SUPPORTING STATEMENT FOR
Cross-Site Evaluation of the Infant Adoption Awareness Training Program
(December 2009 Revision)
Submitted by
Department of Health & Human Services
Children’s Bureau
Washington, DC
Contact person:
Patricia Campiglia
Children’s Bureau
Administration on Children, Youth and Families
1250 Maryland Avenue, SW
Portals Building, Eighth Floor
Washington, DC 20024
202/205-8060
patricia.campiglia@acf.hhs.gov
TABLE OF CONTENTS
Page
1. Circumstances making the collection of information necessary 2
2. Purpose and use of the information collection 3
3. Use of improved information technology and burden reduction 4
4. Efforts to identify duplication and use of similar information 4
5. Impact on small businesses or other small entities 5
6. Consequences of collecting the information less frequently 5
7. Special circumstances relating to the guidelines of 5 CFR 1320.5 5
8. Comments in response to the Federal Register Notice and efforts to consult outside the agency 5
9. Explanation of any payment or gift to respondents 6
10. Assurance of confidentiality provided to respondents 6
11. Justification for sensitive questions 6
12. Estimates of annualized burden hours and costs 7
13. Estimates of other total annual cost burden to respondents and record keepers 7
14. Annualized cost to the Federal government 7
15. Explanation for program changes or adjustments 8
16. Plans for tabulation and publication and project time schedule 8
17. Reason(s) display of OMB expiration data is inappropriate 9
18. Exceptions to Certification for Paperwork Reduction Act Submissions 9
Section B: Statistical Methods 10
1. Respondent universe and sampling methods 11
2. Procedures for the collection of information. 11
3. Methods to maximize response rates and deal with nonresponse 12
4. Tests of procedures or methods to be undertaken 14
5. Individuals consulted on statistical aspects and individuals collecting and/or analyzing data 15
appendices:
Appendix A: Legislation
Appendix B: Best Practice Guidelines for the Infant Adoption Awareness Training Program
Appendix C: Key Pilot Study Findings
OMB Form 83-I Supporting Statement:
Legislative Background and Purpose
Title XII, Subtitle A of the Children’s Health Act of 2000 (42 U.S.C. 254c-6) authorizes the Department of Health and Human Services (HHS) to make Infant Adoption Awareness grants available to national, regional, and local adoption organizations for the purposes of developing and implementing programs that train the staff of public and non-profit private health service organizations to provide adoption information and referrals to pregnant women. As stated in the legislation, the objective of the Infant Adoption Awareness Training Program (IAATP) is to “train the designated staff of eligible health centers in providing adoption information and referrals to pregnant women on an equal basis with all other courses of action included in nondirective counseling [of] pregnant women.” ‘Designated staff’ include individuals who provide pregnancy or adoption information and those who will provide such services after receiving the training. Priority is given to training the staff of Title X (voluntary family planning projects), Section 330 (community, migrant, homeless and public housing health centers), and health centers that receive grants under the Children’s Health Act to provide services in schools. A copy of the Infant Adoption Awareness legislation follows in Appendix A.
The first IAATP grantees were funded in fiscal year 2001. Cooperative agreements were re-awarded in 2006 to six grantees that will provide training to an estimated 10,000 staff nationwide each year. Under the terms of the agreements, funded organizations are required to develop and deliver trainings that are consistent with best practice guidelines established by HHS in consultation with numerous experts from adoption and associated fields. Specifically, the Best Practice Guidelines for the Infant Adoption Awareness Training Program require adoption awareness trainings to: a) impart up-to-date accurate information about adoption to trainees, b) be consistent with applicable State laws and impart information on the legal issues pertaining to adoption, and c) impart information about the impacts of Multiethnic Placement Act/Interethnic Placement Act (MEPA/IEP) and the Indian Child Welfare Act (ICWA) on the adoption process.
The guidelines also require IAATP grantees to instruct participants on: 1) the influence of family and community members on the client’s decision-making process, 2) the availability and accessibility of adoption services in the community, 3) adolescent development and the differences between counseling adolescents and older women, and 4) the psychological and emotional reactions that birth parents are likely to experience throughout the decision-making process. Additional requirements, including the basic knowledge and counseling skills the training should impart and recommended training formats and activities, are also outlined in the guidelines for grantees. Refer to Appendix B for a complete description of the Best Practice Guidelines.
National Evaluation Requirements
The proposed information collection will be conducted for national cross-site evaluation purposes. All IAATP grantees are required, as a condition of receiving funding, to participate in national cross-site evaluation. National evaluation activities are designed to objectively assess the knowledge and skills gained, retained, and applied by trainees as a result of their participation in the Infant Adoption Awareness Training Program. Data collected in the cross-site evaluation will answer the following critical questions:
Do health care workers who participate in the IAATP training
Demonstrate enhanced knowledge, attitudes, skills, and behaviors with respect to adoption counseling following completion of the program?
Provide adoption information to pregnant women on an equal basis with other pregnancy planning options?
Demonstrate enhanced awareness of community adoption-related resources and refer expectant mothers to them as needed?
Are trainees more confident about discussing all three pregnancy planning options (parenting, abortion, and adoption) in a non-directive counseling style than prior to participating in the training?
