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Evaluation Proposal for the I Am Waters Water Program

By: Brittany Kaczmarek

University of Texas Health Science Center

School of Public Health

Houston, Texas

PHWM 1120L, Fall 2015

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ABSTRACT

Background: Dehydration is a health complication in which the body is not receiving enough water to thrive. This condition leads to other diseases as well as poor quality of life. The homeless population commonly experiences dehydration due to lack of accessibility to clean drinking water. Provision of safe, clean drinking water to this population can assist in reducing susceptibility to dehydration and poor quality of life among the homeless.

Program: The I Am Waters water program aims to enrich the lives of the homeless by supplying the population with a continuous source of clean drinking water accompanied by inspirational single-word messages such as hope, peace, love and dream. The program delivers these water bottles during the hottest months of the year (April-October) to 42 participating shelters supporting homeless individuals in an attempt to reduce dehydration among this population. The messages aim to increase self-esteem and raise a sense of belonging within the homeless.

Objectives: The objectives of the evaluation for the I Am Waters water program are to measure changes in knowledge of clean water sources, communication about hydration with housed individuals, perceived barriers of obtaining drinking water, self-esteem, access to potable drinking water, and hydration among homeless individuals participating in the program.

Methods: A nonrandomized two-group quasi-experimental design is proposed for the evaluation of the I Am Waters water program. Post-tests will be administered to both the intervention and control groups during the months of April through October of 2016, while the program is delivering water to participating shelters. In-depth interviews with the homeless, shelter workers, and healthcare providers from both groups will aid in determining the effectiveness of the program on selected outcomes.

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TABLE OF CONTENTS

INTRODUCTION.........................................................................................................................................................5

PART I: PROGRAM DESCRIPTION.......................................................................................................................6

Health Problem.................................................................................................................................................6

Target Population..............................................................................................................................................7

Origins of the Program.....................................................................................................................................8

Environment.....................................................................................................................................................9

Organizational environment...............................................................................................................9

Political environment.......................................................................................................................10

Stakeholders.....................................................................................................................................10

Collaboration....................................................................................................................................11

Program Goals................................................................................................................................................11

Program Components and Activities..............................................................................................................12

Logic Model and Hypotheses.........................................................................................................................14

Causal Hypothesis............................................................................................................................14

Intervention Hypothesis...................................................................................................................14

Information Sources.........................................................................................................................15

Figure 1. Logic Model for the IAW Water Program........................................................................16

PART II: PROGRAM CRITIQUE...........................................................................................................................17

Health Problem...............................................................................................................................................17

Health Problem within the Target Population................................................................................................18

Causal Hypothesis..........................................................................................................................................19

Support for the Causal Hypothesis.................................................................................................................20

Competing Causal Hypothesis........................................................................................................................25

Intervention Hypothesis..................................................................................................................................26

Support for the Intervention Hypothesis.........................................................................................................27

Inclusion.........................................................................................................................................................30

Organizational Relations................................................................................................................................31

PART III: PROCESS EVALUATION.....................................................................................................................31

Program Coverage..........................................................................................................................................32

Questions..........................................................................................................................................32

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Stakeholder Interest..........................................................................................................................32

Data Sources.....................................................................................................................................33

Standards of Comparison.................................................................................................................33

Table 1. Evaluation of Program Coverage.......................................................................................34

Program Delivery............................................................................................................................................36

Questions..........................................................................................................................................36


Data Sources.....................................................................................................................................37

Standards of Comparison.................................................................................................................37

Table 2. Evaluation of Program Delivery........................................................................................38

PART IV: OUTCOME EVALUATION...................................................................................................................42

Outcome Evaluation Design...........................................................................................................................42

Outcome Evaluation Questions......................................................................................................................44

Questions..........................................................................................................................................44

Rationale...........................................................................................................................................45


Potential Harm..................................................................................................................................45

Measurement...................................................................................................................................................46

Table 3. Proposed Measurement for the Self-Esteem Outcome......................................................47

Table 4. Proposed Measurement for the Communication Outcome................................................48

Effect Size.......................................................................................................................................................51

Validity...........................................................................................................................................................52

Internal Validity...............................................................................................................................53

External Validity..............................................................................................................................54

CONCLUSION............................................................................................................................................................55

REFERENCES............................................................................................................................................................56

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INTRODUCTION

Dehydration is a serious health problem defined as an individual consuming an

inadequate amount of water and therefore not meeting their body’s needs (National Institutes of

Health [NIH], 2013). Rates of dehydration in the homeless population are high due to their lack

of accessibility to clean drinking water. Therefore, homeless individuals have an increased risk

for serious health complications and poor quality of life related to untreated dehydration (NIH,

2013). Due to this essential need in the homeless population, I Am Waters (IAW) seeks to supply

the homeless with a continuous source of clean drinking water through their water program. In

addition to supplying this population with clean water, the water is delivered in bottles

containing single-word inspirational messages. These messages instill a sense of self-worth and

belonging within the homeless.

The purpose of this proposal is to discuss the recommended process of evaluation for the

IAW water program. The evaluation proposal is divided into four sections in which program

description, program critique, process evaluation, and outcome evaluation will be addressed. Part

one, the program description, will go into more detail about the mission and components of the

IAW water program. This section will include the hypotheses and logic model for the program.

Part two is the program critique and will cover why the IAW water program is essential in

preventing dehydration within the homeless population. Additionally, this section will discuss

the program’s hypotheses in more detail. Part three will present the proposed process evaluation

questions to assess if the program is functioning as planned. Finally, part four will include

outcome evaluation in which program effectiveness is assessed. This section includes the

proposed outcome evaluation design, outcome evaluation questions, outcome objectives,

proposed measures, and concerns about validity.

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PART ONE: PROGRAM DESCRIPTION

IAW is a nonprofit organization located in Houston, TX aiming to reduce dehydration

among the homeless by supplying a source of potable drinking water for this population. The

program works to not only hydrate the homeless community, but also instill a sense of hope with

inspirational messages on the bottles given. The following proposed evaluation plan will focus

on assessing the effectiveness of the water bottle program.

Health Problem

The primary health problem IAW addresses is dehydration among the homeless

population. Dehydration occurs when an individual is not consuming enough water and fluids to

meet their body’s needs (National Institutes of Health [NIH], 2013). Safe drinking water is a

fundamental necessity for life, yet is something many American homeless often lack. The lack of

accessibility and availability of potable drinking water leads to high rates of dehydration and

related diseases among the homeless. IAW reports two-thirds of homeless claim to have a lack of

access to clean drinking water. Homeless individuals are at greater risk for permanent brain

damage, seizures and premature mortality if dehydration goes untreated (NIH, 2013).

At the initial implementation of IAW, program staff did not determine the need of the

health problem. IAW founder and CEO, Elena Davis, was the one who decided this was an

important health problem to address. Ms. Davis got the idea for IAW from personal experience

rather than from supporting evidence. Her passion for assisting the homeless begins with her

childhood, as she was raised living in poverty. Ms. Davis grew up to be a well-known fashion

model and eventually married into a prominent family. Her success, however, did not blind her

of the need to aid those who are impoverished and homeless. Ms. Davis retired from modeling

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and decided to return to the life of her childhood by photographing homeless on the streets. She

built relationships with these individuals by spending her days with them. One day, Ms. Davis

was stopped at a red light when a homeless woman approached her car. Ms. Davis was prepared

to give her money, but the woman requested water instead. Ms. Davis was astonished by what

she thought at the time was an odd request. Why would a homeless individual deny money and

only want water?

Ms. Davis thought about her time photographing homeless on the streets and what stood

out the most was the lack of basic necessities, especially clean water. The only way for homeless

individuals to have access to fresh running water is if they are living in a shelter. Homeless who

have been living on the streets start to look rugged and are often rejected from entering stores or

restaurants to get water. The homeless are so deprived of water that they often have to drink from

hoses on someone else’s property. After reflection, Ms. Davis was inspired to combat this need

for water in the homeless population. She wanted to not only bring water to the homeless, but to

also instill a sense of hope back into this population.

Target Population

The target population for IAW includes all men, women and children who are homeless

and living on the streets. Identifying the approximate number of participants being served by

IAW is difficult because participating shelters assist a different amount of homeless individuals

every day. The rationale for selecting this population was that there are many more homeless in

great need than expected. On one night in 2011, 636,017 individuals were homeless in the United

States (US Department of Housing and Urban Development [DHUD], 2012). Texas is one of

five states making up half of the entire homeless population in the nation (DHUD, 2012).

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Approximately 3 million Americans endure homelessness every year while 33 million

Americans are only one paycheck away from being homeless (DHUD, 2012). Forty-four percent

of homeless do have jobs, but they still can’t provide the means to have a home (DHUD, 2012).

However, homelessness doesn’t just affect adults. The mean age of a homeless individual in the

United States is nine (DHUD, 2012). 1.6 million children are homeless in the United States, with

the amount of children living in shelters increasing by 1.6 percent between the years of 2007 and

2011 (DHUD, 2012). Ninety-four percent of homeless children are in families while families

make up 43% of the homeless in America (DHUD, 2012).

