A FORMATIVE EVALUATION OF THE CUIDESE FAMILY PLANNING PROGRAM

THESIS

Presented to the Faculty

of the University of Alaska Anchorage

in Partial Fulfillment of the Requirements

for the Degree of

MASTER OF PUBLIC HEALTH

By

Aaron J. Huff, BS, CHES

Anchorage, Alaska

May 2013
 UMI Number: 1536986

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 iii

Abstract

Providing healthcare for underinsured or non-insured non-citizens creates

difficulties for both the insurer and the healthcare system. The Cuidese program is

currently the only state funded family planning program that provides no or low-

cost family planning services for non-citizens in the State of Washington. This

evaluation provided the Washington State Department of Health and Cuidese family

planning clinics with information, from the patient perspective, on how the Cuidese

program affects their family planning and use of the family planning clinics. A mixed

method approach was used in this evaluation, including key informant interviews

and surveys to patients seeking healthcare at family planning clinics in Washington.

Clinic availability, interpreter service, availability of contraception, educational

materials, and male involvement in family planning were major themes identified.

Family planning clinics in Washington will need to continue offering family planning

as well as develop ways in which they can improve male involvement.

 iv

Table of Contents

Page

Signature Page .......................................................................................................................................... i

Title Page.................................................................................................................................................... ii

Abstract ..................................................................................................................................................... iii

Table of Contents ................................................................................................................................... iv

List of Figures ......................................................................................................................................... vii

List of Tables......................................................................................................................................... viii

List of Appendices ...................................................................................................................................x

Acknowledgments ................................................................................................................................. xi

Chapter 1 Introduction .................................................................................................................... 1

Chapter 2 Evaluation Goals and Objectives........................................................................... 4

Chapter 3 Review of the Literature ........................................................................................... 6

Access to Family Planning Services....................................................................................... 6

Barriers to Family Service ........................................................................................................ 8

Evaluation of Family Planning Programs ........................................................................... 9

Chapter 4 Activities and Methods ............................................................................................13

Conceptual Framework............................................................................................................13

Context of the Family Planning Clinics ..............................................................................15

Evaluation Design and Data Collection ..............................................................................18

Evaluation Design ............................................................................................................18

 v

Page

Quantitative Data.............................................................................................................19

Qualitative Data ...............................................................................................................21

Who Was Interviewed ...................................................................................................21

Interview Process ............................................................................................................22

Protection of Human Subjects .........................................................................................................22

Data Management .................................................................................................................................24

Data Analysis ..........................................................................................................................................25

Quantitative ..................................................................................................................................25

Qualitative .....................................................................................................................................26

Integrating Data in Mixed Methods ...............................................................................................27

Chapter 5 Results ..............................................................................................................................28

Qualitative Self-Completion Survey Results ....................................................................28

Response Rate ..................................................................................................................28

Demographic Profile of Respondents .................................................................................31

Clinic Services (Appointment) ..............................................................................................33

Clinic Services (Staff) ................................................................................................................36

Clinic Services ..............................................................................................................................38

Results of Bivariate Analysis..................................................................................................43

Evaluator's Observations ........................................................................................................60

Emerging Themes From Interviews ...................................................................................60

 vi

Page

Support ................................................................................................................................61

Access to Family Planning Clinics..............................................................................62

Contraception ....................................................................................................................63

Chapter 6 Discussion and Recommendations ...................................................................64

Integrative Findings ..................................................................................................................64

Limitations ....................................................................................................................................68

Strengths........................................................................................................................................69

Recommendations .....................................................................................................................71

Conclusion .....................................................................................................................................73

Next Steps......................................................................................................................................74

Public Health Implications......................................................................................................76

References .............................................................................................................................................78

Appendices ............................................................................................................................................81
 vii

List of Figures

Page

Figure 1. Conceptual framework of variables that affect the use of the Cuidese
Program ....................................................................................................................................................14

Figure 2. Work status ..........................................................................................................................32

Figure 3. Where respondents’ would like to receive family planning services ............34

Figure 4. Reason the respondents’ use the clinic .....................................................................35

Figure 5. Reminder about appointment.......................................................................................36

Figure 6. Respondents’ level of happiness with........................................................................37

Figure 7. Comfort level with interpreters ...................................................................................38

Figure 8. Respondents’ value of clinical services .....................................................................39

Figure 9. Respondents’ happiness of educational materials................................................40

Figure 10. Reason respondents’ use family planning services ...........................................41

Figure 11. Barriers to getting family planning services.........................................................42

Figure 12. Are clinic services meeting your needs ..................................................................42

 viii

List of Tables

Page

Table 1. Survey variables ...................................................................................................................26

Table 2. Surveys mailed and returned by clinic ........................................................................29

Table 3. Survey response percentage ...........................................................................................30

Table 4. Respondents’ demographics ...........................................................................................32

Table 5. Days and times respondents’ prefer to visit the clinics ........................................33

Table 6. Comparing perceived value of service between age groups...............................43

Table 7. Comparing reasons for using family planning services and barriers to family
planning services between age groups ............................................................................................ 44

Table 8. Comparing preferred appointment times, location of family planning

services and reason for sing the clinic by age group ................................................................. 46

Table 9. Comparing happiness with staff and comfort level with interpreter between
age groups ...............................................................................................................................................47

Table 10. Comparing how helpful educational materials are between age groups ....48

Table 11. Comparing preferred appointment times, location of family planning

services, reason for using the clinic between those who work and don’t work........... 49

Table 12. Comparing happiness with staff between those who work and don’t
work ..........................................................................................................................................................51

Table 13. Comparing work status to clinic services ................................................................52

Table 14. Comparing work status to clinic services. ...............................................................53

Table 15. Comparing age to migration status ............................................................................54

Table 16. Comparing sex to migration status................................................................................ 54

Table 17. Comparing migration status to clinic services ......................................................56

 ix

Page

Table 18. Comparing migration status to clinic services ......................................................58

 x

List of Appendices

Page

Appendix A. Informed Consent Form ...........................................................................................81

Appendix B. Telephone Interview Script .....................................................................................83

Appendix C. Survey ..............................................................................................................................86

Appendix D. University of Alaska Anchorage IRB Approval ................................................91

Appendix E. Central Washington University IRB Approval .................................................92

 xi

Acknowledgements

First and foremost, I would like to acknowledge my advisor Dr. Rhonda

Johnson. She has helped broaden my understanding of and appreciation for public

health. Additionally, I would also like to acknowledge the Master of Public Health

faculty who helped me develop my public health education and experience

especially my chair, Dr. Gabriel Garcia. I would also like to thank my Thesis

Committee for helping me along the way and taking the time to answer all of my

many questions and guide me through the process. A very special thank you to Dr.

Melody Madlem for being a part of this evaluation project and for providing

additional resources which made this evaluation possible. Her expertise was

invaluable. Additionally, I would like to thank the following for their contribution to

this evaluation: Richardo Del Bosque for his time in translating the surveys and

telephone interviews; Mayra Tecayehuatl and Dayana Diaz for their time in

conducting the telephone interviews; Mark Perez for his motivation and expertise;

and Mt. Baker Planned Parenthood, Family Planning of Chelan Douglas, Okanagan

Family Planning, Family Planning Services of Grant County, and Planned Parenthood

of Greater Washington and Northern Idaho for allowing me to work with their

patients. I would also like to thank my family for their patience and understanding

throughout my years pursuing a Master of Public Health degree.

 1

Chapter 1: Introduction

With an increasing number of Medicaid births among non-citizens in the

State of Washington, the state legislature allocated money in 2005 to the

Department of Health to begin a multi-year project for non-citizens who are

ineligible for family planning services through Medicaid systems. The project called

Cuidese or “Take Charge” is for persons with household incomes at or below 200%

of the federal poverty level (FPL) who are ineligible for family planning services

through the Medicaid program with the intent of serving non-citizen women and

men. The first variation of this project took place in Yakima County and then in

subsequent years expanded to additional counties in the state. From July 1, 2005 to

June 30, 2006 the total number of non-citizen clients receiving some type of

reproductive health services in the Yakima project (the original location) was 1,693,

an increase of 89% from previous non-citizen numbers (WA DOH, 2006).

The purpose of the Cuidese program is to provide access to healthcare for

“those individuals who are in need of family planning services, either because they

are not currently pregnant or they are trying to prevent pregnancy from

occurring”(WA DOH, 2005). The inclusion criteria for the Cuidese program are:

x Household income at or below 200 % of the federal poverty level (FPL),

x Do not qualify for family planning services through Medicaid,

x Not currently pregnant,

x No longer eligible for First Steps (which is a service provided for a period of

12 months after a Medicaid paid birth).

 2

The Cuidese program focuses on two program goals:

x To increase access to family planning services for non-citizens in an effort to

avoid unintended pregnancies.

x To develop a program that was able to fill a gap in health services with non-

citizens men and women.

The Cuidese program provides comprehensive education about:

x birth control methods,

x abstinence and,

x contraceptive services.

The implementation of Washington State’s Cuidese program, which originally

started in Yakima County, has steadily grown over the past several years. Today this

project can be found in seven additional Washington counties—Adams, Chelan,

Douglas, Franklin, Grant, Okanogan, and Skagit—where it is implemented by five

family planning agencies.

There are several important key elements of the Cuidese program. The first is

client participation. According to FPRH (2005), “it was estimated that the project

could serve 1,000 clients with the funding provided” (p. 1). The funding, however

only covered 90% of the estimated clients even though more non-citizens were

served by the family planning clinic. The clinics had to find reimbursement from

other funds or, more likely, were not reimbursed for non-citizen clients beyond the

895 clients supported by the project. Secondly, the Washington State Department of

Health found out that the cost of providing services for this project was higher than
 3

anticipated. This increase in cost is attributed to increased time for translation,

increased staff time to support an additional program, and increased cost of

providing bilingual materials. FPRH (2006), notes the factors that drive costs higher

include:

x bilingual and preferably bicultural Hispanic staff. (In some agencies, this

means hiring additional staff.)

x translation of documents, posters, and forms into additional languages

x additional clinic hours to accommodate migrant work schedules

x staff travel, time, and transportation costs to remote sites

Given the additional burden of the clinics, both in staff time and program

development, it was the focus of this evaluation to look at the various components of

the Cuidese program and determine what aspects are working for the patients and

what their family planning needs are. Since the implementation of the Cuidese

program, no formal outcome or formative evaluation has ever been conducted

among the clinics. Some clinics have in conjunction with the Department of Health

looked at data collected about the patients in efforts to improve the program.

Participating clinics receive money from the Department of Health, and each clinic

can use these funds to develop educational materials, offer low or no cost

contraception, pregnancy testing, and other family planning services. The one

desired outcome all clinics have in common is to reduce and prevent unintended

pregnancies among non-citizens. An evaluation of this program was needed to

determine if they are in fact preventing pregnancies from occurring.

 4

Chapter Two: Evaluation Goals and Objectives

The goal of this thesis practicum was to conduct a formative evaluation of the

Cuidese program. Its objectives were: (1) to document the experience of Cuidese

patients in the five family planning clinics in Washington, and (2) to identify areas of

improvement and strengths in the Cuidese program from the patients’ perspectives.

This evaluation addressed the following questions: (1) What opportunities

exist for program improvement? (2) How are the family planning services meeting

or not meeting the needs of the Cuidese patients? (3) Are there any differences in

the way patients view the program? Key activities of this evaluation included

conducting telephone interviews and a self-completion survey among Cuidese

patients in five family planning clinics.

By conducting this formative evaluation, staff from the Washington State

Department of Health and the five clinics that implemented this project would learn

from the patients’ perspective on how well the Cuidese program is meeting their

needs with respect to family planning services and pregnancy prevention. A

utilization focused evaluation approach allowed the inclusion, as much as possible,

of the intended users and what they wanted to know about the non-citizens that

utilize services through the Cuidese program. This type of approach was critical in

that the focus of the evaluation engaged stakeholders and gave them a sense of

ownership in the evaluation.

This evaluation is important for several reasons. First, the final evaluation

report will be given to the clinics who implement the Cuidese program so that they
 5

can improve their own individual project. Second, this evaluation will provide

information to the clinic staff regarding the struggles of their patients, their views of

the program, what resources they are lacking, and what aspects of the program

work best for them. Ultimately, the intended users will have firsthand knowledge

on the most effective ways to reduce any barriers and create a more comprehensive

program.

According to Ritualo, Cawthon, and Woodcox (2004), the number of Medicaid

births to non-citizens in Washington has increased since 1993. The Cuidese

program works to enhance availability of contraceptive services and family planning

to non-citizens, potentially reduces the negative social consequences (attitudes,

pregnancy, and utilization of health services), may reduce the number of Medicaid

paid births in program participants, and increases access to culturally competent

health care.

Among the five clinics that implement the Cuidese program, basic descriptive

statistics were collected such as age, sex, type of contraception used, and number of

live births. At each of the five clinics, basic patient information was collected by

WA DOH on the patients such as; how they heard about the program, whether they

received emergency contraception, and how many previous live births (both

planned and unplanned) the patient has. In order to determine if the goals of the

Cuidese program are being met, more information was needed on how well the

services were meeting the needs of the patients. In particular, the patients’

perspectives of the care they receive needed to be explored.

