With Every Heartbeat Is Life:  A Community Health Worker's Manual for African Americans

Session 12
Use Evaluation To Track Your Progress (Especially for Community Health Workers)


Contents



Objectives

By the end of this session, community health workers will learn how to:

  • Create a vision for a With Every Heartbeat Is Life project for your community
  • Learn the basics of evaluation.
  • Choose strategies that can be used to implement the With Every Heartbeat Is Life project in your community
  • Learn the role of a community health worker in the evaluation process
  • Collect data to show the results of the project
  • Participate as a team member in the project's evaluation process
  • Create an evaluation workplan for the project's activities

Materials and Supplies

To conduct this session, you will need:

  • "With Every Heartbeat Is Life" manual
  • Blackboard and chalk or large pieces of paper, markers, and tape
  • Color markers and sheets of poster board

Handouts

Give these handouts to each group member during the session:

Session Outline

Introducing the Session

  1. Welcome
  2. About the Session

Conducting the Session

  1. Develop a Vision for the With Every Heartbeat Is Life Community Project for Your Community
  2. Basic Information on Evaluation
  3. With Every Heartbeat Is Life: Three Strategies To Offer in Your Community
  4. Data Collection
  5. The Role of Community Health Workers in the Evaluation Process
  6. How To Work as a Member of the Evaluation Team
  7. Group Activity: Develop an Evaluation Workplan for Your Project

Review of Today's Key Points

Closing


Introducing the Session

  1. Welcome
    • Welcome group members to the session.
  2. About the Session
    1. Say:
      You have learned a lot of information during this training. You have gained new skills and shown great progress and motivation. Now, you are ready to put the With Every Heartbeat Is Life training into action in your community. Congratulations!
    2. Say:
      This session is especially for community health workers. It will teach you how to participate as a team member to evaluate your project.

Conducting the Session

  1. Develop a Vision for the With Every Heartbeat Is Life Project for Your Community
    • Say:
      During this session, you will develop a vision for a With Every Heartbeat Is Life project for your community.
    • Ask:
      Can someone tell me what a vision is?
    • Note: Allow 2 to 3 minutes for group members to respond. Write their answers on the blackboard or a large piece of paper taped to the wall.
    • Add the following answers if they are not mentioned:
      • A vision is your dream, an image, or a picture of what you want to do and what you imagine your community project will do for the people you serve.
      • It is the direction or goal of your project.
      • It is what inspires, motivates, and engages people to take action.
    • Say:
      A vision can be written as a statement or expressed as a drawing.
    • Some examples of vision statements are:
      • A heart healthy and stroke-free community
      • An active, healthy, and informed community
    • Say:
      Now it's time for you to create a vision for a community project. Think of this question when you create your vision: What would you like your community to be like after implementing your heart health project?
    • Note: Divide the participants into small groups.
    • Say:
      Choose one person from your group to share your group's vision.
    • Note: Give each small group a set of color markers and a large piece of paper or poster board. Allow 20 minutes for groups to come up with their visions.
    • Say:
      Now, a member of each group will present each vision to the rest of the group members.
    • Note: Allow 2 to 3 minutes for each group to share its vision. Congratulate the community health workers for their enthusiasm and a job well done.
  2. Basic Information on Evaluation
    • Say:
      When you offer the With Every Heartbeat Is Life project in your community, you will want to know if your project helped you to achieve your vision. Evaluation can help you do this. Now let's talk about what evaluation is and some important steps you need to know when you evaluate a project.
    • Say:
      Evaluation is a well-thought-out process to assess the value of your project.
    • Ask:
      What are some benefits of evaluation?
    • Note: Allow about 2 minutes for group members to respond. Write their answers on the blackboard or on a large piece of paper taped to the wall.
    • Add the following answers if they are not mentioned.
    • Evaluation offers you a way to:
      • Find out if your project is working or is successful.
      • Learn if you are meeting the goals of the project.
      • Find out which project areas need to be changed or improved.
      • Gather information about your project that you can share with the community and those who fund your project.
      • Learn if your project activities are helping people make healthy choices.
    • Give each group member the "Examples of Project Evaluation" handout.
    • Say:
      Now we will look at how evaluation is used in a few projects.
    • Ask volunteers to read aloud each example and tip.
    • Examples of Project Evaluation
    • Example 1

      During the month of May, doctors from a community clinic referred 45 patients to the heart health sessions conducted by community health workers. Thirty participants attended all of the heart health sessions. The other 15 participants only attended a few sessions.

      After the classes ended, the community health workers conducted followup visits. These visits revealed that the 30 participants who attended the classes were using the project's heart healthy recipes, participating in physical activities, and taking their medicines as the doctor told them. The other 15 participants who did not attend the classes were not using the recipes, most were not doing any physical activity, and several were taking their medicines only when they remembered.

      The community health workers saw that the project had a greater positive impact on participants who took part in all of the heart health sessions.

      Tip: Plan to track participants at every stage of your project—(1) referrals, (2) class attendance, and (3) followup after the classes.

      Example 2

      A community health worker is a member of the health promotion team working on a project to increase the physical activity of community members. Participants attended a series of heart health sessions. The community health worker reviewed the results of the project. She found that 15 out of 20 participants who went to at least 6 of the training sessions were now walking for 30 minutes or more per day.

      The community health worker learned that people who attended the heart health sessions increased their physical activity.

      Tip: Learn your project goals and review them throughout your project. Make sure that project activities make sense and are helping you to reach the goals of your project.

      Example 3

      A group of community health workers posted flyers in the community about an upcoming cholesterol screening event. They held the screening, but only a few people showed up. After the poor turnout, the community health workers thought about different ways to get the word out. They met with community leaders, got their input, and developed a new strategy. The new strategy was to go door to door to talk about the importance of cholesterol screening and to ask people to share the information they learned with friends and family. Then, the community health workers held a second screening and had a much better turnout.

      By finding out what didn't work and getting input from the community, the community health workers were able to make changes in the way they recruited participants.

      Tip: Don't focus only on the positive results of the project. You can learn a great deal by looking at what went wrong and what did not work.

      Example 4

      Community health workers conducted several heart health sessions for community members. One participant shared her high blood pressure story. She described how her doctor told her that she had high blood pressure and about all the healthy changes she made. After 3 months, she had lost 10 pounds, and her blood pressure was under control.

      The community health workers asked this participant to share her story at a community gathering. More community members are now interested in taking part in the heart health sessions.

