Development of the Health District Evaluation Framework (HDEF): a multi-method study of population health evaluation in Singapore

Community and population health initiatives recognize that health and wellbeing are shaped by social, environmental, and contextual determinants. However, evaluation often focuses on discrete programs rather than population health interventions at the district or community level, limiting the capture of multi-level determinants, equity, life course influences, and governance complexity. To address this gap, we developed the Health District Evaluation Framework (HDEF), a policy-relevant model for evaluating health and wellbeing in urban districts. HDEF was developed through a review of 36 health and wellbeing frameworks, semi-structured interviews with 15 cross-sector experts, and iterative indicator development. Grounded in a case study of Queenstown, Singapore, the framework integrates life course, social determinants of health, and systems approaches into a multi-level conceptual model. An indicator bank of over 200 measures was appraised for relevance, measurability, replicability, and feasibility. The framework and core indicators were refined through thematic analysis and structured prioritization with stakeholders and an International Advisory Panel. Existing frameworks varied in focus and were predominantly Western-centric with limited attention to intra-urban differences and local contextual determinants. Interviewees emphasized positioning health and wellbeing as a central outcome shaped by interactions across individual, household, and community levels. HDEF organizes these influences across five domains, operationalized through subdomains. Ten core indicators were prioritized, including happiness, self-rated health, functional status, social support from friends, social support from family, social loneliness, labor force participation, food insecurity, financial insecurity, and perceived equity in access to social and economic opportunities. The framework provides a structured basis for assessing population health and wellbeing, identifying priorities, and monitoring change across district contexts. HDEF provides an adaptable framework for assessing health and wellbeing in urban districts. This framework supports cross-sector coordination, population health evaluation, and continuous system learning for community-based health initiatives across diverse urban settings.