Reporting a Process Evaluation Just as in needs assessments, interviews and focus groups are common tools for obtaining information about the proces
Discussion: Reporting a Process Evaluation
Just as in needs assessments, interviews and focus groups are common tools for obtaining information about the processes involved in the implementation of programs. Process evaluation should include specifics about purpose, questions which the evaluation will address, and methods that social workers will use to conduct evaluations.
Review the many examples of process evaluation results described in Chapter 8 of Dudley, J. R. (2020). Social work evaluation: Enhancing what we do. (3rd ed.) Chicago, IL: Lyceum Books, or in the optional resources. Select an example of a process evaluation that produced valuable information. Compare the description of those results with the Social Work Research Qualitative Groups case study located in this week’s resources..
By Day 3
Post a description of the process evaluation that you chose and explain why you selected this example. Describe the stage of program implementation in which the evaluation occurred, the informants, the questions asked, and the results. Based upon your comparison of the case study and the program evaluation report that you chose, improve upon the information presented in the case study by identifying gaps in information. Fill in these gaps as if you were the facilitator of the focus group. Clearly identify the purpose of the process evaluation and the questions asked.
SOCIAL WORK CASE STUDIES: CONCENTRATION YEAR
68
Social Work Research: Qualitative Groups
A focus group was conducted to explore the application of a cross-system collaboration and its effect on service delivery outcomes among social service agencies in a large urban county on the West Coast. The focus group consisted of 10 social workers and was led by a facilitator from the local office of a major commu- nity support organization (the organization). Participants in the focus group had diverse experiences working with children, youth, adults, older adults, and families. They represented agencies that addressed child welfare, family services, and community mental health issues. The group included five males and five females from diverse ethnicities.
The focus group was conducted in a conference room at the organization’s headquarters. The organization was interested in exploring options for greater collaboration and less fragmentation of social services in the local area. Participants in the group were recruited from local agencies that were either already receiving or were applying for funding from the organization. The 2-hour focus group was recorded.
The facilitator explained the objective of the focus group and encouraged each participant to share personal experiences and perspectives regarding cross-system collaboration. Eight ques- tions were asked that explored local examples of cross-system collaboration and the strengths and barriers found in using the model. The facilitator tried to achieve maximum participation by reflecting the answers back to the participants and maintaining eye contact.
To analyze the data, the researchers carefully transcribed the entire recorded discussion and utilized a qualitative data analysis software package issued by StatPac, which offers a product called Verbatim Blaster. This software focuses on content coding and word counting to identify the most salient themes and patterns.
The focus group was seen by the sponsoring entity as successful because every participant eventually provided feed- back to the facilitator about cross-system collaboration. It was also
RESEARCH
69
seen as a success because the facilitator remained engaged and nonjudgmental and strived to have each participant share their experiences.
In terms of outcomes, the facilitator said that the feedback obtained was useful in exploring new ways of delivering services and encouraging greater cooperation. As a result of this process, the organization decided to add a component to all agency annual plans and reports that asked them to describe what types of cross- agency collaboration were occurring and what additional efforts were planned.
,
O R I G I N A L R E S E A R C H
Process evaluation of a multiple risk factor perinatal programme for a
hard-to-reach minority group
Arlette E. Hesselink & Janneke Harting
Accepted for publication 5 February 2011
Correspondence to: A.E. Hesselink:
e-mail: [email protected]
Arlette E. Hesselink PhD
Post Doctoral Researcher
Department of Epidemiology and Health
Promotion, Public Health Service of
Amsterdam, The Netherlands
Janneke Harting PhD
Assistant Professor
Department of Social Medicine, Academic
Medical Centre/University of Amsterdam,
The Netherlands
H E S S E L I N K A . E . & H A R T I N G J . ( 2 0 1 1 )H E S S E L I N K A . E . & H A R T I N G J . ( 2 0 1 1 ) Process evaluation of a multiple risk
factor perinatal programme for a hard-to-reach minority group. Journal of
Advanced Nursing 67(9), 2026–2037. doi: 10.1111/j.1365-2648.2011.05644.x
Abstract Aim. This article is a report of an evaluation of a multiple risk factor perinatal
programme tailored to ethnic Turkish women in the Netherlands.