The only boundary placed on the target population receiving the benefits of the program

is the homeless individuals need to be in or receiving services from one of the IAW shelter

partners. Water bottles are only delivered to the shelters rather than to the streets. If the homeless

individual is on the streets and not involved with any shelter in the area, they would not have

access to the water provided by IAW.

Origins of the Program

IAW was founded by Elena Davis in 2009, and began in Houston, TX in 2010. No

funding was provided or a needs assessment completed to promote the initial start of the

program. Ms. Davis knew there was a need for water in the homeless population by actually

seeing it herself after her experience with the homeless woman at the stoplight. After

establishing this need, Ms. Davis began relationships with the Houston Food Bank and shelters

in the area. Ms. Davis learned about the shelter programs and determined what shelters met

specific needs. In 2010, before the brand of IAW was established, all Ms. Davis could organize

was delivering bottles of Ozarka to shelters using U-Haul trucks.

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As years passed and IAW grew, changes had to be made to sustain the growing need for

the organization. As IAW evolved, distribution of the water had to grow in order to meet the

needs of the target population. With the growth of the organization, there are now partners

transporting the water from the bottling company to the food bank and shelters. IAW made a

connection with Feed America and extended operations to other states such as Louisiana.

Distribution growth increased the need for more staff at IAW. Due to the growth in staff, policies

and development procedures are now in place. Therefore, organizational changes were what

brought about changes in IAW. The program is in the phase of complete implementation and has

been since 2010.

Environment

The environment in which a program is involved makes a substantial impact on the

implementation and effectiveness of that program. One must consider both the organizational

and political environment when evaluating a program.

Organizational Environment: The organizational environment of a program is defined

as the forces outside of the program that can make an impact (Weber, 2000). The organizational

environment of IAW is quite unique. The home office for IAW is located in Houston, TX but

operations are located in multiple states including California and Louisiana. The forces of the

organizational environment of IAW include the board members, an academic partner, the water

bottle supplier, distributors of the water bottles, and shelter partners who receive the water

bottles. The board members of IAW include both a board of directors and a board of advisers.

The board of directors includes founder and CEO Elena Davis as well as other members with a

variety of backgrounds and expertise to contribute to IAW. Such members have knowledge in

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medicine, banking, homeless services and holistic health. The board works as an

interdisciplinary team to ensure effectiveness of IAW. The board of advisers includes members

who are involved in consulting and creating the brand of IAW. IAW also has an academic

partner, Professor William Roy, from the sociology department of the University of California

Los Angeles. Mr. Roy is involved in addressing the social stigma of the homeless as a part of the

mission at IAW.

Political Environment: The political environment of a program involves organizations,

regulations and stakeholders who help operate or influence the program (International

Consortium for Mental Health Policy and Services, n.d.). The political environment of IAW is

quite small. IAW does not receive any government funding; therefore the government does not

have any influence on this particular program. The program relies strictly on contributions,

fundraising, and in-kind donations. There is currently not a presence of internal politics within

IAW because funding comes from sources wanting to support the mission of the program.

However, because IAW works with Feed America, shelters who receive water from the program

must apply to be a part of the program and must in turn meet specific needs.

Stakeholders: Stakeholders are defined as persons, groups or organizations with an

interest in how well a program is run (Rossi, Lipsey & Freeman, 2004). IAW involves the

endorsers, supplier, distributors, and receivers of the program. Many celebrity endorsements are

involved in the promotion of IAW including Apollo 11 astronaut Buzz Aldrin, actress Hilary

Duff, and world heavy weight boxing champion George Foreman. These endorsements help

spread awareness of IAW as well as assist in funding for the program. The water supplier for

IAW is a water bottling company located in Lubbock, TX known as Essence. The company is

involved in the design and distribution of the water for IAW. The distributor delivering the water

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to the shelter partners in Houston is the Houston Food Bank. Houston Food Bank plays a key

role in ensuring the water from Essence reaches the shelters who serve the homeless population

in the city of Houston. These shelter partners, the receivers and participants of the program, are

important stakeholders of IAW as well. They are involved in the final delivery of the water to the

homeless. Shelter partners working with IAW include the Salvation Army, Star of Hope,

Healthcare for the Homeless, Houston Police Homeless Outreach Team, SEARCH Homeless

Services, Goodwill Industries, Covenant House, Palmer Way Station, Lord of the Streets, and

Mission of Yahweh. There are also shelters receiving water in other metropolitan cites of Texas,

Louisiana, Arkansas and Oklahoma. These shelters are Presbyterian Night Shelter-Fort Worth,

Austin Front Steps, Mobile Loaves and Fishes-Austin, New Orleans Covenant House, New

Orleans Mission, John 3:16, and Our House. Without the shelter partners of IAW, the ultimate

goal of the program would never be accomplished.

Collaboration: Collaboration within IAW does not extend beyond the relationships

among the stakeholders of the program. These partners provide resources such as funding, the

actual water bottles, transportation methods for distribution, and assistance in giving out the

water at shelters. There is no conflicting agenda present within IAW because all those working

within the program have the same mission, which is to address the health problem of dehydration

within the homeless population.

Program Goals

The ultimate goal of IAW is to enrich the lives of the homeless by supplying the

population with a continuous source of clean drinking water accompanied by inspirational

messages to raise a sense of belonging to the community. IAW aims to hydrate the bodies of

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homeless individuals who lack a basic necessity of life. Ms. Davis acknowledges that struggling

is an inevitable part of being homeless, but being without a source of clean water should not be a

part of it. IAW also aims to restore a sense of self-worth among the homeless with messages of

hope, peace, love and dream. IAW was founded to hydrate the bodies and minds of the homeless

with bottles not only containing fresh water but also encouragement for the difficult experiences

they face.

Program Components and Activities

The water program of IAW supplies water bottles to shelters, missions and other

organizations tending to the homeless in an effort to eliminate the need for a potable water

source among the homeless population. IAW distributes bottled water using proficient 501c3

partnerships and relationships with organizations serving the homeless. These water bottles

deliver not only physical hydration, but spiritual hydration as well. The water bottles display

single-word messages of hope, peace, love and dream. This part of the water program aims to

provide the homeless with an affirmation of hope in a time of struggle.

The program runs on a cycle, focusing on delivering water bottles to those in need during

the hottest months of the year. In the fall, shelters and other organizations have the opportunity to

fill out an application to either request or remove themselves from the list to receive water from

IAW. Once the number of organizations in need is known, IAW develops a budget and

communicates with Essence about water bottle design. Distribution of water bottles begins the

first week of June, running for approximately 16 weeks until the end of September. Some

shelters receive water once a week while other shelters receive water biweekly. How often water

is delivered depends on the needs and storage capabilities of the site. Select organizations, Such

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as Healthcare for the Homeless, receive year round water delivery. This access is actually only

an extension of the normal allotted delivery time, receiving water for 24 weeks rather than 16

weeks. Throughout the 16 weeks, shelter partner visits take place to strengthen relationships

between IAW and shelters. At the end of the distribution cycle, IAW reaches out to shelters for

administrative paperwork including end of program surveys, testimonials and photos expressing

the impact the water made on the organization.

IAW is located in the city of Houston, but has developed a streamlined distribution

strategy to broaden the reach while reducing cost. This strategy is known as a two-pronged

approach. The bottling company, Essence, delivers water bottles to four sources located in

Houston, Austin, Fort Worth, New Orleans, Tulsa, and Little Rock. The source in Houston,

known as the Houston Food Bank, continues the delivery to participating shelters in the city of

Houston. Only a few shelters receive direct delivery because the method is not cost effective.

IAW now has 42 participating shelters receiving potable drinking water from the program. By

the end of the summer in 2015, 2.9 million water bottles have been delivered to recipients.

The budget for IAW varies every year, but the program has consistently increased growth

in revenue since it began in 2010. The current budget is approximately $705,000, a substantial

growth from the $516,029 budget in 2013. The budget for IAW originates from special events,

community support and the foundation board. The budget is used for water program

coordination, events, salaries, management, common expenses, and education and outreach. It

should be noted that the budget for salaries does not include the president and CEO. Elena Davis

does not receive any compensation for her work at IAW. As of 2013, IAW began selling the

water bottles at Whole Foods stores. One-hundred percent of the net proceeds from these sales

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go towards funding the program. IAW is looking to further diversify their source of revenue in

the future.

IAW is a nonprofit organization; therefore the program relies completely on private

donations to fund activities. With assistance from volunteers and in-kind donations, IAW has a

low overhead and only three paid, full-time staff members. The three staff members for IAW

includes chief of staff, Angela Ambers-Henderson, a program coordinator and an administrative

assistant. General qualifications of the IAW staff include previous experience in a program,

development experience, having good communication skills and are a well-rounded worker.

There are no academic requirements for staff members of IAW.

Logic Model and Hypotheses

Refer to Figure 1 for the logic model of the IAW water program.