      Tip: Be creative. Project evaluation is about more than just numbers. Participants' stories, pictures, and journals can be very powerful tools that describe how your project has affected them.

    • Say:
      You have learned examples of project evaluation. Now, let's go over the seven steps to create a plan for implementing and evaluating your project.
      1. Choose the activities. Work with your agency to choose the activities that you want to do. For example, your project may offer the sessions from the "With Every Heartbeat Is Life" manual.
      2. Implement project activities. Perform the activities of your project as planned. For example, you can recruit 20 parents from a local school and conduct the With Every Heartbeat Is Life project at the school.
      3. Collect data. Collect data to show if your project is helping parents. For example, you can use questionnaires to find out how parents used the information, what they learned in the sessions, and if they made heart healthy lifestyle changes.
      4. Enter data. Enter information from the completed questionnaires into a database. This task can be done by trained community health workers or trained staff.
      5. Analyze the data. An evaluator can analyze the data and summarize the findings. For example, an evaluator may find that parents who walk for 60 minutes daily have lower blood pressures and have lost weight.
      6. Write a report about the results. A report can show how the community has changed as a result of the project. For example, the evaluator may describe how parents' eating habits and physical activity patterns have changed as a result of their participation in the project.
      7. Share the results. Community health workers can share results with community members. For example, sharing results can increase community members' interest in the project and motivate them to take personal action to improve their health.
    • Say:
      You have seen how evaluation can help you. Now, let's take a look at the types of evaluation: process, outcome, and other evaluation methods.
    • Give each group member the "Types of Evaluation" handout.
    • Ask volunteers to read aloud the types of evaluation and each example.

    Types of Evaluation

    Process Evaluation

    Process evaluation tells you about the content of project activities. You can learn if you are doing the activities as they were planned. It also tells you who is participating in your project activities. You can track the specifics on how you carry out your project, such as the time spent on activities and how many participants attended the activities. The results of process evaluation help you to know which activities are more successful than others. It also gives you the feedback you need to improve your project.

    Example: You can collect information about the number of sessions that you taught from the "With Every Heartbeat Is Life" manual and how much time you spent on activities during the training sessions.

    Outcome evaluation

    Outcome evaluation describes the effect your project had on your participants. You can learn how the participants changed or are changing after completing the course. You can track how participants' knowledge, feelings (attitudes), or actions (behaviors) have changed after taking part in the project. You also can track the changes in clinical values. (For example, you can check to see if participants' blood pressure or weight has decreased.)

    Example: A questionnaire is given to participants before the first class. The same questionnaire is given after the last class. The results of the two questionnaires are compared, which will tell you how much participants learned.

    Other Evaluation Methods

    You can use other methods to evaluate your project. You can ask participants for their stories (testimonials) about how the project has affected them, and you can collect the stories as the project evolves. Participants also can submit photographs and journals about the changes they have made during the project.

  3. With Every Heartbeat Is Life: Three Strategies To Offer in Your Community
    • Note: Before the session, read the charts that serve as a guide. These charts list the three strategies in more detail. Each strategy includes: goals, description of activities, setting, and target audience.
    • Say:
      You can offer the With Every Heartbeat Is Life project in your community using three strategies. These strategies are:
      1. Train the Trainer. This strategy consists of using the "With Every Heartbeat Is Life" manual to train a group of community health workers, who then go back to their communities and train other community health workers.
      2. Community Education. In this strategy, trained community health workers use the manual and picture cards to teach community members by using one of the following options:
        • Teaching all lessons from the manual to community members.
        • Teach all lessons from the manual and screen community members. Screenings can include the height, weight, and waist measurements of participants. Blood pressure, blood cholesterol, and blood glucose screenings also can be conducted with the help of other agencies and health professionals. If needed, community health workers can refer participants with elevated values to a medical setting for followup.
      • Ask:
        When you do screenings as part of your community education, why do you think it is necessary to partner with other agencies such as a clinic?
      • Note: Allow about 2 minutes for group members to respond.
      • Add the following answers if they are not said:
        • To secure trained health care staff to screen participants for high blood pressure, high blood cholesterol, or blood glucose.
        • To get an authorized agency to obtain permission forms from participants before they are screened for high blood pressure, high blood cholesterol, or blood glucose.
        • To refer participants with elevated numbers to a health care professional at the clinic to confirm if their levels are high and to get health information.
      1. Lifestyle and Clinical Management. In this strategy, community health workers work in a clinic as part of a health care team. Trained community health workers: (1) teach the manual to patients, (2) monitor patients' clinical measures (blood pressure, blood cholesterol, body mass index (BMI), waist measurements, and blood glucose levels) in collaboration with a health care provider, and (3) follow up with patients to offer support and encouragement in addition to making sure that patients are following their treatment.
    • Note: Some community health workers may be working in clinical settings, and they may teach patients about conditions such as HIV/AIDS, substance abuse, or prenatal care. Community health workers can use these skills to work with patients who have risk factors for heart disease, such as high blood pressure, high blood cholesterol, or diabetes.
    • Give each group member "With Every Heartbeat Is Life: Three Strategies To Offer in Your Community"
    • Say:
      First, let's review the three strategies to plan how you could offer them in your community.
    • Ask:
      Does anyone have questions about the strategies?
    • Note: Allow 2 minutes for group members to respond.
  4. Data Collection
    • Note: Before the session, read the chart that serves as a guide. The outcome evaluation chart describes each strategy, the forms needed to collect outcome data for each strategy, when the forms should be used, and the type of information you can collect to evaluate your project.
    • Say:
      Once you have figured out which strategy or strategies you want to offer in your community, then you need to collect data for each strategy.
    • Give each group member the "Outcome Evaluation Form" handout.
    • Note: Give group members copies of the data collection forms, and describe each form. The data collection forms are:
    • Say:
      Let's look at the data collection forms for the three strategies. We will start with the Train the Trainer strategy. This strategy uses the "Community Health Worker Train the Trainer Pretest and Posttest" forms. The pretest form was used at the beginning of the training, and you will use the posttest form at the end of training.
      The changes in responses from pretest to posttest will help you find out if you learned new information or skills. After the training, you will also complete the "Feedback Form—What Did You Think About the Training?" questionnaire. This form provides information on your likes and dislikes of the training, how confident you feel about training others, and suggestions for improving the training.
    • Say:
      For the second strategy—Community Education—you can use the "My Health Habits Pretest and Posttest" forms to find out if participants are changing their health habits. If you add screenings to your community education strategy, then you can use the "Screening Form" to record the clinical values of participants.
    • Say:
      Using the third strategy—Lifestyle and Clinical Management—you can use the "My Health Habits Pretest and Posttest" to record how patients are changing their health habits. You also can use the "Clinical Measures and Followup Form" to record the patients' changes in clinical values.
    • The "Community Health Worker Activities Form" can be used to keep track of the followup activities that help patients stay on their treatment plan.
    • Say:
      The "Clinical Measures and Followup Form" is useful for community health workers who work in a clinical setting.
    • Ask:
      How many of you work in a clinic, hospital, or other medical setting?
    • Note: Allow 2 minutes for group members to respond.
    • Ask each group member to look at the "Community Health Worker Activities Form" handout again.
    • Say:
      When you work with patients, it is very important to keep track of your followup activities to help patients stay on the medicines prescribed by their doctors. You should also keep track of the followup activities you do to help patients make lifestyle changes.
    • Note: Since you have already reviewed the "Community Health Worker Activities Form" handout, ask volunteers if they have any questions or comments about the activities listed on the handout. Allow 2 minutes for group members to respond.
    • Say:
      Collecting information on followup activities can highlight the important role that community health workers have in helping patients stay on their treatment plans and control their risk factors.
    • Say:
      The last form that we will talk about is the "Recording Log." This log tells you which form to use for each strategy and what type of information to gather for each strategy. The recording log focuses on process evaluation activities.
    • Say:
      Let's review the "Recording Log" handout. The information you will gather for the Train the Trainer strategy is:
      • Number of participants trained
      • Number of sessions taught
      • Number and percentage of participants who rate the training "good" or higher
      • Number and percentage of participants who report that they "will" or "most likely will" change their health habits
      • Number and percentage of participants using the "With Every Heartbeat Is Life" manual 30 days after the training
      • Types of activities that participants are completing 30 days after the training
    • Ask a volunteer to read aloud the information for the community education strategy.
    • Ask a volunteer to read aloud the information for the lifestyle and clinical management strategy.
    • Ask:
      Does anyone have questions?
    • Say:
      The "Recording Log" form is important because the results can help you to know which activities are being implemented and how. It also gives you the feedback you need to improve your project.
    • Say:
      Before using these data collection forms, we recommend that you review the "More Information" box below. This box contains tips for gathering information for your community project.