Background. The programme was directed at multiple risk factors and aimed at
improving maternal lifestyle, infant care practices and psychosocial health during
pregnancy and after delivery. The programme was carried out by ethnic Turkish
community health workers in collaboration with midwives and physiotherapists.
Methods. Our multiple case study included three Parent-Child Centres providing
integrated maternity and infant care. Participants (n = 119) were first and second
generation pregnant ethnic Turkish women with relatively unfavourable risk profiles.
Data were collected between 2005 and 2008 using mixed methods, including field
notes, observations and recordings of group classes, attendance logs, semi-structured
individual interviews, a focus group interview, and structured questionnaires.
Findings. Most participants (82%) were first generation ethnic Turkish; 47% had a
low educational level; 43% were pregnant with their first child; and 34% had a
minimal knowledge of the Dutch language. The community health workers’ Turkish
background was vital in overcoming cultural and language barriers and creating a
confidential atmosphere. Participants, midwives and health workers were positive
about the programme. Midwives also observed improvements of knowledge and self-
confidence amongst the participants. The integration of the community health
workers into midwifery practices was crucial for a successful programme imple-
mentation.
Conclusions. A culturally sensitive perinatal programme is able to gain access to a
hard-to-reach minority group at increased risk for poor perinatal health outcomes.
Such a programme may be well received and potentially effective.
Keywords: antenatal care, childbirth education, community health workers, hard-to-
reach community group, midwifery, perinatal, pregnancy, programme evaluation
� 2011 The Authors 2026 Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd
J A N JOURNAL OF ADVANCED NURSING
Introduction
In many western countries, the largest differences in physical
health and mortality between migrants and host populations
are found during pregnancy and the first year of life
(Alderliesten et al. 2000, Gennaro 2005, Gagnon et al.
2009). Compared with the host population, ethnic minorities
have less favourable scores on various health indicators, such
as premature birth, lower birth weight, excessive infant
crying and sudden infant death syndrome (SIDS) (Steenbergen
et al. 1999, Schulpen et al. 2001, Alderliesten et al. 2008).
This increased health risk can be attributed in part to
modifiable risk factors with a relatively high prevalence
among first- and second- generation migrant mothers during
and after pregnancy. Among these are unhealthy lifestyles,
potentially harmful infant care methods (Schulpen et al.
2001, van Sleuwen et al. 2003, Goedhart et al. 2008),
depressive symptoms, pregnancy-related anxiety, perceptions
of racial discrimination and parenting stress (Huizink et al.
2003, Dole et al. 2004, van der Wal et al. 2007).
Background
In the Netherlands, risk factors for negative perinatal
pregnancy outcomes are addressed in part by midwifery
care. All pregnant women are advised to register with a
midwifery practice before the twelfth week of pregnancy and
to enrol in either a public or commercial perinatal pro-
gramme. Such programmes give information on healthy
pregnancy behaviours, childbirth and maternity care, and
prepare women for the approaching delivery and parenthood.
However, ethnic minority women rarely attend these perina-
tal programmes (Schulpen et al. 2001, Rowe & Garcia
2003). Apart from language and cultural barriers, this non-
attendance may be due to the fact that perinatal programmes
are not an integrated part of most ethnic cultures and are
entirely tailored to the native Dutch population. As these
programmes have the potential to effectively address risk
factors for negative perinatal pregnancy outcomes, and thus
to decrease the existing differences in health between host
and ethnic populations, there have been repeated recommen-
dations to develop perinatal programmes specifically tailored
to ethnic minorities (Schulpen et al. 2001, Alderliesten et al.
2008). Despite this high degree of interest, thus far only
minimal attention has been paid to developing and evaluating
perinatal programmes to reach minorities and change specific
risk factors (Ickovics et al. 2007, Joseph et al. 2009).
