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In 500-550 words, critique the journal article by Martin et al. to answer the overall question, “Did the authors do a good program evaluation of the HIV promotoras program?” Explain your answer using The Program Evaluation Standards and Cultural Competence article reading.

et Journal
al. / A Latino
of Behavioral
HIV Prevention
The Evaluation of a Latino Community
Health Worker HIV Prevention Program
Molly Martin
Rush University Medical Center
Maria Camargo
Lori Ramos
Centro San Bonifacio
Diane Lauderdale
University of Chicago
Kristin Krueger
Rush University Medical Center
John Lantos
University of Chicago
This study evaluated the effectiveness of a community health promotion project to
increase HIV knowledge in an urban, immigrant Latino community in Chicago. Latino
participants (N = 704) answered questions on HIV before and after an education intervention given by community health workers. Outcomes included changes in knowledge
and self-perceived risk. Increases in knowledge scores were greatest for Central/South
Americans (p = .038), women (p = .027), and those with an education level less than 7
years (p = .001). Significant changes in self-perceived risk resulted from the intervention
(p < .001), and the odds ratio for a change in self-perceived risk when the knowledge score increased by 10% was 1.225. The Centro San Bonifacio HIV Prevention Program successfully reached a Latino community, increased HIV knowledge, and changed selfperceptions of HIV risk. Keywords: HIV prevention; Latino health; community health workers Latinos bore a disproportionate burden of new AIDS cases in 2000. The Centers for Disease Control and Prevention (CDC) reported that although Latinos represented 13% of the U.S. population, they accounted for 19% of the total number of new U.S. AIDS cases (CDC, 2002). Different types of programs have been implemented to decrease the disproportionate incidence Hispanic Journal of Behavioral Sciences, Vol. 27 No. 3, August 2005 371-384 DOI: 10.1177/0739986305278146 © 2005 Sage Publications 371 372 Hispanic Journal of Behavioral Sciences of HIV in Latino communities. The main prevention strategy encourages HIV testing and counseling to identify people infected with HIV and modify high-risk behaviors. This approach has shown success in some Caucasian and African American communities but not in Latino communities (Morrobel, 2002; Phillips, 1993; Siegel, Raveis, & Gorey, 1998), thereby demonstrating a need for different strategies for HIV prevention programs among Latinos. An alternative strategy for HIV prevention and risk reduction involves the participation of community health workers. The community health worker model has been used extensively around the world to combat many types of illnesses including HIV. Although the U.S. health care system is primarily market and technology driven, alternative approaches like the community health worker model are being tried here to provide health care services to people who are excluded from the current system because of cultural, language, or legal barriers. The community health worker model uses community empowerment as a tool to reduce health care burdens. Empowerment, defined as “the social action process by which individuals, communities, and organizations gain mastery over their lives in the context of changing their social and political environment to improve equity and the quality of life” (Minkler, 1997, p. 40; see also Rapport, 1984; Wallerstein, 1992), has wide-reaching effects. Social involvement and participation can themselves be significant psychosocial factors in improving perceived control, individual coping capacity, health behaviors, and health status (Cohen & Syme, 1985; Eng & Cunningham, 1990). As communities become empowered and better able to engage in collective problem solving, key health and social indicators may reflect this in the long run with decreasing rates of targeted illness such as HIV. In the Latino community, community health workers (referred to here as promotoras) are members of the target community trained in health promotion who work with families and community groups to educate and advocate. AUTHORS’ NOTE: The project was designed and implemented by many promotoras and the Illinois Institute of Technology Department of Rehabilitation Psychology under the supervision of Chow Lam, Ph.D., with funding from the AIDS Foundation of Chicago. The promotoras involved in project design include Rosa Perea, Rosio Nazimek, Olivia Hernández, Nora A. Coronado, and Marta Perea from Centro Comunitario Juan Diego; Gustavo Sánchez, Guadalupe Lemus, and Felisa Espejel from the Health Advocacy Project of Pilsen Little Village; and Cynthia Bianchi from the PROMESA Coalition. The following promotoras from Centro San Bonifacio were involved in the project design and also in data collection: Tomas Lopez, Margarita Sánchez, Isis Ferral, Marta Morales Aguilar, and Benita Pedrasa. Financial support for the first author was provided by the Robert Wood Johnson Clinical Scholars Program. Martin et al. / A Latino HIV Prevention Program 373 Previous attempts to evaluate the effectiveness of promotora-run HIV and sexually transmitted disease (STD) prevention programs have given only weak evidence to suggest that the promotoras may result in behavior changes that reduce HIV risk (Birkel et al., 1993; Thomas, Earp, & Eng, 2000). Other studies have shown that knowledge is a prerequisite to behavior change (Prochaska & Norcross, 2001) and that associations exist among knowledge, self-perceived risk, and behavior change (Biddlecom & Hardy, 1990; DiClimente, Boyer, & Morales, 