THESIS
By
Anchorage, Alaska
May 2013
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Abstract
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
materials, and male involvement in family planning were major themes identified.
Family planning clinics in Washington will need to continue offering family planning
Table of Contents
Page
Title Page.................................................................................................................................................... ii
Acknowledgments ................................................................................................................................. xi
Conceptual Framework............................................................................................................13
Page
Quantitative Data.............................................................................................................19
Quantitative ..................................................................................................................................25
Qualitative .....................................................................................................................................26
Page
Support ................................................................................................................................61
Contraception ....................................................................................................................63
Limitations ....................................................................................................................................68
Strengths........................................................................................................................................69
Recommendations .....................................................................................................................71
Conclusion .....................................................................................................................................73
Next Steps......................................................................................................................................74
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 3. Where respondents’ would like to receive family planning services ............34
List of Tables
Page
Table 5. Days and times respondents’ prefer to visit the clinics ........................................33
Table 7. Comparing reasons for using family planning services and barriers to family
planning services between age groups ............................................................................................ 44
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 12. Comparing happiness with staff between those who work and don’t
work ..........................................................................................................................................................51
Page
List of Appendices
Page
Acknowledgements
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
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
Chapter 1: Introduction
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,
“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 No longer eligible for First Steps (which is a service provided for a period of
x To develop a program that was able to fill a gap in health services with non-
x abstinence and,
x contraceptive services.
started in Yakima County, has steadily grown over the past several years. Today this
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
providing bilingual materials. FPRH (2006), notes the factors that drive costs higher
include:
x bilingual and preferably bicultural Hispanic staff. (In some agencies, this
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
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
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.
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
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
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
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.
pregnancy, and utilization of health services), may reduce the number of Medicaid
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’
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 a health care provider (Asamoa et al., 2004). Asamoa et al. also concluded that
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
Cejk (2006) noted that healthcare centers and/or clinics are the primary place for
transmitted infections, contraceptive use, and family planning counseling. The use
of contraceptive methods among non-citizen Hispanic women and men still remain
showed that Latinas have a higher birth rate and a proportionally lower use of
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
services and programs. Even when such programs exist, such immigrants are
disinclined to utilize the health care system. Sungkyu and Sunh (2009) found that
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
In Washington for example, very few health centers and programs are
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.
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
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
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,
difficulties. Ku and Waidmann, (2003) noted that “citizenship status (e.g., citizen,
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
(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
program being implemented is producing the desired effect among the target
workers. In 1995, about 13% of all Washington seasonal farm workers were
Although the agriculture industry is strong, the pay remains relatively low. This low
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
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
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.
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
Medicaid paid births un the U.S. Among these Medicaid-paid births, 80% were
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
how Latinos make decisions about their sexual and reproductive health, particularly
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
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
significant role in family planning, other areas of the health care setting have also
Thus far, the literature has addressed limited information on the viewpoints
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
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
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
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
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
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
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
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
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
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
the heart of the apple capital of the world and located on the east side of the Cascade
“to provide and promote full access to services and resources regarding
reproductive life, and prenatal, birth and post-birth care” (Family Planning of
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
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
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
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.
collecting both quantitative and qualitative data. While other research designs such
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
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
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
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
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:
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
The majority of the patients completed the survey while waiting for their
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
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
interviews were conducted among the patients at the clinics. There were a total of
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
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
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
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
This evaluation involved working with patients who are Hispanic non-
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.
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
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,
For the telephone interviews, the two Spanish speaking female students from
Central Washington University who conducted the interviews and the medical
24
form in accordance with the Data Protection Act and the American Sociological
Data Management
Upon obtaining approval from the Institutional Review Board (IRB) of the
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
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 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
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
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
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
data was analyzed from the interviews by the evaluator using step-by-step
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.
statistics, tables, and graphs. The emerging themes from the qualitative analysis
were then used to complement survey findings and respondent quotes enhanced
Chapter 5: 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
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
Table 3
Table 3
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
Table 4
Respondent demographics
Demographic
Characteristics Percent
Sex
Male 6%
Female 94%
Age
18-30 59%
>31 41%
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
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.
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
Table 5
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
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
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.
appointment would be the best time to remind them about their appointment (see
Figure 5).
36
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
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
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
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
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
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.
pregnancies, respondents indicated that health fairs were the most helpful avenue
statistically different their responses to the use of flyers (see Figure 9).
