders

Ripple Effect Mapping application typically brings all stakeholder groups together to create maps that represent the range of possible experiences and interpretations. In some circumstances, different stakeholder groups may participate in the REM sessions alongside one another (blended sessions). However, in other circumstances, blended REM sessions may not be appropriate due to power dynamics or concerns for confidentiality. Therefore, different stakeholder groups may participate in separate REM sessions divided along power structures (split sessions). A third option is to conduct individual interviews with key stakeholders who are unable to attend group sessions (individual sessions). In this third situation, the evaluator can imitate the REM sessions using the previously constructed mind maps.

Using digital mind mapping tools, the evaluator can convert the large paper-based mind maps into condensed, de-identified digital mind maps. Then, in each interview, after the evaluator asks questions similar to those asked in the group REM session s/he shows the digital mind map from the group REM sessions to the interviewee. After the interviewee has a change to review the mind map, the evaluator continues the interview with questions like:

  1. What surprised you about the map?
  2. What themes or patterns do you see in this map?
  3. What was confirmed by the map that you already knew? and
  4. What was missing in the map that you thought you would see?

This line of questions allows for divergent assumptions to emerge about how a program works and compare them with what is developing in the data.

Phase IV: Analysis & Codifying a Theory of Change

Labeling the analysis and theory construction as phase IV is slightly misleading. Since grounded theory leads the evaluator to make use of an iterative, comparative process, each stage of data collection should be followed by a stage of analysis and theory construction generating new levels of complexity and sophistication in the emerging theory. After each REM session or interview, the evaluator transcribes the audio files and creates initial codes. Completing this prior to engaging in subsequent REM sessions helps the evaluator to start forming ideas and hypotheses about the emerging themes to adapt the interview protocol and probing in theoretically important directions. The next step in analysis is coding the transcripts. If you are unfamiliar with qualitative coding, Saldana is a great resource.

The theoretical codes generated from the data should help link program activities, transactional changes, transitional changes, and transformational changes to each other and construct a coherent story about how the program works and its impacts. In thinking about these inter-relationships within the program system, Williams & Hummelbrunner (2010) provide the evaluator several questions to ask themselves:

  1. How do the categories affect each other? Does a category have a reinforcing or dampening effect on the categories to which it is linked?
  2. What controls the way in which resources flow through the situation? How does this affect behavior?
  3. What are the key processes for achieving the outcomes of the program?
  4. How do we make sense of the patterns that emerge from those processes, with what consequences, and for whom?
  5. What are the consequences for achieving effects if those processes do not take place as foreseen?

The theory of change that emerges from this rich, systematic process is grounded in the lived experiences of stakeholders interacting with the program in a given time, rather than a priori beliefs or assumptions of the underlying program mechanisms that link activities to outcomes. The theory of change must adequately connect and describe expected causal connections without becoming so complex that the utility of the model is weakened.  Given the complex system dynamics, this theory must also be open to continuous change as new information emerges.

Phase V: Member Checking

Stakeholder involvement in evaluation is considered good practice and member checking is recognized as a method for enhancing both participation and rigor in qualitative inquiry. This final phase of the REM process aims to improve the plausibility, credibility, and relevance of the evaluation by including stakeholders in the interpretation and confirmation of the emerging theory of change. During member checking, stakeholders are invited to comment on the findings in the form of individual interviews, focus groups, or written communications to “test” the plausibility, credibility, and relevance of the emerging theory. It also helps ensure that evaluation findings are presented in a way that is accessible to all stakeholders. Member checking can increase acceptance of the evaluation findings and implementation of recommendations but requires careful ethical considerations in the evaluation protocol.

Final Thoughts

Ripple effect mapping is a participatory data collection method that helps an evaluator explain program outcomes and the process through which they emerge. Such insights into a program may remain buried with goal-oriented, quantitative evaluation methods. Although this paper makes a distinction between intended and unintended outcomes, this approach to REM within a goal-free evaluation framework can avoid making a distinction between intended outcomes (goals) and side-effects because inn task of evaluating merit, worth and significance, “what counts is not the specific intentions, but the results” (p. 97).

Mixed-method evaluations can help identify and address unintended consequences that may occur during program implementation. It can also improve the credibility, relevance, and ultimate use of the evaluation findings among stakeholders with different information needs. Ripple-effect mapping may be integrated into a mixed-method design that includes additional qualitative or quantitative components. For example, an evaluator may use a survey to examine intended outcomes among a large sample and recruit REM participants. Alternatively, the evaluator might follow the REM process with a survey to assess the theory of change among a larger sample, allowing for additional revision and refinement.   


Thanks for reading! For a sample REM facilitation guide click Ripple Effects Mapping Sample Facilitation Guide.