Causal Hypothesis: A homeless individual’s lack of knowledge of clean water sources,

lack of communication about hydration with individuals who are not homeless, perceived

barriers to obtaining drinking water, and decreased self-esteem, leads to a lack of access to

potable water and decreased hydration, resulting in increased risk for complications related to

dehydration (e.g. cognitive impairment, immune system damage and premature mortality) and

poor quality of life.

Intervention Hypothesis: Distribution of water bottles containing clean drinking water

and single-word inspirational messages to the homeless will a) increase knowledge of clean

water sources among homeless, b) increase communication about hydration among individuals

who are homeless and those who are not, c) decrease perceived barriers of finding clean drinking

water among homeless, and d) increase self-esteem among homeless.

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Information Sources

Information about IAW was obtained using the foundation’s website, the 2014 IAW

Annual Report, the 2013 IAW Financial Report, and interviews with Elena Davis and Angela

Ambers-Henderson.

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Figure 1. Logic Model for the I Am Waters Water Program

Inputs Activities Outputs Short-Term Outcomes

Intermediate Outcomes

Long-Term Outcomes

Personnel: Board members, staff and volunteers

Materials: Water bottles

Funding: Revenue from special events, community support and foundation board

Relationships: Shelter partners, academic partner, bottling company, celebrity endorsements

Distributes fresh and clean water bottles to the homeless living on the streets

Water provides a symbol of hope through an inspirational one-word message imaged on the bottle

Number of staff and volunteers to execute activities

Number of water bottles distributed by site

Number of homeless individuals who receive water bottles

Increased knowledge of clean water sources among homeless

Increased communication about hydration between those who are homeless and those who are not

Decreased perceived barriers of obtaining drinking water among homeless

Increased self-esteem among homeless

Increased access to potable water among homeless

Increased hydration among homeless

Reduced risk for complications related to dehydration (e.g. cognitive impairment, immune system damage & premature mortality) among homeless

Enhanced quality of life among homeless

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PART TWO: PROGRAM CRITIQUE

A program critique is essential in determining whether a program has proper reasoning to

be implemented. The following program critique of IAW will examine the health problem in

both the general and target population as well as evaluate the hypotheses, inclusion and

organizational relations of the program.

Health Problem

The health problem IAW aims to address is dehydration. Dehydration is a water and

electrolyte disorder defined as the loss of body water at a higher rate than what is replaced by the

body (Warren, Bacon, Harris, McBean, Foley & Phillips, 1994; Thomas et al., 2008). Greater

than 1% loss of body weight via fluid loss is considered dehydration (Holm, n.d.). Dehydration

reduces an individual’s metabolism by 3% (Hantske, 2012). Complications of dehydration

include lethargy, headaches, constipation or diarrhea, swelling, inflammation, and decreased

immunity (Hantske, 2012). If dehydration is left untreated, other severe health complications

including cognitive and immune system damage as well as premature morality can occur

(Abdallah, Remington, Houde, Zhan & Devereaux Melillo, 2009). Medical professionals report

approximately 75% of the American population potentially suffers from chronic dehydration

(Ericson, 2013). A study found the prevalence of coding for dehydration at admission to the

hospital was 0.55% (Wakefield, Mentes, Holman & Culp, 2008)

Dehydration can be difficult to identify which explains why epidemiological evidence,

including national prevalence and incidence data for dehydration, is currently unavailable (World

Health Organization [WHO], 1999). Prevalence and incidence for dehydration have also not

been recorded due to the health problem being a consequence of other conditions, including heat

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illness and diarrheal disease. The type of dehydration IAW mainly addresses is associated with

heat illness, as the program delivers water bottles to the homeless within the hottest months of

the year. Incidence of heat illness was found to be approximately 2,000 deaths each year, with

incidence anticipated to increase by 257% in the 2050s (Hajat, Vardoulakis, Heaviside, & Eggen,

2014). From 1999 to 2009, an average of 658 deaths related to heat illness occurred in the United

States every year (Kochanek, Xu, Murphy, Minino, & Kung, 2011). In a study evaluating heat

illness among soldiers, approximately 1% of those hospitalized with heat illness resulted in

mortality and 17% were related with dehydration (Carter, Cheuvront, Williams, Kolka,

Stephenson, Sawka, & Amoroso, 2005). Heat illness and related deaths are preventable as long

as an individual can stay cool and hydrated (Centers for Disease Control and Prevention [CDC],

2013).

Health Problem within the Target Population

The homeless population IAW serves has difficulty staying cool and hydrated due to lack

of resources. This puts the target population at increased risk for dehydration related to heat

illness. Homeless individuals are at increased risk for dehydration, particularly during summer

months and in warmer climates (National Healthcare for the Homeless Council [NHCHC],

2014). Homeless individuals obtain a disproportionate amount of resources, such as potable

drinking water, therefore causing morbidity and mortality rates to be higher as compared to

housed individuals (Valvassori, Montgomery Sklar, Chipon-Schoepp & Messer, n.d). In 2006,

Health Care for the Homeless (HCH) found 1,004 homeless individuals had primary diagnoses

of dehydration from environmental exposure (US Department of Health and Human Services

[DHHS], 2007).

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Though the epidemiological evidence of dehydration among the homeless is scarce, the

available evidence related to dehydration among the target population is convincing. Two-thirds

of homeless individuals report having a lack of access to clean drinking water (US Department

of Housing and Urban Development [DHUD], 2012). Within the homeless population, 32% of

females and 48% of males reported difficulty obtaining potable drinking water (Tarasuk,

Dachner, Poland & Gaetz, 2009). The target population’s regular lack of access to clean drinking

water increases their risk for dehydration (NHCHC, n.d.; Nickasch & Marnocha, 2009).

The extreme climates of urban and suburban cities IAW serves, such as Houston and

Austin, also contribute to dehydration in the homeless population. These residential areas

increase the homeless population’s risk for dehydration from heat waves as a result of the heat

island effect (Burt, Aron, Douglas, Valente, Lee, & Iwen, 1999). The heat island effect transpires

due to the built environment made of concrete, asphalt, and metal specifically absorbing heat,

causing urban environments to be up to 11°C warmer than rural areas (Ramin & Svoboda, 2009).

Homeless individuals have increased exposure and decreased protection from the environment as

compared to their housed counterparts (Ramin et al., 2009). Homeless populations are already

susceptible to heat, but risk for dehydration and related diseases will increase as temperatures

rise (Ramin et al., 2009). Dehydration and heat illness arise during phases of extreme heat

(Maness & Khan, 2014). The main solution for the target population experiencing these

conditions is to be provided fluids to reduce dehydration (Maness et al., 2014).

Causal Hypothesis

A homeless individual’s lack of knowledge of clean water sources, lack of

communication about hydration with individuals who are not homeless, perceived barriers to

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obtaining drinking water, and decreased self-esteem, leads to a lack of access to potable water

and decreased hydration, resulting in increased risk for complications related to dehydration (e.g.

cognitive impairment, immune system damage and premature mortality) and poor quality of life.

Support for Causal Hypothesis

The process of critiquing a health program involves determining whether the hypotheses

of the program are reasonable. To determine whether or not the hypotheses for IAW are

acceptable, evaluation of theoretical and empirical evidence was completed. The relationships of

the short-term, intermediate and long-term outcomes of IAW were evaluated to determine the

plausibility of the causal hypothesis.

Knowledge is represented in communication theory, and is defined as information

leading to understanding or taking action (Finnegan Jr. & Viswanath, 2008). General knowledge

has been found to be distributed unequally within the general population (Finnegan Jr. et al,

2008). Individuals with more formal educations know more about issues, such as cleanliness of

water sources, than those who have less education (Hyman and Sheatsley, 1947). These findings

are presented in the Knowledge Gap Hypothesis in which increased flow of information benefits

those of a higher socioeconomic status (SES) (Finnegan Jr. et al., 2008). Therefore, the homeless

are often lacking basic health knowledge. Without knowledge of ability to access clean potable

drinking water, the homeless are at increased risk for dehydration. Therefore, poor quality of life

and increased risk for sequelae of dehydration occur within this population.

A study conducted by Mathebula and Ross (2013) in Hillbrow, South Africa evaluated

lack of knowledge among homeless youth. The study implemented an exploratory-descriptive

design and used convenience sampling to obtain a sample of ten participants from the homeless

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youth living on the streets of Hillbrow (Mathebula & Ross, 2013). An interview including both

open- and closed-ended questions was conducted allowing a variety of perceptions from the

youth to be gathered (Mathebula et al., 2013). The interview addressed knowledge about health

and social services, if the youth utilized those services, and perceived information needs

concerning those services (Mathebula et al., 2013). One youth stated a portion of the homeless

youth does not have information about services provided and therefore do not utilize such

services (Mathebula et al., 2013). A major problem identified by another participant was the

population is incapable of acquiring information about services due to the lack of education

(Mathebula et al., 2013). The participant felt that some of the homeless youth did not

comprehend what the services were providing (Mathebula et al., 2013). These findings suggest

homeless populations may lack knowledge of services, such as sources of clean drinking water.