The Infant Adoption Awareness Training Program: Trainee Survey is the primary data collection instrument for the national cross-site evaluation. Data obtained in the survey will be utilized to inform the Children’s Bureau about the effectiveness of the Infant Adoption Awareness Training Program. Pre-test and follow-up survey data will be compiled and analyzed, and findings will be presented in briefings and report form to the Federal Project Officer. These survey findings will provide an objective, quantitative assessment of: 1) the extent to which IAATP training prepares health care and other staff who provide information or counseling services to pregnant women to present accurate and non-directive adoption information, 2) whether participants in the training apply any or all components of the training to their subsequent pregnancy counseling work with women, and 3) the extent to which training outcomes vary in relation to different training formats, curricula, trainee demographics, and/or work setting.
Data collected in the pre-test administration of the survey will be used to establish participants’ baseline knowledge, skills, attitudes, and behaviors prior to receiving the IAATP training. Pre-tests will be completed by the trainees at sampled training sessions just before training begins. The “follow-up” administration of the survey will be conducted approximately 90 days (and no later than 180 days) after the training to assess the extent to which trainees’ demonstrate sustained gains in their knowledge about adoption, and to determine the impact of the training on their subsequent work providing options counseling to pregnant women.
Cross-site evaluation data will be collected on an annual basis throughout the five-year funding period. In addition to informing the Children’s Bureau about attainment of training goals, ongoing analysis and reporting of these data will contribute to continuous quality improvement by enabling the federal staff and grantees to identify any areas where modifications may be indicated to improve training processes or outcomes for trainees in a timely manner.
Refer to Section B: Statistical Methods for a complete description of the survey methodology.
Administration of the follow-up survey will be primarily electronic, utilizing email notification and Internet-based survey technologies. Using email address information collected at the time of the pre-test, the national evaluator will email a notification to all trainees who completed a pre-test, inviting them to complete the follow-up survey instrument using one of two options: 1) by accessing a web-link to an online version of the survey; or 2) accessing an attached survey to complete and return via email, mail or fax to the research team. The alternative modes for conducting the follow-up survey for non-respondents will be for research staff to administer the survey by mailing the survey with a self-addressed, stamped return envelope or conducting the survey via telephone.
The majority of trainees are expected to have the capabilities to access the web-link to the post-test survey, however the alternative data collection methods will be provided as a backup for trainees with limited access to the Internet. The alternative methods will enable respondents to elect the response mode that is most convenient and least burdensome.
The national evaluation contractor has worked closely with the IAATP grantees and local evaluators to determine the scope of grantee-level data collection efforts and ensure that the timing and content of the cross-site data collection does not duplicate local evaluation efforts. The national evaluator has met with the grantees and reviewed each grantee’s local instruments and replaced duplicative instruments (i.e., locally-administered grantee pre-tests) with a single cross-site evaluation instrument that meets both local and national needs. The data elements in the proposed cross-site survey incorporate those items from local grantee instruments that are particularly informative and that address the same concepts addressed in the IAATP Trainee Survey. This practice will yield additional efficiency and reduces the risk of burdening respondents with multiple instruments.
The national evaluator will only administer the pre-test and follow-up surveys to persons who attend a sample of IAATP training sessions. IAATP grantees will be free to continue their site-specific evaluation activities with all other training sessions not included in the national sample (e.g., grantee-specific pre-tests and follow-up tests).
The proposed information collection will not duplicate the 2001 cross-site evaluation. In 2001, the Health Resources and Services Administration (HRSA) initiated a cross-site evaluation of the first grantees. The HRSA evaluation collected self-report data on the changes trainees perceived in their knowledge and skills six months post-training. The results of that evaluation are not yet public. In contrast, the current pre-post test design for the IAATP trainee survey assesses actual changes in adoption knowledge, attitudes, and behaviors of trainees and will yield more reliable findings that can be attributed with greater confidence to the effects of IAATP training.
To minimize respondent burden, subjects who participate in the national cross-site evaluation data collection will not receive additional on-site pre-tests or follow-up surveys from the IAATP grantees. Respondents to the cross-site evaluation will be drawn from the pool of new IAATP trainees (i.e., staff who have not previously participated in IAATP training or been included in any prior IAATP data collection efforts). Individuals included in the national cross-site evaluation sample will be identified to local grantees and evaluators to ensure that they will not be included in local data collections that would duplicate or fall within the timeframe of the cross-site data collection. Identifying and eliminating duplication in this prospective manner will foster cooperation among all stakeholders and foster a greater response rates among the trainees selected to complete the cross-site instrument.
In the absence of annual national cross-site evaluation activities, ACF and the Children’s Bureau would not have the necessary timely data to ensure that the training delivered by grantees provides health care and other staff with the knowledge and skills required to provide adoption information and/or counseling to pregnant women in the manner specified in the Infant Adoption Awareness legislation. The Children’s Bureau and other stakeholders also would not have the empirical data needed to determine whether the training leads staff to include presentation of the adoption alternative on an equal basis with all other potential courses of action. Information collected through the IAATP Trainee Survey will enable Federal staff to review post-training behavior changes in terms of the frequency (e.g., the number of clients for whom the health care worker includes adoption in pregnancy options counseling) and quality of services provided (e.g., established relationships with local adoption resources, referral of interested clients to adoption agencies/resources).
No special circumstances impact the information collection.
No public comments were received in response to the notice of the proposed information collection published in the Federal Register, Volume 74, Number 6, Tuesday, April 7, 2009, page number 15727.
Efforts to consult with individuals outside the agency for their views on the data collection have included engagement of the IAATP grantees in review of the proposed data collection instruments and data elements and solicitation of their feedback on the proposed method and frequency of data collection.
The evaluation does not include any form of payment or gift to respondents.