Value for Money: A Utilization-focused Approach to Economic Evaluation



Economic evaluation (EE) is not widely used in food and nutrition program evaluation and has had limited impact on decision-making (Williams, Bryan, & McIver, 2006; Zwart-Van Rijkom, Leufkens, Busschbach, Broekmans, & Rutten, 2000). Under-utilization of economic evaluation represents a missed opportunity to understand the full value of a program investment for the public good.

To advance the use of economic evaluation in food and nutrition programs, this poster:

  1. describes the Value for Money (VfM ) framework of economic evaluation,
  2. reviews existing models of evaluation to identify gaps within the dominant method of economic evaluation that contribute to under-utilization, and
  3. illustrates an approach to integrate VfM into a broader utilization-focused evaluation framework

Barriers to Utilization of Economic Evaluation

Institutional: The institutional barriers to utilizing economic evaluation include inflexible budgets and the often untimely availability of evaluation findings.

Cultural: The cultural barriers to utilizing economic evaluation include perceived irrelevance of evaluation findings and lack of stakeholder (decision-maker) ownership in the evaluation process.

Methodological: The methodological barriers to utilizing economic evaluation include the complexity of standard economic evaluation methods and the credibility of findings based on standard economic evaluation methods among stakeholders (decision-makers).

Utilization-focused Evaluation

Utilization-focused evaluation (UFE)  is an approach to evaluation based on the principle that evaluations should be done “for and with specific intended primary users for specific, intended uses” (Patton, 2008, p. 37)


UFE image

Value for Money

Economic evaluation: an applied moral philosophy and decision-making strategy which provides information about the merit, worth, and significance of resource use in public programs and policies compared to alternatives (King, 2017; Rudmik & Drummond, 2012).

Value for Money (VfM): a comprehensive framework of economic evaluation where value is expanded to include dimensions of efficiency, equity, effectiveness, and economy (4Es) (Fleming, 2013). The VfM framework is a promising framework for enhancing the relevance, credibility, and use of economic evaluation in social programs.

Figure 1 Value for Money Logic Model

  1. Economy: programs that bare the lowest cost, while maintaining a base level of quality
  2. Efficiency: the level of output achieved for a given level of inputs, also while bearing in mind quality
  3. Effectiveness: achieving positive program outcomes, while considering equity
  4. Equity: program activities and outcomes are distributed fairly and reduce disparity, marginalization and discrimination while increasing social and political inclusion (Fleming, 2013; Gaynor, 2017)

Benefits of Rubrics for Economic Evaluation

VfM rubrics are a utilization-focused evaluation tool for primary users and evaluators to draw evaluative conclusions from multiple data sources about the VfM of a program using explicit performance criteria.

Rubric Benefits

Example Community Gardens VfM Rubric

VfM rubric



Practice: Economic evaluation is an important component of evidence-based programs and policy. Increased utilization of economic evaluation contributes to decisions about the feasibility, scalability, sustainability, and equity of food and nutrition programs and policies to help organizations optimize the impact they make with the invested resources

Research: Future research should assess to what extent VfM rubrics improves the utility and use of economic evaluation among food and nutrition program stakeholders.

Price Policies to Promote Healthy Eating: Missing the Forest for the Trees

Champagne wine and fruit salad coctail in a glassAmerican anxiety over healthcare costs and obesity continues to fuel public health advocacy for increased taxes on sugar-sweetened beverages and other unhealthy foods. Proponents of imposing higher taxes on unhealthy food products, such as soda, claim they are a necessary and effective strategy for modifying consumption behaviors and improving health outcomes. The logic is that a tax will make unhealthy foods more expensive, thereby deterring people from consuming them in excess. Advocates argue that excessive consumption of sugar-sweetened beverages not only harms individual health, but also induces increased healthcare costs that cause societal harm. Since rising healthcare costs negatively affects the public, they propose that governments are justified using fiscal policies to intervene to nudge individuals to change their dietary choices. This logic has persuaded residents of Berkeley, Seattle, and Philadelphia to vote in favor of implementing a sugar-sweetened beverage excise tax. Despite fervent support from public health advocates many people remain skeptical of imposing excise taxes on sugar-sweetened beverages as a public health solution.

I have to admit, when I was first exposed to the concept of “nudging” and soda taxes, I found them appealing. However, after in depth reflection about my values as a public health scholar, my perspective has shifted.

In late 2017, Cook County repealed its sugar-sweetened beverage tax due to intense opposition after the tax failed to live up to expectations. A major concern of using taxes to shift dietary choices is their disproportionate impact on low-income households. Higher prices on consumer goods disproportionately affect households of lower socio-economic status than wealthier households. This concern for equity was explored in a recent Lancet article, which has been touted as “a new weapon in their battle against sugar” by a review published in Fortune. The authors of the Lancet article conclude that although price policies DO often bear the largest tax burden, governments can justify this burden if the estimated health benefits of decreased consumption are likely to disproportionately benefit poorer households. This moral trade-off assumes that sugar-sweetened beverage taxes are effective at improving diet patterns and health. However, this assumption is just that-an assumption- since the evidence in support of substantial behavior changes or health impacts is weak. Even so, when it comes to public health, debating the equity of excise taxes of unhealthy food products misses the forest for trees.