To fill this gap, the Public Health Service Amsterdam
(PHSA) has systematically developed a multiple risk factor
perinatal programme for first- and second-generation ethnic
Turkish women. This target group was chosen because of
increasing evidence of an accumulation of unhealthy lifestyle
factors and potentially harmful infant care behaviours
(Steenbergen et al. 1999, van Sleuwen et al. 2003, Goedhart
et al. 2009). The programme, which was called ‘Happy
Mothers, Happy Babies’ (HMHB), carried out by ethnic
Turkish community health workers (CHWs) in collaboration
with midwives and physiotherapists, and pilot-tested from
September 2005 to November 2007. This pilot implementa-
tion was accompanied by a process and effect evaluation.
The study
Aim
The aim of this study was to evaluate a multiple risk factor
perinatal programme tailored to ethnic Turkish women in the
Netherlands.
Design
The implementation process of the programme was evaluated
in a multiple case study. Data were collected between
September 2005 and October 2008 using a mixed-methods
approach (Creswell 2003).
Participants
We selected three of the seven out of fourteen Amsterdam
PCCs that had appointed an ethnic Turkish CHW to improve
perinatal care for ethnic Turkish women. This CHW had to
have a good command of the Dutch language so that she
could use the programme handbook and communicate with
the midwives, physiotherapists, programme coordinator and
researcher involved.
The midwives and CHWs were responsible for recruiting the
participants. The inclusion criteria were that the women
should be less than 24 weeks pregnant and first- or second-
generation Turkish. Eligible participants were invited for
individual consultations with the CHW and, after agreeing to
participate, grouped according to the expected date of delivery.
For logistical reasons, the initial plan was to start four
HMHB groups each year with a minimum of four and a
maximum of 15 participants per group. This was expected to
result in a sample size between 48 and 180 participants.
Conditions and participants were purposefully sampled
based on programme theme and CHW involved. Topic lists
were used for both observations and interviews. Data were
collected until theoretical saturation was reached (Polit &
Beck 2004).
JAN: ORIGINAL RESEARCH Process evaluation of a multiple risk factor perinatal programme
� 2011 The Authors Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd 2027
Programme
To influence the distal outcomes on morbidity and mortality
level, the needs assessment revealed that the HMHB
programme should address the following determinants:
(1) smoking during pregnancy (Goedhart et al. 2008,
2009); (2) depressive symptoms (Karaçam & Ançel 2009);
(3) smothering, shaking and slapping of the baby (Reijne-
veld et al. 2004); (4) parent-child attachment (van der Wal
et al. 1998); and (5) healthy infant care practices such as not
smoking near the baby and using a blanket instead of a
duvet (van Sleuwen et al. 2003). In addition, three topics
subsistent in any perinatal programme were included: (6)
breastfeeding, which is normally good among the ethnic
Turkish population (van der Wal et al. 2001); (7) childbirth,
because of observed language and cultural barriers in
informing ethnic Turkish women (Crebas 2001); and (8)
getting maternity care, because of reported misunderstand-
ings about and suboptimal use of such services (Alderliesten
et al. 2008).
To effectively address these eight factors, evidence-based
and theory-based methods were included as much as possible
during an Intervention Mapping procedure (Bartholomew
et al. 2001). If appropriate, elements of existing perinatal
programmes were adapted to the ethnic Turkish target group.
Further tailoring of the programme was informed by the
practical experiences of key figures. The resulting programme
included various strategies for influencing the different
determinants. For example, education, skill-building activi-
ties and group discussions, a film to improve parent-child
attachment, role-plays to prevent smoking in the baby’s
immediate environment, and a game to promote healthy
infant care practices. A handbook, which included all
relevant information, was drawn up to give guidance for
the programme’s implementation (Jurg et al. 2005). The
handbook was written in Dutch and designed to be user-
friendly so that all information for each meeting was
structured around the topics that would subsequently be
addressed.
Table 1 gives an overview of the different topics and the
timetable. In total, the programme included eight group
classes of 2 hours each (seven before and one after delivery),
two individual consultations of 2 hours each (before deliv-
ery), and two home visits of 1 hour each (after delivery). Both
the mothers-in-law (first group class) and the partners
(second individual consultation) were invited once during
the course of the programme. These family members were
expected to have an influence on the infant care practices of
the mother (Turan et al. 2001, Geçkil et al. 2007) and to
sometimes play an essential role in permitting the women to
attend the programme. All but the first and the last group
class included 45 minutes of physical exercises, and infor-
mation about anatomy and the delivery. After delivery, a
‘baby show’ was scheduled: a final group class in which the
women could show their newborn babies to the other
participants.
