using action research to attain mdg maternal and child health goals in haiti
DESCRIPTION
A proposed action research project to promote MDG goals for maternal and child health in Haiti.TRANSCRIPT
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Running Head: HAITI MATERNAL AND NEWBORN HEALTH CARE ACCESS
Final Project, Capstone Seminar
Action Research
Judith Bond
Dr Alexander
NPMG-6910-3
Walden University
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Abstract
This paper seeks nascent solutions to the Interim Haiti Recovery Commission (IHRC) strategic
goal to improve maternal and newborn access to health care and “build Haiti back better”. An
Action Research paradigm is employed to engage internal and external stakeholders in the
intervention development process, enhance indigenous learning and problem solving capacity.
Post-quake obstacles and challenges are addressed including infrastructure and health worker
deficiencies. Recommended solutions include employing “bridgebuilder” patient advocate, case
manager, and wellness coach positions to bridge gaps in service delivery. Positions are designed
to offer educational and self-management support for sustainable outcomes, web based
technologies, mobile clinics and rural self-management stations. Materials will be adapted for
ethnographic use.
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Action Research
Clinton Bush Haiti Fund
Judith Bond
On January 12, 2010, a massive earthquake hit Haiti, leaving more than 200,000 dead,
300,000 injured and 1 million homeless. An Interim Haiti Recovery Commission (IHRC)
(2011) co-chaired by U.S. President Bill Clinton and Haitian Prime Minister Bellerive was
established to oversee recovery efforts. Clinton plays a multi-dimensional role in Haiti. In May,
2009, he was appointed U.N. Special Envoy to Haiti with a goal of economic recovery and “to
build Haiti back better” after the 2008 hurricanes (Clinton Foundation, 2011). Dr. Paul Farmer,
founder and Executive Vice President of Partners In Health (PIH), was appointed Deputy Special
Envoy (Partners In Health, 2011). Partners in Health has a longstanding history of health care
delivery and poverty alleviation initiatives in Haiti and other undeveloped countries, The Clinton
Foundation, an NGO with multiple global programs, also established a specific Haiti
fund/outreach program and aid for Haiti through its Clinton Global Initiative (Clinton
Foundation, 2011). Immediately after the quake, President Obama asked former Presidents Bill
Clinton and George W. Bush to engage in fundraising efforts and the Clinton Bush Haiti Fund
(CBHaitiFund), a 501©(3) was established to offer grants and program-related investments that
support self sufficiency, sustainable growth and reduce outside aid-dependence. The 501 © (3)
receives logistical and administrative support from the co-chairs respective personal foundations
(Clinton Bush Haiti Fund 2011).
A 115 page Needs Assessment Report was completed indicating the greatest need was in
the social sector: health, education, water and sanitation, food, safety and nutrition (Haiti Special
Envoy, 2011). The IHRC developed a strategic plan to meet needs. One of the health sector
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goals is maternal and newborn access to care with a minimum estimated gap cost of $12 million
(IHRC, 2011).
Attaining these goals is contingent upon addressing multiple challenges. The quake
destroyed a significant portion of indigenous health care infrastructure and diaspora, migration of
health care workers from undeveloped countries to developed countries produced health worker
shortfalls. The current global shortage of more than 4.3 million health care workers is
aggravated by the fact that approximately 34 % of all health care workers reside in the U.S. and
Canada. Kuehm (2007) notes the WHO 2006 World Health Report outlines the many causes of
diaspora including economic conditions, inadequate working conditions, growing aging
populations, and increasingly high-tech health care. Lehmann, Dieleman & Martineau (2008)
note that despite global attention to and attempts to resolve the problem, the crises is worsening,
largely due to disintegrating infrastructure in low income countries, low wages, poor working
conditions and HIV/AIDS. Multiple contextual environmental, psychological and social risk
factors contribute to poor health: lack of hygiene and potable water facilities; indigenous beliefs
and practices including voodoo; childbearing without medical assistance, low levels of self-
efficacy beliefs to effect change; minimal literacy and educational levels; mental health problems
including posttraumatic stress disorder and depression.
In 1978 the Declaration of Alma Ata declared health a basic human right and established
a comprehensive definition of health adopted by the World Health Organization (WHO). Health
is defined as “a state of complete physical, mental and social well being and not merely the
absence of disease” (Hixon & Maskarinec, 2008). A significant amount of research supports the
case for integrated health care. Of the four basic conceptual models of health, medical, World
Health (WHO) holistic model, the wellness model and the environmental model, the WHO
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model is the sole model with a social component. Larson, (1999) notes social health is
associated with “distribution of economic wealth and other socioeconomic factors” “Social
health may be collective or individual” (p126). The Wellness Model is less holistic, focusing on
the impact of the mind on health, the mind/body connection, including biological processes such
as digestion. Larson and others note integrated mental/physical health delivery faces multiple
barriers, despite potential benefits. Findings that 30 to 60 % of primary care patients exhibit
symptoms of anxiety or depression that primary care physicians fail to recognize and go
untreated has yet to result in systemic change. Integrating mind/body health delivery systems is
challenging even in the U.S. Heinrich (2,000) notes the need for a variety of training and
dissemination strategies. Furthermore, questions arise about mental health assessment and
appropriate counseling delivery methods. Available methods including brief psychosocial
treatment, Motivational Interviewing (Miller & Rose, 2009), the 5A’s (Jay, Gillespie, Schlair,
Sherman, & Kalet (2010) and formal cognitive behavioral therapy counseling (Leahy, 2003)
require a wide range of specialized skills and training. Terre (2007) discusses the additional
complexity of broadening mental health counseling to include lifestyle interventions delivered in
a primary care setting. Combining treatment for mood and anxiety symptoms with exercise or
nutrition treatment may reduce risk of adverse effects. This research adopts the WHO definition
of health, and recognizes the importance of integrated mental health care and socio-cultural
influences, including economic factors. Maternal access to integrated biopsychosocial health
care is an essential component of the research.
The United Nations and WHO offer partnership opportunities for Haitian initiatives. For
example the UN Millennium Development Goals (MDG), established in 2000, vowed to end
poverty by 2015. In keeping with the WHO definition of health, the synergistic components of
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poverty and health are recognized in terms of nutrition, hygiene, health care access, and stress.