The Big Neoliberal Distraction

Taxing unhealthy food items to modify individual behavior is part of a neoliberal trajectory in public health discourse. Neoliberalism is the prevailing political-economy paradigm that emphasizes free-market consumerism, individual responsibility, and minimal government spending. A variant of neoliberalsim, referred to as libertarian paternalism, legitimizes the role of private and public institutions in using market-based strategies to influence private behavior so that an individual’s freedom of choice is maintained. Fiscal policies, such as excise taxes, are a market-based strategy that nudge individuals into taking responsibility for their health are a form of libertarian paternalism in public health.

The push for increasing taxes on food items deemed unhealthy is occurring in midst of a larger political-economic wave of tax cuts for wealthy households and corporations, increased corporate consolidation, decreased public investment in education, calls to cut investment in Medicaid and privatize Medicare, restrict SNAP eligibility, threats to environmental regulations, and persecution of labor rights–all policies that contribute to increased economic insecurity that leads to stress (weight gain) and decreased ability to purchase adequate healthy food. This neoliberal agenda erodes an institutional environment that provides the greatest support for health while painting soda-drinkers as social deviants. It is within this context that The Lancet article argues that even though increased price of soda disproportionately affects people of low socioeconomic status, soda taxes may be just because these same people may realize greater health benefits than people from higher socioeconomic statuses. But is the fact that low-income individuals might benefit more in terms of health from this policy enough to claim that the policy is just?

Neoliberal public health strategies that aim to “fix” a single behavior (drinking soda or eating junk food) are reductionist in nature and ignore the underlying socio-cultural determinants of behavior and health. This paradigm of public health views solutions to complex phenomenon like health in terms of singular components isolated from the larger socio-political context. It penalizes people for “what they do wrong and what they fail to do right” while conceptualizing health as an individual responsibility rather than a right or public good. Conceptualizing health as an individual responsibility that governments can encourage through taxation distracts the public health discourse from advocating for strategies such as investment universal healthcare, public education, and living wages. Unhealthy diet patterns and poor health outcomes are in part a symptom of deeper structural factors exacerbated by neoliberal policies and cannot be resolved simply by taxing “bad” food items.

When arguing in support of increased soda taxes, public health advocates often lament the power of “Big Sugar” or “Big Soda” and suggest that the increased cost to consumers, and theoretical decrease in purchases, will shift enough revenue away from large beverage corporations to curb their control over people’s dietary choices. Again, this deflects the public health discourse away from more effective strategies for curbing corporate power like enforcement of anti-trust laws or support for labor rights and casts the individual in the role of starving the beast. It also overlooks the role crop subsidy policies play in making sugar so cheap to begin with. Focusing attention on taxing soda instead of the root causes of extreme corporate power feeds into the neoliberal agenda of deregulation at the macro level that further increases concentration and power in the food industry. The exact opposite of what public health advocates claim they are fighting for.

Beyond Soda Taxes: Seeing the Public Health Forest

Wellness, and not the individualized form of it popularized by self-help health gurus, offers an alternative paradigm through which to think about public health policy. It is a holistic and affirming process that focuses on cultivating factors that support human health and well-being, rather than on just preventing factors that cause disease (i.e., drinking soda). Wellness is a function of, and must be understood in the context of, justice at the interpersonal, organizational, and community (national) level. This goes beyond merely debating the equity burden of a soda tax and forces us to look at soda taxes within a larger institutional environment that determines resource distribution among members of a society. Public health professionals should concern themselves with the wellness implications of sugar taxes in terms of justice and systems that support people to have healthy lifestyles rather than penalizing them for the choices they make within the context of systems or environments that are unsupportive of healthy lifestyles.

Procedural justice is concerned with how resources are distributed to members of society. It is possible that resources can be distributed to low-income households in paternalistic ways that do not affirm dignity. Penalizing low-income individuals for their soda consumption with additional taxes may raise revenues for public institutions to provide nutrition education or fruit and vegetable subsidies to “benefit” these households. But who has the power to determine what constitutes a benefit, or which benefits are valued more highly than others? This resource allocation decision is often made by powerful individuals or institutions to serve their own agendas rather than by the individuals most affected by poor health and/or soda taxes. Therefore, imposing soda taxes to nudge low-income soda-drinkers into changing their behavior and justifying it by “giving” them nutrition programs do not cultivate wellness in the big picture. To truly promote wellness, resources should be distributed to those most in need through procedures that are just. Soda taxes do not meet this criterion.

