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A Guide to Developing a TB Program Evaluation Plan

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Appendix A: A Sample Evaluation Plan

In October 2002, health commissioners in the fictional Lull County funded a program to address the rising incidence of TB among the Salvadoran community. The following year, they asked for an evaluation to be done to show whether or not the program was working, and based on this evaluation future program funding will be decided in April. The following evaluation plan, using the template presented in A Guide to Developing a TB Program Evaluation Plan, was developed to answer their questions.

TB Support Program - Evaluation Plan for January – March 2004

Prepared by:  Ana Garcia TB Nurse

Department of Health and Human Service
Division of TB Control & Prevention Lull County

November 15, 2003

Note: The scope of this evaluation plan is based on a small size program. TB program staff is encouraged to start their evaluation small, focusing on areas or program components where improvements may be needed most.

INTRODUCTION

Tuberculosis was not a major concern in Lull County until in the recent years. According to the county report, an average of 3 cases was reported per year from 1995 to 2001. In 2002, six new cases of TB were identified within three month period. Unlike previous years, the infected suspects were new immigrant Salvadoran men rather than the predominant white population. In response to this epidemic, “TB Support Program” was implemented by the county health department director, Henry Evans, to control and prevent further transmission of TB in Lull County.

Evaluation Goal

The goal of this evaluation is to determine the effectiveness of “TB Support Program” in preventing transmission of TB among Salvadoran immigrants. This evaluation will investigate components of the TB Support Program that are performing optimally and should be expanded and replicated in future initiatives. In addition, this evaluation will help determine the funding needs of TB Support Program for the following year.

Evaluation Team

Our team consists of TB Support program staff and a nurse from the TB clinic who works within the system and can access clinic/program data easily. A member of the county commission was asked to participate on the team to review plans and ensure needs for information are met.Carlos, a leader from the local community who has a background in the social sciences, was also asked to participate to ensure the evaluation is culturally appropriate to the target community.

Table 1. Roles and Responsibilities of the Evaluation Team Members

Individual Title or Role Responsibilities
Ana (TB nurse) Lead Evaluator Oversight of all evaluation activities to ensure the evaluation is conducted as planned

Coordinate meetings for the team

Libby (Program manager) Data Analysis Analyze quantitative data Coordinate the analysis of qualitative data Ensure implementation of findings
Don (County health commissioner) Stakeholder/advisor Provide support and guidance and dissemination of results
John (Outreach worker) Data collection Gather and review data (QA?)
Carlos (Health outreach projects director, Latin American Association, (CBO)) Community liaison Coordinate data collection with community members

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I. STAKEHOLDER ASSESSMENT

Note that stakeholders can be divided into 3 major categories: persons involved in program operations, persons served or affected by the program, and intended users of evaluation findings. Organize the list of stakeholders to make sure no one is left out.

At the monthly TB program staff meeting, the evaluation of TB Support Program was discussed. The following stakeholders were identified, along with their interests and perspectives and how each stakeholder should be involved in the process. After the meeting, Carlos was also contacted to give perspective on how patients and the community should be engaged. The following table summarizes the plan for stakeholder engagement.

Table 2. Stakeholder Assessment and Engagement Plan

a. Persons involved in program operations

Stakeholder categories Interests/
perspectives
Role in the evaluation How to engage
Libby, John, Ana and other staff Fear program (and jobs) may be negatively changed

See program evaluation as a personal judgment

Defining program and context

Identifying data sources

Collecting data

Interpreting findings

Disseminating and implementing findings

Meetings

Direct roles in conducting evaluation

b. Persons served or affected by the program

Stakeholder categories Interests/
perspectives
Role in the evaluation How to engage
Patients of the TB clinic May fear or reject clinic/health system

Want better and accessible services

Providing customer perspective

Interpreting findings

Survey
The foreign born community in general May be suspicious of outsiders to neighborhoods, especially if illegal immigration is an issue Providing community context Inform of findings
Other service programs in the area (employers, hospitals) May or may not be coping with similar challenges Disseminating findings to community audiences Inform of findings

c. Intended users of evaluation findings

Stakeholder categories Interests/
perspectives
Role in the evaluation How to
engage
Libby To show effectiveness

Use findings to enhance the program

Defining information needed from the evaluation

Developing and implementing recommendations

Direct role in conducting evaluation
County Health Commissioners

 

Clinical staff

Know if the program is effective: best use county funds

Provide effective and acceptable treatment and care interventions for TB

Providing administrative/ funding context

 

Interpreting findings

Interpreting findings

Modifying practice (if needed)

Don, direct role; others through a meeting

Meeting

CBOs and community planning board- Carlos Improve community health, well being Disseminating findings Inform of findings

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II. BACKGROUND AND DESCRIPTION OF THE TB PROGRAM AND PROGRAM LOGIC MODEL

Need

Most of this description comes from program materials (i.e. grant application, reports and other program promotional materials).