MDG’s include specific health care goals aimed at improving maternal health (U.N., 2009). A
2010 UN MDG summit pledged $40 billion for women’s and children’s health (U.N. 2010).
Access to these funds could help support the Haitian goals for maternal health. The Clinton
Bush Haiti Fund through its global partnerships including NGO’s and corporations can offer
critical links to the Haitian external environment, offer boundary spanning opportunities to
exponentially increase results obtained from UN funding, offer local health care worker
education opportunities, access to health care services in the US via technology, knowledge
transfer and economic opportunities both in Haiti and the U.S.
The United States, faced with its own health care worker shortage, is developing
innovative health care delivery systems, processes and health worker positions. For example,
case manager positions to integrate fragmented health care systems and multi-modal treatment
plans particularly for chronic care treatment (Corser & Dontje, 2011). Patient navigator/advocate
positions guide patients through the complex healthcare system, offer suggestions for alternative
treatment options, guide patients to health care providers and coordinate multi-step complex
treatment plans (Dorland Health, 2011). Wellness coaching supports health behavior/lifestyle
change, prevention activities, and self-management motivation (Simkin-Silverman, Conroy,
Bhargava, & McTigue, 2011). Training local Haitians to perform these or similar functions
could offer employment/economic opportunities, improve maternal health care access and
promote positive health outcomes. James P. Grant former Executive Director for UNICEF in his
forward to the book Just and Lasting Change (Taylor-Ide & Taylor, 2002) notes “science-based
interventions should be simplified so as to be applied in the home either by family members or
by easy access to peripheral health workers. The most important responsibility of health and
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other services is to promote capacity of families and communities to solve their own problems
with self-reliance “. Dr. Taylor, coauthor of the WHO Declaration of Alma Ata, founder of the
American Public health Association (APHA) International health Division and one time chair of
the John Hopkins school of International Medicine, advocates sustainable global community
health care programs, promoting the capacity of families and communities to solve their own
problems with self-reliance, community participation and simplification of science based
interventions to permit use and adaptation to families and local environments. Dr. Taylor
outlines a paradigm he calls SEED-SCALE designed to promote learning. Werner & Bower
(2005) in their book Helping Health Workers Learn provide guidelines on education delivery
methods to local health workers with low literacy levels. Other studies support the findings that
individuals respond to adaptation of scientific methods, visual presentation, and opportunities to
participate in solving local problems. Gardner’s multiple intelligence theory (Business Balls,
2011) indicates individuals have different learning styles and IQ or education level may not be
the sole measure of capacity to learn. This research will focus on developing indigenous training
and learning methods to increase community capacity to learn, problem solve and “build Haiti
back better”.
Multiple solutions may be available to Haitian communities. For example, Case worker
and Patient Advocate training available in the U.S. through Dorland Health (Dorland Health,
2011) could be adapted ethnographically to local literacy levels, and delivered in the local
language via distance technology. These positions become bridgebuilders between local Haitian
caseworkers, advocates, and coaches and their US based cohorts as well as bridgebuilders
between professional health care workers, health delivery systems and patients. Training and
resource access could be adapted for distance learning and IT delivery through IPads or IPhone
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applications. This research seeks to explore the feasibility and efficacy of employing the above
health care delivery positions and distance access to health services to improve community
maternal health care delivery in Haiti. The research question is: Will employing bridge builder
patient advocate, case manager, and wellness coach positions facilitate maternal health care
service delivery, health, and economic outcomes in Haiti?
Procedures Used
Action Research
An Action Research paradigm, originated by Psychologist Kurt Lewin, to promote social
action research and change management is employed (Lewin, 1951, 1997; cited in Cummings &
Worley, 2001). Stringer’s (2007) three stage action research process: “look, think, act” (p8)
offers research activity guidelines. The process requires cyclical, iterative, evaluation through
recursive reflection. Efficacy of implemented solutions/interventions, aka action, is subject to
reconsideration/adoption/redesign. Adaptations of Lewin’s Action Research model include
participatory action research, action learning and appreciative inquiry (Cummings & Worley,
2001) (p24-26). Adaptations can be integrated into the final process. Unlike quantitative,
experimental research, which measures the relationship between variables, focuses on narrowly
defined problems and “expert” solutions, qualitative action research explores social and
behavioral science problems originating in indigenous contextual environments, experiences and
perception; how things happen rather than why; socio-cultural influences, ethnography, cultural
relativism, and ecological, participative, collegial assessment and solutions The
researcher/consultant is a praxis facilitator, co-learner vice expert (Stringer, 2007). Action
Research aligns with Lewin’s concept of organizational development and change and his
unfreeze, move refreeze change model. Organizational Development (OD) employs an open
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systems change model, noting open systems are influenced by and exchange resources and
information with their external environment. When system components, including external
components fail to coordinate and align, suboptimization occurs. Key components of open
systems include: inputs, transformations, outputs, boundaries, feedback, equifinality, and
alignment (Cummings & Worley, 2001) (p 85). Fontaine (2008) discusses the importance of
systems thinking to strategic thinking and planning. Systems thinking views interrelationships
and their impact on the whole. Mental models,( beliefs and assumptions) are the foundation of
events. Fontaine (2008) employs an iceberg model to describe systems thinking. The tip of the
iceberg is events. Events occur because of beliefs and assumptions. To change events, one must
first ask “what are the beliefs and assumptions” then ask Why – how- what explains this – then
identify what has been happening (p88). Systems thinking requires identification of root causes
– not symptom evaluation and identifying leverage points to change the system. Integrative
thinking in lieu of conventional thinking seeks less obvious causes and contributing factors, sees
nonlinear multi-dimensional attributes of relationships between variables and seeks collective
innovative solutions in lieu of either or choices. Processes and educational tools identify mental
models, seek root causes and challenge thought patterns to enhance creativity, learning, change
and innovation. Design thinking as a creativity enhancing tool is devoid of judgments,
encourages participation, promotes psychological safety and risk taking; requires collaborative,
iterative, solutions; questioning current thinking, assumptions and processes to produce nascent
solutions. Learning is essential to and an outcome of systems thinking and analysis. “Learning
lies at the heart of both innovation and change” (Senge, 1990, cited in Shortell & Kaluzny, 2006)
(p390). Senge’s 1990 book The Fifth Discipline describes five essential innovation disciplines:
systems thinking, personal mastery, mental models, shared vision and team learning (p389).