The current discourse on soda taxes as a desirable public health strategy shifts conceptualization of health away from being a public good that is supported by an institutional environment consistent with standards of distributive and procedural justice. Viewing health as an individual responsibility divorced from one’s social environment further marginalizes disadvantaged populations and reinforces current health inequities. Public health advocates should consider the following wellness-oriented guidelines when supporting public health policies:  (1) look at the public health data differently: instead of looking at populations who have succumbed to a problem like diabetes to find out what they are doing wrong, look at those who are succeeding and try to find out why they are doing well; (2) persuade policy-makers to consider outcomes related to success (e.g., greater consumption of fruits and vegetables), not just outcomes related to problem reduction (e.g., decreased soda consumption); (3) elevate the importance of social justice and consider the harmful effects to health and wellbeing of reductionist policies that penalize or demonize people for health-related lifestyle choices; and finally (4) stimulate the development of innovative policies that cultivate the environmental and institutional conditions for these desired outcomes to occur. Public health advocates need to look beyond soda taxes and use their political capital to advocate for investment in systems like universal health care, public education, and living wages if they are truly concerned about health and equity.






Salutogenesis, Self-determination, and Soda Taxes: What can Positive Health Teach us About Nutrition Policy?


Calls for taxes on sugar-sweetened beverages (SSB) by health professionals and advocates continue to occupy news headlines. Seattle recently joined the growing list of U.S. cities that are experimenting with a tax on SSBs, while Cook County (Chicago) repealed a similar policy after only two months. Advocates of the tax point to studies using economic modelling, which paint rosy pictures of increased tax revenues, decreased SSB consumption and significant health impacts, to argue for the value of this strategy. Although much more empirical research is needed to determine long-term effects of taxing sugar-sweetened beverages, the existing empirical evidence suggests little effect on SSB consumption or health. This is not surprising given that people can purchase SSB from neighboring municipalities, order them from online retailers, substitute from newly taxed beverages to other unhealthy beverages, or switch to a generic brand of soda. Wellness, which draws heavily from self-determination and salutogenesis theories, provides insight into how professionals might think more constructively about nutrition policy.

The Rational vs. The Evidence 

Taxes on sugar sweetened beverages are not new and have been implemented in many areas in many different ways. Thirty-four states currently have a sales tax imposed on soda sold in grocery stores, and 39 states tax vending machine sales. The most prevalent argument in support of levying a sugar-sweetened beverage excise tax (on top of any existing sales taxes) is the potential impact on public health. The CDC suggests that 49% of American adults drink SSB on a daily basis, with the average consumption of 149 calories. Soda and sugar-sweetened beverages have been implicated as a major source of excess calories and sugar, leading to weight gain, diabetes, and dental caries. Advocates argue that an excise tax on SSB will encourage people to decrease their SSB consumption, leading to significant improvements in weight and subsequently health.

But at what cost? Are the actual changes in consumption or health outcomes substantial enough to be considered worthwhile? How sustainable or long-lasting are these changes in consumption? And are there other programs or policies that would lead to more significant health outcomes and have a societal or individual cost that is equivalent to or lower than a SSB tax?

There is little evidence to support the claim that SSB taxes have significant influence on consumption. Although SSB tax supporters cite several studies that estimate 7.9%-21% decreases in SSB consumption, with the greatest impact occurring among low-income individuals, resulting in an estimated 30 fewer ounces purchased each week per household. However, most of these studies have significant limitations that constrain their ability to make substantive conclusions about SSB consumption impacts.

The first important limitation is that even if consumers decrease their consumption of SSB, the studies do not account for the substitution effects that a randomized field experiment shows increases the consumption of water, milk (flavored and unflavored), juice, generic brands, beer, and milkshakes or yogurt smoothies. Consumers may also choose to cut costs in other parts of their household budget to cover the increased cost of SSB or shift their purchases to stores in neighboring areas or online retailers. Most studies do not account for any of these substitution effects.

The second major flaw with studies on SSB taxes is that most do not control for the considerable overall downward societal trend in soda consumption over the past two decades or the effects of tax campaigns on social norming. This is critical since SSB consumption has been decreasing at a rate of nearly 1% a year since 1998 as people recognize the adverse health effects of consuming large amounts of added sugar.

Lastly, the sampling and analytical methods in some studies have been criticized for inflated demand elasticity estimates or weak sampling strategies. Therefore, it is not surprising that evidence based on self-reported soda consumption and household budget surveys suggests that a SSB tax did not significantly change in the case of Berkeley, CA, and that SSB taxes are predicted to decrease body weight by less than one pound in Mexico. So, if SSB taxes show lackluster impacts in practice, how can wellness professionals start to think differently about their policy advocacy?

Self-determination theory

Self-determination (SDT) is a theory of human motivation that begins with the assumption that people evolved to be “inherently active, intrinsically motivated, and oriented toward developing naturally through integrative processes.” Essential to the process of becoming aware of, and internalizing behaviors that move one closer to achieving their full health potential is fulfillment of an individual’s psychological need for competence, relatedness, and autonomy. In the context of food and nutrition, competence refers to developing individual and community capacity to identify, source, and prepare affordable, culturally-appropriate, healthy foods. Relatedness is about providing people with spaces and opportunities that create a sense of personal connection with others who value the health-promoting behavior. Lastly, autonomy means that people must recognize the value of a behavior for themselves and feel that doing this behavior is their own personal choice, free from the external coercion of incentives or penalties.