    More Information

    Here are some tips for gathering information for your community project.

    Before you offer a questionnaire to others:

    • Check with your agency. Your agency may need to approve the questionnaire before you use it. Privacy and consent of project participants are important when doing evaluation. You will want to follow the policies of your organization and your funding agency.
    • Make sure you understand how to fill out the questionnaire before you hand it out. Know the form well, so you can answer any questions participants may have.

    The day you administer the questionnaire:

    • Bring plenty of forms and pens with you.
    • Ask participants to answer each question completely. Missing information will make it hard for you to analyze the data.
    • If the budget allows, give a small prize to people who sign up for the program or fill out your form.
    • Always remember to thank participants.

    Note:During the pretest and posttest, the community health workers or volunteers may ask the questions aloud if people need help with their forms. Questions may be read aloud, but the answers to the questions should not be given.

  5. The Role of Community Health Workers in the Evaluation Process
    • Say:
      Some of you may be thinking that evaluation is too complicated and that there is no role in it for you. But that is not true.
    • Ask:
      Has anyone already worked on the evaluation of a project? Can you share what you did?
    • Note: Allow 3 minutes for group members to respond.
    • Say:
      Here are some examples of the role that community health workers can have in the evaluation process.
    • Community health workers can:
      • Help to decide which activities should be conducted.
      • Hand out questionnaires and other instruments to participants.
      • Collect the forms.
      • Enter data into a computer.
      • Provide feedback on what worked and what didn't work and how the activities could be improved.
      • Share results of the evaluation with the community.
      • Attend training meetings about project evaluation.
    • Say:
      Remember that your involvement in the evaluation process can help show the value of having community health workers on the project team. The actions of community health workers are key in tracking project activities in the community.
    • Ask:
      If you have not been a part of an evaluation team, would you be interested in having a role in the evaluation process of the With Every Heartbeat Is Life project?
    • Note: Allow 5 minutes for group members to respond.
    • Say:
      Thank you for sharing your experiences about being part of an evaluation team. With time and practice, your confidence level will increase. Just as you have been trained in how to conduct the sessions of the "With Every Heartbeat Is Life" manual, you will be trained in how to conduct evaluation activities for your project. In less time than you think, you will be making great contributions to your evaluation team.
  6. How To Work as a Member of the Evaluation Team
    • Say:
      People who evaluate projects need to work as a team. Community health workers can be an important part of this team.
    • Say:
    • A community project team may include:
      • A project manager
      • An evaluator
      • Community health workers
      • Health professionals
    • Ask:
      Do you have an evaluator on your project team or in your agency?
    • Note: Allow 2 minutes for group members to respond.
    • Ask:
      What are some things you can do to get involved with project evaluation when you return to your agency?
    • Note: Allow 2 to 3 minutes for group members to respond. Write their responses on the blackboard or a large piece of paper taped to the wall.
    • Add any of these answers if they are not said:
    • Community health workers can:
      • Find out who does evaluation in their agencies.
      • Share this session on evaluation with supervisors.
      • Ask their supervisors how they can be involved in evaluating the project.
      • Ask their supervisors if they can attend trainings on project evaluation.
    • Say:
      If your agency does not have an evaluator, you can try to link with an outside evaluator who supports community health worker projects.
    • Say:
    • An evaluator can help to:
      • Develop an evaluation plan for the project.
      • Make sure that the project is carried out as intended.
      • Conduct an analysis.
      • Write a report on the data collected.