Table 1 ‘Happy Mothers, Happy Babies’ perinatal education programme
Objectives
timetable
Preventing
smoking
during
pregnancy
Preventing
depressive
symptoms
Coping
with
the infant’s
crying
Increasing
parent-child
attachment
Promoting
healthy
childcare
practices
Preventing
smoking
near the
baby
Promoting
breast-
feeding
Preparing
for
childbirth
Requesting
maternity
care
Conception
After 14 weeks I1 � � . . . . . . . After 24 weeks G1 � . . . � � . . . # G2 . � . . . � . � � # G2 . � � . . . . . . # G2 . � . . . � � . . # I2 � . . � . � . . . # G2 . . . . . . . � � # G2 . . . . � . . � � # G2 . � � . � � . . .
Delivery
After 2–3 weeks H . . � . � � � . . After 8–10 weeks G3 . . . � . . . . . After 5 months H . . � . � � � . .
#, every week; I1, individual contacts; I2, individual contacts with partners invited; G, group class; G1, group class with mothers-in-law invited;
G2, group class including physical exercise with physiotherapist; G3, group class with ‘baby show’ (group class during which, in addition to
providing information, the participants get the chance to show their newborn baby to the other participants); H, home visit.
A.E. Hesselink and J. Harting
� 2011 The Authors 2028 Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd
The HMHB programme was offered through three Parent-
Child Centres (PCCs), which give integrated maternity and
infant care. The programme was carried out by ethnic
Turkish CHWs and physiotherapists. The CHWs had already
received training in doing individual consultations and giving
group classes on health- and pregnancy-related issues for
minorities. They received an additional 2-day training during
which they received instruction on how to accurately
implement the programme in accordance with the pro-
gramme handbook. During the programme’s implementa-
tion, they were personally supervised by the programme
coordinator from the MPHS a midwife or PCC coordinator.
To enhance information exchange, the CHWs were
instructed to give the midwives with notes of each individual
participant contact. The CHWs were contracted in the PCC
for respectively 13 (District I), 12 (District II) and 8 (District
III) hours, depending on the number of ethnic Turkish
inhabitants living in the PCC district. The time available to
carry out the HMHB programme varied per PCC: 6 hours in
Districts I and II, and 4 hours in District III, which meant that
all CHWs also continued to be involved in the regular
maternity and infant care given by the PCC.
Data collection
The qualitative data collection existed of field notes, obser-
vations and recordings of group classes, attendance logs, semi-
structured individual interviews and a focus group interview.
Data were collected by the researcher and, if appropriate, a
research assistant. Triangulation of data and methods was
used to improve the credibility of the qualitative data.
The researcher summarized every contact with profession-
als in the field – such as the CHWs, midwives and PCC
coordinators – and noted interesting contextual information.
Observations were made during eight group classes, one
individual consultation and one home visit, after which the
applicable topics and strategies were discussed extensively
with the CHWs. Three group classes were translated into
Dutch to evaluate how accurately the programme had been
implemented. During the break and at the end of the group
class, the researcher spoke with participants about their
experiences with the programme, what they learned during
the programme and whether they valued it. The CHWs
additionally completed an attendance log after every individ-
ual consultation or group class, which included (a) whether a
participant was present or the reason for being absent; (b)
whether all topics were dealt with in accordance with the
programme handbook; and (c) special information about the
participant, for instance, whether she smoked, lived with her
parents-in-law or was depressed.
Individual semi-structured interviews were conducted with
midwives (one of each participating PCC), two CHWs (with
whom the researcher had the least contact), one PCC
coordinator (at whose PCC the implementation appeared to
be the most difficult), and the programme coordinator. Issues
of interest were the recruitment of participants, the imple-
mentation of the programme, the competencies required and
communication.