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Argyris & Schon (1978; cited in Shortell & Kaluzny, 2006) first described learning as a feedback
process of single loop and double loop learning. Single-loop learning is a relatively simple
problem solving process where solutions are found in established policies, plans, rules and
values, for example, posting hand-washing reminders for health care workers. Double loop
learning occurs when problem solvers seek to change values, assumptions, plans, and policies to
close the gap between current reality and a desired future vision. Double loop learning
promotes generative learning and structural change. For example educating patients to self-treat
illnesses with natural cures or I-phone delivered diagnostics promotes generative learning. Isaaks
(1993) says double loop learning asks the question “What are alternative ways of seeing this
situation that could free me to act more effectively?” (p 6) and adds triple loop learning. Triple
loop learning further expands inquiry by asking, “What is leading me and others to have a
predisposition to learn in this way? Why these goals?” (p 6) For example – Why don’t patients
want to take responsibility for self management? What habits and environmental barriers must be
overcome? Promoting learning is essential to transnational multi-stakeholder interventions.
Stakeholders must re-examine world views, perceptions, cognitive schemas and mental models.
OD learning interventions seek to identify individual “Theories in Use”, (Cummings & Worley,
2001) (p522) mental models or cognitive maps that drive behavior. Methods include the Ladder
of Inference, Action Maps and dialogue. Individual thought patterns and perceptions must be
foregone to create collective vision, collaborative decision making and problem solving.
Taxonomies, theories and tools to assess, train and implement learning promotion practices
include Bloom’s Taxonomy of Learning Domains, Kolb’s learning style model and experiential
learning theory, Kirkpatrick’s four levels of learning evaluation, and Gardner’s theory and
assessment of multiple intelligences (Business Balls, 2011).
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Action research supports organizational development based assessments and
interventions, systems thinking, learning and equifinality. Equifinality implies multiple
processes and solutions can produce similar results. Stakeholders may develop diverse options
for attaining goals, each equally effective. The primary goal in Action Research is to make a
difference in people’s lives and enact action, in lieu of merely collecting data. This research
seeks to integrate the above methods and principles to attain Haitian maternal health goals and
increase community capacity for learning, problem solving and self reliance; community
intellectual and social capital and economic opportunity.
Changes in the health care industry offer opportunities to apply Lewin’s theories of
organizational development and Action Research. The shift from treatment of acute illness to
prevention and chronic disease management; changes in service delivery; shifts to self-treatment
and self-management; increased patient centeredness and emphasis on patient responsibility offer
opportunities for interventions and sustainable solutions (Cummings & Worley, 2001). Health
behavior research often neglects potential psychological and cognitive behavioral contributors
including co-morbidity etiology such as depression. A study conducted by Pace, Chaney,
Mullins & Olson (1995) indicated 60 % of all visits to primary care physicians are associated
with mental, not physical care. Nonetheless physicians are rarely trained to diagnose or treat
these disorders (Pruitt, Klapow, Epping-Jordan, & Dresselhaus ,1998). Bandura (2004) asserts
motivation to engage in healthy behavior is largely associated with self-efficacy beliefs, goals
and “outcome expectations, and perceived environmental impediments and facilitators” (p143).
“Belief in one’s efficacy to maintain control” (p 143) is largely responsible for considering
change, maintaining sustained motivation to change, coping with relapses, and maintaining
change. Additionally, health is largely contingent on social systems. Bandura addresses five
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core sets of health behavior change and health determinants based on Social Cognitive Theory.
Self-determination theory indicates sustained behavior change occurs when individuals do not
feel pressured, controlled or policed (Bellg, 2003) . This research will explore biopsychosocial
interventions, Social Cognitive and Self Determination theories as foundations for health
behavior change and self management.
In the interest of establishing credibility and trust in the research process, replicability,
confirmability, transferability and dependability (Stringer, 2007), a research paradigm is
essential. A one-year timeline is established. Intermittent formative evaluation and year-end
summative evaluation will provide data to assess outcomes.
The role of the researcher in Action Research is unique, acting as a praxis/learning
facilitator, co-learner in lieu of expert (Stringer, 2007), or process consultant (APA, 2007).
Herrera & Kagan (2009) distinguish between two forms of participatory evaluation practical
participatory evaluation (P-PE) and transformative participatory evaluation (T-PE) (p328). The
researcher/evaluator’s role varies depending on the evaluative structure. P-PE evaluations are
designed for program decision making whereas T-PE evaluations are aimed at
“democraticization of social change processes by empowering more marginalized participants”
(p328). The subject research is a P-PE evaluation and thus, in keeping with that classification,
the evaluator/researcher role is “recognition of the function, skills, and abilities of the
stakeholders” to ensure stakeholder capacities are maximized and researcher involvement in
political projects beyond the organizational level. As praxis/learning facilitator, the researcher
will assume four primary roles/functions; adhere to four components of the Action Research
model; and four research guiding principles as follows. First, the Action Research Model and
principles will be based on guidelines offered by Stringer (2007) and Cummings & Worley
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(2001); Appreciative Inquiry guides outlined in Cummings & Worley (2001) and participative
research guides in Suarez-Herrera & Kagan, (2009), White & Verhoef (2005) and van der Riet
(2008) (2). Evaluation and strategic planning will adopt an open systems, OD, learning
paradigm (Fontaine, 2008; Cummings & Worley, 2001). Processes attending to reciprocal
determinism, ecology and external environment evaluation including Force Field Analysis and
SWOT analysis (Mind Tools, 2011) may be considered. Individual and collective learning
(Senge, 1990 cited in Shortell & Kaluzny, 2007; Cummings & Worley, 2001); altering mental
models and schemas (Isaacs 1993; Cummings & Worley, 2001) is a primary focus. Health
psychology precepts will serve as the foundation to explore methods to promote self
management, self efficacy, individual and collective agency, problem solving, and habit change
(Bandura, 2000, 2004, 2006) (Ewart, 1991)(///habit . Delivery of biopsychosocial integrated
health care , functional, preventive medicine (The Institute for Functional Medicine, 2008),
including natural, indigenous cures; food as medicine and nutrition/hygiene needs ( should be
explored. Second, the researcher will ensure community participants have the tools and resources
to serve as active agents in the process and problem solve. Stakeholders, including community
participants will receive ethnographically appropriate education on prior evidence-based
research; technology including computer, IPad and smartphone; action learning and team
building; communication, decision making, and conflict resolution; data collection and
evaluation; and ethics. Participants will be provided local, web based and transnational
resources and tools. Third, the researcher will ensure measurement systems are available,
assessments and evaluations conducted, accountability systems established and results
documented. A fourth role of the researcher is to facilitate collaborative decision making and
conflict resolution. Global Social Change Organizations (GSCO’s) have strong values,
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ideologies and causes, all of which offer intrinsic reward. However, interaction with a broad
range of international constituencies, political environments, profit and nonprofit organizations
can result in high levels of conflict. Conflict resolution processes include employing a facilitator,
dialogue, initiating decision and participation rules, and encouraging design thinking (Cummings
& Worley, 2001). Lay team facilitator training will ensure trained facilitators are available to
research teams. Resistance to change is a basis for a significant degree of conflict. Assessment
of readiness for change and processes to overcome resistance and promote learning (Suarez-
Herrera, Springett & Kagan, 2009) is essential to research success. Stringer (2007) says the
primary task of the researcher is to “ develop a context in which individuals and groups with
divergent perceptions and interpretations can formulate a construction of their situation that
makes sense to them all – a joint constructions” (p41). As a result of this “hermeneutic dialectic
process” (p41) new meanings emerge, new world views, new perspectives and beliefs can be
synthesized and creative, innovative collective solutions developed.