    More Information

    Your agency can get the services of an outside evaluator by contacting:

    • Other community health worker projects
    • A university that has a school of public health
    • A foundation that has community health projects and can refer you to an evaluation consultant
    • Your state health department
  7. Group Activity: Develop an Evaluation Workplan for Your Project
    • Say:
      The purpose of this activity is to develop an evaluation workplan for a community project.
    • Divide group members into the same three groups that they were in when they developed the vision for their community projects. Give each group a different project from the "Develop an Evaluation Workplan for Your Project" handout.
    • Note: Group 1 will work on project 1; group 2 will work on project 2; and group 3 will work on project 3.
    • Say:
      This handout on evaluation includes the project descriptions and a blank chart with questions to help you develop a plan on how to evaluate your activities. The questions are:
      1. Who will be your target audience?
      2. What strategy will you use?
      3. Which forms will you use to collect data?
      4. Describe the activities you will use to conduct the strategy.
        • How will you recruit participants?
        • When will you schedule the classes?
        • Who will teach the classes?
      5. Decide who will manage the data:
        • Who will collect the data?
        • Who will enter the data?
        • Who will analyze the data?
      6. Determine who will write the evaluation report.
    • Community Projects

      Note: Discuss your project and the evaluation workplan using "Develop an Evaluation Workplan for Your Project" as a guide.

      Project 1: Training Community Health Workers To Promote the With Every Heartbeat Is Life Project in Their Communities

      • Your agency has agreed to conduct the With Every Heartbeat Is Life Train the Trainer workshop for 25 community health workers from community agencies that have requested it.
      • Your supervisor asks you and two other community health workers to plan the Train the Trainer workshop and to develop the education program.

      Note: Discuss your project and the evaluation workplan using "Develop an Evaluation Workplan for Your Project" as a guide.

      Project 2: Helping Community Members Make Heart Healthy Lifestyle Changes

      • Your community-based organization is in Baltimore, MD.
      • Your supervisor asks you to help develop the evaluation plan for the With Every Heartbeat Is Life community education project.
      • The course is for adults age 30 to 60.
      • The goal is to recruit, teach, and increase the knowledge, positive attitudes, and skills of the community members attending your classes.

      Note: Discuss your project and the evaluation workplan using "Develop an Evaluation Workplan for Your Project" as a guide.

      Project 3: Helping Patients Manage Their Risk Factors for Heart Disease and Make Lifestyle Changes

      • Your clinic is located in southeast Washington, DC.
      • Your clinic has decided to get involved in a project on heart health to help patients change their behaviors and lower their clinical measures.
      • You and two other community health workers attended a community health workers conference to receive the With Every Heartbeat Is Life training.
      • Now, your supervisor wants your group to develop activities and an evaluation plan for the project.

      Note: Allow about 30 minutes for each group to come up with their evaluation plans.

    • Note: Ask one person from each group to present the group's evaluation plan to the entire group. Allow about 5 minutes for each presentation.
    • Say:
      Thank you for doing such a wonderful job!

Review of Today's Key Points

  • Say:
    Let's review what we learned today.
    • What is evaluation?

    • Evaluation is a well-thought-out process to assess the value of your project. It helps you check to see if you are meeting the goals of the project.

    • What are the benefits of evaluation?

      • Finding out if your project is working as planned, or is successful
      • Learning if you are meeting the goals of the project
      • Finding out which project areas need to be changed or improved
      • Gathering information about your project that you can share with the community and those who fund your project
      • Learning if your project activities are helping people make healthy choices
    • What is the role of community health workers in the evaluation process?

      • Helping to decide which activities should be carried out
      • Administering questionnaires and other instruments
      • Collecting the instruments
      • Entering data into computers
      • Providing feedback on the ways the activities are done and how they can be improved
      • Sharing results of the evaluation with the community
      • Attending training meetings about project evaluation
    • What strategies can you evaluate using the "With Every Heartbeat Is Life" manual?

      • You can evaluate the training of community health workers to promote heart health in the community.
      • You can evaluate what community members have learned and which changes they have made to have heart healthy lifestyles.
      • You can evaluate how patients have been helped in managing their risk factors for heart disease and making changes in their lifestyles.
    • Who forms the community project evaluation team?

      • A project manager
      • An evaluator
      • Community health workers
      • Health professionals

Closing

  • Say:
    Thank you for coming today. What did you think of today's session?
  • Note: Allow a moment for group members to respond.
  • Say:
    Community health workers play an important role in the evaluation of a community project. We hope this session helps you achieve positive results in your work with the community. I wish you success in implementing the With Every Heartbeat Is Life project in your community.

Handouts

Examples of Project Evaluation

Example 1

During the month of May, doctors from a community clinic referred 45 patients to the heart health sessions conducted by community health workers. Thirty participants attended all of the heart health sessions. The other 15 participants only attended a few sessions.

After the classes ended, the community health workers conducted followup visits. These visits revealed that the 30 participants who attended the classes were using the project's heart healthy recipes, participating in physical activities, and taking their medicines as the doctor told them. The other 15 participants who did not attend the classes were not using the recipes, most were not doing any physical activity, and several were taking their medicines only when they remembered.

The community health workers saw that the project had a greater positive impact on participants who took part in all of the heart health sessions.

Tip: Plan to track participants at every stage of your project. You should track referrals, class attendance, and followup after the classes.

Example 2

A community health worker is a member of the health promotion team that is working on a project to increase the physical activity of community members. Project participants attended a series of heart health sessions. The community health worker reviewed the results of the project. She found that 15 out of 20 participants who went to at least 6 of the training sessions were walking for 30 minutes or more per day.

The community health worker learned that people who attended the heart health sessions increased their physical activity.

Tip: Learn your project goals and review them throughout your project. Make sure that project activities are making sense and are helping you to reach the goals of the project.

Example 3

A group of community health workers posted flyers in the community about an upcoming cholesterol screening event. They held the screening, but only a few people showed up. After the poor turnout, the community health workers thought about different ways to get the word out. They met with community leaders, got their input, and developed a new strategy. The new strategy was to go door to door to talk about the importance of cholesterol screening and to ask people to share the information they learned with friends and family. Then, the community health workers held a second screening and had a much better turnout.

By finding out what didn't work and getting input from the community, the community health workers were able to make changes to how they recruited participants.

Tip: Don't focus only on the positive results of the project. You can learn a great deal by looking at what went wrong and what did not work.

Example 4

Community health workers conducted several heart health sessions for community members. One participant shared her high blood pressure story. She described how her doctor told her that she had high blood pressure and about all of the healthy changes that she made. After 3 months, she had lost 10 pounds, and her blood pressure is now under control.

The community health workers asked this participant to share her story at a community gathering. More community members are now interested in taking part in the heart health sessions.

Tip: Be creative. Project evaluation is about more than just numbers. Participants' stories, pictures, and journals can be very powerful tools that describe how your project has affected them.