 6

Chapter 3: Review of the Literature

Access to Family Planning Services

For Hispanic females and males, access to culturally competent family

planning services remains a struggle. Hispanics are the fastest-growing minority

group in the United States (Jones, Bond, & Gardner, 2002). Of those Hispanic

women who were born outside of the U.S., many did not utilize resources available

to them such as access to preventative healthcare, contraception, and routine visits

to a health care provider (Asamoa et al., 2004). Asamoa et al. also concluded that

Title X family planning services contributed to the decrease in Hispanic women

utilizing insurance for preventative health care since Title X helps offset the cost.

Additionally, Gold et al. (2009) also showed in their study that Title X programs

have resulted in an increase in the use of family planning services. However, access

is still an issue, and there is still an ever-growing demand for publicly funded

contraception. For women in lower socioeconomic groups Freeman and Lethbridge-

Cejk (2006) noted that healthcare centers and/or clinics are the primary place for

women to receive preventative family planning services such as treating sexual

transmitted infections, contraceptive use, and family planning counseling. The use

of contraceptive methods among non-citizen Hispanic women and men still remain

scant. What is known is that an evaluation conducted by Rivera et al. (2007)

showed that Latinas have a higher birth rate and a proportionally lower use of

contraceptives compared to women of other ethnic groups. Hispanic non-citizens

have disproportionately low levels of income and of health insurance. Most have no
 7

insurance at all. The only option for healthcare for non-citizen men and women in

Washington is Medicaid, but even this is limited.

Non-citizen immigrants have limited access to publicly funded health care

services and programs. Even when such programs exist, such immigrants are

disinclined to utilize the health care system. Sungkyu and Sunh (2009) found that

the foreign-born populations were not as likely to reveal themselves to health

services staff as the non-foreign born. According to Anderson et al. (2006), family

planning programs that offer reproductive health services are often a “main point of

entry into the health care system (pg. 4).” Studies have shown that programs that

are culturally and linguistically appropriate have the highest success rate of meeting

the needs of the patients (Singleton & Krause, 2009). For example, Anderson et al.

(2006) mentioned that although there are many barriers to immigrants, addressing

cultural and linguistic barriers will foster an improvement in health outcomes.

In Washington for example, very few health centers and programs are

available for non-citizens. Community health centers (CHCs) are non-profit

community-owned health centers that provide a wide range of health services to

Washingtonians regardless of income. Although CHCs offer comprehensive health

care coverage, they don’t offer comprehensive family planning services. Typically,

the client may be given a prescription for contraception which they have to take to a

pharmacy and potentially pay full price. In addition to the CHCs, there is a program

offered by the Washington State Department of Social and Health Services called

First Steps. This program offers low-income pregnant women health care services
 8

that include one year of birth control following a Medicaid paid birth. When this

year is up, many women do not know where to find new or additional contraceptive

services.

Barriers to Family Planning Services

Among non-citizen Hispanic women and men, there are many barriers that

prevent women and men from seeking medical treatment or advice. One such

barrier is fear associated with obtaining health care. Berk et al. (2000) noted in

their study about health care use among undocumented Latinos that, “33 percent of

the undocumented persons in Houston, 36 percent of those in Los Angeles, 47

percent of those in Fresno, and 50 percent of persons in El Paso responded

affirmatively” when asked if they were afraid to seek family planning services due to

their immigration status. The most common themes among non-citizens with

regards to health care are fear, confusion, and language issues (California Immigrant

Policy, 2007). Ku and Waidmann, (2003) concur that, among racial and ethnic

minorities, language and citizenship concerns are disproportionately higher than

their white counterparts. These themes represent very difficult challenges for non-

citizens. Schnur et al. (1995) noted in a study they did about Bridging the Gap of

Immigrant Child Day Care, that even when the best of circumstances are in place,

immigrants have high stress in a new culture and experience communication

difficulties. Ku and Waidmann, (2003) noted that “citizenship status (e.g., citizen,

legal immigrant, or undocumented alien) impacts a person’s ability to obtain health

coverage by affecting the likelihood of having a job that offers health insurance and
 9

a person’s eligibility for Medicaid.” Undocumented persons also are more likely to

report problems communicating with their health care providers compared to their

documented and English-speaking peers. There are often barriers that effect Latino

decisions to use family planning services. In a study conducted by Leonard et al.

(2006), they mentioned that, for Hispanic women in the United States, barriers to

effective contraception services include use of natural family planning, religion, type

of contraception, and access. The author concluded that other studies are needed to

determine the “motivations and reasons for their behavior “with respect to the

utilization of health care services.

Evaluation of Family Planning Programs

Evaluation of any health program is critical in order to verify that the

program being implemented is producing the desired effect among the target

population. Little is known about the non-citizen population in Washington. What

is known is that Washington has a large number of agricultural/farming

opportunities. Due to this, Washington sees many migrant workers in the

agriculture industry. In a study about farm labor trends in Washington, Thilmany

(2001) stated that:

“Washington State employment officials estimate that 30% - 60% of the

seasonal agricultural workforce is made up of illegal or undocumented

workers. In 1995, about 13% of all Washington seasonal farm workers were

migrants (8.5 % were interstate and 4.4% were intrastate workers).”

 10

Although the agriculture industry is strong, the pay remains relatively low. This low

pay is compounded by the lack of year round employment. According to the

Washington State Farm Workers (2007), the range in annual income for farm

workers was $14,300 to $17,400. This low income presents many challenges. One

of them is receiving health care. Providing healthcare for underinsured or non-

insured non-citizens creates difficulties for both the insurer and the healthcare

system. Camarota and Edwards (2001) stated that immigration in the last few years

has contributed to an enlarged number of uninsured children in the United Sates by

more than 700,000. This increase in uninsured children accounted for more than $4

billion a year under the new State Children’s Health Insurance Program.

The Cuidese program is the only program targeted to provide comprehensive

contraceptive education and services to non-citizen women before they become

pregnant. Publicly funded family planning clinics are vital health care resources to

many men and women, especially to those who are in need of health care and who

can't afford insurance.

According to Ritualo et al. (2004), there was a significant increase in

Medicaid paid births un the U.S. Among these Medicaid-paid births, 80% were

attributed to Hispanic non-citizens. The National Council of La Raza (2006), noted

that understanding how Hispanics make decisions about contraception is important.

Since the Hispanic population is typically less studied than their white counterparts,

one must understand their views and reasons about the use of contraception. The

National Council of La Raza stated that the median age of Hispanics who use
 11

contraception was 26 years old compared to their white counterparts who median

age was 35 years old. Additionally, 48% of the Hispanic population is under the age

of 29. Since the Hispanic population is younger, the result is a population that is

prime for planning their reproductive lives. This “necessitates an understanding of

how Latinos make decisions about their sexual and reproductive health, particularly

with regards to contraception” in providing appropriate education and counseling

(National Council of La Raza, 2006)

Literature focusing on the views of non-citizens and their family planning

practices has been scant. What is known about the views of migrant Hispanics and

their use of family planning clinics is that the Hispanic culture plays a significant

role in their decisions to use family planning services (Sable et, al., 2009). For many

females, it is hard to use contraception because of their male partner and the

influence of machismo (male chauvinism) (Samble et al., 2006). “Machismo” is a

term used to describe a Hispanic male’s power and strength. Uhlig stated in an

article, that “a man’s virility is still measured by the number of offspring he sires”

(Uhlig, 1990, p.1). Due to this machismo effect, a women assumes the responsibility

for avoiding pregnancies by using contraception. Although culture plays a

significant role in family planning, other areas of the health care setting have also

been looked at in hopes to drawing conclusions on immigrants’ use of family

planning. In a study conducted by Newbold and Willinsky, (2009), the primary

focus was on understanding the viewpoints from a provider’s perspective in hopes

of drawing conclusions about family planning services to immigrants. They found

 12

four main themes: 1) language barriers to family planning services, 2) cultural

sensitivity, 3) role of gender, and 4) misconceptions about family planning services.

Thus far, the literature has addressed limited information on the viewpoints

of the family planning services received by non-citizens. This formative evaluation

looked at some of the key services received by the patients. The focus of this

evaluation was on the patient’s view of the Cuidese program. An evaluation of this

type has not been done and will provide valuable data to program staff and the WA

DOH.
 13

Chapter 4: Activities and Methods

Conceptual Framework

The specific aim of this evaluation was to collect the patients’ perceptions of

how their needs were met through the services rendered at the clinics. There were

three evaluation questions: 1) What opportunities exist for program improvements?

2) How are the family planning services meeting or not meeting the needs of the

Cuidese patients? and 3) Are there any differences in the way patients view the

program? To address these evaluation questions, both qualitative (telephone

interview) and quantitative (self-administered survey) methods were used. Based

on the conceptual framework, “The Dynamics and Meaning of Unintended

Pregnancy”, there were several key components that influenced unintended

pregnancies (Koo & Woodsong, 1997). Since a goal of the Cuidese program is to

help reduce unintended pregnancies, this evaluation looked at some of the key

factors in this model (see Figure 1) (Ulin et al., 2005).

 14

Environmental

x S o cia l/e co n o m ic
in flu e n ce s
x F a m ily
x P a rtn e r
x P e e rs
x P ro vid e rs

Individual Clinic Pregnancy Outcomes

C h a ra cte ristics Intentions B irth
x E xp e cta tio n s x A cce ss x P h ysica l
x M o tiva tio n s x A va ila b ility x M o tiva tio n s x C h ild ca re /su p p o rt
x C u ltu re x C o n siste n cy
P rio r E xp e rie n ce U tiliza tio n o f H e a lth x C o m p e te n ce x N o n u se A b o rtio n
x P a rtn e r C a re S e rvice s
x E d u ca tio n x R e la tio n sh ip
e xp e rie n ce x A ssista n ce
x S e xu a l/g e n d e r x F in a n cia l
x A g e x M o ra l su p p o rt
x C u ltu re
x V a lu e s

Figure 1. Conceptual framework of variables that affect the use of the Cuidese
program. Adopted from Koo and Woodsong, (1997).

There are several factors that affect a patient’s decision to utilize a program

like Cuidese. They have been generalized below into cluster areas and in figure 1

above. The first is the environment. Within the environment, there are many

factors associated with the utilization of health services including the social,

economic, and interpersonal environment of the patient. The next cluster looks at

the patient’s expectations, motivations, partner experience, culture, and values. The

third cluster is the patient’s pregnancy intentions. Factors such as consistent,

inconsistent, or lack of contraceptive use play a role in the decision whether to take

the steps necessary to prevent an unintended pregnancy. The fourth cluster is the

clinic. The clinic represents unique factors such as increasing access, and education.
 15

These factors are relevant because the patient often relies on the clinic for

emotional support. Support and education come from providers, who are culturally

and linguistically competent, and provide the level of care the patient needs to

prevent unintended pregnancies. Availability of the clinic is also important as

patients need to be able to have access to the clinic at the times that work best for

them. The fifth cluster is outcomes. Some factors within the outcome cluster

include, giving birth to a child, keeping the child, choosing an abortion or giving the

child up for adoption. These factors are affected by financial and partner support or

the lack thereof. These factors can be a result of the decisions the patient makes.

The last cluster is the utilization of health services. All of the above mentioned

clusters ultimately influence the patient’s decision to utilize a health program.

Context of the Family Planning Clinics

The five clinics that participated in this evaluation were located in different

parts of Washington. Since these clinics are the only ones that offer this type of

family planning services, it was important to highlight the specifics of the clinics. It

was also important to note that each of these clinics were part of a highly intensive

agricultural area.

Two of the five clinics are run by Planned Parenthood. These centers are

non-profit family planning clinics that have been helping women, men, and teens

make responsible choices about their sexual health. One of the two clinics is Mt.

Baker Planned Parenthood which is located in the city of Bellingham. This clinic has
 16

a staff of seven and serves an annual average of 320 Cuidese patients. Mt. Baker

Planned Parenthood offers a wide range of sexual health services during weekday ,

evening, and Saturday hours. Many patients qualify for free services. The other

Planned Parenthood clinic is in Sunnyside, WA, located centrally in the Yakima

Valley. The Yakima Valley is responsible for roughly 75% of the hops production in

the United States (Sunnyside Chamber of Commerce, 2012). The Sunnyside clinic

offers a wide range of sexual health services Tuesday through Friday during the

daytime and variable evening hours. The Sunnyside clinic treats an average of 600

Cuidese patients a year and has four staff members.

The other three clinics are independent family planning clinics in

Washington. Family Planning of Chelan and Douglas Counties (FPCD) is nestled in

the heart of the apple capital of the world and located on the east side of the Cascade

foothills. FPCD strives

“to provide and promote full access to services and resources regarding

reproductive and sexual health. Family planning means access to affordable

reproductive health exams, contraceptive methods, emergency

contraception, sexual health education, screening and testing for a healthy

reproductive life, and prenatal, birth and post-birth care” (Family Planning of

Chelan Douglas, 2012).