Taxes on sugar-sweetened beverages as a public health strategy violate the psychological need for autonomy. It is no wonder that many people perceive this tax as intrusive and react negatively toward the idea of health professionals and politicians coercing them to make particular decisions about what they eat and drink. Furthermore, these policies do not support cultivation of competence or relatedness. In this way, SSB taxes undermine self-determination. Public health education campaigns have contributed to a greater societal awareness of SSB adverse health impacts and, like the case of tobacco, contributed to individuals making autonomous choices to decrease their SSB consumption, without the excise tax.

Salutogenesis and Positive Health

Avoiding a bad behavior does not necessarily lead to the existence of good behavior. This subtle aspect of human behavior is the key to framing health strategies that enable people to learn how to live fully if we really mean it when we say “health is more than just preventing disease”. Salutogenesis refers to proactively generating full health potential. The key concept here is “potential”. Health approaches based on salutgenesis study the origins or causes of health. This is conceptually different that the traditional pathogenesis approach which seeks to understand the origins or causes of disease and design interventions that aim to reduce risk and avoid problems.

Reducing disease risk is important, but it is not the same as cultivating health potential. Sugar-sweetened beverage taxes respond to a situation that threatens to cause disease. However, decreased SSB consumption does not inherently lead to healthier eating patterns that include more fruits, vegetables, legumes and whole grains (causes of health). Without policies that enable the conditions for people to cultivate healthy diet patterns (e.g., living wages, shorter work weeks, access to quality fresh produce, cooking skills, affordable healthcare), SSB taxes are not likely to produce better eating habits.

Is there an appropriate use of SSB taxes?

Food policy initiatives warrant special attention because of their ability to cause great benefit or great harm to society. In some cases, regulations that restrict individual choices are necessary to support public health. Although SSB taxes may only have a trivial influence on consumption habits, they may have other important goals, such as providing subsidies for fresh produce or nutrition education, which may be justifiable to promote wellbeing by bring people together, build competence, and support autonomy in nutrition decision-making. Some SSB tax policy initiatives propose using revenue to fund nutrition education and fresh produce subsidies.

This strategy is not without challenges of its own since the revenue typically goes to the city’s general fund for use on whatever programs the city council ultimately decides to fund. In practice, ear-marking tax revenue for specific purposes is politically challenging. However, if the goal is for consumption of SSB to decrease, that also means revenue will decrease. In fact, many cities that implemented an SSB excise tax are reporting lower than projected revenues. For SSB taxes to generate sufficient revenue to fund public health programs, SSB consumption must remain stable or new sources of revenue must be found. A Catch-22. Finally, it is important to consider whether or not the same ends could be financed through a progressive tax that is less burdensome to low-income populations.

Drawing on the works of Antonovsky, referenced by Becker, Glasscoff, and Felts, we can adapt guidelines for developing strategies that advance health can help nutrition and public health professional advocate for salutogenetic public policies:  (1) look at the public health data differently: instead of looking at populations who have succumbed to a problem like diabetes to find out what they are doing wrong, look at those who are succeeding and try to find out why they are doing well (what policies facilitate these behaviors?); (2) persuade policy-makers to consider outcomes related to success (e.g., greater consumption of fruits and vegetables), not just outcomes related to problem reduction (e.g., decreased soda consumption); and finally (3) stimulate the development of innovative policies that cultivate the conditions for these desired outcomes to occur. If SSB taxes are conceived as public health-promoting strategies in themselves, they have an obligation to be evaluated on the extent to which they will support self-determination and salutogenesis and be mindful about the place of health policies in relation to other aspects of well-being.























Establishing Ethical Boundaries: Experience of an Emerging Evaluator

Image result for ethics

Shortly after starting my first semester as a PhD student, I came across an opportunity to get involved in a community food system research project as a data collector. It was a collaboration between a local food coalition, nutrition scholars, and city officials. This was just the type of experience and connections I felt I needed to begin establishing myself as a researcher within a new community and among faculty in my field. Instead, it ended up being a lesson on establishing my ethical boundaries as an emerging researcher and evaluator.

The Situation

The lead researcher on the project was an assistant professor from a large university in the South. In this post, I will refer to her as Dr. Susan. I had little background on the project, so I asked Dr. Susan about the research questions guiding the data collection. She stated that she was working with the primary stakeholders and that they just wanted to do an “assessment”. I pressed for a more precise answer, but it seemed that she either didn’t know the purpose of the study or that the stakeholder group really didn’t have a clear purpose in mind. This was just the start of my discomfort.