Stage I “Look”
The primary objective of the look stage is to gather and analyze qualitative/quantitative
data and information designed to reveal research population participants and stakeholders
contextual experiences, values, reality, assumptions, practices and beliefs. Stringer (2007) offers
an overview of this “building the picture” stage on page 93.
Stakeholders
The first step in Stringer’s (2007) “Look” stage is stakeholder identification. The
transnational nature of this research required identification of internal and external stakeholders.
Evidence-based research typically defines stakeholders as individuals groups and organizations
“who have an interest (stake) and the potential to influence the actions and aims of an
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organization, project or policy direction (Brugha & Varvasovszky, (2000). Stakeholders may
include individuals and organizations who offer potential funding and resources for the project.
Procedures for stakeholder identification include social mapping to identify critical reference
groups (p45), individuals most concerned with the issue, maternal health care, and health care
delivery. Identification of community informal micro-political power bases, gatekeepers and
opinion leaders is conducted at this stage. Stringer (2007) recommends asking visible community
stakeholders who else should be included and asking questions provided on page 53(p53). As a
minimum, community stakeholders will include health care workers; girls over the age of 15,
women of childbearing age; husbands/fathers; hospital/clinic health service delivery
administrators; political representative of the new Haitian government headed by President
Michel Martelly, the Minister of Health, community/camp leaders and decision makers:
representatives from the IHRC and UN Special Envoy including Partners in Health (PIH); local
Haitian operated Aid and public service organizations with an interest in the problem, local
training and education facility operators; local IT service delivery organizations. External
transnational stakeholders include representative of the CBHaiti Fund, NGO’s and foreign aid
organizations with an interest in the problem, e.g. PIH; potential service delivery corporations,
organizations and partners e.g. Dorland Health (Dorland Health, 2011). All national, community
and value-adding transnational stakeholders may be included. McVea (2005) notes the
importance of “knowing” individual stakeholders, employing entrepreneurial strategies to engage
them and bring “idiosyncratic individuals” together to develop solutions beneficial to all (p57).
Researchers and stakeholders must develop an understanding of the “stake” each stakeholder has
in the desired outcome, identify what is most important to the stakeholder and develop
“modular” solutions enabling stakeholders to choose among several options concerning their role
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and contribution. Mind Tools (2009) defines two steps in the stakeholder process: Stakeholder
analysis identifies the key players who must be “won over” (p167) and stakeholder planning
employs steps to obtain their support. Brainstorming helps identify potential stakeholders,
power/interest grids (p 169) help determine the degree individual stakeholder have power over
and interest in desired outcomes. A series of questions can facilitate understanding stakeholders
(p169). Guidelines for managing stakeholder, developing influence maps etc (pp 172-176)
facilitate research record keeping and planning. An integral part of the stakeholder process is
determining the research participant population to whom “treatment” is to be administered and
who will provide data required to measure health care outcomes. Stringer (2007) describes this
process as “purposeful sampling” (p 43). The process differs from experimental research
random sampling. Purposeful sampling focuses on individuals affected by the problem.
Individuals are selected based on specific attributes. In this case, pregnant women and women
who delivered infants within a three month period prior to the beginning of the research will be
selected for the initial round.
Ethics
Minkler (2004) discusses ethical challenges for Community-Based Participatory
Research including racism. Respect for socio-economic, educational and literacy differences,
eliminating ethnocentrism, equal participation by all community members and balance of power
are essential. Process guidelines, decision rules and memos of understanding can establish a
foundation for behavior, respect and collective decision making. Whitbeck (1996, cited in
Cooper, 2006) offers a five step ethical decision making model. Knapp & VandeCreek (2007)
provide guidelines for multi-cultural ethical decision making. While building trust requires
transparency and information sharing, research participants may be concerned about release of
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specific data, particularly health status data. Fisher (2008) discusses ethics issues associated
with protecting confidentiality right. Participants should sign a confidentiality agreement and be
provided a full disclosure statement regarding purpose of research and potential uses of outcome
findings. Informed consent requires four things: (1) the general research purpose is revealed (2)
procedures employed, purposes and possible risks defined (3) information on why participants
were selected and (4) what will be done with the information, limitations on confidentiality and
to whom information will be disseminated (Cooper (2006) (p 259). The Belmont Report
identified three ethical research principles: respect for persons, beneficence and justice (p259)
Five patient centered ethical principles adopted by the Case Management Society of America
include: (1) autonomy (2) non malfeasance (3) beneficence (4) justice and (5) fidelity (CMSA,
2010). All participating professionals should adhere to their individual professional Code of
Ethics. Professional Patient Advocates primary responsibility is to the patient and their family
regardless of the interests of the organization they serve. The code is available at
www.patientadvocatetraining.com. Lowman’s (2006) book The Ethical Practice of Psychology
in Organizations provides guidelines for ethics in Organizational Development and research.