FPCD offers a wide range of sexual health services with typical day time

hours Monday-Friday. FPCD has a staff of seven and treats an average 300 Cuidese

patients a year. The second independent clinic is Family Planning Services of Grant
 17

County (FSGC) which is located in Moses Lake, WA within the Columbia Basin of

Central Eastern WA state. Known for its vast amount of agriculture such as wheat,

potatoes, orchards and corn, FSGC has been located in Grant County since “1973 and

serves over 1,500 men and women each year” by a staff of about 10. Of the 1500

patients, 400 are served through the Cuidese program. “There are many women in

Grant County who would have no health care at all if they could not get their annual

exams at a family planning clinic. A large population of undocumented,

monolingual, Spanish speaking women who work in the fields of Grant County are

not eligible for any other health care. No patient is ever turned away because of

inability to pay” (Family Services of Grant County, 2011). FSGC offers a wide range

of sexual health services such as birth control information; birth control methods

including pills, condoms, Deporprovera Injections, contraceptive patches, IUD’s, and

Nuvarings; pregnancy testing and counseling; sexually transmitted disease testing

and treatment information; and referral for sterilization and infertility.

The last clinic which participated in this evaluation was Okanogan Family

Planning (OFP), located in the North Central part of WA State in a small rural

agriculture town called Omak which is known for its apples. OFP “provides

leadership for the acceptance and use of family planning as an essential element of

healthy communities.” Its medical clinic provides all FDA approved birth control

methods, pap smears, breast exams and other well-women health care, sexually

transmitted disease testing for women and men, pregnancy tests, referrals for

abortion, prenatal care or adoption, emergency contraception (Plan B), and

 18

education for teens and parents. The clinic operates with daytime hours on Monday

through Thursday. OFP has a staff of six and see on average 358 Cuidese patients a

year.

Evaluation Design and Data Collection

Evaluation Design. This evaluation used a cross sectional study design in

collecting both quantitative and qualitative data. While other research designs such

as longitudinal and experimental study designs would have strengthened the

internal validity of this evaluation, the limited human, time, and financial resources

led to a cross-sectional study design. Another reason for the chosen study design is

that a cross sectional study uses pre-defined measurements such as survey

questions and unlike a longitudinal study, a cross sectional approach does not

require any follow-up. Furthermore, this evaluation is essentially a snap shot of the

patient’s views about the Cuidese program unlike a longitudinal study which would

measure the patient’s experience over time.

This thesis practicum used a mixed-method approach in the formative

evaluation of the Cuidese program. The advantage of utilizing a mixed-method

approach is that it allows for “more comprehensive evidence for studying a research

problem” (Creswell, 2006, p.9). This in turn will lead to a better understanding of

the research problem as opposed to just using quantitative or qualitative data.

“Focusing on research questions that call for real-life contextual understandings,

multi-level perspectives, and cultural influences,” were reasons for mixed methods

identified by the (Office of Behavioral and Social Sciences, 2012). The purpose of
 19

the quantitative data was to gather descriptive data and provide measurable

evidence of the findings. The purpose of the qualitative data was to capture the

experience and purpose of the Cuidese patients. The combination of quantitative

and qualitative data drew upon the strengths of each to answer the research

questions.

Quantitative Data. The quantitative data from the survey consisted of basic

descriptive statistics. The survey questions used in this evaluation were derived

from the literature, input from clinic staff at the five family planning clinics, and staff

from the Washington State Department of Health. Each clinic had an opportunity to

provide feedback to the evaluator to make sure that the questions asked on the

survey were going to be of value to them. All comments were combined together

and drafted into a survey questionnaire. The clinics are unique in how they

implement the Cuidese program. For this reason, the distribution of the survey also

varied. It happened:

x At the time of medical visit.

x At the local health fair for migrant workers.

x Through peer educators

x Through outreach conducted by the clinics.

This evaluation used convenience sampling. The reason for this sampling

method was related to accessibility of the patients at the clinics and the variability of

characteristics among the target population. Inclusion criteria for the survey were that

the patients have at some time received services through the Cuidese program at
 20

the clinics and were at least 18 years old. Patients who did not self-report as

Hispanic, who had an income above 200% of the federal poverty level, and who

qualified for one year of contraception through the First Steps program after a

Medicaid paid birth or another publicly funded program were excluded.

The majority of the patients completed the survey while waiting for their

appointment or during their actual appointment with a provider. The number of

unduplicated Cuidese patients seen in 2009 among all five clinics was 1,158

patients. Data collection took place during the spring farm season. The family

planning clinics indicated that this time would be better as the target population

were more likely to come into the clinic for family planning services. During the

summer, there is more of a demand for farm workers and thus the number of

patients that use the program is typically reduced. The survey questions were

piloted at Family Planning of Chelan Douglas in order to address face validity and

content validity. The pilot consisted of six participants who filled out the survey.

Comments from the clinic manager indicated that in general all patients found the

survey easy to read and understand. The translated words in Spanish were

appropriate for this population because zero patients indicated that they did not

understand any words. The reading level of the survey has been confirmed to be a

high fourth grade reading level from a trained Spanish consultant with the

Washington State Department of Labor and Industries. In addition to the patient

pilot, the survey was also given to the staff at all five clinics for review. Of the five

clinics, three responded. All comments were positive and each person indicated
 21

that the questions being asked were of value to them. For the purpose of

confidentiality, the completed surveys were kept in a locked file drawer at each

clinic. The surveys were printed on blue paper and given to the patients to insert

into the envelope titled “blue survey.” Survey data was entered in SPSS version 19.0

and frequencies, bivariate analysis, and univariate analysis were conducted.

Qualitative Data. An additional component of this evaluation was a follow-

up structured telephone interview with some of the survey respondents. These

interviews were conducted among the patients at the clinics. There were a total of

twelve people involved in providing feedback on the telephone interviews. Consent

to participate in the telephone interview was acknowledged by the patient when

they agreed and signed the informed consent form (See Appendix A). If the patients

wanted to participate in the telephone interview, they filled out their first name,

telephone number and indicate the best time to contact them. Once completed, the

respondents detached the consent from the survey and put it into a sealed manila

envelope labeled “green consent form.” To protect patient confidentiality, it was

imperative that the consent form and survey were kept separate.

The twenty potential interviewees were all Spanish speaking females. Since

the evaluator was not fluent in Spanish, two undergraduate Spanish speaking female

students from the Public Health Program at Central Washington University (CWU)

translated for the principal evaluator who conducted the structured interview.

Who was Interviewed. Twenty Cuidese patients from the four family

planning clinics were contacted for interviews. The evaluator randomly drew
 22

twelve patients between the four clinics. To achieve a desired sample of twelve,

twenty interview consent forms were contacted to allow for non-interests and

nutrition. Each interview was recorded via a digital recorder and assigned a unique

ID. All interviews were translated verbatim back to English for analysis. During this

process, only 10 interviews were successful translated. Two respondents could not

be understood by the medical transcriber.

Interview Process. The principal evaluator developed the interview guide

and trained two Spanish speaking CWU students to conduct the interview. The

interviews were conducted in May 2011, and all interviews were transcribed

between June and July 2011. To ensure proper representation from each clinic, at

least two telephone consent forms were verified and drawn from each clinic. The

formative evaluation questions explored the respondents perception and use of

contraception (questions: 3, 3a, 3b, 5, 5a, 5b), support of spouse/partner (questions:

4, 4a, 5, 5a, 5b), clinic services (questions: 1a, 2, 6, 7), and the last question asked

was to elicit perceived strengths and challenges of the clinics by giving them an

opportunity to provide any final comments.

Protection of Human Subjects

This evaluation involved working with patients who are Hispanic non-

citizens, in Washington with or without proper documentation. Protection of the

participant’s information must be strictly adhered to. The respondent’s

documentation status was completely unknown during this evaluation. This

evaluation involved collecting data from five clinics throughout Washington.

 23

Besides age and sex, no other information on the patient survey (See Appendix B)

was collected that could in anyway identify the respondents including citizenship,

name, or current job. Additionally, the survey data in this evaluation does not

include any patient records or details about the respondents and their pregnancy

status. No information was given that would in any way disclose information

regarding the patient’s medical records at the clinics. Attached to each survey was a

telephone interview consent form (See Appendix C). Respondents had the

opportunity to fill out the consent form, detach it from the survey, and put it into a

different sealed envelope. The consent form asked for patient name and contact

phone number, as this was the only way to reach them to conduct the interview.

Telephone interview consent forms were kept separate from survey to protect

patient identity.

The selection of the evaluation participants who completed the survey

and/or telephone interview consent form was not made by the clinic or the

evaluator. All participants in this evaluation who visited one of the five clinics,

either for an appointment or for other reasons, and who met the inclusion criteria

had an opportunity to participate in this evaluation. This population had a low

literacy level, and an explanation of the purpose of this evaluation was given to

them. To address comprehension, all materials including the consent form, surveys,

and telephone interview were translated into and conducted in Spanish.

For the telephone interviews, the two Spanish speaking female students from

Central Washington University who conducted the interviews and the medical
 24

transcriber who transcribed the interviews all signed a confidentiality agreement

form in accordance with the Data Protection Act and the American Sociological

Association, Code of Ethics.

Data Management

Upon obtaining approval from the Institutional Review Board (IRB) of the

University of Alaska Anchorage, and Central Washington University (See IRB

approvals in Appendix D), secondary approval was also obtained from those clinics

which were managed by the Planned Parenthood Federation in order to gain access

and authorization to interact with those patients who are part of the Cuidese

program.

The data used in the evaluation was derived from both a patient survey and

telephone interviews. Both the survey and the telephone interviews were

translated from English to Spanish by the medical transcriber. This project used

several evaluation methods as a source for determining a final recommendation to

the family planning clinics and the Washington State Department of Health.

First, telephone interviews of the patients of the family planning clinics were

conducted and analyzed. Patients who were 17 and younger at the time of visit to

the clinic were not given the telephone interview consent form. There were 123

patients who were given the opportunity to participate in the telephone interviews.

One clinic’s patients were not able to participate as no consent forms were received.

Of the 123 possible telephone interview consent forms, 76 were received. These 76

consent forms were then split into their respective clinics to assure an even
 25

representation by the clinics. Twelve were randomly drawn between the 4 clinics.

The total telephone interview participants was (n=12).

The second evaluation method used was a survey. All five clinics were given

surveys to administer to the patients. The clinics chose the method of delivery.

Some clinics chose to give the survey to patients as they waited for their

appointment, while others administered the survey during their office visit. Of the

five clinics, four clinics returned questionnaires. Among the four clinics, 123

surveys were received, of which 117 participants were female and seven were male.

Given there were five clinics that offered the Cuidese program, the likelihood

of Hispanic patients going to one of these clinics was high. There was a possibility of

patients visiting other clinics in the area, but they would not be included in this

evaluation.

Data Analysis

Quantitative. Descriptive statistics were conducted for all variables of

interest both to determine proportions and statistical significance with other

questions on the survey. Frequencies were run on all questions to determine

proportions (see Table 1.). The age of respondents was the first variable that was

formulated against all survey questions (see Table 1.). Crosstabs were run on three

variables: age, whether respondents migrate in and out of the state, and their

working status. It was important to look at the frequencies of the variables to

determine if there were any relationships. Chi-square was used to test the level of

significant association between variables. For the ordinal questions of the survey,
 26

independent sample T-tests were used to determine the level of significance. The

second variable was Question #1 which asked about migration status and working

status. There were three possible responses. For analysis purposes, this question

was coded into two variables labeled “work status” which looked at whether

respondents worked or didn’t work and “migration status” which looks at whether

patients migrated in and out of the state. The 0.05 level of significance was chosen

for this study as it is the most widely accept p-value used in public health research.

For question #2, “what day of the week is best to come to the clinic,” morning,

afternoon, and evening were reviewed independently of the day of the week. All

analysis was completed using SPSS version 19.0.

Table 1

Survey variables

Variables
Days of the week,
Location of Family Planning Services
Happiness with
Age, Migration Value of Services, More Comfortable With
Status, and Working Helpfulness of Educational Materials
Status Reminder About Appointment
Reason for Using Family Planning
Barriers to Family Planning
Clinic Services Meeting Needs

Qualitative. Since the telephone interviews were conducted by Spanish speaking

students, the surveys needed to be transcribed verbatim into English. Qualitative

data was analyzed from the interviews by the evaluator using step-by-step

guidelines (Braun & Clarke, 2006).

 27

x Phase 1: familiarizing yourself with your data

x Phase 2: generating initial codes

x Phase 3: searching for themes

x Phase 4: reviewing themes

x Phase 5: defining and naming themes

x Phase 6: producing the report

The first step in the analysis was to read through the transcripts several times to

become familiar with the data. The second step was to generate codes. This was

done by highlighting responses in the transcripts that the evaluator thought may

answer evaluation questions. Once codes were identified, they were grouped to

form themes using the thematic map. This phase resulted in the identification of

four major themes: access to family planning services, use of contraception, having

their family planning needs met, and chance of getting pregnant. Once identified

these themes were used to explain and add breadth to the quantitative findings.

Integrating Data in Mixed Methods

This evaluation used a mixed-methods design to strengthen evaluation

findings. Both quantitative and qualitative data were summarized in descriptive

statistics, tables, and graphs. The emerging themes from the qualitative analysis

were then used to complement survey findings and respondent quotes enhanced

the breadth of this evaluation.