The national evaluator has implemented confidentiality procedures to ensure the privacy of individual survey respondents. Only data that have been stripped of individually identifying information will be maintained in the central data repository. System-generated identifiers will be assigned to each respondent, in place of personal information, in order to link the individual’s pre-test and follow-up data. Data sharing agreements have been made with the grantee agencies that specify the types of data that may be exchanged between the evaluator and the grantee in the course of the data collection, the frequency and methods by which data are to be received, and the safeguards to be followed to protect confidential information. As an additional protection, all evaluation project staff, including consultants and those with access to the data in disaggregated form, are required to sign a pledge of confidentiality stating that they are aware of and agree to follow the Procedures for Assuring Confidentiality of Information.
The IAATP Trainee Survey does not include questions related to sexual behavior, religious beliefs, or other matters that are generally considered private. No questions are asked about respondents’ personal experiences or history related to pregnancy and/or adoption. The impact of the training on trainees’ ability to provide non-directive, non-coercive options counseling despite personal attitudes or bias is a critical outcome of the Infant Adoption Awareness Training initiative. Because individual attitudes and biases before and after the training can impact the use of the skills taught in the training, the survey includes five questions regarding opinions about adoption.
Test Iterations – Annual
|
Estimated Number of Respondents (a) |
Number of Responses per Respondent (b) |
Average Burden Hours per Response (c) |
Estimated Total Burden Hours Requested (d) a x b x c |
Hourly Wage Rate (e) |
Respondent Cost – Annual
d x e |
Pre-Test |
1,200 |
1 |
.25 |
300 |
19.46 |
$ 5,838.00 |
Follow-Up |
1,200 |
1 |
.17 |
204 |
19.46 |
$ 3969.84 |
|
|
|
|
504 |
19.46 |
$ 9,807.84 |
The estimate of hour burden is annual. Based on the required annual sample size of 54 classes, an average class size of 25 trainees and our anticipated response rate of 90%, a total of 1,200 respondents will be sampled each year. Refer to Section B of this statement, “Collection of Information Employing Statistical Methods,” Items 2 and 3 for a complete description of the sampling plan.
Pre-test and follow-up versions of the survey are expected to require approximately 10 to 15 minutes to complete. Estimated response time for the follow-up survey includes time for respondents to access the web-based survey, complete the survey online, and submit the survey. Where possible, fields in the follow-up version of the survey will be pre-filled with static data from the respondent’s pre-test (e.g., demographics, agency type) in order to expedite completion of the survey and minimize respondent burden.
No additional cost burden will apply for respondents or record keepers.
The total cost to the Federal Government for the information collection is estimated to be $3,309,579. The total annualized cost is estimated to be approximately $661,916. The total costs include direct labor costs; other direct costs (including travel, postage, document reproduction costs, telephone service, and contracts with outside interviewers and statistical consultants); and a fee on other direct costs.
Not applicable.
The results of the national cross-site evaluation will be analyzed and summarized in periodic briefings, interim reports, and a final report. Reports of research findings will include descriptive analyses, identification of moderating and mediating variables, and the implications of the findings. The findings of annual outcome and process evaluations will be summarized and tabulated beginning in the first year of data collection. The final synthesis report of the project’s findings for all years will be produced and distributed to each of the six IAATP grantees. The findings of the national cross-site evaluation will be made available to the public in formats suitable for multiple uses and audiences, such as research briefs, synthesis papers, and final study reports. The goal in producing these publications will not only be to summarize the research findings, but also to highlight key issues and lessons learned.
The data for analysis will be obtained from the IAATP survey with training sessions as the Primary Sampling Unit (PSU) in a one-stage cluster design. The sampling weight will be the ratio of sampling clusters and total clusters, which will be used for all individuals in the sample. To obtain an unbiased inference of population information, both within and between cluster variances will be used in calculating standard errors. Stata or SUDAAN will be used for the analysis with complex survey data. The analysis will be conducted in the following four steps.
The first step will be to estimate population demographic characteristics including type of organization, type of funding received, services proved to women with unintended pregnancies, etc. Special features in Stata or SUDAAN, such as survey means or survey totals, will be used for the analysis to obtain unbiased estimates. Descriptive statistics will be reported to summarize population parameters.
The second step in the analysis will be to assess the increase in knowledge from pretest to follow-up. Conventional factor analysis will be conducted to classify related survey items into composite scores. The composite scores will represent constructs such as increased knowledge of adoption policies, adoption resources, counseling skills, referral to adoption, and changes in attitudes. Paired t-tests will be conducted to evaluate the change from pretest to follow-up. The composite scores will be the dependent variables and the sampling weight will be included in the t-tests.
The third step will be to examine possible moderators. Assuming significant increases in knowledge from pretest to follow-up, a natural inquiry is whether the increase is the same variance for subgroups including type of organization, services provided, and client categories. Moderator analysis will utilize linear regression techniques. Specifically, a follow-up test score will be the dependent variable, the pre test score will be the moderator, and a product term of the moderator and the pretest score will be the predictors in the linear regression analysis. A significant product term indicates that the change from pretest to follow up is different for subgroups. Interaction plots will be used to facilitate the interpretation of the moderating effects.
The final step of the analysis will be to build models to predict the best learning of the training. The outcome variables in the models will be the composite scores formed in Step 2 from factor analysis. The predictors consist of all demographic variables and selected composite scores. Stepwise linear regression will be used to obtain final models with all significant predictors. Multicollinearity issues will be checked before the stepwise regression analysis.
