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FPBondJ 1 Running Head: HAITI MATERNAL AND NEWBORN HEALTH CARE ACCESS Final Project, Capstone Seminar Action Research Judith Bond Dr Alexander NPMG-6910-3 Walden University

Using Action research to attain MDG maternal and child health goals in Haiti

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A proposed action research project to promote MDG goals for maternal and child health in Haiti.

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Page 1: Using Action research to attain MDG maternal and child health goals in Haiti

FPBondJ 1

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

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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

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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-

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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

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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

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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

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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

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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

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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.

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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,

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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

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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

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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.

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