 28

Chapter 5: Results

Quantitative Self-Completion Survey Results

Response Rate. Survey questionnaire and forms were sent to the five family

planning clinics via United States Postal Service. Each clinic received 50 surveys and

50 telephone interview consent forms. Four of the clinics had a response rate

greater than 50% (see Table 2). One of them did not, having a less than 5%

response rate. Therefore, the findings presented here are more representative of

the four clinics with the higher response rates. Since the clinics administered the

surveys, it is impossible to know how many patients chose not to participate as this

data was not collected. Based on phone conversations with staff and each clinic,

each patient was given an opportunity to fill out the survey and telephone consent

form. Each clinic indicated hardly any patients refused to fill out the survey.

Considering all clinics and the number of sent surveys and surveys received, the

overall response rate was 49% (N= 123) (see Table 2).
 29

Table 2

Surveys mailed and returned by clinic

Total Response Response

Number Number Response Rate for Rate for
Sent Received Rate Males Female
Cuidese Patients at
Okanogan Family Planning 50 2 4% 0% 4%
Cuidese Patients at Chelan
Douglas Family Planning 50 26 52% 12% 88%
Cuidese Patients at Moses
Lake Family Planning 50 32 64% 6% 94%
Cuidese Patients at Mt.
Baker Planned Parenthood 50 29 58% 7% 93%
Cuidese Patients at
Planned Parenthood of
Greater Washington and
Northern Idaho 50 34 64% 0% 100%
Total (N=) 250 123 49% 7% 93%

Not all respondents filled out each question on the survey completely. Some

left questions blank, others seemed to pick and choose the questions they wanted to

answer either because of convenience or their comfort level in answering the

questions (see Table 3).

 30

Table 3

Survey response percentage

Number of Missing Response

Responses Responses Rate
Respondents’ Sex 123 0 100%
Respondents’ Age 123 0 100%
Question #1 (Tell me about
your work?) 115 8 93%
Question #2 (What day of the
week is best to come to the
clinic?) 111 12 90%
Question #3 (Where would you
like to have family planning
services?) 116 7 94%
Question #4 (Why do you use
this clinic?) 107 16 87%
Question #5 (How happy are
you with..?)

Reception Staff 107 16 87%

Nurse 100 23 81%
Provider 95 28 77%
Clinic 101 22 82%
Interpreter 91 32 74%
Price 94 29 76%
Question #6 (What services
would be the most value to
you?)
Weekend Appointments 82 41 67%
Evening Appointments 83 40 68%
In-home services 85 38 69%
Domestic Violence Advocates 70 53 57%
Sterilization/Vasectomy 78 45 63%
STD testing 79 44 64%
Other services 85 38 69%
Question #7 (Do you feel more
relaxed with?)
Bringing your own interpreter 109 14 89%
Relying on a clinic interpreter 109 14 89%
 31

Table 3

Survey response percentage continued

Number of Missing Response

Responses Responses Rate
Bringing a friend or family
member 108 15 88%
Question #8 (Which of the
items below help you prevent a
pregnancy?)
Brochures 102 21 93%
Bulletin 102 21 103%
Flyers 102 21 113%
TV Ads 102 21 123%
Radio 102 21 133%
Health Fair 102 21 143%
Question #9 (When would be
the best time to remind you
about your appointment?) 112 11 91%
Question #10 (Why do you use
family planning services?) 113 10 92%
Question #11 (What prevents
you from getting family
planning services?) 97 26 79%
Question #12 (Are the services
you receiving through this clinic
meeting your needs?) 104 19 85%

Demographic Profile of Respondents. Of the 123 Cuidese respondents, almost all

were women and between the ages of 18 to 30 years (see Table 4). With regards to

their working status, about 50% indicated living in the state but did not work, 44%

worked the state during the farm season but do not leave the state to find other

work, and the rest either work in the state during the farm season but left the state
 32

after the season or for other reasons (see Figure 2). There was no statistically

significant relationship between age and the respondent’s migration status.

Table 4

Respondent demographics

Demographic
Characteristics Percent
Sex
Male 6%
Female 94%
Age
18-30 59%
>31 41%

Tell me about your work?

60%
50%
50%
44%

40%

30%

20%
9% 9%
10%

0%
I work in this state I work in this state I live in this State but Other
during the farm season during the farm season. don’t work
then leave the state I don’t leave to find
other work

Figure 2 Work status (N=123)

Note: Responses to “other” include the following: homeless at the moment, I work, I
work during the summer, I work here and I’m looking for other jobs, I work in Mexican
 33

store, I work part time, I work where I find a job opportunity, worked in a restaurant
but closed but I’m working, working in a restaurant.

Clinic Services (Appointment)

Survey respondents answered several questions that gave insight into what they

preferred from the Cuidese program. With regards to best time and day of the week

to come to the clinic, survey respondents indicated Monday afternoon and evening

was the best time (see Table 5).

Table 5

Days and times respondents prefer to visit the clinic (n=120)

Mon Tue Wed Thur Fri Sat Sun

In the morning 8am-12pm 21% 15% 20% 18% 15% 7% 2%
In the afternoon 12pm-
23% 17% 12% 11% 19% 12% 10%
4pm
In the evening 4pm-7pm 23% 21% 19% 16% 22% 11% 8%

In regards to “where respondents would like to have family planning services,” a

majority of the respondents (88%) indicated “at the clinic with regular hours” (see

Figure 3). A majority of the respondents indicated price was the most important

reason as to why they used the clinic (see Figure 4).

 34

Where would you like to have family planning services?

100%
90% 88%

80%
70%
60%
50%
40%
30%
20% 16% 16%

10% 4%
0%
0%
Clinic with regular After hour clinic Special family Where I work Other
hours (8am-5pm) planning clinic
days

Figure 3. Where respondents would like to receive family planning services (N=116)

Note: Responses to “other” are: 4-7 pm, I take my rest on Friday, In my house, Not
working, Yazmin villa.
 35

Why do you use this clinic?

45%
39%
40%
35%
30% 27%
25%
19%
20%
15%
15%
10%
5%
5%
0%
Close to my home Price Interpreter service Medical staff Other

Figure 4. Reasons the respondents use the clinic. (N= 103)

Note: Responses to “other” are: because I always come here, Brendan is much help.
Very close, everything is good, it helps to have better family planning, it’s the only place
with free assistance, very polite.

An overwhelming number of respondents indicated that one day before their

appointment would be the best time to remind them about their appointment (see

Figure 5).
 36

When would be the best time to remind you about your

appointment?
100%
90%
90%
80%
70%
60%
50%
40%
30%
20%
10% 1%
10%
0%
Reminder about appointment Reminder about appointment Reminder about appointment
same day one day before other

Figure 5. Reminder about appointment (N=120)

Clinic Services (Staff)

Two questions in the survey asked about clinic services in regards to the

staff. One question asked about the respondents’ level of happiness with the staff

and the other about their comfort level with interpreters. These questions were

measured using a 4 point Likert scale with 1= the lowest level of agreement to 4=

the highest level of agreement. The mean score is reported in Figure 6. The

respondents’ mean level of happiness with the reception staff, nurses, providers,

clinic staff, and interpreter staff and with cost of services were all above 3.50 and

not significantly different from each other as the standard deviations of the means

are within range of each other (see Figure 6).

 37

Mean happiness with...

3.66

3.63 (± .652) 3.64 (± .612)

3.64

3.62

3.59 (± .683)
3.60
3.58 (± .725) 3.59 (± .739)
3.58
3.57 (± .753)

3.56

3.54

3.52
Reception Staff Nurses Provider Staff Clinic Staff Interpreter Cost of Service
Staff

Figure 6. Respondents’ level of happiness

When it comes to the utilization of interpreters, respondents had a greater

degree of comfort with the clinic interpreter, however, this was not significantly

higher than their degree of comfort with their own interpreter or with a family

member or a friend interpreting for them (see Figure 7).

 38

Mean comfort level

3.60

3.50 (± 1.060)
3.50

3.40

3.30
3.25 (± 1.523)

3.20
3.13 (± 1.47)
3.10

3.00

2.90
Bring Their Own Interpreter Relying on a Clinic Interpreter Bringing a Friend/Family
Member

Figure 7. Comfort level with interpreters (N=109)

Clinic Services

Five questions on the survey asked about the services respondents receive

when they go to the family planning clinics. In terms of services of most value to the

respondents, most indicated that STD testing was most valuable. There was no

statistical difference between having weekend appointments, evening

appointments, childcare, in-home services, domestic violence services, sterilization

or vasectomy, or STD testing (see Figure 8).

 39

Mean value with..

4.00 3.62 (± .845)
3.17 (± 1.063) 3.61 (± .788) 3.53 (±.817) 3.18 (± 1.035)
3.50 3.07 (± 1.045) 2.98 (± 1.042)
3.00
2.50
2.00
1.50
1.00
0.50
0.00
Evening Appointments

Childcare

In-Home Services

Domestic Violence
Weekend Appointments

Sterilization/Vasectomy

STD Testing
Advocates
Figure 8. Respondents’ value of clinical services

Note: Responses to “other” are: everything is good, family planning, pap smear.

In terms of how helpful items received at the clinics are in preventing

pregnancies, respondents indicated that health fairs were the most helpful avenue

in receiving information which aided in preventing pregnancies, but it was not

statistically different their responses to the use of flyers (see Figure 9).
 40

Mean level of helpfulness

3.80

3.69 (± 1.186)
3.70

3.58 (± 1.278) 3.58 (± 1.206)

3.60 3.56 (± 1.294)
3.55 (± 1.310)

3.50

3.37 (± 1.125)
3.40

3.30

3.20
Flyers Brochures Bulletin Boards TV Ads Radio Ads Health Fairs

Figure 9. Respondents’ happiness with educational materials

Sixty-six percent of the respondents indicated that they use the clinic for

birth control and 48% for other family planning services (see Figure 10).
 41

Why do you use family planning services

66%
70%

60%

50% 48%

40%
34%
30%

19%
20%
13%
10% 8%
5%

0%
Birth Plan a Health Pregnancy Prevent Unplanned Other
Control Pregnancy Information Test Pregnancy Pregnancy

Figure 10. Reasons respondents use family planning services

Note: Responses to “other” are: doing something with papanicolao, everything is good,
for a pap smear, testing for HIV, to be in good health, to prevent sexual diseases.

When asked about what prevents them from receiving family planning

services, 74% of respondents indicated that no health insurance is what causes

them to not use family planning services. 48% indicated inability to pay for

planning services (see Figure 11).

 42

What prevents you from getting family planning services?

80% 74%
70%
60%
45%
50%
40%
30% 19%
20%
5% 4% 8% 5%
10%
0%

Social pressure
No babysitter
No transportation to

No health insurance
Can't pay for family

Awkwardness

does not want me to

My spouse/partner
planning services

receive services
the clinic

Figure 11. Barriers to getting family planning services

When asked about whether the clinics are meeting the respondents’ family

planning needs, approximately 86% said that they always are (see Figure 12).

How often the clinics are meeting patients needs

100%
90% 86%
80%
70%
60%
50%
40%
30%
20% 12%
10% 2% 1%
0%
Always Usually Seldom Never

Figure 12. How Often the Clinics are Meeting Patient Needs
 43

Results of Bivariate Analysis

A bivariate analysis was conducted in order to determine what the specific

status, needs, and concerns are of the Cuidese respondents based on age, work

status, and migration status. In the bivariate analysis, age was compared to survey

questions. There were two variables that were statistically significant (p value ζ

0.05) (see Table 6).

Table 6

Comparing perceived value of service between age groups

Value of Services Age Mean ± SD P-value

18-30 3.08 ± 1.13
Weekend Appointments 0.30
31+ 3.33 ± 0.99
18-30 2.92 ± 1.09
Evening Appointments 0.08
31+ 3.33 ± 0.92
18-30 3.54 ± 0.83
Childcare 0.26
31+ 3.75 ± 0.70
18-30 2.89 ± 1.04
In-Home Services 0.30
31+ 3.17 ± 1.05
18-30 3.42 ± 0.91
Domestic Violence Advocates 0.09
31+ 3.71 ± 0.60
18-30 3.04 ± 1.08
Sterilization/Vasectomy 0.12
31+ 3.44 ± 0.89
Respondents value of STD 18-30 3.62 ± 0.88
0.78
testing 31+ 3.66 ± 0.79
Are the Services you receiving 18-30 3.12 ± 0.59
from this clinic meeting your 0.04
needs? 31+ 3.93 ± 0.27
SD= ± Standard Deviation
Mean scale = 1.0 is least satisfied through 4.0= Most satisfied
 44

When asked “are the services you receive from this clinic meeting your

needs,” there was a statistically significant difference between the responses of 18-

30 age group and 31+ age group. Whereas 89% of the older age group 31 and older

indicated that the services at the clinic were always meeting their needs, only 78%

of the younger group (18-30) indicated that the services always met their needs.

When asked what most “prevents you from getting family planning services,”

approximately 17% of the younger group indicated that lack of transportation is the

main reason why they don’t seek family planning services compared to just 2% of

the older group (see Table 7).