The OMB expiration date for the information collection will appear on the survey instrument.
No exception is requested to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB Form 83-I.
Section B: Statistical Methods
The target population consists of all trainees who received one-day IAATP training provided by grantees across different organizations.
The sampling design for this study will be one-stage cluster sampling (Levy & Lemeshow, 1999). The primary sampling unit (PSU) will be the training sessions without stratification. These PSUs will be constructed as the sampling frame with information collected from IAATP grantees. A simple random sampling will be conducted based on the sampling frame on training sessions as the PSU. No further sampling is planned within training session. One-stage cluster sampling is preferable in terms of cost and efficiency, because all registrants in a sampled training session are provided the opportunity to respond to the survey, rather than data collection from individual registrants across sessions.
One-stage cluster sampling does not assume the same number of trainees across sessions. This is an advantage of the sampling design to deal with the problems of attrition and non-respondents. The proposed study is a pretest-follow-up comparison and attrition is inevitable in the study. The final analysis will be based on respondents who have data on both pre and follow-up tests. In the
one-stage cluster sampling, since the PSU is the training session, the problem of attrition and non-respondents within sessions will not be as serious as that in a random sampling on individuals. The attrition and non-respondents within sessions can be excluded from analysis, assuming no difference in demographic factors between the respondents and non-respondents.
Individuals included in the national cross-site evaluation sample will be identified to local grantees and evaluators to ensure that they will not be included in local data collections that would duplicate or fall within the timeframe of the cross-site data collection. Identifying and eliminating duplication in this prospective manner will foster cooperation among all stakeholders and foster greater response rates among the trainees selected to complete the cross-site instrument.
Sample size estimation in one-stage cluster sampling is based on required confidence interval, between cluster variance of the outcome variable, the effect size, and the specified precision of the study. Specifically, the number of sampled clusters is estimated using the following formula (Levy & Lemeshow, 1999; p. 259):
m = z2 M V2 z2 V2 + HM − 1Lε2
where z2 is reliability coefficient for 100 (1 – (α / 2)) confidence; M is the total number of clusters in the population; and ε is the required precision. V = σ / d, where σ is the between cluster standard deviation of the outcome variable and d is the effect size of the study. It is evident from the formula that when M is large, it does not weight too much on the estimation of the sampled clusters.
In a pre-post study, the null hypothesis is that the mean of the gain score (the difference between pre and post scores) is zero in the population. By Cohen’s standard (Cohen, 1988), the mean of the gain score in the standardized form = 0.3, 0.5, and 0.8 is defined as a small, medium and large effect size, respectively. Assuming that the effect size is 0.5 (this information can be obtained more accurately from a pilot study
or a previous study) with a between group standard deviation = 0.2, a 95% confidence interval (z = 1.96), 424 total training sessions, and the required precision of 10% (ε = 0.1), the required annual sample size is:
m = 1.962 ×424 × H0.2ê0.5L21.962 ×H0.2ê0.5L2 + H424 − 1L× 0.12 = 53.79
Therefore, about 54 training sessions are needed for the study. Because the change in required precision and in between-cluster variance may dramatically influence the sample size, selected combinations of the parameters are listed in the following table.
_____________________________________________________________________
z σ ε d Sample Size (sessions)
-------------------------------------------------------------------------------------------------------
1.96 0.2 0.100 0.6 39
1.96 0.2 0.075 0.6 64
1.96 0.2 0.075 0.5 87
1.96 0.2 0.050 0.5 156
1.96 0.2 0.100 0.4 78
1.96 0.2 0.075 0.4 122
1.96 0.3 0.100 0.5 104
1.96 0.3 0.075 0.5 156
__________________________________________________________________
The above table shows that the change in precision and in between-session variance play
important roles in the estimation of required annual sample size for the study. More information from the pilot or previous studies will improve the estimate of sample size for the main study.
Pre-Test Survey techniques
All IAATP trainees complete a pre-test as a prerequisite to beginning the training, regardless of whether they are included in the national cross-site data collection. For national evaluation purposes, the pre-test will be administered to all trainees registered in 54 sessions selected for the annual cross-site sample. Based on our anticipated response rate of 90%, and average class size of 25, a total of 1,200 respondents will be sampled each year. (Note: As explained in Item 4 of Section A, “Efforts to Identify and Eliminate Duplication,” the cross-site pre-test will be available to the IAATP grantees to use in local evaluation efforts). The baseline survey will be administered in paper form onsite at the training location immediately prior to the start of training. This mirrors the current approach by each training site, in which a pre-test is administered prior to the start of each training class. Forms will be copied and then shipped to the national evaluation center for entry.
Follow-Up Survey techniques
Maximizing response rates will be most critical during the follow-up administration of the IAATP survey. The proposed methodology is designed to ensure that completion of the follow-up survey is convenient for trainees. The survey process also includes plans to contact non-respondents to increase the number who will complete the survey.
By administering the follow-up survey soon after training (optimally 90 days post-training), we will maximize survey response rates by avoiding high levels of staff turnover, flagging interest or recall of the IAATP training, etc. Administration of the follow-up survey will be primarily electronic. The national evaluator will email a notification to all trainees who completed a pre-test, inviting them to complete the follow-up survey instrument using one of two options: 1) by accessing a web-link to an online version of the survey; or 2) accessing an attached survey to complete and return via email, mail or fax to the research team. Electronic testing will allow respondents the flexibility to complete the survey at the most convenient time with minimal burden and will substantially reduce the need for data entry and processing of materials by evaluation staff.