We moved on to discussing the data collection instruments. As we read through the survey items together, there were several that required explanation because of ambiguous wording, so I pressed for clarification. By the third or fourth unclear item, Dr. Susan appeared to be impatient. She instructed me to let the respondent decide what the item means to them, or to have them “think about it hypothetically” if it did not pertain to their life experience. I was frustrated. If I had trouble interpreting the items as a PhD student with a nutrition background, what did that mean for the reliability of our data among a less-educated population?

Finally, we came to the demographic items on the survey. With the exception of the income questions, none of the demographic items included a response choice of “prefer not to answer.” I asked Dr. Susan if she wanted to make them consistent by adding a “prefer not to answer” response option to the other items. She declined. I followed up and asked if we could include an introduction to the survey where we could inform respondents of their right to decline to answer any questions, without risk of losing their monetary incentive. Dr. Susan explained that if we let them know they have the option to skip questions, then they might choose to not answer some of the items and we would have missing data. I could feel my muscles tightening and a feeling of panic.

I left the meeting anxious and unsure about continuing with the data collection. On the one hand, I really wanted to build a relationship with the food and nutrition community in this city and worried that backing out of the data collection would make me appear difficult or arrogant. But, the ethical gnawing in my gut was keeping me up at night. Fortunately, my professors had introduced several tools during my nascent PhD career that helped me navigate the situation and make a decision that put my mind at ease.

Researcher Journal

Reflexivity is a critical evaluator competency. In the qualitative methodology class I took during this first semester, we were required to start a journal to explore our growth as researchers. In one exercise at the beginning of the semester, we were asked to write down things that were ethically important to us in conducting research. There was a moment of clarity when I referred back to key words from this statement while reflecting on my options: self-determination, transparency, and autonomy. I also described how it was important to me that individuals providing their data were respected and that I felt the particular methodological choice did not provide voice to the community members. I wrote that it “reinforced a power structure of researchers and government officials deciding on an intervention based on (flawed) data they collect through an instrument that they designed in isolation.” Two themes emerged from my journal entries over those few days: concerns about data integrity and social justice.

American Evaluation Association Guiding Principles

The concerns I saw emerging in my journal are addressed explicitly in the Guiding Principles of the American Evaluation Association. We were asked to reflect on these principles early on in the semester. Two areas in particular provided the direction I needed to make a decision about moving forward with the data collection.

Integrity/honesty: If evaluators determine that certain procedures or activities are likely to produce misleading evaluative information or conclusions, they have the responsibility to communicate their concerns and the reasons for them. If discussions with the client do not resolve these concerns, the evaluator should decline to conduct the evaluation.

Respect for people: Evaluators should abide by current professional ethics, standards, and regulations regarding risks, harms, and burdens that might befall those participating in the evaluation; regarding informed consent for participation in evaluation; and regarding informing participants and clients about the scope and limits of confidentiality.

One of my concerns was that the poorly constructed survey items would provide misleading information about the population. This could potentially lead to an ineffective and wasteful intervention in this community. Furthermore, without a clear understanding of the purpose of the data collection or provision of informed consent to respondents, I could not confidently conclude that my work would maximize benefit and reduce unnecessary harm. Since Dr. Susan was not receptive to modifying the survey items or establishing informed consent, I felt the right decision was to decline the opportunity to participate in the data collection.

Trusted Mentor

Although I felt fairly confident that I needed to let go of this opportunity and focus on research and evaluation work that aligned with my ethical boundaries, there was a lingering feeling of self-doubt. I was a first-year PhD student with little experience. Who the hell was I to question the protocol of a more experienced assistant professor? What did I know about conducting field research anyway? The AEA Guiding Principles provided direction, but was that how evaluation really worked in practice?

I turned to a faculty member in my department for advice. I knew this person had made similar ethical choices as an emerging researcher because she had talked about her experience in class. As I shared my experience with her, I felt sensations of vulnerability. My face was trembling like I wanted to cry. She reassured me that this protocol was not business as usual in field research and that even though this project was not subject to IRB review, it should still adhere to the ethical treatment of research subjects. She described three courses of action I could consider: 1) walk away from the project with no explanation, 2) walk away from the project and give an exit interview with the researcher to let her know my reason for leaving the team, or 3) move forward with the data collection and use it as a learning experience of what not to do.

My Ethical Boundaries

Later that evening, I went home and wrote an email to the researcher. I explained that I was unable to continue with the project and communicated my concerns about informed consent, coercion and respect for research participants. As a learning experience, this situation highlighted the importance of actively articulating ethical boundaries as part of one’s research philosophy early on in the graduate career. I was fortunate that the faculty in my program provided the tools and mentorship for navigating these situations on several occasions early in my first semester.

Advancing the Wellness Profession: Is it Time for Competency Standards and Professional Certification?