Table 7

Comparing reasons for using family planning services and barriers to family planning
services between age groups

Age
18-30 30+
Reason for Using Family (N=72) (N=51) P-Value
Planning Services % %
Birth Control 62% 59% 0.96
Plan a Pregnancy 18% 16% 0.86
Get Health Information 31% 31% 0.72
Get a Pregnancy Test 15% 8% 0.26
Prevent a Pregnancy 43% 45% 0.57
Unplanned Pregnancy 8% 6% 0.68
Barriers to Family Planning
Services
No Transportation to Clinic 17% 2% 0.05
No Babysitter 18% 10% 0.23
Can't Pay for Family Planning
36% 35% 0.95
Services
Social Pressure 1% 6% 0.16
Awkwardness 7% 6% 0.82
No Health Insurance 58% 59% 0.88
My Spouse/Partner Does Not
3% 59% 0.38
Want Me To Receive Services
 45

When the two age groups were compared (young clients, aged 18-30 years,

versus older clients, aged 31 years or more) in terms of areas of needs and concerns,

there were six variables that were not statistically significant but still compelling (p

value ζ 0.09) Approximately 56% of the younger respondents prefer Mondays

compared to 53% of the older respondents (p-value =.08). Eighty nine percent of

younger respondents preferred after hour clinic hours as opposed to 76% of the

older respondents (p-value = 0.07). When asked about reasons for using the clinic,

40% of the younger populations used the clinic because it close to their home as

opposed to 24% of the older population (p-value = 0.08) . When asked about the

best time to remind respondents about their appointments, 82% of the older

respondents prefer a reminder one day before compared to 81% of the younger

respondents (p-value = 0.09). Regarding the values of services, the older

respondents (mean = 3.33) indicated that evening appointments were more

valuable compared to the younger respondents (mean = 2.92) (p-value =.09).

Additionally, the older clients found domestic violence services more valuable

(mean = 3.71) compared to the younger clients (mean = 3.42) (p-value =.09) (see

Tables 8 - 10).
 46

Table 8

Comparing preferred appointment times, location of family planning services and

reason for using the clinic by age group

18-30
30+ (N=51)
(N=72) P-value
%
Preferred Clinic Days %
Monday 56% 53% 0.08
Tuesday 40% 49% 0.34
Wednesday 39% 41% 0.82
Thursday 33% 39% 0.51
Friday 49% 39% 0.34
Saturday 28% 18% 0.19
Sunday 19% 12% 0.26
Morning 39% 37% 0.85
Afternoon 42% 39% 0.79
Evening 38% 39% 0.85
Location of Family Planning Services
Clinic with regular hours 64% 38% 0.15
After hour clinic 89% 76% 0.07
Special family planning hours 86% 80% 0.31
Where I Work 0% 0% N/A
Reason For Using The Clinic
Close To My Home 40% 24% 0.08
Price 51% 50% 0.94
Interpreter services 14% 21% 0.31
Medical Staff 26% 26% 0.99
Best Time to Remind about Appointment
One Day Before 81% 82% 0.09
Same Day 13% 4% 0.13
 47

Table 9

Comparing happiness with staff and comfort level with interpreter between age
groups

Happiness With Age Mean ± SD P-value

18-30 3.59 ± 0.71
Reception Staff 0.53
31+ 3.67 ± 0.57
18-30 3.62 ± 0.66
Nurses 0.66
31+ 3.68 ± 0.53
18-30 3.56 ± 0.75
Provider Staff 0.88
31+ 3.58 ± 0.77
18-30 3.56 ± 0.71
Clinic Staff 0.61
31+ 3.63 ± 0.75
18-30 3.56 ± 0.74
Interpreter Staff 0.61
31+ 3.64 ± 0.59
18-30 3.55 ± 0.78
Price 0.58
31+ 3.64 ± 0.68
More Comfortable With
18-30 2.41 ± 1.03
Bring Their Own Interpreter 0.61
31+ 2.54 ± 1.20
18-30 3.26 ± 0.96
Relying on a Clinic Interpreter 0.58
31+ 3.38 ± 1.01
Bringing a Friend/Family 18-30 2.44 ± 1.16
0.47
Member 31+ 2.65 ± 1.29
SD= ± Standard Deviation
Mean scale = 1.0 is least satisfied through 4.0= Most satisfied
 48

Table 10

Comparing how helpful educational materials are between age groups

Helpfulness of Educational
Age Mean ± SD P-value
Materials
18-30 3.15 ± 1.02
Flyers 0.76
31+ 3.22 ± 1.06
18-30 2.94 ± 0.99
Brochures 0.81
31+ 3.0 ± 1.14
18-30 2.91 ± 1.01
Bulletin Boards 0.76
31+ 2.83 ± 1.13
18-30 3.06 ± 1.00
TV Ads 0.94
31+ 3.08 ± 1.00
18-30 2.76 ± 0.96
Radio Ads 0.20
31+ 3.08 ± 1.06
18-30 3.1 ± 0.98
Health Fairs 0.45
31+ 3.29 ± 1.04
SD= ± Standard Deviation
Mean scale = 1.0 is least satisfied through 4.0= Most satisfied

Comparing the areas of needs and concerns based on work status (those that

work and those that do not work), there were six areas where the differences

between the groups were statistically significant and two that were not significant,

but worthy of further study with a p-value<= .09. When asked about preferred clinic

days, 24% of respondents who work preferred to have clinics hours on Sunday

compared to 10% of those who don’t work (p=0.06). Additionally, 52% of those

respondents who work preferred clinic days during the afternoon (p-value = 0.04)

and during the evening (p-value = 0.03).compared to those who do not work (see

Table 11).
 49

Table 11

Comparing preferred appointment times, location of family planning services and

reason for using the clinic between those who work and don’t work

Work Status
Don't
Work Work
P-value
(N=50) (N=50)
Preferred Clinic Days % %
Monday 60% 58% 0.84
Tuesday 42% 52% 0.31
Wednesday 38% 44% 0.54
Thursday 42% 38% 0.68
Friday 56% 44% 0.23
Saturday 32% 20% 0.17
Sunday 24% 10% 0.06
Morning 44% 52% 0.10
Afternoon 52% 32% 0.04
Evening 52% 30% 0.03
Location of Family Planning Services
Clinic with regular hours 88% 89% 0.83
After hour clinic 18% 17% 0.89
Special family planning hours 18% 15% 0.68
Where I Work 0% 0% N/A
Reason For Using The Clinic
Close To My Home 29% 31% 0.82
Price 53% 49% 0.67
Interpreter Services 22% 13% 0.27
Medical Staff 33% 22% 0.24
Best Time to Remind about Appointment
One Day Before 87% 94% 0.28
Same Day 13% 4% 0.13

In terms of helpfulness of educational materials, 61% of respondents who

work found radio ads more helpful than those who don’t work (p = 0.05) (see Table

12).
 50

Table 12

Comparing happiness with staff between those who work and don’t work

Happiness With Work Status Mean ± SD P-value

Work 3.69 ± 0.56
Reception Staff
Don't Work 3.58 ± 0.66 0.41
Work 3.70± 0.46
Nurses
Don't Work 3.51 ± 0.68 0.13
Work 3.63 ± 0.62
Provider Staff
Don't Work 3.54 ± 0.78 0.57
Work 3.57 ± 0.76
Clinic Staff
Don't Work 3.56 ± 0.74 0.97
Work 3.61 ± 0.68
Interpreter Staff
Don't Work 3.63 ± 0.55 0.91
Work 3.61 ± 0.69
Price
Don't Work 3.56 ± 0.79 0.74
More Comfortable With
Bring Their Own Work 2.40 ± 0.93
Interpreter Don't Work 2.56± 1.12 0.43
Relying on a Work 3.55 ± 0.78
Clinic
Don't Work
Interpreter 3.27 ± 0.92 0.14
Bringing a Work 2.48 ± 1.09
Friend/Family
Don't Work
Member 2.57 ± 1.31 0.77
Helpfulness of
Educational Materials
Work 3.16 ± 1.08
Flyers
Don't Work 3.11± 1.01 0.85
Work 2.83 ± 1.09
Brochures
Don't Work 3.00 ± 1.08 0.57
Work 2.67 ± 1.12
Bulletin Boards
Don't Work 3.04 ± 1.02 0.21
Work 2.90 ± 1.03
TV Ads
Don't Work 3.25 ± 1.01 0.19
Work 2.83 ± 0.91
Radio Ads
Don't Work 3.00 ± 1.02 0.05
Work 3.03 ± 1.00
Health Fairs
Don't Work 3.48 ± 0.85 0.75
 51

Table 12

Comparing happiness with staff between those who work and don’t work continued

More Comfortable With Work Status Mean ± SD P-value

Bring Their Own Work 2.40 ± 0.93
Interpreter Don't Work 2.56± 1.12 0.43
Relying on a Clinic Work 3.55 ± 0.78
Interpreter Don't Work 3.27 ± 0.92 0.14
Bringing a Friend Work 2.48 ± 1.09
/Family Member Don't Work 2.57 ± 1.31 0.77
Helpfulness of
Educational Materials
Work 3.16 ± 1.08
Flyers
Don't Work 3.11± 1.01 0.85
Work 2.83 ± 1.09
Brochures
Don't Work 3.00 ± 1.08 0.57
Work 2.67 ± 1.12
Bulletin Boards
Don't Work 3.04 ± 1.02 0.21
Work 2.90 ± 1.03
TV Ads
Don't Work 3.25 ± 1.01 0.19
Work 2.83 ± 0.91
Radio Ads
Don't Work 3.00 ± 1.02 0.05
Work 3.03 ± 1.00
Health Fairs
Don't Work 3.48 ± 0.85 0.75
SD= ± Standard Deviation
Mean scale = 1.0 is least satisfied through 4.0= Most satisfied

Although not statistically significant, 72% of respondents who work

indicated that weekend appointments are most valuable compared to 59% of those

respondents who don’t work (p-value = 0.07). Furthermore, there is a statistically

significant difference between those respondents that work who value evening

appointments (p-value= 0.02) and domestic violence advocates (p-value = <0.001)

compared to those respondents that don’t work) (see Table 13).

 52

Table 13

Comparing work status to clinic services

Work
(%) Mean ± SD P -value
Status
Value of Services
Work 72% 3.44 ± 0.97
Weekend Appointments
Don't Work 59% 2.97 ± 1.13 0.07
Work 74% 3.37 ± 0.94
Evening Appointments
Don't Work 59% 2.76 ± 1.12 0.02
Work 79% 3.77 ± 0.65
Childcare
Don't Work 55% 3.60 ± 0.81 0.33
Work 64% 3.20 ± 0.96
In-Home Services
Don't Work 47% 3.07 ± 0.94 0.61
Work 69% 3.89 ± 0.32
Domestic Violence Advocates
Don't Work 55% 3.29 ± 0.90 0.00
Work 72% 3.37 ± 0.91
Sterilization/Vasectomy
Don't Work 53% 3.23 ± 0.97 0.56
Respondents value of STD Work 74% 3.70 ± 0.74
testing Don't Work 63% 3.79 ± 0.59 0.57
Are the Services You Receiving Work 86% 3.84 ± 0.53
From This Clinic Meeting Your
Don't Work
Needs? 86% 3.86 ± 0.41 0.82
SD= ± Standard Deviation
Mean scale = 1.0 is least satisfied through 4.0= Most satisfied

Lastly, in terms of barriers to family planning services there is a statistically

significant difference in the importance of no health insurance for those

respondents who work compared to those respondents who don’t work (p-value =

0.03). Those patients that work felt no health insurance was more of a barrier then

those patients that don’t work (see Table 14).

 53

Table 14

Comparing work status to clinic services continued

Work Status
Don't
Work
Work
(N=47) P-Value
Reason for Using Family Planning (N=46)
%
Services %
Birth Control 64% 70% 0.56
Plan a Pregnancy 13% 20% 0.37
Get Health Information 30% 30% 0.95
Get a Pregnancy Test 9% 15% 0.32
Prevent a Pregnancy 45% 48% 0.76
Unplanned Pregnancy 11% 4% 0.25
Don't
Work
Work
(N=47) P-Value
Barriers to Family Planning (N=46)
%
Services %
No Transportation to the
Clinic 5% 7% 0.66
No Babysitter 19% 21% 0.83
Can't Pay for Family
Planning Services 40% 44% 0.73
Social Pressure 2% 7% 0.32
Awkwardness 7% 7% 0.98
No Health Insurance 86% 65% 0.03
My Spouse/Partner Does
Not Want Me To Receive
Services 5% 5% 0.98

As with age and work status, the needs and concerns based on migration

status (i.e., whether the respondents migrate in and out of the state or not) was

intended to be assessed in this evaluation. However, the survey had a very low

sample of respondents who migrate (n = 9) as compared to the respondents who do

 54

not migrate (N = 91), thus only the needs and concerns of those who do not migrate

are reported here (see Table 15).

Table 15

Comparing age to migration status

Age Migrate (n=9) Do not migrate (n=91)

18-30 4 54
30+ 5 37

The survey also had a very low response rate from male patients (n=9) as

compared to female patients (n= 91) (see Table 16).

Table 16

Comparing sex to migration status

Sex Migrate (n=9) Do not migrate (n=91)

Male 1 4
Female 8 87

Regarding the days of the week, respondents who do not migrate indicated

Mondays and Fridays as the two best days to come to the clinic. These respondents

also indicated that they would rather go to a clinic with regular hours (n=78) as

opposed to an after hours clinic, place of work, or special family planning hours.

When asked about features of the clinic that they use, the majority of non-migrating

respondents indicated that they prefer the interpreter services that the clinics offer.