Stringer (2007) also provides a checklist (p57) and guidelines to promote trust and process
integrity. Studies should be (1) credible (2) transferable (3) dependable and (5) confirmable.
Quinn (2004) discusses ethics issues in community based participatory action research,
particularly informed consent.
Data Collection
Unlike experimental research, Action Research relies more on data and information
concerning the environment in which participants experience and seek to solve the problem and
the participants experiences and perceptions. Formal and informal interviews and environmental
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“guided tours” (Stringer, 2007) (p71) offer opportunities to gather impressions to examine
participants contextual worlds and everyday experiences.
Additional data collection methods include focus groups, observation, questionnaires,
documents, records and reports, surveys, and research literature (p 68). Where facilitated focus
groups appear appropriate, Stringer (2007) offers a facilitation framework (pp74-75). Guidance
for developing surveys is available on pages 78-79. Surveys can be developed and administered
orally, via Survey Monkey, online (Survey Monkey, 2011), or in hard copy depending on
participants literacy and IT skills.
The subject research seeks to improve population health and economic outcomes. Both
quantifiable and qualitative measurement data are required to determine outcomes and
effectively analyze the value of interventions developed. Appreciative Inquiry, focusing on what
is positive and right can reduce defensiveness, and enhance learning (Cummings & Worley,
2001). This process may be particularly effective for interviewing physicians, political leaders
and health care service delivery providers. Additional “hard” data required includes (1)
epidemiology surveys to identify the general state of community participants health and risk
factors; (2) demographics to determine the total population, number of participants impacted by
the problem and their age; (3) Psychometrics to determine research population readiness for
change, self efficacy levels, self management skills, mental health, perceived health and actual
health and perceived social support systems, nutrition and food access, environmental and social
stressors, coping skills;(4) Potential case manager, patient advocate and coach skills,
competencies, intelligence, and learning style; including literacy levels, health care knowledge,
IT skills, and readiness to learn Business Balls, 2011). “Taking a tour” and observation can
identify environmental obstacles and opportunities, living condition, the built environment, food
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security. Stanford School of Medicine’s chronic care self management program offers
comprehensive evidence based research instruments (Stanford, 2011). Survey instruments are
also available through Statistics Solutions (Statistics Solutions, 2011). Intelligence and learning
assessment instruments are available on the Business Balls web site (Business Balls, 2011). All
instruments will be ethnographically adapted to local language and literacy levels. Examples of
potential evaluation/assessment tools include: Gardner’s Multiple Intelligence Test (Business
Balls, 2011) A Lexicon for Measuring Maintenance of Behavior Change (Seymour, Hughes,
Ory, Elliot, Kirby, Migneault, Patrick, Roll, & Williams, 2010); Measuring Social Value
(Mulgan, 2010); Behavioral Risk Factor Surveillance System Questionnaire (www.cdc.gov,
2011); the Health Status Questionnaire (Statistics Solutions, 2011); Perceived Medical
Condition Self-Management Scale (PMCSMS) (Wallston, Osborn, Wagner & Hilker, 2011); Is
Yours a learning Organization? (Garvin, Edmondson & Gino, 2008).
OD assessments are conducted at three levels: organizational, group and individual
(Cummings & Worley, 2001). The OD/Open Systems focus of this study indicates data should
include external environment data, for example data on IT delivery services, external training
delivery options; Job training opportunities e.g. Dorland Health. Haiti national data e.g.
demographics, resources, infrastructure replaces organizational data. “Group” data includes
health care service providers data; research population data; research participant population data;
and local IT delivery system group data. Individual data is primarily applicable to intervention
recipients needs and preferences as well as preferences of individual health workers. Identifying
trends and themes e.g. local health worker preference for delivering coaching, advocacy or case
management services provides “big picture” oversight. For example, if a minimal number of
health workers are interested in delivering wellness coaching and the majority prefers case
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management, feasibility and cost effectiveness, ROI on establishing a separate coaching training
program is not justified. If the majority of the subject research maternal population prefers
coaching to case management, researchers can identify these differences as a major effective
intervention delivery obstacle. The recursive aspect of Action Research offers opportunities to
“rethink” readjust, ask additional questions such as why patients prefer coaching management
and why health workers prefer case management and how these preferences can be addressed in
sustainable collective intervention development.
Additional data may include applicable national and international regulations, rules and
policies. Historical data increases understanding, particularly in Haiti, where multiple natural
disasters, high rates of HIV/AIDS and the recent quake wreak havoc on family relationships and
support groups, and generate a disproportionate percentage of unemployed youth and orphans.
Religious, spiritual, and health care beliefs and practices potentially affect proposed local health
worker positions and health care delivery systems. Videos, pictures and visual representation
enhance the visual image of the problem within its environment and offer opportunities for
“before and after” comparison. A community profile assists in attaining a contextual ecological
view, while an external environmental influence map promotes systems thinking and divergent
integrated solutions. A SWOT analysis (Mindtools, 2011) identifies external threats
opportunities, weaknesses and threats.
Information collection may include review of similar efforts elsewhere. For example,
within Haiti, Africa and Boston, PIP employs trained community health worker models. The
Boston model, PACT focuses on assistance for HIV patients. (PACT, 2011). Cuba’s dependence
on telecommunications health delivery systems and potential outcomes is discussed by Seror
(2006). The Massachusetts Forum for Creating healthier Communities offers online learning and
FPBondJ 21
training including coaching and mentoring, all designed for learning and positive change
(MassForum 8, 2011). The California Healthcare Foundation (CHCF) self management program
offers multiple resources and information on telemedicine and coaching (CHCF, 2011). The
Maternal Health web site offers examples of global maternal health programs and tolls (Maternal
Health, 2011).
Applicable Prior Research findings
Review of prior research findings applicable to the problem can facilitate analysis and
decision making. The following Annotated Bibliographies of five applicable articles offer
information perspectives, guidelines, pros and cons of various methodologies.