A culturally competent TB prevention program such as TB Support Program is needed to combat the rise of TB incidence among the Salvadoran immigrant community of Lull County. Newly arrived persons from a high TB incidence country to Lull County are a major concern. Persons with TB disease and infection are not being reached for timely treatment. Consequently, TB cases are found on hospital admission after extensive health damage has occurred and community transmission demonstrated. Some newly discharged TB patients are lost to follow-up.Treatment cost increases along with the rising morbidity, ill-health, and suffering of the community members. The need for immediate attention to TB is great. If the problem is left unattended, backlash against foreign born population is possible.

Context

Historically, Lull County has been a low TB incidence area. Recent surge in the number of TB cases has raised concerns in the community. TB prevalence among the large number of newly arrived immigrants was fairly high. Although the need for TB elimination and prevention in this community is great, the capacity and resources needed to address the magnitude of these surging TB issues in Lull County is limited. TB Support program, an outreach program using “lay health advisors” (LHAs) to target new immigrants in the community, is implemented in response to this need. Under TB Support program, Spanish-speaking lay health advisors are to provide directly observed therapy (DOT) and social support in the immigrant community to increase targeted testing and treatment adherence and promote early case finding in the community.

Target Population

The target population for TB Support Program is newly arrived Salvadoran immigrants who cannot speak English, have limited resources, a small pool of family and friends if any at all, and may possibly have legal problems with their immigration status.

Objectives

The goal of TB Support Program is to eliminate TB transmission in the Salvadoran community, improve quality of life, and ultimately, to eliminate TB in Lull County. In order to achieve this overarching goal, program objectives were identified for the first year of the program.

  1. Increase percentage of newly arrived, foreign born Salvadoran TB patients who adhere to treatment to 100% by December 2003.
  2. Increase the number of newly arrived, foreign born Salvadoran patients being treated for TB or LTBI by December 2003.
  3. Increase percentage of Salvadoran community members who understand what to do if someone has a productive cough for 3 weeks or more by March of 2004.

Because the program and problem are new, specific baselines, i.e., how much of an increase can be expected, is unknown.

Stage of Development

The program is relatively new; in operation for less than a year.

Resources/Inputs

Lay heath advisors (LHAs), TB staff, funding, community based organizations and community health centers serving the Salvadoran community are key inputs of TB Support program.

Activities

Lay health advisors (LHAs) training, community outreach/education, TB screening/testing, prescribing treatment, and DOT visits make up the major activity categories.

Outputs

As a result of the efforts done in TB Support Program, LHAs were hired and trained, counseling provided, TB outreach/education conducted, test conducted, referrals made, a treatment plan developed, and DOT was administered.

Outcomes

A list of short-term outcomes include: patient’s knowledge increased, trust is built, patients accept treatment for TB or LTBI, patients identify contacts and possible source of cases, and patients use TB and other services. Intermediate outcomes: patients adhere to treatment, complete treatment, reduce hospital admissions for TB among Salvadorans, and reduce transmission of TB. Long-term outcomes: Salvadoran patients are healthier; eliminate TB in Salvadoran community, and healthier community.

The resources, activities, outputs and outcomes are listed in sequence in the following table. The logic model, after drawing arrows, “fleshes out” how the components link together and interconnected to produce results.

Table 3. Project Description of TB Support Program

Logic Model

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III. FOCUS OF THE EVALUATION

Stakeholder Needs

What the stakeholders need to learned from the evaluation is explored in stakeholder assessment in section I under intended users of evaluation findings. Information from that section can be refined and adopted for assessing stakeholder’s needs here.

From the beginning, four groups of people were identified as the core users of the evaluation findings. They will be using the findings in different ways and for different purposes. The table below summarizes the users of this evaluation, what information they need or would like to get from the evaluation, and how they intend to use that information to achieve what they need or set out to do.