All respondents who don’t migrate indicated that they would prefer to have a

reminder about their appointment one day prior. Respondents were asked to
 55

indicate their top two reasons for using family planning services. The majority

(n=74) indicated to receive a pregnancy test followed by to receive birth control

(n=57). In regards to what prevents respondents from receiving family planning

services, no health insurance was the number one reason (n=57). When asked

about the respondent’s level of happiness with specific services, a majority of the

respondents indicated that they were either happy or very happy with the reception

staff, nurses, medical provider, clinic staff, interpreters, and price. However, the

mean score for reception staff was slightly higher (mean=3.64) indicating that

respondents were the most happy with reception staff. Another question on the

survey asked about value of some of the services offered at the clinics. Of the

services listed, STD testing scored the highest value with a mean =3.75. In addition,

respondents indicated that they were more relaxed with using the clinic

interpreters with a mean=3.38 and felt that health fairs were the best ways to

receive information about preventing pregnancies, mean=3.25. The last question on

the survey asked about the services in general that they receive through the clinic.

The majority of the respondents indicated that the services always met their needs

(n=70) (see Tables 17-18).

 56

Table 17

Comparing migration status to clinic services

Don't Migrate
(n=91)
Preferred Clinic Days
Monday 60%
Tuesday 47%
Wednesday 41%
Thursday 40%
Friday 52%
Saturday 26%
Sunday 16%
Morning 44%
Afternoon 41%
Evening 42%
Location of Family Planning
Services
Clinic with regular hours 86%
After hour clinic 18%
Special family planning
18%
hours
Where I Work N/A
Reason For Using The Clinic
Close To My Home 26%
Price 46%
Interpreter Services 76%
Medical Staff 25%
Best Time to Remind about
Appointment
One Day Before 88%
Same Day 12%
 57

Table 17

Comparing migration status to clinic services continued

Don't Migrate
(n=91)
Reason for Using Family
Planning Services
Birth Control 63%
Plan a Pregnancy 16%
Get Health Information 26%
Get a Pregnancy Test 81%
Prevent a Pregnancy 49%
Unplanned Pregnancy 7%
Barriers to Family Planning
Services
No Transportation to the
5%
Clinic
No Babysitter 19%
Can't Pay for Family
36%
Planning Services
Social Pressure 4%
Awkwardness 7%
No Health Insurance 63%
My Spouse/Partner Does
Not Want Me To Receive 3%
Services
 58

Table 18

Comparing migration status to clinic services continued

Don't
Migrate
(n=91) Mean ± SD
Happiness With
Reception Staff 88% 3.64 ± 0.61
Nurses 82% 3.60 ± 0.59
Provider Staff 80% 3.58 ± 0.71
Clinic Staff 85% 3.57 ± 0.72
Interpreter Staff 78% 3.62 ± 0.59
Price 77% 3.61 ± 0.69
More Comfortable With
Bring Their Own Interpreter 65% 2.49 ± 1.01
Relying on a Clinic Interpreter 85% 3.38 ± 0.87
Bringing a Friend/Family
Member 66% 2.53 ± 1.20
Helpfulness of Educational Materials
Flyers 75% 3.06 ± 1.05
Brochures 56% 2.86 ± 1.08
Bulletin Boards 56% 2.80 ± 1.10
TV Ads 59% 3.04 ± 1.05
Radio Ads 55% 2.86 ± 0.97
Health Fairs 58% 3.25 ± 0.96
Value of Services
Weekend Appointments 69% 3.19 ± 1.06
Evening Appointments 73% 3.02 ± 1.07
Childcare 69% 3.65 ± 0.77
In-Home Services 58% 3.13 ± 0.94
Domestic Violence Advocates 67% 3.59 ± 0.74
Sterilization/Vasectomy 66% 3.33 ± 0.93
Respondents value of STD testing 71% 3.75 ± 0.66
Are the Services You Receive From
This Clinic Meeting Your Needs? 77% 3.74 ± 0.61
SD= ± Standard Deviation
Mean scale = 1.0 is least satisfied through 4.0= Most satisfied
 59

Evaluator’s Observations

During the interview process, the evaluator took notes on overall general

observations about the interview process and during the debrief of each interview.

The two students who conducted the interviews observations were also included.

In general, what was discovered was that the respondents appeared to be happy to

answer the interview questions. They were glad to be asked about their family

planning decisions. Some of the questions in the interview asked about partner

support and contraception use. All respondents answered these questions and

appeared to not be apprehensive to do so.

Emerging Themes from Interviews

This section reports on structured telephone interviews. Questions asked

during the interview elicited three major themes: support, access to family planning

clinics, and contraception. These themes also provided insight on how well the

program met the needs of the respondents and where the programs could make

adjustments. A systematic sample of 12 representing all four clinics, was drawn

from the total list of respondents who had agreed to participate in the interview.

Coding of each clinic’s interviews assured representation from the clinics.

Okanogan Family Planning was not able to participate in the telephone interview so

12 were chosen from among the other four clinics. The interviews took place at

Central Washington University and were conducted by two Spanish speaking female

students. The two Spanish interviewers were given a script and were given time to

familiarize themselves with the evaluation. The interviews on average lasted about
 60

five minutes. In the end, 10 interviewees were included in this evaluation as two

were not able to be understood from the recording.

Support. Support was defined as both clinical support and partner support.

An overwhelming number of interviewees indicated that their partner(s)’ support

doesn’t affect their decision to use or not use contraception. Communication

responses indicated that the interviewees did not communicate often with their

partner about their use of birth control to prevent unplanned pregnancy. Women

were more likely to make their own decisions regarding their use of contraception.

Their partner typically agreed with or did not communicate with their partner as

supported by the following three quotes:

“ He has not mentioned anything to me. I protect myself”

“ He is fine, he likes it, because we don’t want kids till we are older”

“ It is my decision”

The second support theme was clinical support. The Cuidese program serves

a special population in Washington who are primarily Hispanic females, many of

whom are undocumented. Based on the interviews, support from their partners for

many respondents is minimal. Of equal importance is receiving support from the

clinic as this is where many feel most comfortable. A couple of interviewees

commented on the support they receive at the clinic:

“They give me the necessary 3 months supply of the pills that I need, and

therefore I don’t have to go that often. You know we get busy. They support

us well.”
 61

“They give good attention and care”

Although communication between partners was sometimes lacking, many

interviewees did mention that their partner supports their decision in using

contraception as noted by the following two respondents:

“We have two kids and because we are planning, he helps me with that”

“He is my husband and he supports my decision. He basically supports my

contraceptive decisions.”

Access to Family Planning Clinics. The availability and cost of service of

the family planning clinics defined access to family planning clinics. Many

interviewees noted that if they did not have access to family planning clinics, they

would seek family planning someplace else. Their suggested places included “the

farmer’s clinic,” “regular clinic like the one I take my children to,” and “private

doctor.” The main service of the Cuidese program is to offer contraception at little

or no cost to the respondents. Many respondents indicated that family planning

services were important to them, and that cost was a concern of theirs if there was

no Cuidese program. This is supported by the following quotes:

“I don’t know because everything is expensive”

“Any other clinic if they charge”

Some interviewees suggested that if they could not receive contraception at a

family planning clinics, that they would not use family planning at all. Said one

interviewee, “Well if that clinic wouldn’t be available I probably won’t use them, I
 62

want to use then because I won’t buy them.” According to another, “without birth

control I have no idea.”

Contraception. The final theme of the interview was contraception. A

majority of the respondents indicated to some degree how important contraception

was. Some even mentioned that if they were not able to receive contraception at the

family planning clinics, they would purchase contraception at a pharmacy or other

clinic. This is supported by the following interviewee’s comments:

“I don’t want to become pregnant. It’s important to me to have

contraception.”

“I have a sexual active life, and use contraception.”

The main barrier which prevented the use of contraception was cost. The

Cuidese program appears to have helped reduce the worry of affording

contraception by offering free or low cost contraception. Opportunities for the

Cuidese program to continue its efforts in offering contraception will continue to

improve access to contraception.

 63

Chapter 6: Discussion and Conclusions

Integrative Findings

This evaluation addressed the following questions: What opportunities exist

for program improvement? How are the family planning services meeting or not

meeting the needs of the Cuidese patients, and are there any differences in the way

respondents view the program? The aforementioned questions were answered in

this thesis practicum by means of a mixed method design. The implementation of

the Cuidese program is working as it was intended based on evaluation findings.

With funding from the legislature, it was hoped that the Washington State

Department of Health could provide family planning services to non-citizens in

Washington. Among the five clinics that implement this program, access to family

planning services has increased since original implementation (WA DOH, 2006).

The family planning clinics provide comprehensive education about birth control

methods, abstinence, and contraceptive services. What was unknown was whether

these comprehensive services were of benefit to the respondents in helping them

reduce unintended pregnancies. Based on evaluation findings in this study, it

appears that the services that the clinics offer are of benefit to the respondents.

During the telephone interview additional information gathered affirmed that the

respondents were satisfied with the current services and the education materials

available and that they realized the importance of contraception.

Since mostly all women come to clinics to seek family planning, age,

migration status, and working status were important factors to look at to determine
 64

specific needs, concerns, and respondents’ viewpoints. This was important from a

program planning standpoint in order to provide family planning services that are

appropriate for each client specifically.

Access to healthcare was a major theme identified from interviewees.

Respondents indicated the importance of having a clinic where they could seek

family planning services. Respondents from this formative evaluation who don’t

migrate (n=91) prefer clinics with regular hours as opposed to after hour or special

family planning clinic hours. Those clients who don’t migrate and are over 30 prefer

evening appointments. Respondents were, for the most part, happy with the

services they received. Respondents who were 18 to 30 years of age felt that the

Cuidese program met their needs more so than the 30 and older age group (n=70).

Those respondents that don’t migrate were most happy with the reception staff. A

large number of respondents preferred to be notified about their appointments one

day in advance. A majority of the respondents indicated that they utilized the

Cuidese program to receive birth control and STD testing. For many Cuidese

respondents, it appears that the low cost or free birth control was in fact helping

reduce the incidence of unintended pregnancies while increasing access to health

care. As noted by Ku and Waidmann, (2003), obtaining health insurance is a

struggle for immigrants. Respondents that work or don’t migrate indicated that

health insurance is what prevents them from receiving family planning services.

During the interview process, respondents indicated that access to family

planning services was important to them. Many mentioned that the clinics gave
 65

them the necessary tools to prevent unplanned pregnancies. Support from their

partner regarding the use of contraception is minimal and many expressed they

wished that their partner would support them more. The literature shows that

language barrier maybe a challenge for Hispanics (Ku & Waidmann, 2003),

(California Immigrant Policy, 2007). All clinics that implement the Cuidese program

offer interpreter services. During the interview, several respondents commented on

how good the level of care was and the helpfulness of having an interpreter. For

those survey respondents that don’t migrate, they felt that relying on a clinic

interpreter was of more value to them. Interviewees specified that the support they

received from the clinics was very helpful in making the decisions for family

planning. Contraception was found to be a major theme of importance to the

respondents and was the number one reason why respondents used family planning

services.

The evaluation findings presented in this study are fairly positive. WA DOH

took an active role in helping the clinics with funding to establish this program and

to make this program work. The positive results of this study may be attributed to

lessons learned during the beginning stages of the program. WA DOH left

implementation of the program to each clinic. Based on community needs, and

outreach, the family planning clinics were able to learn about their population needs

and therefore develop the Cuidese program in such a way that works for the target

population.
 66

In general, some strengths of the Cuidese program are the services being

provided. Despite non-citizen status, respondents felt comfortable coming to the

clinics and receiving contraception. The educational materials, in conjunction with

the provider, seemed to be an effective way in communicating with the respondents.

Some general disadvantages of the Cuidese program mainly revolve around a lack of

strengthening partner support. Many respondents noted that their partners did not

support them in their decision to use family planning services. Respondents also

mentioned that their partners’ opinion do not affect their use of contraception. It

could be that the respondents do in fact want their partners' support in making a

joint decision, but do not want to follow their partners' unilateral decisions

regarding family planning

 67

Limitations

A limitation of this study is the inability to generalize the evaluation results

to all undocumented Hispanic females who participate in the Cuidese program, and

to generalize the evaluation results to all clinics that offer the Cuidese program.

Data collected from the survey was not always complete. Some respondents chose

to answer some questions and skip others. Not all Cuidese respondents filled out

the survey during data collection. Between all five clinics, 60 patients were seen on

average each month. About twenty-five surveys were received from each clinic

during the data collection period. It is not clear if the respondents differed from

non-respondents in important ways.

Another limitation of this evaluation is the survey relies on self-reported

data. Although all efforts have been made to assure that the survey was translated

into Spanish and that the literacy level was appropriate for the population,

information may not be entirely representative of the true target population.

Additionally, there is the possibility that if the respondents asked for clarification on

particular questions that their responses may have been influenced by clinic staff's

clarifications creating standardization issues.

A third limitation is that this survey did not capture the entire meaning of

what a person feels for each question. Instead, the respondents had to answer the

questions without an explanation. Internal validity is weak because causal

relationships between the variables under review of interest among the non-citizen

population in Washington cannot be established. The use of a structured telephone

 68

interview did not allow the two interviewers to expand or ask for additional

information during the interview. Having the freedom to ask follow-up questions

regarding respondents’ viewpoints on partner support and partner use of

contraception would have been beneficial to have gained more insight.