Simkin-Silverman, Conroy, Bhargava, & McTigue (2011). Development of an online
diabetes prevention lifestyle intervention coaching protocol for use in primary care practice. The
Diabetes Educator, 37(2), 263-268. Sage Publications Database.
The authors describe a 1 year pilot personalized, web-based, lifestyle coaching protocol
developed for use in primary care practice. Models include the Chronic Care Model and the
Diabetes Prevention program (DPP) lifestyle intervention. Personalized counseling delivered via
secure e-mail messaging provides feedback, motivation, resource and daily lifestyle requirement
reminders and a self-management plan. Coaching e-mail notes are ethnographically adapted to
the patients “personal resources and challenges, lifestyle, education, and culture” (p265),
learning style, and lifestyle. Benefits included cost-saving, reduced staffing requirements;
enhanced participation due to anonymity; improved outcomes over automated feedback, non-
personalized systems; increased access for rural or time challenged patients. Challenges
included potential miscommunication in part due to lack of visible nonverbal communication
cues. Recommendations include employing skilled trained counselors and employing counselors
FPBondJ 22
as remote members of health care service delivery teams. This article demonstrates the efficacy
of employing remote, technology based, wellness coach positions to promote self-management.
Corser, W. & Dontje, K. (2011). Self-management perspectives of heavily comorbid
primary care adults. Professional Case Management 16(1), 6-15. Medline Database.
Researchers explore self management and communication strategies of heavily comorbid
patients in primary care settings. Research questions address individual self-management
practices and perceived experiences during primary care office visits. Six focus groups and 499
interview comments produced four themes and nine subthemes. Chief among patient complaints
was non-supportive physician behaviors including pushing pills, lack of respect and courtesy and
fear health care systems will not offer the staffing and resources for effective care delivery and
self management. Few patients believed they could control the office visit agenda sufficiently to
develop a patient-provider partnership. Recommendations included employing case managers to
coordinate fragmented health care services, particularly in co-morbid patients and offer
assessment, treatment and self-management support and care. Case managers can increase
patient self efficacy and capacity to self-manage and actively participate in care decision making.
This article supports the role of case managers as bridge builders between primary care practices
and patients; multi-modal care delivery systems and patients; and patient skill facilitators.
Zander, K. (2010) Case management accountability for safe smooth and sustained
transitions. A plea for building “wrap-around” case management services now. Professional
Case Management, 15(4) 188-199. EBSCO Database.
The author discusses the need for “wrap-around” case management services to prevent
post acute hospital care readmissions and facilitate transition to home recovery care.
“Wraparound” case management requires three things: safe discharge and assurance that post-
FPBondJ 23
acute care needs can be met in the transition environment; “smooth” discharge as perceived by
the patient and family with a central event coordinator; sustained discharge. Recommendations
include 15 interventions, many of which can be performed by the case manager. Three of the 15
interventions include having the case manager assess all patients in person for potential referral
to social worker/patient teachers; coordinate daily care rounds; and schedule home care visits.
This article supports the role of case managers in post-natal care, their role as transitional care
providers between hospitals/clinics and home care; and patient/care-giver educators to promote
quality post natal care, following hospitalization, particularly in rural underserved areas.
Ewart, C. K. (1991). Social Action Theory for a public health psychology. American
Psychologist. 46(9), 931-946. EBSCO Database.
The author discusses the role of personal behavior in the etiology and exacerbation of
illness and advocates a social theory of personal action and self-regulation to promote population
health. Social action emphasizes “social interdependence and interaction...and mechanisms by
which environmental structures influence cognitive action schemas, self-goals and problem
solving activities critical to sustained behavior change” (p 931). Sustained behavior change
requires effective problem solving skill in addition to health education. Problem solving can be
taught by “enabling people to identify potential obstacles to self-change and generate appropriate
strategies to overcome them” (p935). Individuals often underestimate their capacity to change.
Self efficacy can be increased by social modeling i.e. following examples of others, and
graduated performance of feared activities. Setting moderately difficult outcome goals guides
selection of action strategies and promotes personal mastery. Cognitive schemas impact goal
setting, resisting temptation, and novel strategy creation. Schemas involving core assumptions
about personal vulnerability may be particularly difficult to change. Problem solving is highly
FPBondJ 24
dependent on social interactions and support. Environments also impact change and people
actively seek environments and/or create environments that support their goals. Environmental
settings and community resources such as access to health-enhancing foods, information, time
and money all impact behavior. The article provides an excellent contextual model (p939)
demonstrating the multiplicity of influences on behavior and a table citing potential interventions
(P941). Use of biopsychosocial, agentic, ecological interventions is supported, as is reciprocal
determinism as a guiding principle.
DeGruy, F. V. & Etz, R. S. (2010). Attending to the whole person in the Patient-
Centered Medical Home. The case for incorporating mental healthcare, substance abuse care
and health behavior change. Families, Systems & Health. 28(4). 298-307. EBSCO database.
The authors describe ideal characteristics of primary care including integrated health care
services and sustained, contextual, community, partnerships according to the 2006 Institute of
Medicine Committee on the Future of Primary Care. Consistent with the research title, the
authors briefly discuss prototypes, including patient centered medical homes (PCMH).
However, the majority of the paper discusses more diverse solutions developed contextually by
community stakeholders. Conclusions indicate communities must engage their resources and
develop preventive strategies, challenge assumptions that health must be delivered by physicians
at primary care offices. Solutions should incorporate mental and physical health, behavioral
health; patient motivation to change and self manage; and comprehensive individualized
personal care plans. Mode of delivery may include health care teams, peer-led therapies, web-
based therapies and horizontal health practitioner collaboration. Overcoming self interest and
diverse values and beliefs may require the services of a convener and development of solutions
that offer value to all community participants. Use of randomized clinical trials to assess results
FPBondJ 25
should be discarded in favor of new evaluative criteria. This article supports use of an Action
Research evaluative model, integrative health care, IT delivery of diagnostic and self-
management services outside the primary care environment, and self-management strategies.