1988; Morrobel, 2002; Phillips, 1993). Based on this work, we evaluated an ongoing HIV/AIDS prevention project in Chicago asking the following questions: Can promotoras increase HIV knowledge and what factors are associated with these changes? Can promotoras change self-perceived risk for HIV and what factors are associated with these changes? Method Setting Centro San Bonifacio is a grassroots community center that was founded in 1991 by a group of families responding to the closing of a local church in Chicago. Their mission is to promote personal and collective selfdevelopment within the immigrant Latino community through projects based on health, education, solidarity, and human rights. They train promotoras to engage in HIV/AIDS prevention education among their peers. New promotoras are recruited from the target communities and trained by advanced promotoras. Centro San Bonifacio currently has 16 salaried staff promotoras and a large number of volunteer promotoras. Their funding comes from private and public grants, and they have no institutional affiliation. As one of their service projects, the promotoras provide HIV/AIDS prevention education with risk-reduction follow-up visits and street outreach services in four contiguous Latino Chicago neighborhoods (West Town, Logan Square, Humboldt Park, and Hermosa). Twenty-six promotoras received training in HIV education from the Red Cross HIV/AIDS training course (40 hours and an exam) and a separate promotora-led training course at Centro San Bonifacio (13 sessions and an exam). These promotoras were all Spanish-speaking Latinos, primarily women, and most had received primary education up to 12th grade in their country of origin. Some had been involved in health promotion in their countries of origin, some had been promotoras for several years, and some were newly trained promotoras. 374 Hispanic Journal of Behavioral Sciences Table 1. Sociodemographic Characteristics of HIV Prevention Program Participants in Analysis Groupsa Total, % (n = 704) Gender Male Female Age Less than 30 years 30 to 40 years 40+ years Marital status Single Married Separated, divorced, widowed Ethnic group Puerto Rican Mexican Central/South American Other Education level 6 years or less 7 to 12 years Graduated high school, General Equivalency Diploma, university b Acculturation score 1 (low) > 1 and < 3 (med) 3+ (high) Complete Complete Knowledge Knowledge and Self-Risk Data, Data, % (n = 589) % (n = 438) 36 54 39 54 43 52 46 28 18 45 30 20 43 33 20 24 60 24 60 26 62 10 12 10 6 76 10 1 6 78 10 1 5 79 11 1 25 28 25 29 25 30 24 23 25 38 30 10 39 29 10 37 30 11 a. Demographics did not differ significantly for participants with and without complete data for the outcomes. b. Acculturation is measured using the G. Marín and Marín (1991) Language Use Scale. The range is from 1 to 5 where 1 is the lowest acculturation (Spanish only) and 5 is the highest (English only). The Intervention The promotoras recruited 704 adults to participate in the HIV Prevention Program during a 3-year period. The sociodemographic characteristics of the participants can be seen in Table 1. The majority of participants were female (54%), married (60%), Mexican (76%), and educated either 6 years or less (25%) or 7 to 12 years (28%). Their ages ranged from 13 to 69 years with a Martin et al. / A Latino HIV Prevention Program 375 mean age of 31.3 years. Most participants had low language acculturation scores, meaning that they knew very little English. Participants were recruited primarily from other Centro San Bonifacio programs, community centers, and by word of mouth. The program sessions were performed mainly in Spanish using one of three settings: in the home for individual or family groups, at a home in a Tupperware-party style for small groups, or at schools and churches for larger groups. Each program session consisted of introductory exercises to make people comfortable, a pretest, an education session (using aids such as videos, charts, handouts, and condoms), a posttest, and referrals. The education session content and format varied depending on the needs of the audience and the style of the promotora. The Illinois Institute of Technology, Centro San Bonifacio, and promotoras from several other community centers collaborated to design the preeducation and posteducation session testing forms (referred to here as pretest and posttest forms) from 1997 to 1999 under a grant from the AIDS Foundation of Chicago. The promotoras received training on the transtheoretical model of behavior change during this time. The questions and format were decided through group discussion sessions with subsequent translation and decentralization to make easy-to-understand forms that encompassed a wide range of measurable goals. The pretest contained questions on general HIV/AIDS knowledge (16 true/false questions), demographics, self-perceived risk and perceived partner risk, communication, and condom use. Language acculturation was measured using the G. Marín and Marín (1991) Short Language Use Scale, which is a 4-question scale asking about language preference in different daily settings. Self-perceived risk was measured by the question, “Do you think you are at risk for HIV? Yes or no.” The posttest contained the same knowledge and risk questions in addition to an evaluation of the education session. The entire form was five pages and available in English and Spanish. Data Analysis To measure knowledge, we created pretest score and posttest score variables from the 16 knowledge questions and performed a two-tailed t test analysis. The pretest and posttest score variables