Lastly, the sample population for those respondents that migrate (n=9) compared to

those that don’t migrate (n=91) was lower than expected. Evaluation findings were

limited due to the low sample of those that migrate, and some planned comparisons

were not possible because of the low numbers.

Strengths

A strength of this evaluation was the mixed methods approach. The use of

the self-administered questionnaire in addition to the structured telephone

interview gave insight as to how the respondents felt about the clinics,

contraception, partner support, and their family planning. Though this evaluation

may not suggest major short-term changes, it may prove to be useful from a

program improvement standpoint and thus benefit the intended users. Data from

the survey may also help guide program staff to implement new components to

improve support and access to family planning services.

An additional strength of this evaluation is that this was the first program

evaluation that the family planning clinics participated in. This evaluation provides

a starting point and a baseline for the clinics to build on. The results of this

evaluation could be used to help strengthen the program by giving them the

opportunity to see what the Cuidese respondents value most and what services are
 69

or are not working for them. Respondents who use the Cuidese program are non-

citizens, who, if asked to participate in a focus group from someone outside their

community/network, may feel threatened and have fear of getting caught. Despite

some of the drawbacks, conducting a survey with a follow-up telephone interview

appeared to minimize fear, as the participants had the opportunity to answer any

question they chose freely in their home and did not hesitate to answer questions.

This evaluation provides a rich snapshot of the current program which will offer a

source of learning for future Cuidese programs. This evaluation utilized a mixed

methods approach in order to add breadth and depth to the quantitative analysis.

Based on the data presented and the interviews it appears as if the Cuidese program

is making a difference to the target population. Due to the sensitivity of the target

population in regards to being undocumented, the evaluator was expecting a lower

response rate on the survey. The number of respondents was greater than

anticipated and the interviews proved to be a viable method of collecting additional

data as respondents were receptive to answering questions. Lastly, an added strong

point of this evaluation was that it yields immediate, concrete, and observable data

which could be useful for future Cuidese program enhancements at both the state

and family planning clinic level.

 70

Recommendations

Evaluation data suggests that the respondents were satisfied with the

services they received at the clinics. The use of clinic interpreters was most

comfortable for respondents. Clinics should continue to offer the use of clinic

interpreters. Respondents use the clinics mostly for contraception and/or to

prevent a pregnancy. Respondents seem to understand the importance of

contraception and family planning as many indicated that they would continue to

seek family planning should funding for the Cuidese program halt or get reduced. If

the Cuidese programs were not available, almost half of those interviewed would try

to find contraception at some other clinic or place where contraception was

available. The downside to this is that the cost of this contraception is likely to be a

lot higher and thus respondents may not purchase it. This could cause respondents

to not use contraception and potentially have unintended pregnancies.

Results point to six recommendations for improvement based on evaluation

findings in this study. The first is to develop educational programs that involve

males. Although the Cuidese program is offered to both males and females, the low

response rate from males on the survey suggest that they don’t use the clinics for

family planning. In addition, based on the telephone interviews, many interviewees

commented that their partners do not play a role in helping them make family

planning decisions.

The second recommendation is to consider offering evening appointments.

Results from the survey suggested that respondents aged 30 and older (n=51)
 71

favored evening appointments. This might be due to their work status or having to

wait for their partner to get home to watch their children so they have an

opportunity to take care of their family planning needs. Once a week clinic hours

between 5:00 pm to 8:00 pm may be a viable option.

The third recommendation is to develop tailored educational programs.

Respondents aged 30 years and above indicated that they would like programs

where they could learn more about other services in the community, particularly

domestic violence services. This finding is consistent with the literature in

that Barcaglioni (2010) noted that “a study by the National Latino Alliance for the

Elimination of Domestic Violence found that 48 percent of Latinas reported that

their partner’s violence had increased since they immigrated to the United States.”

Additionally, Erb (2009) indicated that “up to 49.3% of undocumented Hispanic

immigrants may be physically abused by their spouses.”

The fourth recommendation is to increase access to health fairs. The use of

health fairs according to survey respondents was the best way to communicate the

importance of family planning, and birth control to respondents.

The fifth recommendation is to assist with transportation issues to the clinic.

Respondents indicated that transportation to family planning clinics could be a

challenge. Depending on the services provided, clinics may need to look for ways to

help respondents with transportation issues. Bus vouchers, mobile clinics, or

satellite clinics may also be helpful.

 72

Finally, the sixth recommendation is to continue to look for ways in which

the family planning clinics offer free to low cost contraception for non-citizens.

Funding sources could come from local State government, Federal government, and

from private organizations. During the interviews respondents indicated the

importance of the services provided to them. In addition respondents also wanted

more information and services related to sterilization for both males and females.

Conclusions

The information in this formative evaluation is intended to help the five

family planning clinics in Washington along with the Washington State Department

of Health to understand how non-citizens view the Cuidese program. Specifically,

program staff wanted to know if the Cuidese program is helping the patients in

preventing unintended pregnancies, how they view their family planning, and their

use of the clinics. This evaluation was conducted in order to provide the

Washington State Department of Health and the family planning clinics with

information from the patients’ perspectives on how the Cuidese program affects

their family planning and their use of family planning clinics. Results from this

evaluation could be used to answer how respondents view the program and what

components of the program are working and or missing.

Based upon the data collected for this evaluation during the measurement

period, it appears that the respondents in general are satisfied with the program

and what it offers. During the telephone interviews, a majority of the interviewees

indicated that they would not change anything about the program except to offer
 73

pap smears and contraception for men such as vasectomies if the program funding

would allow it. As a follow-up to this evaluation, a more thorough and focused

evaluation might reveal detailed information regarding male involvement,

partner/spouse support, barriers to family planning, and the differences in those

respondents that migrate and those that don’t. Additional semi-structured

telephone interview questions might help provide more data that could be used to

enhance the program. Future research should consider focusing on male

involvement and the decisions partners make in family planning, and the

development of educational programs. Additionally, when collecting data from the

clinics it would be helpful to assure Okanogan Family Planning has a representative

sample.

Next Steps

In addition to this formative evaluation, it would be helpful to conduct focus

groups with the Cuidese patients to better understand their views of partner

support and decision making when it comes to family planning. This information

would be helpful for future planning as the programs could develop activities that

foster better partner support. Additionally, two other evaluations would be helpful.

The first would be a process evaluation. This type of evaluation would be

particularly helpful to help assess the implementation of the program. Each clinic

implements the program slightly differently. It would be interesting to see if these

differences in strategies yield better results in both prevention of unintended

pregnancies and male involvement. For the Cuidese program, the process evaluation
 74

should look to who, what, where, when, and how much the Cuidese program has

been delivered/received by the participants. The process evaluation should include

a quantitative component through which dosage could be measured.

Lastly, fidelity of the implementation of the Cuidese program should be

examined. Such components are looking to see if there are any barriers

encountered in the implementation and the quality of the services offered. The

second evaluation following a process evaluation, is an outcome evaluation. This

type of an evaluation will help answer what has happened as a result of the Cuidese

program and whether the desired results occurred. Components of the outcome

evaluation should include the specific attitudes, knowledge, and behaviors of the

Cuidese patients as well as the number of intended and unintended pregnancies.

Specific outcome examples may be employment, sexual activity, contraceptive use,

number of partners, and measuring/assessing the cultural appropriateness of the

program.

In retrospect, a longer period of data collection would also help to increase

the response rate for some questions, which in turn may provide additional support

for survey questions. Furthermore, additional telephone interviews would also

strengthen the external validity of this evaluation. A greater sample of those that

migrate is needed in order to understand better the needs and concerns of the

respondents. Future research should consider focusing on male involvement and

the decisions partners make in family planning, and the development of education

programs.
 75

Public Health Practice Implications

The Cuidese Program has several public health implications. First is related

to the monitoring of the health status of the Cuidese patients. This program collects

information on patient access and utilization of the Cuidese program. By doing so,

clinic staff are able to determine the health needs of the patients and in turn use

proven public health models to help reduce unintended pregnancies.

Second is related to disease investigation. The Cuidese program provides an

avenue for respondents to seek family planning services where they have access to

other personal health services such as STI testing. Being able to seek diagnosis and

treatment for STIs is critical in overall health. The Cuidese program gives providers

an opportunity to treatment medical conditions and in some cases assist in partner

notification to help prevent the spread of STIs.

Third is related to informing and educating people about health issues. The

Cuidese program provides collaboration with active personal health care providers

who could help respondents with health promotion. Additionally, some clinics offer

special women’s groups which increases access to health information and resources

in the community. This in turn gives patients access to the healthcare system where

they can receive specialized health services based on their needs. Additionally, the

program provides an avenue to partner with other resources in the local community

which increase awareness about other health issues.

The fourth implication deals with partnership to solve health problems and

policy development. The Cuidese program was developed to increase access to

 76

family planning services to non-citizens in Washington due to the high incidence

rates of Medicaid paid birth. Among all health interventions, family planning is

considered to be the most cost effective (Burkman & Sonnenberg, 2000) ;(Smith,

Ashford & Gribble, 2009). Policies put in place by the Washington State Department

of Health, in conjunction with Title X funding, have made it possible to offer

respondents free or low cost contraception. In the most current article found, the

Population Council of New York (1994) indicated that moving beyond just

contraception and pregnancy prevention, such reproductive services should

encompass “the treatment of STIs, gynecological services, and child health care.”

Reproductive health should encompass services for women of all ages. The ultimate

goal is "to achieve mutually caring, respectful, and responsible sexual relationships.”

Linking people to needed personal health services is another essential service of

public health. The Cuidese program provides an avenue where clinic staff could

provide culturally and linguistically appropriate materials to non-citizens in order

to help increase access to personal health services.

The last public health implication is evaluating the effectiveness of

population-based services. This evaluation is one example where family planning

clinics could use the data presented to continue to develop and refine the Cuidese

program.
 77

References

Alreck, P., & Settle, R. (1995) The Survey Research Handbook, p.400. McGraw Hill
Companies.

Anderson, K., Won, S, H., & Frasca, T. (2006). Promoting Cultural Competency
among Family Planning Providers: Lessons from the Field. The Education
Fund of Family Planning Advocates of New York State.

Asamoa, K., Rodriguez, M., Gines, V., Varela, R., Dominguez, K., Mills, C. G., et al.
(2004). Report from the CDC. Use of preventive health services by
Hispanic/Latino women in two urban communities: Atlanta,Georgia, and
Miami, Florida, 2000 and 2001. Journal of Women’s Health, 13, 654-661

Barcaglion, J. (2010) Retrieved from http://safeharborsc.org/blog/domestic-

violence-in-the-hispanic-community/

Camarota, A., & Edwards ,J. R. (2001). Uninsured Immigrants Burden the Health
CareSystem. The Heartland Publisher Institute. Retrieved
from http://www.heartland.org/policybot/results/456/Uninsured_Immig
rants_Burden the_Health_Care_System.html

Creswell, J., (2006) Retrieved from

http://www.sagepub.com/upmdata/10981_Chapter_1.pdf

Berk, M, L., Schur, C, L., Chavez, L, R., Frankel, M. (2000) Health Care Use Among
Undocumented Latio Immigrants

Braun, V., Clarke, V. (2006). Using thematic analysis in psychology. Qualitative

Research in Psychology, 3: 77-101.

Burkman, R,T., Sonnenberg, F, A. (2000) Health Economics of

Contraception. Obstetrics & Gynecology Clinics of North America,27(4):917-
931. viii.

Erb, M., (2009) Domestic violence among undocumented Hispanic immigrant

couples: an ecological solution to the problem (Powerpoint). Retrieved
from. http://discoverarchive.vanderbilt.edu/xmlui/handle/1803/1711

Freeman, G., & Lethbridge-Cejku, M. (2006, April 20). Access to health care among
Hispanic or Latino women: United States, 2000–2002. Advance Data, 368, 1-
25.
 78

Gold, R, B., Sonfield, A., Richards, C, L., Frost. J,J. (2009). Family Planning Program.
Leveraging the Potential of Medicaid and Title X in a Evolving Healthcare
System. Retrieved from http://www.guttmacher.org/pubs/NextSteps.pdf

Immigrants and the U.S Health Care System. (2007). California Immigrant Policy
Center. Retrieved from http://www.nilc.org/dc_conf/flashdrive09/Health-
Care-Access-Reform/pb15_imms&ushealthcare-2007-01.pdf

Jones, M. E., Bond, M. L., & Gardner, S. H. (2002). Acculturation level and family
planning patterns of Hispanic immigrant women. American Journal of
Maternal/Child Nursing, 27, 26-32.

Ku, L., & T, Waidmann. (2003). How Race/Ethnicity, Immigration Status and
Language Affect Health Insurance Coverage, Access to Care and Quality of
Care Among the Low-Income Population prepared for the Kaiser Commission
on Medicaid and the Uninsured.
Retrieved http://www.kff.org/uninsured/upload/How-Race-Ethnicity-
Immigration-Status-and-Language-Affect-Health-Insurance-Coverage-
Access-to- and-Quality-of-Care-Among-the-Low-Income-Population.pdf

Leonards, C, J., Chavira, W., Coonrod, D. V., Hart, K. W., & Bay, C. (2006) Survey of
attitudes regarding natural family planning in an urban Hispanic population.
Contraception, 74, 313-317.