Types of Evaluation

Process Evaluation

Process evaluation tells you about the content of project activities. You can learn if you are doing the activities as they were planned. It also tells you who is participating in your project activities. You can track the specifics on how you carry out your project, such as the time spent on activities and how many participants attended the activities. The results of process evaluation help you to know which activities were more successful than others. Evaluation also gives you the feedback you need to improve your project.

Example: You can collect information about the number of sessions that you taught from the "With Every Heartbeat Is Life" manual and how much time you spent on activities during the training sessions.

Outcome Evaluation

Outcome evaluation describes the effect your project had on your participants. You can learn how the participants have changed after completing the course. You can track how participants' knowledge, feelings (attitudes), or actions (behaviors) have changed after taking part in the project. You also can track changes in clinical values. (For example, you can check to see if participants' blood pressure or weight has decreased.)

Example: A questionnaire is given to participants before the first class. The same questionnaire is given after the last class. The results of the two questionnaires are compared, which will tell you how much participants learned.

Other Evaluation Methods

You can use other methods to evaluate your project. You can ask participants for their stories (testimonials) about how the project has affected them, and you can collect the stories as the project evolves. Participants also can submit photographs and journals about the changes they have made during the project.

With Every Heartbeat Is Life: Three Strategies To Offer in Your Community

Strategy Goals Description of Activities Settings Target Audience
1. Train the Trainer
  • Increase the number of community health workers who are prepared to train others.
  • Increase the use of the "With Every Heartbeat Is Life" manual by trained community health workers.
  • Increase knowledge about heart health.
  • Increase positive attitudes and behaviors toward a healthy lifestyle.
  • Increase the ability to identify risk factors for cardiovascular disease in participants.

Trained community health workers train others by:

  • Recruiting community health workers
  • Teaching the "With Every Heartbeat Is Life" manual to other community health workers
  • Administering the pretest and posttest.
  • Doing followups to make sure that trained community health workers are using the manual

Clinical and nonclinical:

  • Community-based organizations
  • Clinics
  • Hospitals
  • Public health programs
  • Community health workers
  • Other health professionals like nurses, registered dietitians, nutritionists, and public health educators
2. Community Education
a. Teach the educational manual only.
  • Increase knowledge about heart health.
  • Increase positive attitudes to make lifestyle changes.
  • Increase the adoption of healthy lifestyle behaviors.

Trained community health workers who work in nonclinical settings:

  • Recruit members of the community.
  • Teach the "With Every Heartbeat Is Life" manual.
  • Administer the "My Health Habits Pretest and Posttest."

Nonclinical:

  • Community-based organizations
  • Resource centers
  • Homes
  • Schools
  • Faith-based organizations
  • Senior centers
  • Families and community members with signed informed consent forms
   Community Education
b. Teach the educational manual and screen program participants.
  • Increase knowledge about heart health.
  • Increase positive attitudes to make lifestyle changes.
  • Increase the adoption of healthy lifestyle behaviors.
  • Track participants' clinical data.
  • Refer participants with elevated levels to health care professionals to confirm if levels are high.

Trained community health workers working in nonclinical settings:

  • Recruit members of the community.
  • Teach the "With Every Heartbeat Is Life" manual.
  • Administer the "My Health Habits Pretest and Posttest."
  • Take height, weight, and waist measurements.
  • Measure participants' blood pressure, blood cholesterol, and blood glucose levels.
  • Refer individuals with elevated clinical measures to health care professionals to confirm if their levels are high.
  • Nonclinical in partnership with a health care professional
  • Families and community members with signed informed consent forms
3. Lifestyle and Clinical Management
  • Increase knowledge about heart health.
  • Increase positive attitudes for making lifestyle changes.
  • Increase adoption of healthy lifestyle behaviors.
  • Lower body mass index (BMI), high blood pressure, high blood cholesterol, and high blood glucose.

Trained community health workers who participate as members of the health care team:

  • Teach the "With Every Heartbeat Is Life" manual to patients with heart disease risk factors and to patients who are interested in learning about heart health.
  • Administer the "My Health Habits Pretest and Posttest."
  • Take patients' height, weight, and waist measurements.
  • Work with health care professionals to track patients' blood pressure, blood cholesterol, and blood glucose.
  • Do followup activities (home visits and phone calls) to make sure patients are following their treatment plans and making lifestyle changes.
  • Provide social support and encouragement.
  • Clinics
  • Hospitals
  • Managed- care programs
  • Health centers
  • Private doctors' offices
  • Health departments
  • Patients with heart disease risk factors
  • Patients interested in learning about heart health

Outcome Evaluation Form

Strategy Forms Use This Form Outcome Evaluation
1. Train the Trainer Community Health Workers Train the Trainer Pretest and Posttest
  • Before and after the training
  • Number and percentage of participants who change their knowledge levels
  • Number and percentage of participants who change their skills
2. Community Education
a. Teach the educational manual only.
My Health Habits Pretest and Posttest
  • Before and after teaching the manual
  • Number and percentage of participants who change knowledge, attitudes, and behaviors
2. Community Education
b. Teach the educational manual, and screen program participants.
My Health Habits Pretest and Posttest
  • Before and after teaching the manual
  • Number and percentage of participants who change knowledge, attitudes, and behaviors
Screening Form
  • Before and after teaching the manual
  • Number and percentage of participants referred to a health care professional
  • Number and percentage of participants who actually followed up with a health care professional
3. Lifestyle and Clinical Management My Health Habits Pretest and Posttest
  • Before and after delivering the manual
  • 12 months after collecting initial data (baseline data)
  • Number and percentage of patients who change knowledge levels, attitudes, and behaviors
Clinical Measures and Followup
  • Before delivering the manual (baseline)
  • 6 months after baseline
  • 12 months after baseline
  • Number and percentage of patients who change clinical values
  • Number and percentage of patients who are taking their medications
Community Health Workers Activities Tracking Form
  • First followup encounter (after the manual is taught)
  • 3-month followup
  • 6-month followup
  • 12-month followup
  • Number and percentage of patients contacted for followup

Community Health Worker Train the Trainer Pretest and Posttest

FOR INTERNAL USE ONLY (For Strategy 1)
Start Date (//): / /
End Date (//): / /
Date of contract (//): / /
Was the participant contacted 30 days after training ended to get information about how she or he is using the "With Every Heartbeat Is Life" manual?    

Participant Information

Please tell us some information about yourself by completing this form before the training. Ask for assistance if you need it.