were then combined into a change-in-knowledge score variable. Because of occasional logistic problems with test form distribution, some participants did not receive the pretest or posttest. These observations were dropped (pretest: n = 10; posttest: n = 110) We incorporated gender, age, marital status, education, ethnic group, and language acculturation into multiple linear regression models to analyze what factors were associated with changes in knowledge. Missing observa- 376 Hispanic Journal of Behavioral Sciences tions for predictor variables were incorporated into the regression models using a dummy variable for the missing category. We measured changes in self-perceived risk using dichotomous perceived risk variables. Observations were dropped if data were missing for selfperceived risk (n = 151). McNewar’s test for paired analysis was used to evaluate whether the HIV education changed self-perceived risk. Variables were created to represent a change in self-perceived risk, a change from no to yes in self-perceived risk, and a change from yes to no in self-perceived risk. Multivariate logistic regression analysis was used to analyze what factors were associated with changes in self-perceived risk. The data were analyzed using Stata 7.0 (StataCorp, 2001). Institutional review board approval for the analysis was obtained from the University of Chicago. Results Participants differed in education level and language acculturation based on their ethnicity. Mexicans were more likely to be educated 6 years or less, whereas Puerto Ricans and Central/South Americans were more likely to have graduated high school or have a General Equivalency Diploma (GED). Mexicans have lower acculturation scores than the other ethnic groups. Participants with low language acculturation scores were more likely to report low education levels. The unadjusted analysis of knowledge showed a significant increase from the pretest score to posttest score (p < .001) with mean pretest scores of 75% (SD = 16%; 95% confidence interval [CI] = 73, 76) and mean posttest scores of 87% (SD 15%; 95% CI = 86, 88). Factors associated with the change in knowledge were identified in the multivariate linear regression model separately for pretest and posttest scores. Participants in the Puerto Rican category were more likely to score higher on the pretest than the other ethnic groups (p = .014; 95% CI = .015, .13). Participants in the education category of 6 years or less education were more likely to start at lower scores (p = .001, 95% CI = –.099, –.029). In the regression model predicting posttest score, being female was associated with significantly higher posttest scores than being male (p = .029; 95% CI = .0027, .05). Participants in the education category of 6 years or less now had posttest scores similar to the reference group (p = .878; 95% CI = –.033, .028). In Table 2, the full model of the change-in-knowledge score reveals that a significant increase in the knowledge score is associated with being Central/ South American (p = .017; 95% CI = .01, .10) and being educated 6 years or less (p = .001; 95% CI = .025, .098). Adding the pretest score to the model shows that as pretest scores increase, the likelihood of a change in the knowl- Martin et al. / A Latino HIV Prevention Program Table 2. 377 Multiple Linear Regression Analysis of the Change-inKnowledge Score: Full Model and Full Model With Pretest Score Full Model Coefficient (β1) Pretest score Gender Male Female Ethnic group Mexican Puerto Rican Central/South American Education level 6 years or less 7 to 12 years Graduated high school or General Equivalency Diploma Attended university Obtained licensure Missing a Acculturation Missing Constant (β0) Full 95% Model With Confidence Pretest Score Interval Coefficient (β1) –.67* 95% Confidence Interval –.74, –.61 .— .022 –.0069, .05 .— .025* .0029, .047 .— –.023 .056* –.085, .039 .01, .10 .— .027 .038* –.021, .075 .0022, .073 .062* .— .025, .098 .019 .— –.0097, .047 .0065 –.04 –.064 –.054* .014 –.027 .096 –.038, .051 –.098, .018 –.14, .0087 –.094, –.013 –.0053, .033 –.073, .019 .047, .15 –.011 –.025 –.019 –.086* .0095 –.075* .63 –.046, .022 –.069, .019 –.075, .038 –.12, –.055 –.0053, .024 –.11, –.04 .56, .69 NOTE: The model was also adjusted for marital status and age. a. Acculturation is measured using the G. Marín and Marín (1991) Language Use Scale. The range is from 1 to 5 where 1 is the lowest acculturation (Spanish only) and 5 is the highest (English only). *p < .05. edge score decreases (p < .001; 95% CI = –.74, –.61). When controlling for the pretest score, we now see that being Central/South American (p = .038; 95% CI = .0021, .073) or being female ( p = .027; 95% CI = .0029, .047) is associated with a larger change-in-knowledge score. The knowledge score change in people with education levels of 6 years or less disappears, thus suggesting it was the pretest scores that accounted for their initial large knowledge score changes. Self-perceived risk increased after the intervention (McNemar’s χ2 = 14.82, p = .0001). Fifty-six participants changed their answers from no to yes, whereas 22 participants changed from yes to no (n = 438). The multivariate logistic regression model of the self-perceived risk change 378 Hispanic Journal of Behavioral Sciences Table 3. Multiple Logistic Regression Analysis of Change in SelfPerceived Risk Odds Ratio 10% Knowledge score change Gender Male Female Ethnic group Mexican Puerto Rican Central/South American Education level 6 years or less 7 to 12 years Graduated high school or General Equivalency Diploma Attended university Obtained licensure Missing a Acculturation Missing 95% Confidence Interval 1.22* 1.04, 1.44 .