Additionally, services need to provide information to the homeless in ways which can be

understood by a less educated individual (Mathebula et al., 2013). If a homeless individual lacks

the knowledge to obtain clean drinking water, they are at an increased risk for dehydration as

well as complications related to dehydration and decreased quality of life. A limitation of this

study was that there were only male participants because females were not available; therefore

females are not represented in the results of this study (Mathebula et al., 2013). This limitation

could limit the generalizability of the study results.

The lack of general communication between the homeless and the housed population

often stems from the stigmatization of homeless individuals (NHCHC, n.d.; Lankenau, 1999).

The homeless feel isolated and judged by those who are not homeless, creating a barrier between

them and the general population (NHCHC, n.d.). This lack of interaction between homeless and

non-homeless individuals potentially limits the opportunities for access to potable drinking water

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for the homeless individual. A qualitative longitudinal study assessed social interaction of 60

homeless and mentally ill individuals who had just been discharged from a state psychiatric

hospital (Drury, 2003). Drury (2003) followed these individuals for up to two years as they

resided in community housing. The study evaluated the personal, cultural and environmental

circumstances of the individuals as well as the synergy between each individual’s needs and

resources available (Drury, 2003). Drury (2003) found a pattern of common avoidance between

the homeless and the general population, therefore limiting delivery of services to the homeless.

In theory, this lack of communication between the homeless and the general population is known

as communication inequality (Finnegan Jr. & Viswanath, 2008).

A field experiment designed by Hocking and Lawrence (2000) examined the effects of

communication with and attitudes toward homeless individuals among 134 undergraduate

students. Nineteen participants in the experimental group worked at a local homeless shelter for

15 hours (Hocking & Lawrence, 2000). The experimental group’s responses to a post-experiment

questionnaire measured a range of attitudes toward the homeless and were compared with

responses from the control group who did not work at the shelter (Hocking et al., 2000). The

participants who worked in the shelter had increased communication with the homeless and

stated more responsibility and commitment to assisting the homeless than the control group

(Hocking et al., 2000). The findings of this study suggest as a lack of communication between

the homeless and general population persist, social stigma surrounding the homeless remains.

Therefore, individuals who do not communicate with the homeless tend to lack a sense of

responsibility toward the population, and services such as providing clean drinking water to the

homeless aren’t provided as often. This will lead to a greater chance of homeless individuals

experiencing dehydration, complications related to dehydration and an overall poor quality of

22

life. The main limitation of this study was the small sample size (Hocking et al., 2000). The lack

of a larger sample could potentially affect the significance of the results found in the study.

Perceived barriers, a construct of the Health Belief Model (HBM), is the belief about the

costs for doing a specific action (Champion & Skinner, 2008). Evidence has found perceived

barriers are the most powerful predictor of behavior within the HBM (Champion et al., 2008).

The many perceived barriers of the homeless can prevent this population from receiving

adequate hydration from clean water sources. Research has found homeless adolescents report

finding themselves limited in their use of societal resources, which can include barriers to basic

needs such as drinking water (Raleigh-DuRoff, 2004; Rice, Milburn, Rotheram-Borus, Mallett,

& Rosenthal, 2005). Another barrier of feeling separated from the social network prevents

homeless from receiving assistance from shelters designed to help the population (O’Sullivan

Oliveira & Burke, 2009). Common barriers of the homeless include lack of hope and motivation

(Raleigh-DuRoff, 2004).

Kurtz, Surratt, Kiley and Inciardi (2005) found homelessness among street-based women

sex workers generates needs for services; however there are barriers to accessing services. The

study collected data from interviews with 586 sex workers and 25 focus groups in Miami,

Florida to observe barriers to access of services (Kurtz, Surratt, Kiley, & Inciardi, 2005). The

women most frequently reported need for services such as fresh water (Kurtz et al., 2005).

Barriers included social stigma, transportation, and fear (Kurtz et al., 2005). These findings

suggest that women sex workers, who often experience homelessness like the target population

of IAW, find barriers to obtaining services such as potable drinking water. With lack of

transportation, social stigma, or fear preventing the population from receiving services,

individuals are at an increased risk for dehydration and related complications. Additionally, these

23

barriers are not only physical but also mental and decrease an individual’s overall quality of life.

A limitation for this study was the small subsample of the focus groups (Kurtz et al., 2005).

Another limitation was that street-based sex workers do not have the exact characteristics as the

general homeless population (Kurtz et al., 2005). These limitations could affect the significance

and generalizability of the results found.

Self-esteem is not a theoretical construct itself, but is related to multiple theories. First,

self-esteem is associated with the construct self-efficacy of Bandura’s Social Cognitive Theory

(SCT) (McAlister, Perry, & Parcel, 2008). Self-efficacy deals with an individual’s confidence to

perform a behavior (McAlister et al., 2008). An individual’s confidence commonly stems from

feelings of self-worth and a high self-esteem. Self-esteem is also related to the Self-

Determination Theory. This theory predicts human behavior is determined by three needs:

competence, autonomy, and relatedness (Street Jr. & Epstein, 2008). These needs are often

correlated with an individual’s self-esteem.

Lack of self-esteem related to dehydration, associated complications and poor quality of

life has been found in the literature as well. A study by Raleigh-DuRoff (2004) interviewed

individuals who were once homeless in Seattle. Participants of the study were ten adults, ages

ranging from 18 to 39 years old, who had once been living on the street for six months to nine

years (Raleigh-DuRoff, 2004). The interviews were in person and lasted approximately 30

minutes to an hour (Raleigh-DuRoff, 2004). The interview consisted of 23 open- and closed

ended questions aimed at promoting conversation with the participants (Raleigh-DuRoff, 2004).

Participants suggested self-esteem and skills were essential to locating resources (Raleigh-

DuRoff, 2004). A participant suggested their self-confidence was an influence in whether or not

they were successful in locating resources (Raleigh-DuRoff, 2004). The findings of the study

24

suggest if the homeless enhance their self-esteem they can improve their quality of life (Raleigh-

DuRoff, 2004). Low self-esteem among the homeless is involved in limiting these individuals

from striving to obtain needs and reduces quality of life. This study was found to be limited by

the small number of subjects in the sample (Raleigh-DuRoff, 2004). Additionally,

generalizability to other homeless individuals would differ with the location and population

(Raleigh-DuRoff, 2004).

The limitations of the studies presented consisted mainly of small sample sizes and

possible lack of generalizability. These limitations could affect how well the evidence can be

applied to the target population of the program. An additional limitation of the evidence is all of

the studies collected qualitative data. Quantitative studies would be beneficial in determining

significance of findings. However, the evidence found in these studies still suggests the causal

hypothesis is suitable for IAW. The causal hypothesis formulated for this proposal is a model

and should be utilized for the justification for other causal hypotheses of the program.

Competing Causal Hypotheses

Considering any competing causal hypotheses to the one provided for IAW is essential to

the program critiquing process. A possible competing hypothesis for a homeless individual

resulting in complications related to dehydration and poor quality of life is if the individual has

an existing chronic disease. Research has found that individuals with preexisting chronic

diseases are at an increased risk for becoming severely dehydrated. A study by Lavizzo-Mourey,

Johnson and Stolle (1988) researched another population who is at increased risk for

dehydration, the elderly. In this study, the researchers evaluated 339 elderly individuals residing

in two nursing homes who required hospitalization due to an acute illness (Lavizzo-Mourey,

25

Johnson & Stolle, 1988). One of the greatest contributors to being severely dehydrated was if the

patient was previously diagnosed with more than four different chronic diseases (Lavizzo-

Mourey et al., 1988). The study concluded that an individual’s risk for dehydration can be

defined by the number of chronic diseases they are diagnosed with (Lavizzo-Mourey et al.,

1988). This evidence relates to the homeless population because homeless individuals tend to

suffer more from chronic disease due to stress, environmental exposure, repressed immunity, and

malnutrition (Valvassori, Montgomery Sklar, Chipon-Schoepp & Messer, n.d.)

A second competing hypothesis for determining dehydration, dehydration-related

complications and poor quality of life among homeless individuals would be substance abuse.

Salz (2014) reports substance abuse has been found to cause poor nutrition, including

dehydration. The body’s response to drugs and alcohol is to increase body temperature (National

Institute of Health [NIH], 2012). This response causes the body to lose moisture, resulting in a

dehydrated state. The Substance Abuse and Mental Health Services Administration (2003)

approximates 38% of homeless people depend on alcohol and 26% abuse other drugs. Therefore,

substance abuse is prevalent in the homeless population and could potentially be a contributing

factor to dehydration in the community.

Intervention Hypothesis

Distribution of water bottles containing clean drinking water and single-word

inspirational messages to the homeless will a) increase knowledge of clean water sources among

homeless, b) increase communication about hydration among individuals who are homeless and

those who are not, c) decrease perceived barriers of finding clean drinking water among

homeless, and d) increase self-esteem among homeless.