Follow-up with non-respondents will be conducted by email, phone, and mail as outlined below.
Follow-up by email: A reminder email message will be sent to all non-respondents 2 weeks after the initial survey invitation was sent. The reminder message will include a link to the survey website and offer the trainee the option to download an attached survey to complete and return via email, mail or fax.
Follow-up by phone: Two weeks following the email reminder, the national evaluator will contact the trainee by phone to determine whether the original and reminder email messages were received. Three attempts will be made to reach the trainee by phone. Once reached, the trainee will be given the option to complete the survey online through the original web link to receive a third email of the survey, or to receive a mailed copy. If the trainee needs to be resent the web link or the email, the email address will be verified and the information will be resent. If the trainee is unable to access the Internet or does not want to complete the survey by downloading the attachment from the email, a hard copy of the post-training survey will be offered. The survey will then be mailed to the non-respondent with a stamped, return-addressed envelope.
Follow-up by mail: Trainees that are not reachable by email or phone will be mailed the request to complete the survey. The mailing will include a hard copy of the survey in addition to the link to the survey website within the cover letter.
Table I provides an overview of the data collection points, format, and timeframes for the pre-test and follow-up survey.
Table I
Summary of IAATP Survey Methodology
Data Collection Point |
Sample |
Instrument |
Timeframe |
Format |
A1 |
All registrants from a sample of scheduled training sessions |
Pre-test of adoption knowledge, attitudes, behaviors |
Onsite immediately prior to training |
Paper form |
A2 |
Same as A1
|
Follow-up test of adoption knowledge, attitudes, behaviors |
90-180 days (3-6 months) after training |
Email invitation to complete online survey
OR
Download attached survey and return completed form via email, fax, or mail
(with administration of the survey via telephone and mail for non-respondents) |
The survey methodology described above was pilot tested in Spring 2008 in order to confirm its viability and to identify possible procedural or methodological challenges in need of attention or improvement. Using the class as the primary sampling unit (PSU), a total of three classes were sampled for the pilot study. In addition to providing a test of survey item validity, the pilot test was instrumental in confirming ease of administration in terms of the amount of time required to complete the pre-test survey, and user access and responsiveness to web-based and alternative methods for completing the post-test survey.
The proposed methodology and specific items in the survey instrument did not require revision as a result of the pilot test. The results of the pilot indicated the survey instruments were able to discern knowledge gains and retention of knowledge, change in trainee attitudes about adoption, and change in the behaviors and skills applied in the counseling of pregnant women as a result of trainees’ participation in the IAATP training. A description of the key findings in each of these areas follows in Appendix C.
Survey items were validated through the pilot process by testing the questions among respondents who were representative of the population that would be completing the final survey (i.e., individuals in health care settings who provide services to pregnant women and are participating in the IAATP training). The survey items were also validated prior to the pilot test using cognitive testing procedures. The purpose of this activity was to field test the survey instruments and make final improvements in the wording and layout of the two instruments. The respondents for the cognitive testing activity were the project directors of the six IAATP grantees, who were both familiar with the training objectives and experienced in testing IAATP trainees. All grantees were provided the instruments to review and participated in a joint conference call to review the surveys question-by-question and state their impressions about the items. Modifications were then made to the survey items based on the feedback received from the grantees.
National Cross-Site Evaluation Contractor:
James Bell Associates, 1001 19th Street, N., Suite 1500, Arlington, VA; (703) 528-3230.
Statistical Consultant:
Rusan Chen, Senior Statistician, 3520 Prospect Street, Suite 314, Car Barn Building, Georgetown University, Washington DC, NW 20057; (202) 687-6602.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Lawrence
Erlbaum Assoc.: New Jersey.
Levy, P. S. & Lemeshow, S. (1999). Sampling of populations (3rd ed.). John Wiley & Sons, Inc: New York.
Appendices
Appendix A: Legislation
Title XII, Subtitle A – Infant Adoption Awareness
TITLE XII—ADOPTION AWARENESS
Subtitle A — Infant Adoption Awareness
SEC. 1201. GRANTS REGARDING INFANT ADOPTION AWARENESS.
Subpart I of part D of title III of the Public Health Service Act, as amended by section 801 of this Act, is amended by adding at the end the following section:
‘‘SEC. 330F. CERTAIN SERVICES FOR PREGNANT WOMEN.
‘‘(a) INFANT ADOPTION AWARENESS.—
‘‘(1) IN GENERAL.—The Secretary shall make grants to national, regional, or local adoption organizations for the purpose of developing and implementing programs to train the designated staff of eligible health centers in providing adoption information and referrals to pregnant women on an equal basis with all other courses of action included in nondirective counseling to pregnant women.
‘‘(2) BEST-PRACTICES GUIDELINES.—
‘‘(A) IN GENERAL.—A condition for the receipt of a grant under paragraph (1) is that the adoption organization involved agree that, in providing training under such paragraph, the organization will follow the guidelines developed under subparagraph (B).
‘‘(B) PROCESS FOR DEVELOPMENT OF GUIDELINES.—
‘‘(i) IN GENERAL.—The Secretary shall establish and supervise a process described in clause (ii) in which the participants are—
‘‘(I) an appropriate number and variety of adoption organizations that, as a group, have expertise in all models of adoption practice and that represent all members of the adoption triad (birth mother, infant, and adoptive parent); and
‘‘(II) affected public health entities.