NWI Wellness Promotion Competency Model Graphic

The wellness profession has grown significantly over the past 50 years as more and more companies offer worksite wellness programs. Nevertheless, one of the key challenges currently faced by practitioners as how to implement best-practices and pull together the multi-disciplinary nature of these practices to form cohesive wellness programs. Although the literature on wellness strategies and methods is abundant, little is known about the professional competencies required for the practitioner to be effective at wellness promotion.

Wellness is defined as an active process through which people become aware of, and make choices toward, a more successful existence (National Wellness Institute, n.d.). It is a positive and affirming method of personal growth and becoming aware of our multi-dimensional and holistic nature. Counselors, social workers, nurses, health educators, and chiropractors, among others, are integrating wellness concepts into their practice to address the needs of their patients, clients, or employees through a whole-person approach. Despite the growing popularity of the wellness profession and wellness programs, some researchers argue that a misalignment between the philosophy and actual practice of wellness promotion continues to exist, leading to criticism of the wellness paradigm for discriminatory and unethical practices.

As an approach to improving quality of life, wellness promotion lacks a clearly defined set of competencies to guide the academic preparation and professional development of practitioners. The need for professional wellness competencies is evident from the conflation of methods to promote disease management with those that aim to promote wellness. For example, the use of conditional incentives is popular in worksite wellness programs to motivate employee health behavior change, despite being inconsistent with person-centered wellness methods and the human values of fairness and equity. Furthermore, many health behavior change strategies focus on eliciting emotions such as fear, shame, or guilt to motivate individuals to lose weight, become more active, or eat more vegetables to reduce their risk of disease.

While control-oriented methods like contingent incentives or fear-based messaging might motivate individuals to change their behavior short-term, it may have adverse consequences to their capacity to exercise practical autonomy and work toward their own vision of what makes life worth living. Wellness promotion offers an alternative paradigm to the traditional methodologies of health promotion and public health. However, to be fully realized, a standard of wellness practice that is consistent with the philosophy and theory must be adopted.

Competency standards are recognized world-wide as a tool to ensure professionals can competently perform skills and behaviors required to be successful in their role. As an approach to improving quality of life, wellness promotion has lacked a clearly defined set of competencies to guide the academic preparation and professional development of practitioners. Recently, however, the National Wellness Institute published a set of wellness competencies for entry-level wellness professionals. This preliminary iteration is an attempt to bring wellness professionals together in establishing a foundation and vision for the education and professional development of practitioners. Bridging the gap between philosophy, theory and practice by identifying the core competencies of wellness promotion is an essential step in training practitioners to successfully promote ethical and effective wellness strategies.

Local Food Policy Councils: Innovative Solution or Steward of the Status Quo?


FPC meme

Food policy councils (FPCs) are a component of local food networks emerging across the United States that seek to coordinate policies affecting the various components of a food system. Food policies are often siloed within disparate government offices responsible for overseeing agricultural production, food processing and distribution, nutrition education, food residual recovery, and environmental protection (Clayton, Frattaroli, Palmer, & Pollack, 2015). The result is policies and programs that target problems in isolation, creating gaps and inefficiencies within the system as a whole (Harper, Shattuck, Holt-Giménez, Alkon, & Lambrick, 2009; Lang, Barling, & Caraher, 2009). This haphazard food policy environment contributes to the poor wages for food system workers, chronic hunger, diet-related diseases, environmental damage that impact community and individual well-being (Anderson, 2008; Neff, Palmer, McKenzie, & Lawrence, 2009; Lang, Barling, & Caraher, 2009). While specific goals of FPCs vary, their primary aim is to provide a place for a variety of stakeholders to engage in dialogue and act collectively on local food system development initiatives.

The number of active local FPCs is growing as a way for local communities to exercise their voice over policies that promote economic development, promote social justice, and reduce the prevalence of food insecurity (Clayton, Frattaroli, Palmer, & Pollack, 2015). However, few FPCs engage in systematic evaluation and little is known about their actual impact (Dharmawan, 2015; Harper, Shattuck, Holt-Giménez, Alkon, & Lambrick, 2009; Scherb, Palmer, Frattaroli, & Pollack, 2016; Sussman & Bassarab, 2016). Shared evaluation processes that elicit stakeholder participation are important elements of effective collective action on food policy strategies (Kania & Kramer, 2011; Ventura, 2013). Furthermore, because many food policy councils receive public support in the form of meeting space, volunteers from public agencies, and sometimes grant funding, it is important to understand how they engage in evaluation of their work and its impact on the public good.


Evaluation is process of systematic inquiry for judging the value, worth, or merit of a program or strategy (Cousins, Goh, Elliott, Aubry & Gilbert, 2014; King & Volkov, 2005). It can take on many forms, including measurement of needs, performance, programs processes, outcomes, and cost-benefit analyses. However, even when organizations manage to conduct evaluations, the results and recommendations are not always used to enhance organizational learning or improve performance. Even though evaluation reports are an important source of information that contribute to evidence-based policy-making, evaluation results have had little impact on political decision-making (Daigneault, 2014; Weiss, 1990). Evaluation capacity is important as part of the broader theories of empowerment, participatory, and utilization-focused evaluation in which the contributions of all stakeholders are solicited and valued in the evaluation process (Preskill & Boyle, 2008). Within empowerment evaluation theory, self-determination is fostered through a process designed to “help people help themselves and improve their programs using a form of self-evaluation and reflection (Fetterman, 2001, p. 3).”