Data Analysis
The first round of data analysis is conducted by small homogenous focus groups with a
second round of data review by diverse integrated stakeholder focus groups to facilitate
objectivity and reduce potential for bias or data manipulation. Third a report compilation task
force can prepare a comprehensive data finding report for strategic planning and decision
making. Meetings benefit from employing a facilitator/mediator to reduce conflict and enhance
decision making. Groups can compile data into meaningful reports, profiles, descriptive
statistics graphs or any tangible, confirmable format. Assertions, assumptions and perspectives
as well as the contextual environmental conditions can be included in the community profile or
assessed separately (Stringer, 2007).
Group meeting frameworks improve group processes, focus and harmony. Potential
frameworks include ground rules and agendas, procedures, decision making processes and rules
and a statement of appropriate venues (Stringer, 2007) (pp90-91. Conflict resolution processes
may also be critical including guidelines for ensuring respect, promoting diversity and equal
participation. Hunt (2007) notes the importance of active listening, respect for cultural identity,
and attention to subtle nuances including body language. A cultural profile of the Haitian
community (approved by Haitian members) may assist in understanding indigenous people, their
communication methods and cultural practices. Profiles of U.S. counterparts may also promote
communication and understanding. Trompenaar and Hofstede both distinguish national cultural
values including individualism and collectivism (Laskowska-Rutkowska, 2009). Decision
FPBondJ 26
making role play or presentation of intercultural decision making case studies can promote
understanding. Perceived power differences in dyadic and group relations may be the primary
impediment to efficient, effective Action Research. Outcomes that require equal participation
from the marginalized, disadvantaged population to whom assistance is to be rendered can be
compromised by perceived imbalance of power or ineffective communication. For example,
physician acceptance of patient participation in health care decisions may require changing
mental models and assumptions including physician perception of incapacity of uneducated
individuals to learn. Patient self-efficacy levels and communication skills impact effective
dyadic communication. McGee & Cegala (1998) discuss the need for communication skills
training to improve dyadic skills including direct and indirect questions, information verifying
skills and information recall. In dyadic relationships such as patient/provider, social influence
can be health enhancing or health compromising depending on the nature of the dyadic
relationship and the nature of the behavior. Social influence is most effective in changing health
behaviors when relationships are characterized by mutual trust, respect and shared power and
decision making. Ability of an agent to influence behavior change is located in six power
sources: expert, legitimate, coercive, reward, informational and referent. Referent power is
considered the most influential because the target views the other as the self, sees commonality,
security and trust. Empowering patients and clients to effectively engage in mutual problem
solving with health care practitioners builds referent power. Targets need to feel comfortable
asking questions not be intimidated by fear of reprisal and comfortable with mutual decision
making for positive outcomes. Under these conditions, patients often attribute behavior change
to themselves (Lewis, DeVillis, & Sleath (2002). Self-determination theory offers suggestions
for promoting patient self-regulation and behavior change. Reducing patient’s perception of
FPBondJ 27
being controlled, nagged, or required to make undesired change and being “policed” reduces
conflict and supports autonomy (Bellg, 2001) (p119). Helping health workers understand the
value of collaborative decision making can change mental models and open opportunities for
collaborative efforts. Transnational corporate stakeholders/partners must adopt a new business
paradigm of openness, partnership, shared resources and shared decision-making. Corporate,
NPO and NGO research partners may be accustomed to operating under a more traditional
hierarchal command and control structure based on competition in lieu of collaboration.
Assessing Corporate culture may be as important as national culture to communication, decision
making and intervention development (Laskowska-Rutkowska, 2009). Learning capacity and
systems may also be lacking in organizational partners. Garvin, Emondson & Gino (2010) offer
a toolkit for assessing learning in organizations. The survey can be adapted to assess learning
capacity in indigenous organizations and groups. These skills will be effective in group data
analysis and decision-making processes as well as intervention development and should be
developed in the incipient research stage. The art of questioning is critical to all group decision
making and analysis. Stringer (2007) (p84) recommends using how and what questions at this
stage and provides examples of active questioning.
Stage II Think
In the “think” stage participants begin “interpreting and analyzing” what is happening
and how it is happening, identifying key themes and concepts required to prepare an assessment
finding report (Stringer, 2007). Identifying root causes can be facilitated by using the “5 Whys”
(Mindtools, 2010) (p 63). Why can’t women obtain adequate neonatal care? Why are
insufficient numbers of trained health workers available? Why don’t women have the skills,
resources and education to self-manage care? Why hasn’t action been taken to overcome
FPBondJ 28
obstacles? Argyris (1991) notes professionals and senior managers are often defensive and
resistant to this process due to fear of failure or challenges to their authority. Argyris
recommends developing a case study to examine theories in use. The case study is then
examined by participants which defuses personal attacks, emotional attachment and
defensiveness as individual behavior is not challenged. The composite final data collection and
analysis report must be comprehendible at all literacy levels and include visual presentations,
graphics, and pictures. The report is delivered to all stakeholders for review. Stringer offers
example of ethnographic report presentations (p120) including role plays, simulation, and art.
The final report provided to internal and external transnational stakeholders should include
videotapes of indigenous ethnographic presentations.
Stage III Act
Stringer (2007) views this stage as the stage where participants determine what they will
do to resolve problems, how they will do it, and how solutions can be sustained. Steps include
strategic planning, action plans, goals, tasks, person, time frames and resources (p144).
Organizational development defines this stage as the intervention development stage (Cummings
& Worley, 2001). Interventions may be developed at all three primary levels: organizational,
group, and individual. A hypothetical conclusion of this research is that the three proposed
positions, case managers, patient advocates and wellness coaches should all be implemented.
The positions will serve as bridgebuilders, ensuring access to and training in remote technology
based diagnostics and self management tools.
Final strategic planning, goal setting and oversight/evaluation report preparation will be
completed by an implementation committee comprised of one representative from each of the
primary stakeholders. The researcher will facilitate and guide change/evaluation processes.