— 0.99 0.56, 1.74 .— 0.18 0.39 0.022, 1.46 0.13, 1.11 0.89 .— 0.45, 1.79 0.74 0.66 2.63 1.14 1.061 0.56 0.31, 1.82 0.17, 2.50 0.69, 10.091 0.48, 2.70 .73, 1.55 0.21, 1.47 NOTE: The model was also adjusted for marital status and age. a. Acculturation is measured using the G. Marín and Marín (1991) Language Use Scale. The range is from 1 to 5 where 1 is the lowest acculturation (Spanish only) and 5 is the highest (English only). *p < .05. incorporated the change-in-knowledge score in addition to the other predictors used previously (see Table 3). For each 10% gain in the knowledge score after the intervention, the odds ratio for a change in self-perceived risk was 1.22 (p = .016; 95% CI = 1.04, 1.44). This was similar for those who changed their self-perceived risk from no to yes. A large group of participants neglected to answer the education question (23%) and the acculturation question (22%) in the initial demographics. Both groups were more likely to start at lower pretest scores (no education reported: p = .016; 95% CI = –.086, –.009; no acculturation reported: p = .001; 95% CI = –.12, –.028) and end at lower posttest scores (no education reported: p < .001; 95% CI = –.14, –.068; no acculturation reported: p < .001; 95% CI = –.14, –.061). When controlling for pretest scores in the full model of the change-in-knowledge score, less change in the knowledge score occurred for participants who failed to answer the acculturation question (p < .001; 95% CI = –.11, –.04) or the education question ( p < .001; 95% CI = –.12, –.005). No changes were seen in self-perceived risk for these groups. Martin et al. / A Latino HIV Prevention Program 379 Discussion This study highlights the effectiveness of the community health worker model to reach Latino community members who are frequently excluded from HIV outreach efforts because of language, cultural, and educational barriers. The promotoras successfully increased HIV knowledge, and this knowledge change was associated with less initial knowledge and being Central/South American, female, or in a low education level. Significant changes in self-perceived risk for HIV were also seen, and these changes were associated with increases in knowledge scores. This HIV program succeeded in reaching its target population and achieving its original education goals given the involvement of the promotoras in the program design and recruitment. Because HIV rates are rising so rapidly in Latino women (CDC, 2002) and because Latino men participate in many high-risk behaviors (Darbes, Kennedy, Peersman, Zohrabyan, & Rutherford, 2002; Fernandez, Perrino, Royal, Ghany, & Bowen, 2002; Hines & Caetano, 1998; B. Marín, Gomez, & Hearst, 1993; Nyamathi, Bennett, Leake, Lewis, & Flaskerun, 1993; Sabogal & Catania, 1996; Sabogal, Faigeles, & Catania, 1993; Sabogal & Perez-Stable, 1995), this program attempted to direct its services toward both genders and all sexual orientations. Being a part of this HIV prevention program involved overcoming stereotypes about HIV and generating motivation for education and change. The demographics of the study participants confirm that the promotoras were able to recruit people of both sexes from different Latino ethnic subgroups and of low education and language acculturation levels. The community outreach was so effective perhaps because the promotoras are themselves members of the target communities and therefore they understand and face the same barriers as the program participants. The study also suggests that in addition to reaching the community, these promotoras increased the community’s knowledge of HIV/AIDS. The effectiveness of the intervention varied throughout our study population. HIV knowledge in Latinos has been attributed to strong cultural gender norms that result in Latinas having less knowledge of HIV than non-Latino White women (Gomez & Marín, 1996). The Latinas in our community scored the same on the pretest as men and then outscored men on the posttest. Because men and women started at equal levels and the women responded more to the intervention than the men, we can conclude that although cultural gender norms may exist that control sexual behaviors, they do not apply to HIV knowledge and its acquisition in this specific community. The change-in-knowledge score was significantly higher for Central/ South Americans, thereby implying that the intervention increased knowl- 380 Hispanic Journal of Behavioral Sciences edge more in this group than in the other ethnic subgroups. This increase cannot be attributed to an initial lower knowledge level and is likely due to either a background of higher formal education or less prior exposure to the material. We had expected the lowest education group to be the most difficult to educate, but although they started at lower knowledge levels, they ended up at levels equal to the other education groups. This suggests that opportunities for education do not predict the ability to learn this type of information and that this intervention can be effective for all education levels. HIV knowledge has been shown to be related to acculturation into U.S. culture (Flaskerud & Calvillo, 1991; B. Marín & Marín, 1990), but in our study, language acculturation was not associated with any significant changes in knowledge. Multiple studies looking indirectly at self-perceived risk have shown that acculturation levels are associated with high-risk behaviors in women more than men (B. Marín et al., 1993; Sabogal & Perez-Stable, 1995; Sabogal et al., 1993). We did not find any association between self-perceived risk or gender and