Food policy initiatives warrant special attention when it comes to evaluation because of their ability to cause great benefit or great harm to society (Werkheiser, 2016). Outcomes such as innovation, inclusiveness, self-determination, and community empowerment should be factored into the evaluation measures of these new political spaces (Cohen & Reynolds, 2014; Werkheiser, 2016). However, few FPCs report engaging in evaluation of their networks or policy efforts (Dharmawan, 2015; Scherb, Palmer, Frattaroli, & Pollack, 2016; Sussman & Bassarab, 2016). Lack of time, funding, expertise, and low organizational priority are common constraints (Calancie, Allen, Weiner, Ng, Ward, & Ammerman, 2017; Webb, Pelletier, Maretzki, & Wilkins, 1998). Despite some recent advancements in self-assessment survey tools for FPCs, is important that individual councils and their stakeholders develop the internal capacity to design evaluation plans, criteria, and data collection methods that are meaningful in their particular context and promote engagement in the organizational learning process (Patton, 2008). Without consistent and credible evaluation, is unclear whether FPCs are truly promote sustainability, economic development, and social justice within local food systems.


The local food system movement has been criticized for its equation of the proximity or scale from which food is derived with desirable characteristics such as social justice, nutrition, quality, and environmental sustainability (Born, & Purcell, 2006). This un-reflexive conceptualization of local food systems can overlook elite privilege and contextual differences in food systems, which may undermine the movement’s ability to challenge existing structural inequities and affect meaningful change on a large scale (Allen, Fitz-Simmons, Goodman, & Warner, 2003; DeLind, 2011; Rice, 2015). Furthermore, food policy councils without a lens for equity may inadvertently reinforce existing privilege by overlooking opportunities to advocate for indirect policies that improve food security, such as living wages in food industries, land ownership, access to healthcare, and historical traumas (Hoey, Colasanti, Pirog, & Fink Shapiro, 2017). To address criticisms of the local food movement and demonstrate their value for improving economic vitality, environmental sustainability, and social justice, FPCs need to engage in transparent evaluation of their processes and outcomes. Evaluations can be used to determine program impact, inform future action, persuade stakeholders, and legitimize the existence of the council in the eyes of the community (Fleisher & Christie, 2009; Højlund, 2014; Patton, 2008).

Cookie-cutter approaches to evaluation and external experts are often perceived as inappropriate or unhelpful to local food policy councils. Empowerment and participatory are bottom-up evaluation methodologies that aim to bolster self-determination and community empowerment by actively involving food policy council members in evaluation decision-making (Fetterman, 2001; Patton, 2008). Effective empowerment processes and evaluation use require substantive participation from a diverse range of stakeholders (Cousins & Chouinard, 2012; Patton. 2008; Emerson & Nabatchi, 2015). Substantive participation refers to the broad, equitable, inclusive, and balanced representation of stakeholders whose needs are formally reflected in the official agenda of the organization to be actively involved in the collaborative process (Koski, Siddiki, Sadiq, & Carboni, 2016; Ventura, 2013, p. 21). The use of empowering processes and attention to substantive participation in institutional and community relationships promote well-being through fostering self-determination, respect for dignity, and expression of voice and choice in personal and social affairs (Prilleltensky, 2007).

So what? Evaluation Capacity & Food Policy Councils

It is easy to get excited about new solutions to the problems facing our food system. However, without systematic evaluation of these strategies, efforts can be misappropriated and distract from solutions capable of having a greater impact. Food policy councils are relativity new in the food system landscape and evaluation has so far been limited. Many councils focus on building relationships that increase awareness of and access to farmers’ markets, urban gardens, food pantries, and SNAP. While these are certainly valuable programs, they are largely reactionary or piece-meal solutions that overlook the root causes of chronic food insecurity, unintentionally reinforcing the status quo of food dependency. This begs the questions: are the strategies advanced by food policy councils making a substantial and worthwhile contributions to the improvement of local food environments and food security of marginalized communities? How sustainable or long-lasting are these improvements? And, given scarce resources, are there other programs or policies that would lead to more significant health outcomes at an equivalent or lower cost? Building the evaluation capacity of food policy councils and other collective impact networks in the food systems arena is one important action that could leverage the passion and commitment for a more just food system in ways that provide substantial benefit in terms of innovation, economic development, self-determination, and inclusive institutions. Systematic and consistent evaluation of food policy council strategies would provide the much needed evidence that they meaningfully impact their local communities.



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