26

Support for Intervention Hypothesis

Similar to the causal hypothesis, theory and empirical evidence was obtained to

determine plausibility of the intervention hypothesis. Many aspects of behavioral theory support

the intervention hypothesis for IAW. Behavioral capability, also known as facilitation, from SCT

represents knowledge in the hypothesis. Facilitation refers to an individual's capability to

perform a behavior using necessary knowledge (Boston University School of Public Health,

n.d.). A program must offer tools, resources or environmental changes to make behavior, such as

hydration, easier to achieve (McAlister, Perry, & Parcel, 2008). IAW distributes potable drinking

water at no cost as their strategy for addressing facilitation, thus increasing knowledge of clean

water sources.

Communication can be derived from communication theory. Human communication is

the idea of generating and trading information between individuals in some way (Gerber, 1985).

Communication has the capacity to influence and shape human relationships (Finnegan Jr. &

Viswanath, 2008). Information flow of those who are not homeless to those who are homeless is

important and is often lacking due to social norms and stigma. IAW builds strong, trusting

relationships between the two populations by increasing opportunities for the homeless to

communicate and learn from those who are not homeless. Perceived barriers are a part of the

HBM and are the obstacles of an individual partaking in a preferred behavior, in this case

hydration (Champion & Skinner, 2008). To reduce perceived barriers, a program must support

the population, correct misinformation, provide incentives and assist the population (Champion

& Skinner, 2008). IAW assists the homeless by providing easily accessible clean drinking water

to the population at no cost. Finally, the intervention hypothesis addresses self-esteem. In theory,

the most relatable construct to self-esteem is self-efficacy. Self-efficacy is another aspect of SCT

27

and is defined as an individual’s belief about the ability to perform a behavior leading to

preferred outcomes (McAlister, Perry, & Parcel, 2008). Self-efficacy and self-esteem often go

hand-in-hand by improving an individual’s belief in themselves and their abilities. IAW does this

by motivating the homeless using single-word inspirational messages on the water bottles and by

creating relationships with these individuals.

There is a gap in the literature concerning interventions addressing dehydration among

homeless populations. However, there are a few interventions available that have addressed

similar issues and theoretical constructs as the IAW intervention hypothesis. A study conducted

by Graham-Jones, Reilly and Gaulton (2004) created a health center advocacy group for the

homeless population in an attempt to improve multiple dimensions of the relationship between

the homeless and the general population. Homeless patients registering temporarily at a health

center in Liverpool, England between the years 1993 and 1995 were entered into the study

(Graham-Jones, Reilly, & Gaulton, 2004). Participants were assigned to the intervention group

containing outreach services or a control group receiving usual care alternating every one to

three months for over a total of three years (Graham-Jones et al., 2004). The outreach services

provided visits by a health worker to connect the homeless with a primary health care team or

other agencies providing services (Graham-Jones et al., 2004). The health worker was

recognized as a contact and established a relationship with the homeless individual (Graham-

Jones et al., 2004). Communication between the homeless and the health worker was essential in

the outreach services. The outreach group had a significant improvement (p<0.05) as compared

to the control group on the social isolation dimension with a mean difference of 24.55 (Graham-

Jones et al., 2004). Therefore, there was an improvement seen in communication and

relationships between the homeless and the non-homeless (Graham-Jones et al., 2004). There

28

was also a significant change (p<0.001) in material fulfillment seen, because the availability of

an outreach program kept the homeless from having to seek out services (Graham-Jones et al.,

2004). With a mean difference of 3.5, the outreach group improved significantly (p<0.05) more

than the control group on ‘being happy with yourself’; therefore exhibiting an increase in self-

esteem (Graham-Jones et al., 2004).

Additional evidence of other outreach services to homeless populations, like the IAW

program, has been found to support the intervention hypothesis. Interventions involving

education, support sessions, and therapeutic communities were found to reduce grief and

improve self-esteem (Speirs, Johnson, & Jirojwong, 2013). These programs increased knowledge

(p = 0.001) within the homeless population, increased general communication (p = 0.017) about

various topics with the homeless during sessions, decreased barriers to receiving services

(p<0.001) by reaching out to the homeless population, and increased self-esteem (p = 0.01) by

focusing on psychological aspects (Speirs et al., 2013). Programs involving education, support

sessions and therapeutic communities have shown to be successful in improving various

outcomes IAW is also seeking to change. IAW could consider including such methods within the

program to enhance effectiveness in increasing knowledge, communication, and self-esteem as

well as decrease perceived barriers among the homeless.

The single-word messages are an innovative method used by the IAW water program;

therefore scientific evidence is not available to support the effectiveness of the messages.

However, methods supported by theory related to the single-word messages are effective in

changing behavior. The major theoretical method supporting the single-word messages of the

IAW water program is imagery (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011).

Imagery originated from the theories of information processing and utilizes images related to a

29

specific process or behavior (Bartholomew et al., 2011). When an individual sees the image,

such as the single-word message, an individual is encouraged to respond to the image with the

desired behavior change (Bartholomew et al., 2011). In the case of IAW, the single-word

messages aims to initiate a sense of hope and an increase in self-esteem among the homeless

individual. The intervention hypothesis presented in this proposal is an example and should be

used for the reasoning behind other intervention hypotheses for the program.

Inclusion

When critiquing a program, it is important to consider under- or over-inclusion of the

target population. Inclusion is a factor when coverage is being measured and monitored (Rossi,

Lipsey, & Freeman, 2004). Under- inclusion can be measured by the amount of the target

population in need of the program implemented actually participating in the program (Rossi et

al., 2004). Under-inclusion can be a problem with IAW because the program only serves

homeless individuals who are receiving services from a shelter. Homeless individuals living on

the street are still in need of the services IAW provides but will not be receiving the benefits.

Under-inclusion can also occur with homeless individuals who are participating in a shelter that

is not currently receiving the services of IAW. A shelter must meet certain criteria to be a shelter

partner with IAW. If the shelter does not meet this criterion or has not applied for a partnership

with IAW, the homeless individuals being served by the shelter are still in need but will not be

included in the target population of IAW. Over-inclusion is determined by the amount of

program participants who are not in need as compared to the total number of participants of the

program (Rossi et al., 2004). Over-inclusion is not an issue for the IAW program because all

participants receiving the services of IAW are in need. IAW serves homeless individuals as their

target population; therefore it is assumed that the entire target population is in need of clean

30

drinking water and single-word messages of hope, peace, love and dream. Overall, determining

inclusion is important to the evaluation because proper inclusion ensures appropriate use of

program resources (Rossi et al., 2004). The most common issue when measuring inclusion of a

program is when the size of the target population cannot be specified (Rossi et al., 2004). This

problem is likely to occur with IAW because population data on the homeless is difficult to

obtain.

Organizational Relations

With only three employees working for IAW, the intra-organizational environment is

currently quite small. With such a small intra-organizational environment, there aren’t any

foreseeable problems within this environment that would hinder the implementation of the

program. The inter-organizational environment has grown quite substantially in the past five

years. However, even with a bigger inter-organizational environment, IAW is not threatened by

potential problems within this environment. All of the stakeholders and partners involved in

IAW have the same mission to provide clean drinking water to the homeless population.

Therefore, any kind of predicted problems within the inter-organizational environment of IAW

that would inhibit the implementation of the program is not plausible at this time.

PART III: PROCESS EVALUATION

When evaluating a program, it is essential to incorporate a form of evaluation known as

process evaluation. Process evaluation determines whether a program is delivered to the target

population as planned (Rossi, Lipsey, & Freeman, 2004). Process evaluation will assess both the

coverage and the delivery of the program. Coverage and delivery questions have been developed

31

for the IAW water program and are presented in the following sections. These questions will

assist in the process evaluation of IAW.

Program Coverage

Program coverage is defined as the extent to which participation in a program is reached

by the target population (Rossi, Lipsey, & Freeman, 2004). The target population IAW addresses

is the homeless population. Therefore, measuring coverage within the program of IAW will

involve determining the extent to which the IAW water program reaches the homeless

population.

Questions: When measuring coverage of a program, important questions to consider

include 1) how well is the program reaching the target population, 2) who in the target

population is being neglected, 3) are there populations the program is reaching unintentionally,

and 4) what amount of the target population the program is intended for is participating in the

entire program (Peskin, Hernandez, & Addy, 2015a)? These coverage questions measure

awareness, actual participation, nonparticipation, dose of the program, drop-outs, and differences

across sites (Peskin et al., 2015a). However, coverage questions addressing drop-out will be

excluded from the process evaluation for the IAW water program. These questions are excluded

because the IAW water program is an outreach program designed to supply clean water to

homeless individuals in need; therefore there are no sessions or active involvement of the target

population in the program. Thus, drop-out rates are not a topic needing to be addressed in the

process evaluation of the IAW water program.

Stakeholder Interest: The stakeholders of the IAW water program include the IAW staff

and board members, endorsers, the water bottle supplier, distributors of the water bottles, the

32

shelter partners and the participants of the program. Questions of interest to a stakeholder

regarding coverage of the target population will depend on the stakeholder’s role in the program.