1. Today's date (//): / /
2. Date of birth (//): / /
4. Gender:    
5. Do you consider yourself Latino or Hispanic?    
6. Which race do you consider yourself to be?





7. How many years of school have you completed?









8. Have you worked as a community health worker before?    
9. If yes, for how long?
10. What health topics have you taught? (You may select more than one answer.)






11. Have you used manuals to teach community members?    

12. Is this your first training with the "With Every Heartbeat Is Life" manual?    

Please circle only one answer for each question.

Mrs. Jones, who is 65 years old, is Gloria's mother. Mrs. Jones has diabetes and her blood pressure is 148/98 mmHg (millimeters of mercury). Her blood cholesterol is 250 mg/dL (milligrams per deciliter). Mrs. Jones always has a salt shaker at her table and likes salty food.

  1. What are the risk factors that put Mrs. Jones at risk for heart disease?
    1. Using small amounts of salt, being physically inactive, and being overweight
    2. Having high blood pressure, having high blood cholesterol, and having low blood sugar
    3. Being a female older than age 55, having high blood pressure, having high blood cholesterol, having diabetes, and eating foods high in sodium
    4. Having high blood cholesterol, having low blood pressure, using lots of salt, and being physically inactive

  2. A community health worker explains to Mrs. Jones what high blood pressure is:
    1. High blood pressure is the number that you get when you add 100 to your age
    2. High blood pressure is when the body circulates more blood based on your height and weight
    3. High blood pressure is a measurement of 140/90 mmHg or greater
    4. High blood pressure is when the blood suddenly stops going to the brain

Gloria, the daughter of Mrs. Jones, is 30 years old. She cooks with a lot of fat, and she is 15 pounds overweight. She prepares fried chicken and likes nachos with lots of cheese. When Gloria does not have time to cook, she buys a super-sized hamburger, french fries, and a regular soda. Instead of walking, Gloria drives her car, even to the corner. Her "best friends" are the remote control for her television and her green chair. Gloria's cholesterol level is 240 mg/dL.

  1. Gloria's risk factors and lifestyle habits that put her at risk for developing heart disease are:
    1. Having high blood cholesterol, walking, and being age 30 and overweight
    2. Being overweight, having high blood pressure, and having a family history of heart disease
    3. Being overweight, physically inactive, and cooking and buying foods high in fat
    4. Being age 30, having had a heart attack before, and having low blood pressure

  2. Which of these lifestyle changes can help people prevent heart disease? Mark your answer with an X.
  3. a. Reading the food label to choose foods with less than 5 percent of the Percent Daily Value for sodium.
    b. Preparing foods by baking, broiling, or boiling, instead of frying.
    c. Drinking a lot of whole milk.
    d. Stocking the kitchen with lots of snacks like potato chips.
    e. Cooking with lard.
    f. Eating large portions of food.
  1. This question is about food serving sizes. Mark your answer with an X.
  2. a. Is 1 cup of cooked rice one serving?
    b. Is ½ cup of strawberries one serving?
    c. Is 1 cup of orange juice one serving?
    d. Is ½ cup of cooked beans one serving?
    e. Is 1 slice of bread one serving?
  1. Do you think that the following actions help you take steps toward a healthier lifestyle? Mark your answer with an X.
  2. a. Removing the skin from chicken.
    b. Cooking with lard instead of canola, olive, or corn oil.
    c. Buying canned vegetables instead of fresh or frozen vegetables.
    d. Choosing regular sandwiches instead of super-sized sandwiches when eating out.
    e. Adding fruits and vegetables to your meals.
  1. Mark your answer with an X for the following statements.
  2. a. Secondhand smoke is not dangerous to your heart health.
    b. The desirable level for LDL, bad cholesterol, is less than 100 mg/dL.
    c. Having a waist measurement greater than 35 inches is healthy for a woman.
    d. Adults need about 60 minutes of moderate to vigorous physical activity on most days to prevent weight gain.
    e. The hemoglobin A1C (Hb A1C) test shows the average blood glucose level during the last 24 hours.
    f. People know when they have high blood cholesterol because they begin to gain weight.
8. A heart healthy diet should be followed by:
(Choose the answer below that you think correctly completes this statement.)




9. How important is it to you to reduce your risk of heart disease? Mark your answer with an X.



10. How confident are you about teaching the "With Every Heartbeat Is Life" manual to community members? Mark your answer with an X.



Feedback Form—What Did You Think About the Training? (for Strategy 1)

Date (//): / /

Choose only one answer for each question.

1. The training you attended was:
2. The handouts in the manual were:
3. The picture cards were:
4. The demonstrations were:
5. The audiovisuals were:
6. The content presented was:
7. The educational materials were:
8. The trainer's knowledge of the manual content was:
9. The way the trainer taught the manual was:
10. The activities you participated in (e.g., role plays and pledges, etc.) were:

Write your answers to the following questions.

Circle only one answer for each question.

14. Will you teach the With Every Heartbeat Is Life course to community members?
15. Will you change your health habits?
16. Will you share the information from the training with your family?
17. Will you share the information from the training with friends?
18. Will you share the information from the training with community health workers?

19. Are there other ways that you can share the information?    

My Health Habits Pretest and Posttest

FOR INTERNAL USE ONLY (For Strategy 2a, 2b, and 3)
Start Date (//): / /
End Date (//): / /
Project Location:





Participant Information

1. Today's date (//): / /
3. Gender:    
4. Do you consider yourself Latino or Hispanic?    
5. What race do you consider yourself to be?





6. Have you been told by a health care professional that you have diabetes?        
7. Does your family have a history of heart disease?        

Salt and Sodium

How often do you do the following things? Mark your answer with an X.

1. Do you buy fresh vegetables instead of canned vegetables?
2. Do you use bouillon cubes when you cook?
3. Do you read labels to choose foods with a low-sodium content?
4. Do you add salt to fruit?
5. Do you add salt to the water when you cook beans, rice, pasta, or vegetables?
6. Do you buy meats such as ham, bologna, hotdogs, or sausage?
7. Do you use a salt shaker at the table?
8. Do you fill the salt shaker with a mixture of herbs and spices instead of salt?
9. Do you choose fruits and vegetables instead of potato chips, french fries, and pork rinds?

Cholesterol and Fat

How often do you do the following things? Mark your answer with an X.