A focus group interview was held with the three CHWs
and the programme coordinator. During this interview, each
topic of the HMHB programme was discussed in terms of its
relevance, how it was elaborated and presented in the
programme handbook, and how it was presented to and
received by the participants.
The quantitative data were collected using structured
questionnaires. All Turkish pregnant women were inter-
viewed twice: the first time between 3 and 5 months after
conception (by the CHW), the second time 8 months after
conception (by a female Turkish interviewer). Information
was collected about the participants’ characteristics, such as
age, gender, ethnicity and knowledge of the Dutch
language. The second interview included five open ended
questions on how the participants had experienced the
programme, on what they had learned and on what was
lacking in the programme. No reliability checks were
performed for the quantitative demographic data; the open
ended questions served as method triangulation for the
qualitative data.
Ethical considerations
Committee approval was obtained from the Department of
Social Development, the Youth Health Care Institution and
the Public Health Service. Written informed consent from
all participants was obtained before the baseline measure-
ment.
Data analyses
All interviews were recorded, and transcribed verbatim. The
interviews were entered in MaxQDA and organized by topic.
Data from the focus group interview, observations and self-
administered notes were summarized manually. All qualita-
tive data were then subject to a content analysis (Polit & Beck
2004). To ensure inter-rater reliability, half of the data were
double coded by the researcher and the research assistant and
differences in coding were discussed until consensus was
reached. Descriptive statistics (frequencies and means) for the
quantitative information were obtained using the statistical
package SPSS 17 (SPSS Inc., Chicago, IL, USA).
JAN: ORIGINAL RESEARCH Process evaluation of a multiple risk factor perinatal programme
� 2011 The Authors Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd 2029
Results
Participants
The HMHB programme ran 16 times in 2 years. Due to the
high workload in District III and the low number of
participants in District II, the CHWs were allowed to reduce
the number of HMHB programmes to three each year.
A total of 119 Turkish women started HMHB. The
questionnaires revealed that the mean age of the participants
was 27 years, that 83% were first-generation Turkish, and
that 40% were pregnant with their first child (Table 2). The
data recorded in the logbook showed that many women
attending the HMHB programme also had problems with
their partners, their parents-in-law and/or their financial
situation.
The number of women invited to participate was not
recorded systematically. According to the CHW, women who
refused to participate did not have time because they were
working, studying or had children at home; did not think
they needed a prenatal education programme; were not
allowed to attend by their husbands or parents-in-law; or felt
too Dutch to follow a course in Turkish.
Some Turkish women were more Dutch than Turkish and spoke the
Dutch language well, and were therefore not interested in HMHB.
(Midwife I)
Of the 119 women who had a first individual HMHB
consultation with the CHW, 105 (88%) actually took part
in one or more of the HMHB meetings (Table 3). Reasons
to drop out were: unclear (n = 7); moved elsewhere (n = 2);
busy with work or school (n = 4); or having other children
to care for (n = 1). The number of participants was the
lowest in District II (n = 24), the highest in District III
(n = 45) and somewhere in between in District I (n = 36).
This was not congruent with the number of ethnic Turkish
inhabitants and deliveries per month. One possible reason
for this was that the CHW was not integrated into
midwifery care.
Implementation sites
The HMHB programme was the easiest to implement in the
only PCC where both maternity and infant care were actually
available at the same location (District III). The integrated
nature of this PCC clearly improved the collaboration
between the midwives and the CHWs. This continuity was
lacking to a great degree in the other two districts.
I recognize that especially in District II, where the midwifery practice
is geographically further away from the main PCC, the contacts
between the different disciplines are more problematic than in the
other districts. (HMHB coordinator)
The integrated PCC in District III also allowed the CHW
to combine her work for the HMHB programme with her
regular work for both the midwives and the maternity care
workers in the PCC. This made her a familiar presence,
and as such, easy to approach for both clients and
professionals.