The board and staff of IAW would likely be interested in rate of participation for funding as well

as determining whether or not goals of participation are being met. These stakeholders might

also be concerned with coverage bias in order to generate ideas on how to reach the entire target

population. Those who endorse IAW would likely be interested in questions including

participant and nonparticipant characteristics in order to be aware of who their donations are

benefiting. The water bottle supplier for IAW would likely be interested in the demand for the

program. This will help the supplier determine how much of the product needs to be provided.

The distributors of the water bottles and shelter partners would likely be interested in the dose of

the program the target population is receiving and how to make sure participants are receiving

the full benefits of the program. The distributors would also likely be concerned with changes of

need in specific shelters over time. Finally, the program participants would likely be interested in

being made aware of IAW as well as reduced barriers to receiving the program.

Data Sources: The sources of data that will be used to measure the questions addressing

program coverage of IAW will include surveys completed by participants and data from records

taken by the participating shelter partners. The surveys will assist in answering the qualitative

questions, while the records will answer quantitative questions. It should be noted that the

surveys administered to program participants will be delivered verbally to avoid any literacy

barriers.

Standards of Comparison: Program staff expectations, expert opinion, evidence from

existing literature, and performance of similar programs will be the standards of comparison used

in measuring program coverage of the IAW water program. Staff expectations and goals the

33

program has set will be used as a standard of comparison for questions assessing quantitative

data such as percentage of participation and proportion of targets receiving the program. The

evidence from existing literature and how programs similar to IAW performed will be used to

compare coverage results. Finally, expert opinion will be used for the questions resulting in

qualitative answers. The experts will be able to report what they find common with the target

population. These answers will be compared to those of the actual target population.

Table 1. Evaluation of Program Coverage

Questions Sources of Data Standard of Comparison

Awareness

What percent of the homeless population is aware of the IAW water program?

-Surveys administered verbally to target population

-Program staff expectations based on established goals

How did program participants find out about the IAW water program?

-Surveys administered verbally to program participants


Actual Participation

What percent of the aware homeless individuals actually participate in the IAW water program?

-Records from participating shelter partners

-Data from previous studies

Why did homeless individuals participate in the IAW program?


-Expert opinion

What enabled the homeless individuals to participate in the IAW water program?


-Expert opinion

Are there specific subgroups (e.g. race, gender, education level) of the homeless population who are underrepresented in the IAW water program?

-Demographic records from participating shelter partners


Nonparticipation

34

What percent of the aware homeless individuals did not participate in the IAW water program?



Why did aware homeless individuals not participate in the IAW water program?


-Expert opinion

Are there barriers to homeless individuals participating in the IAW water program?


-Expert opinion

What are the socio-demographic characteristics of the homeless individuals who do not participate in the IAW water program?


- Data from previous studies

Dose of Program

How many times in the 16 weeks of water delivery does a homeless individual receive an IAW water bottle?



What proportion of homeless individuals receives an IAW water bottle at every delivery during the entire 16 weeks of operation?



Differences Across Sites

Is there a variation in coverage between the sites implementing the IAW water program?



Differences in Time

Is there a variation in participation rates depending on the time of year the IAW water bottles are delivered (e.g. June vs. September)?



35

Program Delivery

Delivery of a program encompasses how the program is implemented to the target

population. Program delivery is determined by fidelity, defined as the degree in which program

activities are executed as planned and resources are accessible when necessary (Peskin, Hernandez,

& Addy, 2015b).

Questions: Questions addressing delivery for the IAW process evaluation will include

quality and accuracy, duration, staffing and training, facilities and resources, materials and supplies,

consistency, delivery style, participant satisfaction, coordination with other agencies, and procedures

and protocols (Peskin, Hernandez, & Addy, 2015b). Unlike the questions addressing program

coverage, all of the program delivery questions will be utilized in the process evaluation for IAW.

Stakeholder Interest: Similar to the questions for program coverage, the stakeholders of

IAW will also have different interests in the questions concerning program delivery. The IAW board

and staff would likely be interested in questions concerning program delivery including: differences

across sites, quality and accuracy, staff and training, consistency, satisfaction, coordination, and

procedures and protocols. These topics are of major concern to the board and staff because they are

areas that can be readily addressed by these stakeholders. The endorsers of IAW would likely be

concerned with facilities, resources, materials and supplies because information found would

enlighten these stakeholders about where their donations are going and any potential funding

needs. The water bottle supplier would likely be interested in quality of services, specifically the

water bottle itself. The supplier would also be concerned with materials and supplies to ensure

enough water bottles are being supplied at each shelter. The distributors would likely be

concerned with questions assessing quality and accuracy as well as consistency. The distributors

could then know about accuracy of delivery to shelter partners and whether distribution to the

36

various shelter partners is overall consistent. The shelter partners are likely to be concerned with

duration, staff and training, delivery style, and satisfaction. These stakeholders will want to

ensure the workers are knowledgeable about how to implement the program as well how to

deliver the program to ensure participant satisfaction. Finally, the program participants would

likely be attentive to questions about satisfaction. If the participants are not satisfied with the

IAW water program as a whole, the program will not be beneficial for the target population.

Data Sources: The sources of data used to evaluate program delivery within IAW are similar

to what is used for program coverage. Such sources include records from participating shelters about

a variety of information and surveys conducted verbally with program participants. Additional data

sources used for program delivery include the schedule of water bottle delivery to shelters,

interviews, observation of the program being implemented, and inventory of the shelters. The

schedule of water bottle delivery and shelter inventory will be used to answer quantitative questions

while interviews and observation will supply more qualitative answers.

Standards of Comparison: Standards of comparison for program delivery are similar to

what is utilized for program coverage. However, program delivery uses additional standards of

comparison including needs of target population, IAW budget, and participant preferences. The

needs of the target population will be used to evaluate if speed of program delivery meets the needs

of those IAW is serving. IAW budget is used as a standard of comparison when considering if the

funding for IAW is sufficient for proper program delivery. Finally, participant preferences are

utilized when evaluating participant satisfaction of the program.

37

Table 2. Evaluation of Program Delivery

Questions Sources of Data Standard of Comparison

Quality and Accuracy

Are the IAW water bottles actually delivered to each shelter partner as planned?

-Delivery schedule

-Records from shelter partners


Are the IAW water bottles delivered to each shelter partner according to the assigned schedule?

-Delivery schedule



Is the speed of the delivery of IAW water bottles to the shelter partners appropriate to meet the needs of the target population???

-Interviews with program implementers


-Needs of target population

-Performance of similar programs

Duration

Did program implementers allot enough time for IAW water bottles to be distributed?




Does the distribution of IAW water bottles occur frequently enough to meet the needs of the target population?




Staff and Training

Is there an adequate amount of workers at each participating shelter to deliver the IAW water bottles to participants?

-Staffing records from shelter partners



38

Are the workers knowledgeable in addressing dehydration?

-Observation of program implementation by evaluator


-Expert opinion


Are the workers at the shelters attentive of the needs of the program participants?




Are the workers at the shelters experienced in working with the target population? Are they knowledgeable of the culture?



Are the shelter workers readily available?



What is a shelter worker’s typical length of service?



Facilities, Resources, Materials, and Supplies

Do all participating facilities support the implementation and delivery of IAW water bottles?





What assets support the delivery the IAW water bottles compared to what was intended?



Is funding for the program adequate to implement distribution of IAW water bottles?


-IAW budget


Is there enough time given to -Interviews with program -Program staff expectations

39

implement distribution of IAW water bottles?

implementers based on established goals


Are there enough IAW water bottles available for distribution?


-Shelter inventory

-Staff expectations based on program goals


Consistency

Is delivery of the IAW water program consistent across the different shelters? Why or why not?




Is the IAW water program delivered at each shelter the same way every time?




Is there significant variation in qualifications between workers who implement the program?



Delivery Style

Is there a notable variation between how workers deliver the IAW water program to participants?



Are some workers more dynamic and personable when implementing the program as compared to others?




Are participants more likely to be satisfied with the IAW water program if they receive services from a particular worker?



Do participants engage more with particular workers as compared to others?



40


Satisfaction

How satisfied are participants with the IAW water program as a whole?





-Participant preferences

How satisfied are participants with the workers who implement the IAW water program at the shelter?





-Participant preferences

Coordination

Does the program staff coordinate with the workers implementing the IAW water program at the shelter?

-Interviews with program implementers and IAW staff


Does coordination between IAW staff and shelter workers exhibit a respectable working relationship?



Does the IAW staff coordinate with other program partners (e.g. water bottle supplier, distributors, endorsers, and academic)

-Interviews with program partners and IAW staff


Does coordination between IAW staff and other partners (e.g. water bottle supplier, distributors, endorsers, and academic) exhibit a respectable working relationship?

-Interviews with program partners and IAW staff


41

Protocols and Procedures

How is the delivery of the IAW water program applied and monitored?



Are workers mindful of protocols established to ensure effective implementation of the IAW water program?



If changes are made to the IAW water program, are these changes effectively communicated to workers implementing the program in the shelters?