acculturation. The results of this study give new potential for the promotion of HIV testing, an important area of HIV prevention that has not been very successful previously in Latino communities (Morrobel, 2002; Phillips, 1993; Sabogal & Catania, 1996; Sabogal & Perez-Stable, 1995; Siegel et al., 1998). Half of heterosexual Latinos at high risk have not been tested for HIV, with the odds of getting tested increasing with education (Sabogal & Catania, 1996). Behavioral theory suggests that these results are due to the relationship between self-perceived risk and behavior changes (Ajzen, 1991; Morrobel, 2002). Our intervention showed that changes in self-perceived risk were related to increases in knowledge scores thereby suggesting that increases in HIV knowledge lead to increases in self-perceived risk and may subsequently encourage people to seek HIV testing. This study has multiple limitations. The initial funding and goal of the program was to do HIV education outreach. Thus, it was designed using program evaluation strategies, not as a randomized, controlled study. The participants were recruited from the community using already established referral patterns set up by the promotoras, which limits the generalizability of the results. The promotoras varied in the presentation and location of the education sessions; whereas most were done in the home by individual promotoras, a few group sessions were also held. Participants were not asked about sexual orientation, sexual practices, or intravenous drug usage, and therefore, we are unable to fully understand the participants’ risk for HIV. The knowledge and self-perceived risk questions used were not validated, so we cannot predict their reliability. In addition, a ceiling effect may have occurred because Martin et al. / A Latino HIV Prevention Program 381 of the limited amount of questions. Acculturation is very difficult to measure; the scale used in this study is a language scale that has been shown to misclassify only about 12% of respondents (G. Marín & Marín, 1991). Many of the forms used in this study were not completely filled out by participants, which may have been a result of low education levels, time constraints, improper guidance on the part of the promotoras, or highly sensitive questions. The power of the study was reduced because these participants had to be excluded. Also, a significant number of participants neglected to answer the education and acculturation questions. Not answering one of these questions was highly correlated with a failure to answer the other. From discussions with the promotoras, we suspect most people skipped these questions because they did not understand the question wording or were embarrassed to answer them. Participants who skipped these questions were more likely to be male and older than the average. These participants may have been reluctant to reveal low literacy, so they attempted to answer all the questions in written form instead of having them read orally. The analysis of the missing acculturation and education variables shows that these participants started and ended with lower knowledge scores, meaning they were more resistant to learning from the intervention. Despite these limitations, we can conclude that the Centro San Bonifacio HIV Prevention Program promotoras successfully reached members of their Latino community, increased HIV knowledge, and changed self-perceptions of HIV risk. This program, as an example of the community health worker model, illustrates how encouraging people in a Latino community to take control of their own health care can raise their awareness and knowledge of HIV disease. The next step in the evaluation of this model is to study if the changes in knowledge and risk that these promotoras inspired can be associated more directly with changes in behavior such as a reduction in high-risk behaviors or an increase in HIV testing. Finally, the model needs to be evaluated in other ethnic and socioeconomic groups. References Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179-211. Biddlecom, A., & Hardy, A. (1991). AIDS knowledge and attitudes of Hispanic Americans: United States, 1990. Advance data from vital and health statistics; no 207. Hyattsville, MD: National Center for Health Statistics. Birkel, R. C., Golaszewski, T., Koman, J. J., Singh, B. K., Catan, V., & Souply, K. (1993). Findings from the Horizontes Acquired Immune Deficiency Syndrome Education Project: The impact of indigenous outreach workers as change agents for injection drug users. 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Prevention in Human Services, 3(2/3), 1-7. Sabogal, F., & Catania, J. (1996). HIV risk factors, condom use, and HIV antibody testing among heterosexual Hispanics: The National AIDS Behavioral Surveys (NABS). Hispanic Journal of Behavioral Sciences, 18(3), 367-392. Sabogal, F., Faigeles, B., & Catania, J. A. (1993). Multiple sexual partners among Hispanics in high-risk cities. Family Planning Perspectives, 25(6), 257-262. Sabogal, F., & Perez-Stable, E. J. (1995). Gender, ethnic, and acculturation differences in sexual behaviors: Hispanic and non-Hispanic White adults. Hispanic Journal of Behavioral Sciences, 17(2), 139-150. Siegel, K., Raveis, V. H., & Gorey, E. (1998). Barriers and pathways to testing among HIVinfected women. AIDS Education and Prevention, 10(2), 114-127. Martin et al. / A Latino HIV Prevention Program 383 StataCorp. (2001). Stata statistical software: Release 7.0. College Station, TX. Stata Corporation. Thomas, J. C., Earp, J., & Eng, E. (2000). Evaluation and lessons learned from a lay health advisor programme to prevent sexually