Collaboration and integration
Integrating the CHWs into the midwifery practices appeared
to be critical to implementing the HMHB programme. In two
districts, the CHWs were attached to the midwifery practice
and supervised by the midwives themselves (Districts I and
III). This made the midwives feel responsible for the CHWs,
enthusiastic about the CHWs’ role and performance and keen
about the HMHB programme itself. This resulted in a close
collaboration (i.e. regular face-to-face contact) in which the
Table 2 Sociodemographic characteristics of the HMHB partici- pants (n = 105)
HMHB
group, n (%)
or mean ± SDSD
Age (years) 27 ± 4Æ8 First generation* 87 (83)
First generation partner* 95 (81)
Length of residence in the Netherlands� 9Æ5 ± 7Æ5 Woman’s educational level�
Low 49 (47)
Moderate 24 (23)
High 32 (31)
Financial situation
Using savings or accumulating debts 49 (47)
Exactly enough 24 (23)
Good financial situation 32 (30)
Nulliparous (first child) 42 (40)
Smoking (yes) 20 (17)
Living with their parents (or parents-in-law) 19 (18)
Minimal knowledge of the Dutch language�,§ 36 (34)
Ethnic self-identification: feeling exclusively Turkish 85 (82)
*First generation: participant was born in Turkey; second generation:
one of her parents was born in Turkey. �First generation only. �Low: none or primary education; moderate: lower vocational
training and lower general secondary school; or high: intermediate
and higher vocational training, advanced secondary education and
university. §Combination of three questions about speaking, reading and
understanding the Dutch language.
A.E. Hesselink and J. Harting
� 2011 The Authors 2030 Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd
CHWs were treated as an integrated part of midwifery care.
The CHWs were involved in additional tasks, such as
interpreting during midwife consultations, helping midwives
during home visits, and giving pregnant women information
on specific topics during extra consultations. In one district
(District III), the midwives even invited themselves to one of
the HMHB classes.
The most important reason we give information ourselves is to show
the participants that the CHW is part of our team and that we
support the information she is giving. (Midwife III)
In the other district (District II), the CHW was not
integrated into the midwifery practice. Most individual
consultations took place at the PCC, and some took place at
the midwifery practice on days when there were no midwife
consultations planned. For this reason, the communication
with the midwives remained limited mainly to the notes
recorded by the CHWs of their individual consultations
with the participants. Despite mediation efforts by the PCC
manager and the HMHB coordinator, the communication
and collaboration in this midwifery practice remained
problematic.
Recruiting participants and keeping them involved
The recruitment and continued involvement of participants in
the programme appeared to be the most difficult parts of the
intervention.
Recruitment is usually the biggest problem. When you want to invite
people for group classes, you tell people what it’s about, you explain
it again, and then someone else explains it. It’s something that needs
your constant attention and energy. (HMHB coordinator)
However, recruiting second-generation ethnic Turkish
women appeared easier than recruiting women from the first
generation.
Women from the second generation get in touch on their own and are
more independent, while women from the first generation are
reluctant. (CHW III).
At the start of HMHB, midwives asked the women to attend
the programme, and if they agreed, the CHWs invited them
for the first individual consultation. Since the number of
women approached was initially rather low, the CHWs in
Districts I and III started to collect patient records with
Turkish names and to invite these women by phone. Most
interviewees regarded the CHWs as being able to inform the
potential participants more effectively.
She (the CHW) can tell the women about the programme in their
own language, as well as why it is offered to them and what they can
expect. (Midwife III)
As in District II, the CHW was not an integrated part of
midwifery care, and she was not allowed to look for Turkish
names in the midwife’s patient records or to contact
women independently. Therefore, the recruitment of women
Table 3 Number of participants per district
Total District I District II District III
Total number of inhabitants* 41,335 43,913 33,847
% inhabitants with a Turkish background* 17 8 9
Absolute number of inhabitants with a Turkish background* 6806 3686 2914
Deliveries per month 38 25 27
Number of HMHB programmes given 16 6 5 5
Initial number of participants� 119 45 27 47
Participants who attended the programme� 105 (88%) 35 (78%) 24 (89%) 45 (96%)
Present for�
0–3 group classes 15 (14%) 8 (23%) 3 (13%) 3 (7%)
4 or 5 group classes 36 (34%) 13 (37%) 9 (38%) 14 (31%)
6 or 7 group classes 54 (
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