FPBondJ 29
Mental models influence data interpretation. Fontaine recommends employing visual simulation
to implement potential strategic goals and plans to assess and reveal additional obstacles, missing
information or data. Case studies can also be developed for multiple options to assist in
evaluating strategies prior to implementation. Kotter & Schlesinger (2008) discuss strategies for
implementing change. People resist change for four primary reasons: “desire not to lose
something of value, a misunderstanding of the change and its implications, a belief that the
change does not make sense for the organization and a low tolerance for change” (p2). Ordonez,
Schweitzer, Galinsky & Bazerman (2009) recommend caution when establishing goals. Ten
questions should be asked (p26-27). Narrow goals can decrease intrinsic motivation. If goals are
too challenging self-efficacy can be compromised. “Can goals be idiosyncratically tailored for
individual abilities and circumstances while preserving fairness? (p26).
A multi-level, multi-dimensional goal may be implementation of a Motivational
Interviewing process to be employed by Haitian professional physicians and health care workers;
case workers, patient advocates and coaches; and available to patients via interactive remote
delivery IT systems (IPhones, IPADS or computers) strategically placed at local, rural health
delivery stations. Motivational Interviewing (Miller & Rollnick, 1991 cited in Lewis, DeVellis,
& Sleath, 2002) has proved effective to promote multiple positive health behaviors.
Interventions can be completed in one day or several minutes. Motivational Interviewing (MI)
uses non-judgmental approach that neither seeks accountability nor forces change. Rather
empathetic or reflective listening and directive questioning guides the patient/client towards
individual behavior change goals. A second strategy to assist in implementation of behavior
change is to assess readiness for change (Prochaska & Norcross, 2001). Individuals typically
progress through six stages when implementing behavior change: pre-contemplation,
FPBondJ 30
contemplation, preparation, action, maintenance and termination. Implementing innovation
through individuals at the preparation stage increases possibility of success. A third strategy is to
employ Diffusion of Innovations Theory. Rogers (1995 cited in Oldenburg & Parcel, 2002)
finds a significant gap between innovation development and diffusion of innovations in health
care. Evidence indicates attempts at implementing innovative health care programs rarely leads
to sustained use. Four main elements of diffusion of innovation are: (1) the innovation (2)
communication channels, including opinion leaders and communication technology (3) time and
(4) the social system including (a) norms (b) availability of change agents (c) opinion leadership
and (d) the degree to which individuals can influence others attitudes or overt behavior.
Successful innovation is largely dependent on influencing early adopters, the 13.5% (normally)
of individuals in a system who form the critical mass necessary to sustain innovation ( National
Network of Libraries of Medicine, 2006).
Action plans may wish to consider agentic, ecological, biopsychosocial
interventions and reciprocal determinism as a means of promoting sustainable change. Training,
education, and implementation by community opinion leaders and early adopters can improve
human agency. The ecological approach integrates self management with clinical professional
patient care health service delivery, coalitions and partnerships, developing solutions where
resources are limited e.g. self managed rural interactive assessment centers. Biopsychosocial
assessments and delivery options include mental health assessments, particularly for depression
and Post Traumatic Stress Disorder (PTSD), following earthquake events. Psychosocial factors
include self efficacy, motivation, and social support systems. Reciprocal determinism indicates
individuals can influence their environment as well as be influenced by it. Access to services
can be promoted through mobile clinics, rural self management stations, and IT based health
FPBondJ 31
service delivery. Patient nutritional and natural medicinal needs can be met in part by
agricultural interventions such as planting gardens. Community gardens promote social support
and collective efficacy. Self-determination theory indicates sustainable change is contingent
upon participants’ willingness to engage in activities, rather than feel forced to participate.
Action research offers opportunities for participants to determine intervention methods.
Education and training will be provided to enhance self efficacy, agency and locus of control.
Habitual behavior is contingent on stimulus cues. Cues often occur in the environment, itself,
cultural and support systems and practices. Sustained behavior change is also contingent on
behavior change, new ways of thinking, problem solving, and behaving. Wood, (2005) notes
habit change is facilitated through context/environment change. Social marketing and
communicating with patients and health workers via multi-modal communication channels
increases awareness and use of new health care delivery options. Health worker/patient
community events and meetings can be scheduled to discuss ongoing, contextual maternal health
access problems, innovative delivery methods, provide technology, training, mentorship,
coaching and support to reduce recidivism.
Multiple implementation tools/tactics include professional training programs, on line
resources, Health e-Games, and Health Education Kiosks. For example, St. Andrews
Development (St. Andrews Institute, 2009) employs health education kiosks for self assessment
and health education, the Stanford School of Medicine offers educational material, diagnostic
and assessment tools associated with its Chronic Disease Self-Management program (Stanford,
2011); the California Healthcare Foundation (CHCF) (CHCF, 2011) offers multiple training,
health care delivery, patient motivation and self management tools; the Institute for Healthcare
Improvement (IHI) offers patient self-management logs, tools, patient decision balance
FPBondJ 32
worksheets and interactive tools (IHI, 2011). Dorland Health (2011) offers case management
and patient advocate training; Stanford University offers training for Self-Management programs
(Stanford, 2011); the Patient Advocate Institute (PAI) (PAI, 2011) offers training and resources
for Patient Advocates ; the Case Management Society of America (CMSA) (CMSA, 2011) offers
training and resources for members Motivational Interviewing training is available through
Miller and Rollnick’s Motivational Interviewing Network of Trainers (Miller & Rollnick, 2011);
Van Horn Consulting (Van Horn Consulting, 2011); and a simplified MI Algorithm available on
the UCLA Center for Human Nutrition web site (UCLA, 2011); Wellcoaches (Wellcoach, 2011)
offers training for core competencies in health and wellness coaching. The Harvard associated
program has roots in psychology MI practice.
Conclusions/Summative Report
Stringer (2007) notes as interventions are implemented stakeholders work through
the “recursive process of observation, reflection, planning and review” (p161). At the conclusion
of the one year Action Research project a summative review and report will be developed.
Guidelines are provided on page 173, page 185 and Appendix A page 217.Stringer states the
report should include “the extent to which the process has made an impact on the lives of the
people for whom the project was formulated” (p161). Mulgan (2010) discusses methods for
measuring social value by determining what participants’ value. Economic impact can be
measured in part based on the U.N. description of poverty as included in its MDG goals. Poverty
is defined as the percentage of people living on less than $1.00 per day. Health outcomes can be
measured in maternal and neonatal mortality, patient satisfaction, and overall biopsychosocial
health. Self reliance and problem solving can be measured via collective efficacy and self-
management scales.
FPBondJ 33
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