‘‘(ii) DESCRIPTION OF PROCESS.—The process referred to in clause (i) is a process in which the participants described in such clause collaborate to develop best-practices guidelines on the provision of adoption information and referrals to pregnant women on an equal basis with all other courses of action included in nondirective counseling to pregnant women.
‘‘(iii) DATE CERTAIN FOR DEVELOPMENT.—The Secretary shall ensure that the guidelines described in clause (ii) are developed not later than 180 days after the date of the enactment of the Children’s Health Act of 2000.
‘‘(C) RELATION TO AUTHORITY FOR GRANTS.—The Secretary may not make any grant under paragraph (1) before the date on which the guidelines under subparagraph (B) are developed.
‘‘(3) USE OF GRANT.—
‘‘(A) IN GENERAL.—With respect to a grant under paragraph (1)—
‘‘(i) an adoption organization may expend the grant to carry out the programs directly or through grants to or contracts with other adoption organizations;
‘‘(ii) the purposes for which the adoption organization expends the grant may include the development of a training curriculum, consistent with the guidelines developed under paragraph (2) (B); and
‘‘(iii) a condition for the receipt of the grant is that the adoption organization agree that, in providing training for the designated staff of eligible health centers, such organization will make reasonable efforts to ensure that the individuals who provide the training are individuals who are knowledgeable in all elements of the adoption process and are experienced in providing adoption information and referrals in the geographic areas in which the eligible health centers are located, and that the designated staff receive the training in such areas.
‘‘(B) RULE OF CONSTRUCTION REGARDING TRAINING OF TRAINERS.—With respect to individuals who under a grant under paragraph (1) provide training for the designated staff of eligible health centers (referred to in this subparagraph as ‘trainers’), subparagraph (A) (iii) may not be construed as establishing any limitation regarding the geographic area in which the trainers receive instruction in being such trainers. A trainer may receive such instruction in a different geographic area than the area in which the trainer trains (or will train) the designated staff of eligible health centers.
‘‘(4) ADOPTION ORGANIZATIONS; ELIGIBLE HEALTH CENTERS; OTHER DEFINITIONS.—For purposes of this section:
‘‘(A) The term ‘adoption organization’ means a national, regional, or local organization—
‘‘(i) among whose primary purposes are adoption;
‘‘(ii) that is knowledgeable in all elements of the adoption process and on providing adoption information and referrals to pregnant women; and
‘‘(iii) that is a nonprofit private entity.
‘‘(B) The term ‘designated staff’, with respect to an eligible health center, means staff of the center who provide pregnancy or adoption information and referrals (or will provide such information and referrals after receiving training under a grant under paragraph (1)).
‘‘(C) The term ‘eligible health centers’ means public and nonprofit private entities that provide health services to pregnant women.
‘‘(5) TRAINING FOR CERTAIN ELIGIBLE HEALTH CENTERS.— A condition for the receipt of a grant under paragraph (1) is that the adoption organization involved agree to make reasonable efforts to ensure that the eligible health centers with respect to which training under the grant is provided include—
‘‘(A) eligible health centers that receive grants under section 1001 (relating to voluntary family planning
projects);
‘‘(B) eligible health centers that receive grants under section 330 (relating to community health centers, migrant health centers, and centers regarding homeless individuals and residents of public housing); and
‘‘(C) eligible health centers that receive grants under this Act for the provision of services in schools.
‘‘(6) PARTICIPATION OF CERTAIN ELIGIBLE HEALTH CLINICS. — In the case of eligible health centers that receive grants under section 330 or 1001:
‘‘(A) Within a reasonable period after the Secretary begins making grants under paragraph (1), the Secretary shall provide eligible health centers with complete information about the training available from organizations receiving grants under such paragraph. The Secretary shall make reasonable efforts to encourage eligible health centers to arrange for designated staff to participate in such training. Such efforts shall affirm Federal requirements, if any, that the eligible health center provide nondirective counseling to pregnant women.
‘‘(B) All costs of such centers in obtaining the training shall be reimbursed by the organization that provides the training, using grants under paragraph (1).
‘‘(C) Not later than 1 year after the date of the enactment of the Children’s Health Act of 2000, the Secretary shall submit to the appropriate committees of the Congress a report evaluating the extent to which adoption information and referral, upon request, are provided by eligible health centers. Within a reasonable time after training under this section is initiated, the Secretary shall submit to the appropriate committees of the Congress a report evaluating the extent to which adoption information and referral, upon request, are provided by eligible health centers in order to determine the effectiveness of such training
and the extent to which such training complies with subsection (a) (1). In preparing the reports required by this subparagraph, the Secretary shall in no respect interpret the provisions of this section to allow any interference in the provider-patient relationship, any breach of patient confidentiality, or any monitoring or auditing of the counseling process or patient records which breaches patient confidentiality or reveals patient identity. The reports required by this subparagraph shall be conducted by the Secretary acting through the Administrator of the Health Resources and Services Administration and in collaboration with the Director of the Agency for Healthcare Research and Quality.
‘‘(b) APPLICATION FOR GRANT.—The Secretary may make a grant under subsection (a) only if an application for the grant is submitted to the Secretary and the application is in such form, is made in such manner, and contains such agreements, assurances, and information as the Secretary determines to be necessary to carry out this section.
‘‘(c) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of carrying out this section, there are authorized to be appropriated such sums as may be necessary for each of the fiscal years 2001through 2005.’’.