transmitted diseases. International Journal of STD and AIDS, 11, 812-818. Wallerstein, N. (1992). Powerlessness, empowerment, and health: Implications for health promotion programs. American Journal of Health Promotion, 6, 197-205. Molly Martin, MD, attended medical school at the Medical College of Wisconsin and pediatrics residency at the University of Chicago. She then completed the Robert Wood Johnson Clinical Scholars Program at the University of Chicago and obtained a master of arts in public policy from the Harris School of Public Policy. She is currently an assistant professor at Rush University Medical Center where her research focuses on community health workers, community-based participatory research, and Latino health. Her favorite pastime is exploring the world with her 7-month-old daughter, Madeline. Maria Camargo has a master’s in public health and a bachelor’s in biology with a French minor. Her general field of interest is Mexican community health and well-being in Chicago. She has concentrated her efforts on work in small not-for-profit community centers in Chicago. Her general research interest is in studying health education/promotion programs and their outcomes with the future goal of including noninvasive biochemical markers for health outcomes. She enjoys spending hours just talking and hanging out with close friends and family. She has also begun attending many plays at the Chicago Goodman Theatre. Lori Ramos is the executive director of Centro San Bonifacio. She holds an M.P.H. in population and family health and an M.A. in Latin American studies, both from the University of California—Los Angeles. Her research interests include cross-cultural health care and medical anthropology, community health workers, and popular education. She also likes gardening, camping, and hanging out with her kids and Homer, the dog. Diane Lauderdale is an epidemiologist with M.A. degrees in divinity and library science from the University of Chicago and a Ph.D. in public health from the University of Illinois at Chicago. She is an associate professor in the Department of Health Studies at the University of Chicago. Her research focuses on social determinants of chronic disease risk and on the health and health care of immigrant populations. She collects public health educational materials from the first half the 20th century and loves silent movies. Kristin Krueger is a postdoctoral fellow in neuropsychology at the Rush Alzheimer’s Disease Center. She holds a B.A. in psychology from the University of Wisconsin—Madison, an M.A. in linguistics from Northeastern Illinois University (Chicago), and a Ph.D. from the Illinois Institute of Technology (Chicago). She completed an internship at Jackson Memorial Hospital/University of Miami in neurotrauma rehabilitation and spinal cord injury. Her research focuses on adapting cognitive abilities tests for Spanish-speaking populations. Clinically, she provides cognitive evaluations, psychological assessments, and therapeutic interventions in English and Spanish. She speaks German and Portuguese and enjoys travel, dance, and green-living activities. 384 Hispanic Journal of Behavioral Sciences John Lantos received a B.A. in semiotics from Brown University, his MD from the University of Pittsburgh, and completed a residency in pediatrics at the Children’s Hospital National Medical Center in Washington, D.C. After a brief stint in southern West Virginia as a member of the National Health Service Corps, he took a fellowship in clinical medical ethics at the University of Chicago. He is currently professor of pediatrics and chief of General Pediatrics at the University of Chicago. His latest book, Neonatal Bioethics: A Success Story, will be published by Johns Hopkins University Press in 2006. He will take any excuse to go skiing and, living in Chicago, needs excuses to get to a mountain. THE PROGRAM EVALUATION STANDARDS and CULTURAL COMPETENCE Evaluation standards are the benchmarks used to address the quality of an evaluation effort. As professional evaluators, these standards are the foundation of our work. Since 1975, the Joint Committee on Standards for Educational Evaluation has established standards that are endorsed by most evaluation professional organizations. The Centers for Disease Control and Prevention’s Framework for Program Evaluation in Public Health embraces these standards by literally placing them at the center of the evaluation steps. While stakeholder involvement always has been a cornerstone of the standards, the third edition further advances the need to understand the cultural context in which the evaluation occurs. Below are listed the standards and possible strategies that can increase cultural competence. For more detail, see Practical Strategies for Culturally Competent Evaluation. Standards Utility U1. Evaluator Credibility— Evaluations should be conducted by qualified people who establish and maintain credibility in the evaluation context. U2. Attention to Stakeholders—Evaluations should devote attention to the full range of individuals and groups invested in the program and affected by its evaluation. Strategies to Increase Cultural Competence     U3. Negotiated Purposes—Evaluation purposes should be identified and continually negotiated based on the needs of stakeholders.  