PART IV: OUTCOME EVALUATION

Conducting an outcome evaluation is essential to assess effectiveness of a program

achieving desired outcomes. Outcome evaluation measures the changes in outcomes in relation

to the program (Rossi, Lipsey, & Freeman, 2004). The proposed outcome evaluation design,

outcome evaluation questions, use of measurement, effect size, and validity for the IAW water

program are discussed in the following sections.

Outcome Evaluation Design

The outcome evaluation design proposed for the evaluation of the IAW water program is

a nonrandomized two-group quasi-experimental design with post-tests given to intervention and

comparison groups. Although an evaluation including a pre-test as well as a post-test is preferred

in order to determine differential and selection issues, this type of design was chosen to be

proposed for the program outcome evaluation because the IAW water program is already in the

implementation phase (Peskin, Hernandez, & Addy, 2015c). Therefore, the utilization of a pre-

42

test before the program is implemented is not plausible. A randomized control trial is considered

the “gold standard” for evaluation; however the design for the IAW water program is proposed

to be nonrandomized because the design is more appropriate for the homeless population (Rossi,

Lipsey, & Freeman, 2004). This design is also less time-consuming, less expensive, and will

provide results more likely to be generalizable to the target population (Rossi et al., 2004). The

outcome evaluation design notation for the IAW water program is presented below:

X O1

NR ----------- O1

The proposed design for the IAW water program will use an individual unit of

assignment. The evaluation is proposed to be implemented April of 2016 and conclude in

October of the same year. The date and duration of the evaluation was selected by IAW CEO

Elena Davis. The rationale behind selecting this time frame involved the desire to evaluate the

program during water distribution. The post-tests used in the evaluation will be administered

throughout the selected time period. The intervention group in the evaluation will include all

individuals involved in the facilitation and participation of the IAW water program including

shelter workers, health care providers, and homeless individuals receiving IAW water bottles.

The comparison group will consist of similar individuals who are not involved in the IAW water

program. Therefore, this group will include shelters and providers not participating in the IAW

water program as well as the homeless individuals utilizing nonparticipating shelters. Homeless

shelters located in Houston not involved in the IAW water program that could be utilized as a

comparison group include Depriest Outreach Mission and The Life Center for the Homeless. It is

essential for the comparison group to be as similar as possible to the intervention group to ensure

both groups are experiencing the same threats to internal validity (Perskin et al., 2015c).

43

However, without the utilization of a pre-test, the similarity of the groups before program

implementation is not known (Peskin et al., 2015c). This issue will be further explored in the

internal validity section of this proposal and should be taken into consideration as a limitation of

the evaluation.

Outcome Evaluation Questions

Questions: An outcome is defined as the condition of either the priority population or a

circumstance a program is anticipated to change (Rossi, Lipsey, & Freeman, 2004). Analyzing

outcome change is essential in the program evaluation process. Outcome change is the difference

between outcomes at different points in time, therefore exhibiting program effect (Rossi et al.,

2004). To evaluate outcome change and program effect, outcome evaluation questions must be

drafted for a program. Outcome evaluation questions are formulated using outcomes determined

in the logic model for the program. The outcomes used in the outcome evaluation questions for

the IAW water program will be short- and intermediate outcomes from the program logic model.

The following outcome evaluation questions are proposed to be used for the outcome evaluation

of the IAW water program:

Q1. In comparison to homeless individuals in the control group, how do homeless

individuals receiving IAW water bottles differ in knowledge about sources of clean water

by October 2016?

Q2. How does communication about hydration between those who are homeless and

those who are not differ between the intervention and control groups by October 2016?

44


individuals receiving IAW water bottles differ in perceived barriers of obtaining drinking

water by October 2016?


individuals receiving IAW water bottles differ in self-esteem by October 2016?


individuals receiving IAW water bottles differ in accessibility to potable water by

October 2016?


individuals receiving IAW water bottles differ in hydration status by October 2016?

Rationale: As previously mentioned, the proposed outcome evaluation questions were

derived from the short- and intermediate outcomes of the IAW water program logic model. The

long-term outcomes presented in the logic model do not have their own outcome evaluation

questions because the length of time it would take to measure these outcomes extends the time

frame of the evaluation for the program. Within the outcome evaluation questions, all the

outcomes of the intervention group are compared to those of the comparison group.

Stakeholder Interest: IAW stakeholders will be interested in what the proposed

outcome evaluation questions address because it is important for them to know if the IAW water

program is increasing knowledge, communication, and self-esteem while also decreasing

perceived barriers among the target population. These short-term outcomes determine the

intermediate outcomes, increasing access to potable drinking water and hydration, which are the

45

mission of the program. Therefore, there will be stakeholder interest in all of the outcome

evaluation questions assessing the program effect on both short- and intermediate outcomes.

Potential Harm: There are no foreseeable potential harms caused by the IAW water

program. IAW provides clean drinking water containing single-word inspirational messages to

homeless individuals. The water and messages aim to prevent dehydration while also

encouraging the homeless population and instilling a sense of belonging within the community.

The program is noninvasive and provides a basic necessity of life to those in need. Therefore, the

IAW water program poses no evident threat to anyone involved in the program.

Measurement

During the measurement process of an outcome evaluation, it is essential to choose

adequate measures to assess the program constructs. In a complete outcome evaluation proposal,

outcome evaluation objectives are created for each outcome being assessed and measures are

selected to evaluate constructs related to each objective. This program proposal presents

examples of outcome objectives and selected measures for two outcomes from the IAW water

program logic model. The objectives were formulated to be specific, measurable, achievable,

realistic, and time-bound (Peskin, Hernandez, & Addy, 2015d). The measures selected in the

examples were validated for use by existing empirical research. Refer to the following tables as

examples of objectives and selected measures for the self-esteem and communication outcomes

chosen from the IAW water program logic model.

46

Table 3. Proposed Measurement of the Self-Esteem Outcome for the IAW Water Program

Outcome: Increased self-esteem among homeless

Measurement Construct

Description of Measure TimeReliability /Measurement Validity Information

Primary Reference Article/SurveyType of Variable

Self-esteem among homeless individuals

Rosenberg Self-Esteem Scale, 10-item Likert scale questionnaire

Example item: “I feel I do not have much to be proud of.” Choose: strongly disagree, disagree, agree, strongly agree

At follow-up

Internal consistency = 0.77; minimum Coefficient of Reproducibility at least 0.90

Stahler, G.J., Shipley, J.T.E, Kirby, K.C., Godboldte, C., Kerwin, M.E., Shandler, I., & Simons, L. (2005). Development and initial demonstration of a community-based intervention for homeless, cocaine-using, African-American Women. Journal of Substance Abuse Treatment 28, 171–179.

Ordinal variable

Outcome Objective: By October of 2016, 30% of homeless individuals who participate in the IAW water program will exhibit increased self-esteem when compared to the control group.

Table 4. Proposed Measurement of the Communication Outcome for the IAW Water Program

48

http://www.sciencedirect.com.utsph.idm.oclc.org/science/article/pii/S0740547204001576#200000764

Outcome: Increased communication about hydration between those who are homeless and those who are not

Outcome Objective: By October of 2016, 80% of homeless and housed individuals involved in the IAW water program will exhibit increased communication about hydration when compared to the control group.

Measurement Construct Description of Measure TimeReliability /Measurement Validity Information

Primary Reference Article/SurveyType of Variable

Communication between homeless and housed individuals about hydration

In-depth interviews conducted individually with both participants (homeless individuals) and facilitators (housed individuals)

Example item for participant: “Do you feel like you talk to the shelter workers and/or doctors more since they started giving you water?”

Or

Example item for facilitator: “Has communication with the homeless improved since distribution of the water began?”

At follow-up

Interview schedulepretested

Mathebula, S.D. & Ross, E. (2013). Realizing or relinquishing rights? Homeless youth, their life on the streets and their knowledge and experience of health and social services in Hillbrow, South Africa. Social Work in Health Care, 52(5), 449-66.