Appendix B: Best Practice Guidelines for the Infant Adoption Awareness Training Program
On October 17, 2000 the U.S. Congress, under Public Law 103-310, amended the Public Health Services Act to authorize specific activities pertaining to Infant Adoption Awareness (title XII, Subtitle A). The legislation requires the Secretary of the Department of Health and Human Services (DHHS) to award grants to adoption organizations to develop and implement programs to train the designated staff of eligible health centers in providing adoption information and referral to pregnant women on an equal basis with all other courses of action included in nondirective counseling for pregnant women. The term "eligible health centers" means public and nonprofit private entities that provide health services to pregnant women. The legislation also requires the Secretary to establish a set of best-practice guidelines to which the DHHS-funded training programs will adhere in providing training to staff of eligible health centers.
In response to these legislative requirements, the Department of Health and Human Services has developed the following "best-practice" guidelines to be followed by recipients of cooperative agreements in developing curriculum and providing training to implement the Infant Adoption Awareness Training Program (IAATP). This "best-practice" guideline is critical for attaining the primary IAATP goal- enhancing the ability of health center personnel to provide adoption information and referral on an equal basis with all other courses of action included in nondirective counseling for pregnant women.
Consistent with the intent of the legislation, these guidelines were developed in consultation with 29 experts in the fields of adoption, child welfare, health services, medicine, law, and adoption counseling, as well as adoptive parents.
The training will impart up-to-date and accurate information about adoption, including the various types of adoptions (e.g., closed adoptions and adoptions involving varying levels of "openness" with respect to the amount of contact or information exchanged between adoptive parents and birth parents).
The training will be consistent with applicable State law, imparting information on the legal issues pertaining to adoption, including the rights of the birth mother and father.
The training will impart information to the trainees about the Multiethnic Placement Act/Interethnic Placement Act (MEPA/IEP), particularly as it relates to the circumstances under which a birth parent may or may not choose adoptive parents for the child.
The training will impart information to the trainees about the Indian Child Welfare Act (ICWA), and particularly will explain that organizations that work with birth parents on adoption will ascertain as soon as possible whether a child is or will be subject to ICWA prior to proceeding with the adoption process.
The training will impart information about how family members and the birth mother's community may impact her pregnancy decision process.
The training will impart information about the role of the birth father in the pregnancy decision.
The training will impart information about various adoption services available within the community and how to assess the quality of those services and their appropriateness for a particular woman.
The training will impart information on adolescent development and the differences between counseling adolescents at varying ages and counseling older women.
The training will impart information about the psychological and emotional reactions such as shame, grief, loss, guilt, and depression that the birth mother is likely to experience throughout the decision-making process as she considers various pregnancy options, as well as the emotions the birth father is likely to experience.
Basic Skills
Trainees will increase their awareness of their attitudes and biases pertaining to adoption so that they are able to present the adoption option in an objective, non-biased manner.
Trainees will increase their sensitivity, understanding and skills regarding the influences that both a birth mother and birth father may experience from family, peers, and community.
Trainees will improve their basic counseling skills, including cultural competence, listening, building rapport, recognizing someone in crisis, being empathetic and treating clients with respect.
Training participants who will counsel pregnant women will be skilled in non-directive counseling to ensure that adoption information, and information about other pregnancy options, is presented objectively, without bias or judgment.
Consistent with State and Federal law, trainees will increase their knowledge of adoption and adoption procedures so that they are able to present accurate and up-to-date information during counseling consistent with State and Federal law.
Training participants will increase their knowledge of available adoption-related referral resources and how to assess the quality and/or appropriateness of these resources.
Trainees who will counsel pregnant women will have basic case management skills, including the ability to assess service needs and make appropriate referrals.
Curriculum
The training curriculum will include interactive exercises that promote skills development, such as role-playing and discussions of potential responses to various scenarios.
The training curriculum will include exercises, such as attitude awareness activities, that promote awareness of personal biases, prejudices, and negative attitudes and how they impact the provision of adoption information, as well as information on other pregnancy options.
The training curriculum will include a component in which birth parents, adoptive parents, and/or adult adoptees present their experiences with adoption.
The training curriculum will include resource materials that trainees can take with them to refer to when they are providing counseling on pregnancy options and to disseminate to the women they are counseling.
Training Structure
The training should involve no more than 2 (6-hour) days.
The training should be conducted by experienced trainers.
The training should include presentations and opportunities for interaction with professionals from both the health field and the adoption field.
Appendix C: Key Pilot Study Findings
Key Pilot Study Findings
Trainee Knowledge Before and After IAATP Training
Prior to completing the IAATP training session, more than half (57%) of the pilot class participants described themselves as very familiar (18%) or somewhat familiar (39%) with the adoption process. Based on trainees’ responses at pre-test to knowledge-based True and False items, pre-training knowledge was greatest regarding non-directive, non-coercive counseling practices in general (e.g., rapport building, responsiveness to client preferences, and eliminating personal biases from discussion with clients) and referral practices. Knowledge was less evident regarding the unique cultural considerations that may arise in the context of options counseling (e.g., the need to be responsive to client perceptions of the health care professional as an authority figure).
Participants had limited knowledge at pre-test about the characteristics of the various types of adoption arrangements (i.e., open, semi-open, closed, and kinship) and adoption terminology; or Federal and state laws pertaining to adoption and the rights of birth parents, adoptive parents, and adopted individuals. The unique considerations pertaining to the counseling and rights of birth fathers and teenagers were areas in which knowledge was particularly low. All of these areas are a major focus in the IAATP training.