U4. Explicit Values— Evaluations should clarify and specify the individual and cultural values underpinning purposes, processes, and judgments. U5. Relevant Information—Evaluation information should serve the identified and emergent needs of stakeholders. U6. Meaningful Processes and Products—Evaluations should construct activities, descriptions, and judgments in ways that encourage participants to rediscover,     Assess yourself and the fit between your skills with culturally different groups and the evaluation context. Engage a co-evaluator and/or an evaluation team to enhance credibility with stakeholders. Actively recruit and engage a range of stakeholders, including program participants or those affected by the program. Ensure participation for affected groups that are typically overlooked or excluded. Use communication norms appropriate for the stakeholders to ensure that the purposes are understandable and meaningful. Ensure evaluation purposes address diverse needs of stakeholders. Use inclusive practices to resolve conflicts among purposes proposed by different groups of stakeholders. Take time to learn what different stakeholders value about the program and its evaluation. Communicate clearly about these values through the evaluation process, and address important conflicts.  Encourage stakeholders to think broadly about what constitutes relevant data sources and collection methods; discuss competing viewpoints.  Teach evaluation principles and skills to establish common ground for understanding and using evaluation processes and products. Adapt activities and processes to incorporate cultural norms.  reinterpret, or revise their understandings and behaviors.  Ensure evaluation products are understandable to diverse audiences. U7. Timely and Appropriate Communicating and Reporting—Evaluations should attend to the continuing information needs of their multiple audiences.  Tailor information sharing to meet cultural needs: ensure that information is shared through appropriate translation, formats, and channels as well as comfortable venues. U8. Concern for Consequences and Influence—Evaluations should promote responsible and adaptive use while guarding against unintended negative consequences and misuse. Feasibility F1. Project Management—Evaluations should use effective project management strategies.  Anticipate possible ways that evaluation information can be used or misused within the program’s cultural and operational context. Protect information so that it is not misused in a manner harmful to vulnerable populations.  Build in sufficient time and resources to address contextual and cultural needs: time for stakeholder interactions, translation, appropriate data collection staff, and diverse communication needs. F2. Practical Procedures— Evaluation procedures should be practical and responsive to the way the program operates.   F3. Contextual Viability— Evaluations should recognize, monitor, and balance the cultural and political interests and needs of individuals and groups. F4. Resource Use— Evaluations should use resources effectively and efficiently. Propriety P1. Responsive and Inclusive Orientation— Evaluations should be responsive to stakeholders and their communities.  Respect the organizational culture of the program itself. Recognize diversity of perspectives within the program’s operations. Select processes and methods that are responsive to the organizational culture and the cultural background of participants. Understand the cultural, political, and economic context of the program; engage stakeholders to ensure understanding among diverse perspectives. Foster and monitor communications to ensure balance among stakeholders throughout the evaluation.      Recognize different perceptions of costs and benefits. Be careful not to prioritize the needs of one stakeholder group over another on the basis of cost alone.  Include a wide range of stakeholders, including program participants and those affected by the program, and substantially engage them throughout the evaluation. Consider power relations within the program when determining the breadth and depth of stakeholder involvement. Optimize the benefits of stakeholder involvement by focusing on the unique assets and strengths of individuals and their cultures rather than on their deficits.    P2. Formal Agreements— Evaluation agreements should be negotiated to make obligations explicit and take into account the needs, expectations, and cultural contexts of clients and other stakeholders. P3. Human Rights and Respect—Evaluations should be designed and conducted to protect human and legal rights and maintain the dignity of participants and other stakeholders.  P4. Clarity and Fairness— Evaluations should be understandable and fair in addressing stakeholder needs and purposes. P5. Transparency and Disclosure—Evaluations should provide complete descriptions of findings, limitations, and conclusions to all stakeholders, unless doing so would violate legal and propriety obligations.  P6. Conflicts of Interests—Evaluations should openly and honestly identify and address real or perceived conflicts of interests that may compromise the evaluation. P7. Fiscal Responsibility— Evaluations should account for all expended resources and comply with sound fiscal procedures and processes.  Accuracy A1. Justified Conclusions and Decisions—Evaluation conclusions and decisions should be explicitly justified in the cultures and contexts where they have consequences.             