Newbold, K. B., & Willinsky, J. (2009). Providing family planning and reproductive
healthcare to Canadian immigrants: perceptions of healthcare provider.
Culture Health and Sexuality, 11, 369-382

Ritualo, Cawthon, Woodcox. (2004). COUNTY PROFILES: Birth and Unintended

Pregnancy Statistics 1990 to 2002. DSHS RDA Report Number 9.70.

Schnur, E., Koffler, R., Wimpenny, N., Giller, H., & Rafield, E. N. (1995) Family child
Care and New Immigrants: Cultural Bridge and Support. Child Welfare, 74,
1237-48.

Singleton, K., & Krause,M,S,E. (2009). Understanding Cultural and Linguistic Barriers
to Health Literacy. The Online Journal of Issues and Nursing, 14.

Smith, R., Ashford, L., Gribble, J., et al. (2009) Family Planning Saves Lives. 4th
edition. Washington, DC: Population Reference Bureau; 2009.
 79

Sungkyu, L., & Sunha C. (2009). Disparities and Access to Health Care Among Non-
Citizens in the United States. Health Sociology Review, 18, 307-320

National Council of La Raza. Entre Parejas (2006) An exploration of Latino

Perspectives Regarding Family Planning and Contraception. Conference
Edition. Retrieved from www.nclr.org

The Population Council of New York. (2004).Reproductive Health Approach to

Family Planning. Retrieved from
http://www.popcouncil.org/pdfs/ebert/rephapproachfamplanning.pdf

Thilmany, D.D. (2001). Farm Labor Trends and Management in Washington State.
Journal of Agribusiness, 19, 1.

Uhlig, A, Mark. (1990). Machismo Slows Family Planning For Mexicans. Retrieved
from http://articles.sun-sentinel.com/1990-11-
09/news/9002240504_1_birth-control-family-planning-population-growth

Ulin, P. R., & Robinson, E.T., & Tolley, E. E. (2005). Qualitative Methods in Public
Health. pp.36-38). Family Health International, Jossey-Bass.

U. S Department of Health and Human Services. Office of Behavioral and Social

Sciences Research. (2012). Retrieved
from http://obssr.od.nih.gov/scientific_areas/methodology/mixed_methods
_research/pdf/Best_Practices_for_Mixed_Methods_Research_the_nature_and_
design_of_mixed_methods_research.pdf

WA DOH. (2006). Cuidese Project Report: Report to the Legislature

WA DOH. (2005). Non-Citizen Family Planning Pilot Project

Washington State Farmer Workers Rural. (2007). Volume 13 number 4

 80

Appendix A

Informed Consent Form

Thank you for filling out the survey. We would like to ask you a few more questions.

What is this study about? This study is to learn how you view family planning

services.

What is the phone call about? This phone call is to learn what you like about the

Cuidese program, and your family planning needs.

What do we want you to do: If you agree to the phone interview, we will ask you

seven questions about your family planning needs? The phone call will take less

than 20 minutes depending on how much you want to share with us.

Risks and benefits: Being part of the phone call will not cause any harm, although

you may feel uncomfortable answering some of the questions. There are no benefits

for answering our questions although it may help us to improve services to you and

others like you. As a ‘thank you’ for your time, you will be given a $10 gift card to

Wal-Mart.

Your answers will be private. Your responses to the questions will be kept private.

Your responses will be recorded and then translated into English. We are recording

your responses for data collection accuracy purposes. Also we want to make sure

that we get your comments written down correctly, and so that we can refer back to

your response should we need to. All responses will be in a locked file cabinet. Only

the student evaluator will have access to the records. All records will be destroyed
 81

after the evaluation. Your response to these questions will be put into a paper

which will be given to the family planning clinic, and be available at the University of

Alaska Anchorage Library. Your name or any other information that could identify

you will not be used.

The phone call is optional: You may chose not to answer any question or chose to

stop the interview at any time.

Questions: Please contact Ricardo Del Bosque at 360- 229-1162

Yes, I would like to be interviewed.

What is your fist name?_____________________

What number can we call you on? _______________

Best time and day to contact you…..Time:_______________Day:______________

Thank you.
 82

Appendix B

Telephone Interview Script

Questioning route: Fixed and standardized

Role of probing: Very little probing will occur except for clarification or repeating of
questions.
Interview script.
Hello, my name is _______ (name) and with me on the phone today is Aaron the
student evaluator from the Alaska Anchorage college and we are gathering
information about the Cuidese program and family planning needs. Recently, you
filled out a survey about the Cuidese program. Thank you for doing this.
(Part A) We would like to record this conversation so we can refer back to it later.
Is this ok with you? If “yes” Ok, thank you. Turn
recorder on.
If “no” Ok, we will not record this
conversation.
Would it be ok to take notes
instead?
Are you over the age of 18? If “yes” Thank you.

If “no” Thank you. We will not be

able to conduct the
interview. Thank you for your
time (Hang up phone).
Now that the recorder is on, we need to ask you if it is ok to continue with the
interview.
Is this still ok?
If “yes” Ok thank you. (Got
to part B)
If “no” Thank you very much for
your time, and have a
nice day. (Hang up phone)

(Part B) To all Participants:

Thank you for agreeing to participate in this phone interview. This phone call is to
learn what you like about the Cuidese program, and to learn about your family
planning needs. Being part of the phone call will not cause any harm, although you
may feel uncomfortable answering some of the questions. There are no benefits for
answering our questions, although it may help us to improve services to you and
others like you. As a ‘thank you’ for your time, you will be given a $10 gift card to
Wal-Mart. The phone call should take less than 20 minutes depending on how much
you share with us.
 83

The information that you give us will be stored on the evaluator’s secured computer
until the evaluation is complete. Once all responses are collected and used in the
evaluation, all information will be permanently erased. You don’t have to answer
any questions you don’t want to and you may choose to end the interview at any
time. If you would like us to turn the recorder off while you answer any questions,
please let us know. (Go to part C)

(Interviewer note: All questions will be asked to each participant in the same order).
(Part C)
1. If there was no Cuidese program, where would you go for family planning
services?
A. What would you do for family planning if you could not attend this clinic?
(Space for comments about participant’s response such as hesitation, change
of voice, etc…)
(If clarification is needed repeat question)
2. Do you believe the clinic is meeting your family planning needs?
If they say “yes” ask: Please explain how the clinic is meeting your family
planning
needs?
If they say “no” ask: Please explain why the clinic is not meeting your family
planning needs.
(Space for comments about participant’s response such as hesitation, change
of voice, etc…)
(If clarification is needed repeat question)
3. Who makes the decision whether or not you should use contraception?
(Space for comments about participant’s response such as hesitation, change
of voice, etc…)
(If clarification is needed repeat question)
4. In your perception, how do you think your partner/spouse feels when you use
“contraception”
How do you think your partner/spouse feels when you don’t use
contraception?
(Space for comments about participant’s response such as hesitation, change
of voice, etc…)
(If clarification is needed repeat question)

5. Would you say your partner is supportive whether or not you use contraception?
(Space for comments about participant’s response such as hesitation, change
of voice, etc…)
(If clarification is needed repeat question)
6. Do you feel that you need support from the Cuidese program to help you and your
spouse/partner to talk about issues and/or making decision about using
 84

contraception? In what way can the Cuidese program can support you and
your spouse/partner regarding this matter?
(Space for comments about participant’s response such as hesitation, change
of voice, etc…)
(If clarification is needed repeat question)
7. If you had the opportunity to make changes to the Cuidese program, what would
they be?
(Space for comments about participant’s response such as hesitation, change
of voice, etc…)
(If clarification is needed repeat question)

Closing Statement: Thank you for taking the time to participate in this evaluation.
We have no more questions. Do you have any final thoughts or comments that you
would like to share with us? We would like to give you a gift card for your time. The
gift card will be at the clinic for you to pick up at your convenience.
 85

Appendix C

Survey

Cuidese Survey

Dear Patient,
This survey is about the services you receive at this clinic. This survey is being used
in a study which is taking place in other clinics in Eastern Washington. This study
is being done by a student at the University of Alaska Anchorage. This survey will be
used to help improve services to you. Your input is voluntary and you can chose to
not answer any question. Your survey will remain private. Your name or in other
information that could identify you will not be used in any written reports. Once the
study is completed your completed survey questionnaires will be destroyed.

What is your current age? __________

What is your sex? (Circle one) a. Male b. Female

Tell me about your work? (Circle only one)

a. I work in this state during the farm season then leave the state
to find other work after the farm season.

b. I work in this state during the farm season. I don’t leave to find other work

c. I live in this State but don’t work

d: Other__________________________________________________________________
 86

1. What day of the week is best to come to the clinic? (Circle top two days)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

In the
morning
8am-
12pm
In the
afternoon
12pm-
4pm
In the
evening
4pm-7pm

2. Where would you like to have family planning services? (Circle top two)
a. Clinic with regular hours (8am-5pm)
b. After hour clinic
c. Special family planning clinic days
d. Where I work
e. Other _____________________________________________________________

3. Why do you use this clinic? (Circle only one)

a. Close to my home
b. Price
c. Interpreter service
d. Medical staff
e. Other _____________________________________________________________

4Ǥ‘™Šƒ’’›ƒ”‡›‘—™‹–Šǥǫȋ—–ƒ‘”–Š‡„‘š‡•„‡Ž‘™Ȍ
Not Happy Somewhat Happy Very Happy
Happy
a. Reception
Staff
b. Nurse
c. Provider
d. Clinic
d. Interpreter
e. Price
 87

5ǤŠƒ–•‡”˜‹…‡•™‘—Ž†„‡–Š‡‘•–˜ƒŽ—‡–‘›‘—ǫȋ—–ƒ‘”–Š‡„‘š‡•„‡Ž‘™Ȍ
No value Some Value Value Most
Value
a. Weekend
appointments
b. Evening
appointments
c. Childcare
d. In-home service
e. Domestic Violence
Advocates
f. Sterilization/
Vasectomy)
g. STD testing
h. Other services
_________________________

_________________________

6Ǥ‘›‘—ˆ‡‡Ž‘”‡”‡Žƒš‡†™‹–Šǥǥǫȋ—–ƒ‘”the boxes below)

Not Relaxed Somewhat Relaxed Very Relaxed

Relaxed
a. Bringing your
own
interpreter
b. Relying on a
clinic
interpreter
c. Bringing a
friend/family
member
 88

7. Which of the items below help you prevent a pregnancy? (Put a

‘”–Š‡„‘š‡•„‡Ž‘™Ȍ

Not Somewhat Helpful Helpful Very Helpful

Helpful
a. Brochures
b. Pamphlets
c. Flyers
d. TV Ads
e. Radio
f. Health Fairs

8. When would be the best time to remind you about your appointment? (Circle only
one)
a. Same day as appointment
b. One day before
c. Other_________________________________________________________________

9. Why do you use family planning services? (Circle top two)

a. To get birth control
b. To plan a pregnancy
c. To get health information
d. Pregnancy testing
e. To prevent a pregnancy
f. Unplanned pregnancy
g. Other ____________________________________________________________

10. What prevents you from getting family planning services? (Circle any)
a. No transportation to the clinic
b. No babysitter
c. Can’t pay for family planning services
d. Social pressure
e. Awkwardness
f. No health insurance
g. My spouse/partner does not want me to receive services
 89

11. Are the services you are receiving through the clinic interview your needs?
(Circle only one)
a. Always
b. Usually
c. Seldom
d. Never

Thank you for filling out this survey. Please fold the survey and put it into the
envelope and seal it.
 90

Appendix D

UAA IRB Approval

 91

Appendix E

CWU IRB Approval

October 7, 2010

Dear Mr. Huff:

Thank you for submitting an exemption request for your study, Evaluation of the Cuidese Program. The
application as submitted was screened for exemption status according to the policies of CWU and the
provisions of the applicable federal regulations. Your research was found to be subject to CWU oversight
but exempt from federal regulation because it involves collecting telephone interview data from volunteer
adult participants and the responses could not harm participants if made public [see 45 CFR 46.101b(2)].
This certification is valid for one year (through October 6, 2011) so long as the approved procedures are
followed.
Your responsibilities with respect to keeping this office apprised of your progress include the following:
1. File a Project Modification Request form for HSRC approval before modifying your study in any
way except formatting of documents (e.g. any change in recruitment, subjects, co-investigators,
consent forms, any procedures). If there is a major change in purpose or protocol, you may be
asked to submit a new application. Please call if you have questions.
2. File a Termination Report form with this office upon completion of your study.
3. Immediately contact the HSRC for further guidance should you encounter unanticipated problems
with your research. Follow up with an Unanticipated Problems report may be required.
4. Provide a current contact address and phone number if either should change prior to termination of
the study.
All of the HSRC forms referred to above are available on our website. Refer to your HSRC study number
(H10129) in all related future correspondence with this office. If you have questions or concerns, please
feel free to contact me.
I have appreciated working with you; may you have a productive research experience.

Sincerely,

Sandra M. Martinez, M.A.

Human Protections Administrator

c: HSRC File
Dr. Leo D’Acquisto, HSRC Chair
Dr. Melody Madlem, Faculty Sponsor