Qualitative data

49

The first outcome used in the examples is a short-term psychosocial outcome focusing on

increasing the self-esteem among the homeless. To assess the construct of self-esteem, the

chosen measure is the Rosenberg Self-Esteem Scale utilized in a study by Stahler and colleagues

(2005). This study evaluated a program known as Bridges to the Community which focused on

the support of social networks to promote healthier behaviors among the homeless population

(Stahler, Shipley, Kirby, Godboldte, Kerwin, Shandler, & Simons, 2005). The study utilized 118

homeless African-American women in the evaluation of the effectiveness of the Bridges

program. Among many different outcomes in the evaluation, increased self-esteem was included

(Stahler et al., 2005). Self-esteem was assessed using the Rosenberg Self-Esteem Scale, a ten-

item questionnaire measuring global self-esteem (Stahler et al., 2005). The questionnaire utilizes

a four-point Likert scale format with answers ranging from strongly agree to strongly disagree

(Rosenburg, 1965). Global self-esteem is measured in the Rosenberg Self-Esteem Scale using an

individual’s positive and negative feelings about themselves (Rosenburg, 1965). Stahler and

colleagues (2005) used the Rosenberg Self-Esteem Scale at baseline and follow-up to assess

changes in self-esteem among the participants in the study. Due to the difference in outcome

evaluation design, the IAW water program is proposed to use the questionnaire in the

intervention and comparison groups to evaluate change in self-esteem. The Rosenberg Self-

Esteem Scale has exhibited promising ratings in reliability, with both high internal consistency

and minimum Coefficient of Reproducibility (Rosenburg, 1965). An ordinal variable is used

when utilizing the Rosenberg Self-Esteem Scale as evidenced by the utilization of a Likert scale

to obtain a rating from the respondents (Peskin, Hernandez, & Addy, 2015e). The Rosenburg

Self-Esteem Scale was effective in determining change in self-esteem in the Bridges to the

Community program, a program with similar goals in increasing self-esteem among the

50

homeless population. Therefore, this measure is encouraged to be used in the outcome evaluation

of the IAW water program. The present evaluation will analyze the ordinal variable by utilizing

the ratings as a representation of the overall self-esteem of the individual. Overall self-esteem

will be compared between the homeless individuals participating in the IAW water program and

those in the control group. In this comparison, the intervention group is expected to have a higher

self-esteem compared to those who don’t receive IAW services.

The second outcome used in the examples is a short-term behavioral outcome aimed at

increasing communication about hydration between homeless and housed individuals. To

evaluate the construct of communication between the two populations, in-depth interview

measures are proposed for use. In-depth interviews were used by Mathebula and Ross (2013) in a

study evaluating the experiences of ten homeless young men living on the street of Hillbrow,

Johannesburg as well as whether or not they were aware of health and social services provided to

their population. The interviews conducted among the homeless individuals collected qualitative

data about a variety of topics such as poor health, psychological trauma and public hostility

(Mathebula & Ross, 2013). The interview addressed communication among the participants and

the general population as well as the experiences of these social interactions (Mathebula et al.,

2013). The interview schedule was pretested with three homeless individuals who were not

participants of the study to improve reliability and validity (Mathebula et al., 2013). The pretest

found the need for the interviews to be conducted in the dialect of the target population

(Mathebula et al., 2013). Therefore, wording of the questions asked in the interviews should be

carefully constructed in order to avoid any communication barriers between the interviewer and

the participant. For the present evaluation, the facilitators of the IAW water program will also be

interviewed and wording of questions with these interviewees will not be as much of a concern

51

as compared to the interviews with the homeless population. Mathebula and Ross (2013)

collected the qualitative data from the in-depth interviews by meeting individually with the

participants face-to-face. This method allowed the interviewer to elucidate questions and

participants to expand on any information that was not previously included in the interview

schedule (Mathebula et al., 2013). This proposal suggests the IAW water program utilizes a

similar method when interviewing both the participants and facilitators. The qualitative data

collected from these in-depth interviews is the variable for the measure. The data is analyzed in

themes based off of the interviewee’s responses (Mathebula et al., 2013). The categorization of

the theme should be validated to enhance dependability of the qualitative data (Mathebula et al.,

2013). With the success of using in-depth interviews with the homeless population to evaluate

social interaction, this measure is proposed to be utilized for the IAW water program outcome

evaluation.

As previously mentioned, the objectives and measures presented in this proposal are

examples of how to measure outcomes in an evaluation. However, in a comprehensive outcome

evaluation, all short- and intermediate outcomes would be assessed. These examples are to be

used as a guideline for the IAW water program to evaluate all short- and intermediate outcomes.

Effect Size

The outcome from the IAW water program logic model to be used for the basis of the

effect size estimate will be increased hydration among homeless. This outcome is a part of the

mission of the IAW water program and is therefore important to the program. Rather than

determining estimates for the pre-and post-test measures, this evaluation proposal will be

assessing the performance of the intervention and comparison groups on the measure. Existing

52

literature on programs supplying clean drinking water to the homeless are not currently available.

However, a similar study by Patel and colleagues (2011) evaluated water consumption among

middle school students when clean water accessibility is increased. The study utilized a change

in percentage effect size metric by conducting two-sample t tests for outcome variables of

intervention and comparison groups (Patel et al., 2011). Patel and colleagues (2011) also used an

odds ratio metric by utilizing multivariate logistic regression models to calculate the odds of

drinking water post-intervention (Patel et al., 2011). The study found an unadjusted change of 9

percentage points (−3.7 to 5.7) for drinking water between students in the intervention school

and students at the comparison school (P=.006) (Patel et al., 2011). After adjustment, water

intake between the two groups was still significantly different (P =.003) (Patel et al., 2011). The

odds ratio found for the control group was 0.81, while the odds ratio found for the intervention

group was 1.43 (Patel et al., 2011). The adjusted odds ratio of drinking water when comparing

the two groups was found to be 1.76; indicating exposure to increased accessibility of clean

water is associated with higher odds of drinking water (Patel et al., 2011). These findings exhibit

what to expect from how well both the intervention and comparison groups will perform on the

outcome for the IAW water program. Therefore, the expected odds ratio for the intervention

group of the IAW water program evaluation is 1.6, while the expected odds ratio for the control

group is 0.7.

Validity

Validity is defined as the degree to which a measure actually evaluates what it is anticipated

to assess (Rossi, Lipsey, & Freeman, 2008). There are two types of validity to consider in an

outcome evaluation design: internal validity and external validity. Internal validity determines

whether there is an actual causal relationship between the program and the outcome, while

53

external validity is the degree to which the results of an evaluation can be generalized to the

overall target population (Peskin, Hernandez, & Addy, 2015f).

Internal Validity: Selection is a common issue of a two-group design and is therefore a

potential internal validity threat to the proposed IAW water program outcome evaluation design.

Specific internal validity threats include selection, or differential, maturation and history.

Maturation is a development in the target population over time that could be mistaken for

program effect while history is events occurring during program implementation and evaluation

producing outcomes not related to program treatment (Peskin, Hernandez, & Addy, 2015f).

These internal validity threats are a possibility due to the lack of a pre-test in the program

evaluation design. The utilization of pre-tests in an evaluation is beneficial in assessing whether

or not the intervention and comparison groups are similar before the program is implemented.

When the groups are known to be similar, evaluators know the groups experience similar internal

validity threats and can rule these threats out for reasons of effect (Peskin et al., 2015e). Without

a pre-test, it is not possible for the evaluators to know if both groups experience comparable

maturation or history (Peskin et al., 2015e). For example, if one of the groups makes a change to

services provided at a shelter, than observed changes will be confused for program effect due to

differential history. Additionally, if one group has more chronically dehydrated individuals

whose bodies have adapted to the dehydrated state than differential maturation could occur.

Another type of selection bias that could potentially be an internal validity threat to the proposed

design for the IAW water program is differential attrition. Attrition is defined as the loss of

program participants which can create outcomes confused as program effects (Peskin et al.,

2015f). The homeless population relocates often; therefore losing respondents from both the

intervention and comparison groups is possible and can threaten internal validity as a result.

54

Lastly, instrumentation is a potential threat to validity for the IAW water program.

Instrumentation is defined as changes in measurement processes (Peskin et al., 2015f). This

threat typically occurs over time as changes are made unknowingly to the measure (Peskin et al.,

2015f). The evaluation for IAW utilizes in-depth interviews, a method commonly threatening

internal validity of programs because interviewers can become more experienced at interviewing

participants as time goes on (Peskin et al., 2015f). Therefore, there would be measurement

changes rather than actual program affect in altering behavior (Peskin et al., 2015f).

External Validity: External validity asks questions about whether the observed association

between the program and an outcome will be generalizable for other people, places, times,

settings, treatments, and outcomes (Peskin, Hernandez, & Addy, 2015g). To determine whether

or not the results found from the IAW water program outcome evaluation are generalizable, the

targets of generalizations must be considered (Peskin et al., 2015g). The targets of generalization

for the IAW water program will transition from narrow to broad, in which the results will be

applied from the homeless receiving the program to the entire homeless population (Peskin et al.,

2015g). Random selection of the study population enhances external validity; however this

evaluation will not be using such method (Peskin et al., 2015g). Therefore, there is a threat to

external validity for the IAW water program outcome evaluation and the results found may not

be able to be generalizable to the general homeless population. However, there are other methods

in which this outcome evaluation can use to enhance external validity. Such methods include

assuring participation and limiting attrition, describing contexts for assessment of similarity

between program participants and the general population, and reproducing the evaluation in

various settings and times (Peskin et al., 2015g).

55

CONCLUSION

This evaluation proposal has addressed a variety of recommended evaluation strategies

for the IAW water program. This proposal is encouraged to be utilized by the stakeholders of the

IAW program in assessing the program’s effectiveness of accomplishing desired outcomes.

Conducting an evaluation of the IAW water program will assist stakeholders in determining if

changes need to be made for the program to be more effective. In doing so, the IAW water

program is more likely to reach the program’s ultimate goal of reducing the risk for health

complications related to dehydration as well as an enhanced quality of life among the homeless

community.

56

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