Users Need/Want to Know Uses
County administrators Whether the program is working or not Determine whether the program should be funded to continue or expand its services
Program Manager How to enhance or refine the program Implement change to increase effectiveness of the program
Clinical staff Clinical outcomes Adjust clinical practice if needed
CBO representatives Social health outcomes Advocacy to community

Evaluation Questions

Note that the evaluation questions do not address all of the program objectives. Priorities must be set based on need for information and resources available.

Although the evaluation team generated many possible questions in a brainstorming session, the evaluation team prioritized the following as representing the most important aspects of the program that could be examined at this time.

To determine if the program has been implemented as planned:

  • Has appropriate (Spanish-speaking with a good understanding of Salvadoran culture) staff been recruited?
  • Has the staff (all TB program employees) been trained appropriately (in TB practice and cultural competency)?

To determine if the program is meeting its objectives:

  • Have more Salvadoran persons been tested and treated appropriately (clinically sound, in Spanish, in a culturally sensitive manner) for LTBI or TB?
  • Are Salvadoran patients adhering to treatment (not lost to care and follow-up)?

Evaluation Design

The evaluation team decided to use multiple data sources because the program was small (few number of people served), the need to obtain information to improve the program was high, and in-depth information was needed. No control or comparison group seemed appropriate.The team discussed reviewing records for Salvadoran patients in the past and comparing these data to current program information, but realized that it would be difficult since data in the files were incomplete. The decision was made to assess the data against the benchmarks the program has set. Further, it was decided that the data collected for this evaluation would serve as a baseline for later evaluations.

Resource Consideration

Assessing the treatment adherence rate of Salvadoran patients will tell us whether the program is reaching its objective. However, the logic model shows that addition data may be needed to provide us with important information and insight into why the objective is achieved or not, and what can be done to improve the program.

Resource available for evaluation is limited. Manpower consists of 1 full time staff member who is only able to devote a few hours a week to the evaluation. The other evaluation team members are able to devote only a limited amount of time to the evaluation.However, several of the evaluation team members work together and most stakeholder groups meet regularly.Thus, some evaluation work can be done as part of existing routines. Personnel records, training curriculum and clinical records are available as existing data sources.

Additional data collection measuring patients’ perception will be needed to understand whether patients feel trust is built with their health care providers and whether their TB knowledge has increased.

Evaluation Standards

The evaluation team agreed that the evaluation data will be useful, and should be feasible to collect. Propriety will be addressed through consent form and all data will be kept confidential. While the group agreed that there may be some issues regarding record keeping or patient willingness to answer honestly, the accuracy of the strategy was judged to be acceptable.

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IV. GATHERING CREDIBLE EVIDENCE: DATA COLLECTION

Indicators

The evaluation team recognized that the terms used the evaluation questions, e.g., “appropriately,” needed to be operationalized, and the following list of indicators show the team’s decisions. Since several program objectives were vague, the evaluation team had to determine benchmarks that seemed reasonable, given the limited information available. Each member of the evaluation team informally talked with other stakeholders to ensure consensus.

Table 4. Indicators and Program Standards for Evaluation Questions

Evaluation Question

Indicators

Program Benchmarks

Has appropriate staff been recruited? Number of qualified (bilingual/bi-cultural) staff Two LHAs of different gender are on staff, both speak Spanish and are familiar with the Salvadoran culture
Has the staff been trained appropriately? LHAs received appropriate/adequate training in TB, interviewing and DOT

Other clinic staff were trained in working with LHAs and TB competency strategies for Salvadorian culture

All staff attended trainingTraining covered essential topics
Have more Salvadoran persons been treated appropriately for LTBI or TB? # Salvadoran persons treated by clinic for TB or LTBI

Clinical treatment standards

Signs, forms available in Spanish

Clerks/staff know to access translators/LHA

Patient’s attitude of trust for TB program staff recommendations

Each month of program operations has shown an increase in the number of Salvadoran patients

Clinical standards met

Patient education signs and forms in Spanish

Staff knows how to access and use translators

90% of Salvadoran patients report they believe what their provider tells them about TB and trust their provider’s recommendations.