1. Do you drink fat-free milk or 1% milk?
2. Do you eat low-fat cheese?
3. Do you use vegetable oil spray to grease baking pans and skillets instead of using lard or butter?
4. Do you read the food label to help you choose foods lower in saturated fat, trans fat, and cholesterol?
5. Do you remove the skin before cooking chicken?
6. Do you drain the fat and throw it away when you cook ground meat?
7. Do you choose fat-free or low-fat salad dressing or mayonnaise?
8. Do you use oil to prepare your food instead of using lard?

Weight Management

How often do you do the following things? Mark your answer with an X.

1. Do you read labels to choose foods lower in calories?
2. Do you bake or grill chicken or other foods instead of frying them?
3. Do you serve more vegetables on your plate than you do meat?
4. Do you serve yourself large portions of food?
5. Do you drink water instead of regular soda?
6. Do you drink lemonade with sugar or powdered drinks with sugar?
7. Do you eat fruits instead of desserts or snacks that contain high amounts of sugar?
8. Do you eat more when you feel stressed?

Physical Activity

Mark your answer with an X.

1. Do you do any type of physical activity at your job?    
2. Not including what you do at your job, do you do any other physical activity?     (GO TO SMOKING)
If yes, answer the following questions.
2a. What type of physical activity do you do? (You may select more than one answer.)




2b. How often do you do physical activity?


2c. How many minutes per day do you do physical activity?


Smoking

Mark your answer with an X.

1. Do you smoke?    
2. Does anyone else smoke in your family?    
3. Do you allow people to smoke in your home?    

Alcohol

Mark your answer with an X.

Note: One drink is one beer (12 ounces) OR one glass of wine (5 ounces) OR 1 ½ ounces of spirits (liquor or whiskey, straight or in a mixed drink). Drinking may occur every day, some days, or just on the weekend.
1. Do you drink alcohol?     (GO TO KNOWLEDGE)
If yes, answer the following questions.
1a. How often do you drink?




1b. When you drink, how many drinks do you have per occasion?

Five or more drinks
1c. How often do you drink more than three drinks in one day?



Knowledge

Mark your answer with an X.

1. Can your waist measurement indicate that you have a high risk of heart disease?
2. Can the Body Mass Index (BMI) chart tell you if you are overweight?
3. Does your liver make all of the cholesterol your body needs to be healthy?
4. Can eating foods that are high in sodium increase your risk for high blood pressure?
5. Does lard have a low amount of saturated fat?
6. Can eating too much saturated fat and trans fat raise your cholesterol level?
7. Is a blood pressure of 140/90 mmHg considered high?
8. Do people know that their cholesterol is high because they have gained weight?
9. Is being physically active a way to reduce your risk for heart disease?
10. Only people with high blood cholesterol should follow a heart healthy diet.
11. Can nonsmokers die from secondhand smoke?
12. Is having a fasting blood sugar of 126 mg/dL or higher considered diabetes?
13. Is having a waist measurement greater than 35 inches healthy for a woman?
14. How confident are you in your ability to cook heart healthy foods?




A Day With the Harris Family

People act in different ways when they learn that they need to make lifestyle changes to lower their chances of getting heart disease.

Read about how the members of the Harris family react to the news about their risks for heart disease. Then place an X next to the name of the family member with whom you identify the most.
Darnell learns that he is at risk for heart disease, but he is not concerned about it. He gets upset when reminded about changing his unhealthy habits. He does not intend to make lifestyle changes for better health. "Nothing's going to happen to me," he says.


James is frustrated because he's aware of his risk factors for heart disease but has been unable to control them. He feels trapped by life situations and wonders whether he can overcome the obstacles that prevent him from maintaining a heart healthy lifestyle. "Sometimes you can try as hard as you can, but if there's a brick wall standing between you and your goal, what can you do?" says James.


Pam learns that she's at risk for heart disease and intends to take action, but every day she puts off making changes. She feels guilty because she knows she should take steps to improve her health. "Walking the walk is harder than talking the talk," says Pam.


Ms. Diane (Grandma Harris) learns that she is at risk for heart disease and quickly draws an action plan. She gets information and attends classes to learn how to improve her health. Ms. Diane practices what she learns and feels optimistic and enthusiastic. She makes healthy lifestyle changes, sets reasonable goals, and helps others to do the same. "Once you know better, you owe it to yourself to do better," says Ms. Diane.


Tina is very motivated to make changes to improve her health. She knows it's easy to fall back into old habits. She makes plans to prevent setbacks, and she starts over again when necessary. Tina believes that she and her family can achieve a heart healthy lifestyle. She has a positive attitude toward life, asks for help when needed, and does not give up. "If I just believe it, then I can do it!" says Tina.

My Health Habits Posttest Only

Please answer these questions after completing all of the sessions of the "With Every Heartbeat Is Life" manual. Mark your answer with an X.

  1. How satisfied are you with the With Every Heartbeat Is Life sessions presented by community health workers?



  2. With whom have you shared the information from the sessions?
    Mark your answer with an X. You may select more than one answer.




Screening Form

FOR INTERNAL USE ONLY (For Strategy 2b)

Project Location:

Use this chart to record the screening information from each project participant.

(MM/DD/YYYY):

(MM/DD/YYYY):
Blood Pressure
Average of two readings:
Systolic (top number):
Diastolic (bottom number):

Overweight and Obesity Height:
Weight:
Body Mass Index (BMI):
Waist measure: or
Height:
Weight:
Body Mass Index (BMI):
Waist measure: or
Blood Cholesterol Total:
LDL:
HDL:
Triglycerides:
Total:
LDL:
HDL:
Triglycerides:
Blood Glucose


Hb A1C:
Blood glucose level (nonfasting):
Blood glucose level (fasting):
Hb A1C:
Blood glucose level (nonfasting):
Blood glucose level (fasting):
All participants with elevated levels are to be referred for further evaluation.
Does participant have elevated level(s)?    
Did the participant go for followup care?    

Clinical Measures and Followup Form

FOR INTERNAL USE ONLY (For Strategy 3)

Project Location:

Participant Information

1. Today's date ( / / ): / /
3. Gender:    
4. Do you consider yourself Latino or Hispanic?    
5. What race do you consider yourself to be?