40
3.69 (± 1.186)
3.70
3.50
3.37 (± 1.125)
3.40
3.30
3.20
Flyers Brochures Bulletin Boards TV Ads Radio Ads Health Fairs
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
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
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
them to not use family planning services. 48% indicated inability to pay for
Social pressure
No babysitter
No transportation to
No health insurance
Can't pay for family
Awkwardness
receive services
the clinic
When asked about whether the clinics are meeting the respondents’ family
planning needs, approximately 86% said that they always are (see Figure 12).
Figure 12. How Often the Clinics are Meeting Patient Needs
43
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
Table 6
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
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
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
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
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
Table 10
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
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
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
Table 12
Comparing happiness with staff between those who work and don’t work continued
indicated that weekend appointments are most valuable compared to 59% of those
significant difference between those respondents that work who value evening
Table 13
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
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
Table 14
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
not migrate (N = 91), thus only the needs and concerns of those who do not migrate
Table 15
The survey also had a very low response rate from male patients (n=9) as
Table 16
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
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
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
Table 17
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
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
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
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
from the total list of respondents who had agreed to participate in the interview.
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
Support. Support was defined as both clinical support and partner support.
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
“ 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
whom are undocumented. Based on the interviews, support from their partners for
“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
interviewees did mention that their partner supports their decision in using
“We have two kids and because we are planning, he helps me with that”
contraceptive decisions.”
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
services were important to them, and that cost was a concern of theirs if there was
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
was. Some even mentioned that if they were not able to receive contraception at the
contraception.”
The main barrier which prevented the use of contraception was cost. The
Integrative Findings
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
With funding from the legislature, it was hoped that the Washington State
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
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
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
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
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
struggle for immigrants. Respondents that work or don’t migrate indicated that
health insurance is what prevents them from receiving family planning services.
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
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
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
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
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
Limitations
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
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,
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
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
relationships between the variables under review of interest among the non-citizen
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
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
Strengths
A strength of this evaluation was the mixed methods approach. The use of
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
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
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
response rate on the survey. The number of respondents was greater than
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
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
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
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
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
commented that their partners do not play a role in helping them make family
planning decisions.
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
Respondents aged 30 years and above indicated that they would like programs
where they could learn more about other services in the community, particularly
that Barcaglioni (2010) noted that “a study by the National Latino Alliance for the
their partner’s violence had increased since they immigrated to the United States.”
health fairs according to survey respondents was the best way to communicate the
challenge. Depending on the services provided, clinics may need to look for ways to
the family planning clinics offer free to low cost contraception for non-citizens.
Funding sources could come from local State government, Federal government, and
more information and services related to sterilization for both males and females.
Conclusions
family planning clinics in Washington along with the Washington State Department
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
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
telephone interview questions might help provide more data that could be used to
involvement and the decisions partners make in family planning, and the
sample.
Next Steps
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.
particularly helpful to help assess the implementation of the program. Each clinic
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
examined. Such components are looking to see if there are any barriers
encountered in the implementation and the quality of the services offered. The
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
program.
the response rate for some questions, which in turn may provide additional support
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
the decisions partners make in family planning, and the development of education
programs.
75
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
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
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
The fourth implication deals with partnership to solve health problems and
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
respondents free or low cost contraception. In the most current article found, the
Population Council of New York (1994) indicated that moving beyond just
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.”
public health. The Cuidese program provides an avenue where clinic staff could
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
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
Berk, M, L., Schur, C, L., Chavez, L, R., Frankel, M. (2000) Health Care Use Among
Undocumented Latio Immigrants
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
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
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.
Appendix A
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
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
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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
The phone call is optional: You may chose not to answer any question or chose to
Thank you.
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Appendix B
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.
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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.
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
d: Other__________________________________________________________________
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1. What day of the week is best to come to the clinic? (Circle top two days)
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 _____________________________________________________________
4ǤǥǫȋξȌ
Not Happy Somewhat Happy Very Happy
Happy
a. Reception
Staff
b. Nurse
c. Provider
d. Clinic
d. Interpreter
e. Price
87
5Ǥ
ǫȋξȌ
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
_________________________
_________________________
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_________________________________________________________________
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
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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.
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Appendix D
Appendix E
October 7, 2010
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,
c: HSRC File
Dr. Leo D’Acquisto, HSRC Chair
Dr. Melody Madlem, Faculty Sponsor