Acknowledge the contributions of all stakeholders to the evaluation. Take advantage of formal agreements to clarify differences in culturally based assumptions. Use the writing process to educate stakeholders about evaluation. Limit the use of jargon, and instead use community communication norms and requirements when writing agreements. Understand the relevance of certain rights and how they vary across the cultures within the community. Recognize that vulnerable groups may need specific protections. Only select evaluation methods that respect cultural sensitivities. Use the co-evaluator or evaluation team to monitor the evaluation to ensure respect is maintained. Actively engage less powerful or less vocal stakeholders in decision-making processes. Think through and avoid ways that the evaluation can contribute to inequities. Maintain open lines of communication with stakeholders holding diverse cultural perspectives. Use culturally appropriate ways to share information about the evaluation and to disseminate findings. Explain and disclose information in an understandable manner. Avoid jargon and build evaluation knowledge and skills among participants. Acknowledge that stakeholder values and interests may conflict and build an open process to resolve conflicts. Ensure that the perspectives of less powerful participants are respected.  Ensure that evaluation costs take into account activities and processes necessary to meet cultural and community needs (e.g., translations, additional meetings and trainings, appropriate dissemination to community audiences).  Reflect on how different or conflicting values may affect the way that evaluation findings are viewed or justified. Ensure that less powerful stakeholders are engaged in drawing conclusions and making decisions. Accept that accuracy is defined differently among different stakeholders.   A2. Valid Information— Evaluation information should serve the intended purposes and support valid interpretations.    A3. Reliable Information—Evaluation procedures should yield sufficiently dependable and consistent information for the intended uses. A4. Explicit Program and Context Descriptions— Evaluations should document programs and their contexts with appropriate detail and scope for the evaluation purposes. A5. Information Management—Evaluations should employ systematic information collection, review, verification, and storage methods. A6. Sound Designs and Analyses—Evaluations should employ technically adequate designs and analyses that are appropriate for the evaluation purposes. A7. Explicit Evaluation Reasoning—Evaluation reasoning leading from information and analyses to findings, interpretations, conclusions, and judgments should be clearly and completely documented. A8. Communication and Reporting—Evaluation communications should have adequate scope and guard against misconceptions, biases, distortions, and errors.  E1. Evaluation Documentation— Evaluations should fully document their negotiated purposes and implemented       Identify when key evaluation terms have different meanings for different stakeholder groups and build understanding between these perspectives. Learn and use key terms as they are understood by the communities involved with the program. Reconcile how stakeholders understand the meanings of key terms; guard against giving privilege to the way they are understood by the most powerful stakeholder groups. Remember that reliability is dependent on who and what is being tested; don’t assume reliability across cultures or contexts. Tap diverse informants to describe the program and its context. Recognize that perspectives and descriptions change over time and the evaluation process itself may affect the program and its context. Work with stakeholders to select methods they feel are credible and of which they can take ownership. Be open to a variety of methods and sources of data. Select information storage procedures that protect the rights of the individuals providing the information.  Help stakeholders to understand how different designs and analysis may be viewed in a different cultural context.  Select designs and analyses that will be credible to the stakeholders.  Engage stakeholders in developing findings from data, interpreting findings, and drawing conclusions. Recognize that stakeholders may have different ways and styles of reasoning and that logic is contextual. Clearly articulate all assumptions involved with the reasoning process.      Build in checks early in the evaluation to ensure shared understanding of evaluation results among stakeholders. Create and implement a communication plan that meets audience preferences and ensures that different language needs are met. Ensure that key concepts are not “lost in translation.” Be explicit in documentation about decisions made to increase cultural competence and justify why the values of certain stakeholder groups were given precedence over those of other groups. designs, procedures, data, and outcomes.   E2. Internal Metaevaluation—Evaluators should use these and other applicable standards to examine the accountability of the evaluation design, procedures employed, information collected, and outcomes. E3. External Metaevaluation—Program evaluation sponsors, clients, evaluators, and other stakeholders should encourage the conduct of external meta-evaluations using these and other applicable standards.     Ensure that all documentation is clear and understandable to all stakeholders. Fully record the contributions made by all of the stakeholders within the process. Build capacity within the evaluation team to enable team members to apply evaluation standards to assess the quality of the evaluation over time; help them reflect on their own worldview and culturally-based assumptions. Clarify cultural competence as part of the purpose and standards for the meta-evaluation. Seek out persons from diverse cultural backgrounds to serve as reviewers. Avoid the use of meta-evaluation and other jargon when communicating with stakeholders. Purchase answer to see full attachment

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