After completing the IAATP training session, virtually all (97%) of the respondents described themselves as “very familiar” (29%) or “somewhat familiar” (68%) with the adoption process. Three months post-training, the trainees’ responses to knowledge-based True and False items, indicated that knowledge remained high regarding non-directive, non-coercive counseling practices and referral practices. Knowledge remained less evident regarding how to be culturally responsive in the context of options counseling.
Participants exhibited substantial improvement in their post-training knowledge about the characteristics of the various types of adoption arrangements (i.e., open, semi-open, closed, and kinship) and adoption terminology; or Federal and state laws pertaining to adoption and the rights of birth parents, adoptive parents, and adopted individuals. Respondents scores related to birth fathers and teenagers were markedly high compared to the pre-test scores.
Trainee Attitudes/Opinions about Adoption Before and After IAATP Training
Prior to the training, trainees were asked to describe their overall opinion about adoption. Nearly three-quarters (72%) of trainees responded “very favorable” and an additional 22% characterized their opinion as “somewhat favorable” prior to the training. Trainees also expressed favorable opinions regarding the appropriateness of the adoption option. Ninety-seven percent (97%) “strongly agreed” or “agreed” that the adoption option should be presented when a woman is unsure of her decision regarding her pregnancy. Similarly 86% of trainees expressed agreement that adoption is an equally viable option to the other options for an unintended pregnancy.
At three months post-training nearly two-thirds (62%) of trainees reported a “very favorable” opinion about adoption. An additional 29% reported that their opinion was “somewhat favorable.” Trainees continued to express favorable opinions regarding the appropriateness of the adoption option. Eighty-eight percent (88%) of follow-up respondents “strongly agreed” or “agreed” that the adoption option should be presented when a woman is unsure of her decision regarding her pregnancy. Eighty-two (82%) of trainees responding at follow-up expressed agreement that adoption is an equally viable option to other pregnancy options.
Conversely, 4% of trainees “strongly agreed” or “agreed” at pre-test that placing a child for adoption was a kind of abandonment. Six (6%) of follow-up respondents “strongly agreed” or “agreed.” Given a variety of scenarios in which children adopted as infants could be more, equally, or less likely to have problems or perform well than non-adopted children (e.g., be well adjusted, have problems with drugs and alcohol), trainees consistently reported adopted children were “equally likely” to perform or not perform as well as other children. “Equally likely” responses were given by at least 85-90% of respondents for each scenario at pre-test and 79-85% of respondents at 3-month follow-up.
Trainee Behaviors/Skills Used in Options Counseling Before and After IAATP Training
Non-directive, non-coercive counseling skills
Prior to receiving the IAATP training, participants were likely to apply non-directive counseling techniques when providing options counseling. Nearly half of all trainees reported that when talking to clients with an unintended pregnancy about their options they “often” utilized open-ended questions (43%); helped clients find their own answers (40%); and tried to make the conversation interactive (49%). Similarly, more than half (57%) of participants did not let their own values guide the discussion, reporting that they “rarely” (17%) or “never” (40%) allowed their own values into the discussion.
At three months post-training, a greater proportion of respondents reported that they applied non-directive counseling techniques when providing options counseling. Sixty-eight percent (68%) of trainees reported that when talking to clients with an unintended pregnancy about their options they “often” utilized open-ended questions; 59% helped clients find their own answers; and a full 86% tried to make the conversation interactive (up from 49% at pre-test). As many as 81% of participants reported that they did not let their own values guide the discussion, stating that they “rarely” (33%) or “never” (48%) allowed their own values into the discussion.
Discussing the adoption option
In terms of discussing the adoption option, of those participants that provided options counseling prior to the training, more than half (52%) reported that they were “very likely” or “likely” to present adoption as an option with clients experiencing an unintended pregnancy. Twenty-eight percent (28%) were “somewhat likely” and 20% were “not likely” or “not likely at all” to discuss adoption as an option.
At follow-up more than three-quarters (77%) of participants that provided options counseling reported that they were “very likely” or “likely” to present adoption as an option with clients experiencing an unintended pregnancy. Eighteen percent (18%) were “somewhat likely” and 5% were “not likely” to discuss the option of adoption.
Other related counseling activities
At pre-test more than half of participants that provided options counseling prior to the IAATP training reported that they “often” engaged in discussing the client’s reaction to the pregnancy (58%), discussing the advantages and disadvantages of the various pregnancy options (50%), and assessed the client’s need for other supportive services (54%). Counseling activities that were more culturally based or that required legal knowledge of adoption were less often engaged in. These less frequent activities included discussing the possibility of including other family members in future discussions (41%) and explaining the rights of birth mothers, birth fathers, and families according to applicable federal and state laws (20%).
Following the IAATP training, a greater percentage of trainees reported engaging in more in-depth discussion with clients. Nearly three-quarters (71%) of participants that provided options counseling “often” engaged in discussing the client’s reaction to the pregnancy, discussing the advantages and disadvantages of the various pregnancy options (70%), and assessed the client’s need for other supportive services (65%). Counseling activities that required additional focus on culture also increased among respondents. As an example, discussing the possibility of including other family members in future discussions increased to 55% of respondents. However, no change was indicated in the number of trainees that addressed more legally-based information about adoption. The number of respondents reporting that they engaged in explaining the rights of birth mothers, birth fathers, and families according to applicable Federal and state laws remained at 20%.
| File Type | application/msword |
| File Title | OMB Form 83-I Supporting Statement |
| Author | Keating |
| Last Modified By | keating |
| File Modified | 2009-12-08 |
| File Created | 2009-12-08 |