6. Does your family have a history of heart disease?        

7. Blood cholesterol

Baseline
6 Months After Baseline
12 MonthsAfter Baseline
Have you ever been told by a doctor or other health professional that you have high blood cholesterol?
Are you on medication?
Total
LDL
HDL
Triglycerides

8. Blood pressure

Baseline
6 Months After Baseline
12 MonthsAfter Baseline
Have you ever been told by a doctor or other health professional that you have prehypertension?
Have you ever been told by a doctor or other health professional that you have high blood pressure?
Are you on medication?
Average of two readings      
Systolic
Diastolic

9. Diabetes

Baseline
6 Months After Baseline
12 MonthsAfter Baseline
Have you ever been told by a doctor or other health professional that you have prediabetes?
Have you ever been told by a doctor or other health professional that you have high blood glucose?
Are you on medication?
Hb A1C
Blood glucose level (fasting)

10. Overweight and obesity

Baseline
6 Months After Baseline
12 MonthsAfter Baseline
Weight
Height
Body mass index (BMI)
Waist measure

11. Medication (If the patient is on medication[s], ask the question below.)

Do you take your medication as prescribed by the doctor?

12. If the answer to question 11 is "no," please ask the patient: "Can you tell me why you are not taking your medication?" (Based on the patient's response, please check all the answers that apply.)

Baseline
6 Months After Baseline
12 MonthsAfter Baseline
a. I believe that taking medication every day is not good for me.
b. I forget to take my medication.
c. I did not understand what the doctor told me.
d. I stopped taking medication when I felt better.
e. I feel sick when I take the medication.
f. I do not have anyone to help me.
g. I do not have money to buy the medication.
h. Other reason (please specify):

Community Health Worker Activities Form

FOR INTERNAL USE ONLY (For Strategy 3)
Please complete this form after the manual is taught to record the encounters with the patient.


Project Location:

Which of the following activities do you do? Mark your answer with an X.

ACTIVITIES First Followup Encounter
3-Month Followup
6-Month Followup
12-Month Followup
1. Listen to the patient's concerns.
2. Make an appointment for the patient.
3. Remind the patient to keep the appointment.
4. Make transportation arrangements for the patient.
5. Serve as interpreter for the patient.
6. Provide counseling/educational materials to the patient.
7. Go over counseling/educational materials with the patient.
8. Ask the patient if he or she has any questions about the medication.
9. Encourage patient to stay on treatment plan.
10. Give suggestions to the patient on how to remember to take the medication.
11. Ask the patient about difficulties in changing his or her lifestyle habits.
12. Explain benefits of changing lifestyle habits to patient.
13. Encourage patient to participate in support groups.
14. Refer patient to health and community services.
15. Conduct followup home visit.
16. Conduct followup phone call.
17. Write down what you discussed during the home visit or phone call.
18. Meet with supervisor on a regular basis.
19. File notes in patient's chart.

Recording Log (for Strategies 1, 2a, 2b, and 3)

Strategy Use This Form Information
1. Train the Trainer Attendance Record

1. Train the Trainer Feedback Form
1. Train the Trainer Community Health Workers Train the Trainer Posttest only

2. Community Education

a. Teach the educational manual only.

Attendance Record

2. Community Education

a. Teach the educational manual only.

My Health Habits Posttest

2. Community Education

b. Teach the educational manual, and screen project participants.

My Health Habits Posttest

2. Community Education

a. Teach the educational manual only.
b. Teach the educational manual, and screen project participants.

Screening Form
3. Lifestyle and Clinical management Attendance Record
3. Lifestyle and Clinical management My Health Habits Posttest
3. Lifestyle and Clinical management Clinical Measures and Followup Form
  Baseline 6 months 12 months
Number of patients screened
Number of patients with Prehypertension
Number of patients with High blood pressure
Number of patients with High blood cholesterol
Number of patients with Prediabetes
Number of patients with High blood glucose
Number of patients with Body mass index (BMI) of 25 or more
Number of patients with Waist measurement greater than 35 inches for women
Number of patients with Waist measurement greater than 40 inches for men
Number of patients who are taking medications for High blood pressure
Number of patients who are taking medications for High blood cholesterol
Number of patients who are taking medications for Diabetes
3. Lifestyle and Clinical management Community Health Worker Activities Form

Develop an Evaluation Workplan for Your Project

Write your workplan to evaluate each project using the guide below.

Project 1: Training Community Health Workers To Promote the With Every Heartbeat Is Life Project in Your Community

  • Your agency has agreed to conduct the With Every Heartbeat Is Life Train the Trainer workshop for 25 community health workers from community agencies that have requested it.
  • Your supervisor asks you and two other community health workers to plan the Train the Trainer workshop and to develop the evaluation plan.

Setting:

Who will be your target audience? What strategy will you use? Which forms will you use to collect the data? Describe the activities you will use to conduct the strategy. Decide who will manage the data. Determine who will write the evaluation report.
How will you recruit participants?

When will you schedule the classes?

Who will teach the classes?
Who will collect the data?

Who will enter the data?

Who will analyze the data collected?

Write your workplan to evaluate each project using the guide below.

Project 2: Helping Community Members Make Heart Healthy Lifestyle Changes

  • Your community-based organization is in Baltimore, MD.
  • Your supervisor asks you to help develop the evaluation plan for the With Every Heartbeat Is Life community project.
  • The course is for adults aged 30 to 60.
  • The goal is to recruit, teach, and increase the knowledge, attitudes, and skills of the community members attending your classes.

Setting:

Who will be your target audience? What strategy will you use? Which forms will you use to collect the data? Describe the activities you will use to conduct the strategy. Decide who will manage the data. Determine who will write the evaluation report.
How will you recruit participants?

When will you schedule the classes?

Who will teach the classes?
 

Write your workplan to evaluate a project using the guide below.

Project 3: Helping Patients Manage Their Risk Factors for Heart Disease and Make Lifestyle Changes

  • Your clinic is located in Southeast Washington, DC.
  • Your clinic has decided to get involved in a comprehensive project on heart health to help patients change their behaviors and lower their clinical measures.
  • You and two other community health workers attended a community health workers conference to receive the With Every Heartbeat Is Life training.
  • Now, your supervisor wants your group to develop activities and an evaluation plan for the project.

Setting:

Who will be your target audience? What strategy will you use? Which forms will you use to collect the data? Describe the activities you will use to conduct the strategy. Decide who will manage the data. Determine who will write the evaluation report.

 

 

 

How will you recruit participants?

When will you schedule the classes?

Who will teach the classes?
 

 


Go To SESSION 11 Go To APPENDIX



Last Updated December 2010




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