Are Salvadoran patients adhering to treatment? Attendance at DOT and clinic visits 100% Salvadoran TB and LTBI patients who miss an appointment are immediately rescheduled and keep appointment; no one is lost to care

Data Collection

The evaluation utilizes several methods of data collection in various ways: interview, survey, observation, and record review. Staff interview will be conducted to assess knowledge and behavior in accessing translators and LHAs. Written survey (in Spanish) will be administered to the patients in the clinic waiting room to assess patients’ perception of the clinic (access to care, hours, acceptable environment/staff) and their comfort level (attitudes and beliefs) about the staff (a compromise due to limited funding). Observation will be conducted to assess staff behaviors and language used in TB awareness signs. Lastly, review of records, charts and training materials will be conducted. Table 5 summarizes the data source and data collection methodology that will be used to gather evidence for evaluation.

Table 5. Data Collection Plan

Indicators Data source Data Collection Method
Number of qualified (bilingual/bi-cultural) staff LHA staff

Personnel records

Observe presence of staff

Review records if staff not present

  • Carlos
  • Feb.4-10
LHAs received training in TB, interviewing and DOT Other clinic staff were trained in working with LHAs and cultural competency Training attendance records

Curriculum

Review records of training sessions and attendance, materials presented
  • John
  • Feb.6 -15
# Salvadorian immigrants treated by clinic for TB or LTBI Clinical treatment standards (calendar of standard appointment dates based on initiation of TB drugs) Signs, forms available in Spanish Clerks/staff know to access translators/LHA Patients feel they can trust the TB program Clinic records, interviews with staff

Clinic charts

Signs and forms

Staff knowledge and behaviors

Patient perceptions

Review records for country of origin and date of arrival in US, notes in file, ask staff to identify from client list
  • Libby
  • Feb.8 -15

Chart review

  • TBA

Observation

  • Staff Feb.3 -25

Interviews/observations

  • TBA

Survey sample of patients (forms and drop box in clinic waiting room, in Spanish, no identifiers asked)

  • Feb. 1-28
Attendance at DOT and clinic visits (appointment system and missed appointment follow-up) Program visit records Review records, noting if any patients are lost of care
  • TBA

Plan Timeline

Table 6. Illustrative Timeline for Evaluation Activities

Evaluation Activities Timing of Activities for Jan – Mar. 2004
Jan Feb Mar April
Evaluation planning
+
 
 
 
Data collection
 
+
 
 
Analysis/interpretation
 
 
+
 
Report/dissemination
 
 
 
+

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V. JUSTIFY CONCLUSIONS: ANALYSIS AND INTERPRETATION

Analysis

Both quantitative and qualitative methods will be used to analyze the data. Simple counts of frequency will be use for quantitative data analysis. Qualitative methods such as content analysis will be used to review training curriculum, patient charts and records for themes and patterns.

Table 7. Analysis Plan

Data Analysis Technique

Responsible Person

Quantitative – frequency/counts

Libby

Qualitative – content analysis

Libby, Ana and staff

Interpretation

Stakeholders including the county administrator, program manager/staff, LHAs, medical staff and CBO representatives will be included in a scheduled meeting to interpret the findings. The data from the evaluation will be compared to the established program benchmarks. Stakeholders and those involved in program operations will be given an opportunity to justify the findings and make recommendations accordingly.

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VI. ENSURE USE AND SHARE LESSONS LEARNED: REPORT & DISSEMINATION

Dissemination

Evaluation finding will be disseminated via various channels. Presentations will be given at the program staff meeting and to the health care providers at regular staff meetings. A short report will be drafted and a presentation offered for the county health commissioners. An article will also be added to the newsletter the health department periodically compiles. Carlos will also write an article to go in a local Spanish newspaper and offer to present at community meetings.

Table 8. Dissemination Plan

Yes

Dissemination Medium

Responsible Person

 

Presentations at staff meeting

Presentation to health care providers

Libby

 

Report and briefing to county administrator and commissioners

Ana

 

Article in HD newsletter

Libby/John

 

Article for community newsletter, briefings to community groups

Carlos

Use

Libby, the program manager, and staff will use the findings to refine program strategies for TB Support Program. The findings will help guide the program to focus on areas that are most crucial for effective service delivery. Health care professional will use the finding to improve their medical practices in serving Salvadoran community. County health department administrators, led by Don, will use the findings to determine the future funding distribution for the program. The community liaison, Carlos, will use the findings in advocacy efforts. Finally, findings from this evaluation will be used for future evaluations.

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