The city of Baltimore has an increasing issue with STD infection rates. In conjunction with the aim of the Health People 2020 goal, our program, STI Prevention for Baltimore City High School Students, will promote healthy sexual behaviors, strengthen community capacity, and increase access to quality services to prevent sexually transmitted diseases. Our overarching goal will aim to reduce STI transmission by 20% in Baltimore City public high school students by 2020.

The framework for the program will utilize the Theory of Reasoned Action/Planned Behavior Model. By utilizing this theory, the students will have the tools and resources to develop attitudes and behaviors that encourage safe sex. The combination of this theory and our implementation activities will aid in not only changing the attitudes of individuals within the ages of 14 to 18, but also those of the community as a whole.

Our intervention methods will include working directly with high schools to provide educational programs and resources. This will be done by conducting STI awareness health fairs throughout these schools in conjunction with providing on-site school based health centers. These will provide students with contraception and STI/HIV testing at their will.

A comprehensive evaluation will be utilized to measure the effectiveness of our implementation and overall impact of the program. A process evaluation will be conducted to determine the quality of the program as it will be implemented. This will also include the administering of a Pre-Test that will later be a reflection on the attitudes of the students towards sexual behaviors.

Later, an impact evaluation will be held with the aid of a Post-test . For the students to participate they will be given incentives such as gift cards which will be included in our 1.5 million dollar evaluation budget. This post-test will aid in evaluation the direct effect of the health intervention of the program. A year after the program has been implemented, an outcome evaluation will be held. This will be an additional follow-up with the students to determine if their attitudes have changed or remained different after their participation in the program. This will be conducted through the use of an online survey with question that resemble the Pre- and Post-test.

With the implementation of this comprehensive evaluation, we hope to provide the necessary resources to create a change in attitudes and behaviors for the students. If implemented and measured correctly, the program will have possibility to achieve its goal in reducing STI transmission by 20% in Baltimore City public high schools by 2020.

Background

Healthy People 2020 provides a science based, 10-year national objectives for improving the health of all Americans. Among the Healthy People 2020 goals and objectives a topic is sexually transmitted diseases. According to the Centers for Disease Control and prevention (2016) nearly 20 million new sexually transmitted infection occur every year, accounting for almost 16 billion in health care cost annually (Centers for Disease Control and Prevention[CDC],2016). The program STI Prevention for Baltimore City High School Students is designed to target the Healthy people 2020 goal for sexually transmitted diseases. The goal of this topic is to promote healthy sexual behaviors, strengthen community capacity, and increase access to quality services to prevent sexually transmitted diseases (STDs) and their complications. STI prevention for Baltimore City High Schools Students aims to reduce STI transmission by 20% in Baltimore City public high school students by 2020.

Health Promotion Program

Theory

The theory we will be using is the Theory of Reasoned Action model. This theory was developed in the late 1960’s by Fishbein and Icek Azjen (Lezin, 2017). This theory focuses on a person’s intention to behave a certain way. Theory of Reasoned Action looks at a person’s or population attitude towards that behavior as well as the subjective norms of influential people.This theory implies that a person’s behavior is determined by his/her intention to perform the behavior. Therefore the best predictor of behavior is intention(University of Twente,2017). In our program we are trying to measure whether Baltimore City public high school students will perform specific behaviors such as having safe sex and getting tested.This will be measured by implementing a STI education program on STI’s and measuring intention to perform behavior which will be an indication of behavior. The first step our program includes conducting pre-tests to help us better understand the attitude of the population. The pre-test will include questions e.g. (I trust my partner and do not feel the need to use condoms, I feel comfortable going ). See appendices for the rest of the test. Using the results of our pre- and post tests, we will identify the outcomes of the students behavior and determine whether or not they are positive or negative and what influences their decisions. By differentiating the types of situations and factors we should be able to identify the specific contributions of attitudes and subjective norms.

Target Population

Baltimore City STD rates last recorded in 2016 included diseases such as chlamydia, gonorrhea, and syphilis. Chlamydia rates were listed at 1,192 per 100,000 population (Baltimore City Health Department, 2017A). Gonorrhea ranged from 569 per 100,000 population (Baltimore City Health Department, 2017B). Syphilis was found least common among the three ranging at 31 per 100,000 population (Baltimore City Health Department, 2017C). HIV infection in Maryland as a whole is estimated to be at 1,347 people in 2015, putting the state at 7 out of the 50 in diagnoses that year (Centers for Disease Control and Prevention, 2017). The program will focus on ages 14 to 18 attending public high schools in Baltimore City. Aiming to change the attitudes of these teens targets the beginning of STDs and can help promote healthy sexual methods, condom use, and health services.

Logic model

Inputs

Activities

Evaluation

Process (outputs) Impact (impact) Outcome(outcome)

Develop curriculum & resources

Funding

Educators & Students

Monitoring

Attendance slips for assembly and health fair to confirm we are reaching intended audiance

Pre-and post-test comparison

Living with an STD/STI guest speakers

Maintain & reduce STD rates

-Long term attitude changes (likert questionnaire)

Collaborate with Baltimore City Health Department

Teens (male & female) ages 15-19

Intentions likert questionnaire

Monitoring program resources (fiscal)

Monitor teacher satisfaction with the WRAP IT program

STD/STI awareness After school health fair

Decrease initial rate of STD

Hands-on session on how to use female and male condoms.

Incentives

Assumptions

Programs will be conducted at Baltimore City public high schools

External Factors

Students receive school credit for attending class.

One class a week.

Activities

The program will aim to increase the perceptions of risk when engaging in unhealthy sexual behaviors. With the aid of community health workers, students will receive education on developing attitudes and values that support healthy decision making on refusing pressures, negotiating safer choices and seeking help. This will be done by conducting STI awareness health fairs throughout the Baltimore City public high schools. At each health fair, students will be given raffle tickets for completing pre-tests and post-tests in the hopes of winning prizes. The program will also aim to establish on-site school based health centers to provide students with easy access to condoms, contraception, and STD/HIV testing. Throughout the implementation, the program will also launch an assembly of individuals infected with STIs to give their individual testimonies on living with a sexually transmitted disease. They will travel to each public high school to speak with the students on their experiences and provide a first-hand look on risks of unsafe sexual behaviors.

Comprehensive Evaluation

We will be evaluating the effectiveness of the WRAP IT intervention program via comprehensive analysis. A comprehensive evaluation consists of a process evaluation, impact evaluation, and outcome evaluation. Process evaluations help stakeholders see how a program outcome or impact is achieved (Linnell, 2014) and focuses on the implementation of the program. Impact evaluations assess the efficacy and effectiveness of an intervention in terms of intended and unintended health, social, and economic outcomes (Spiegelman, 2016). Outcome evaluations “seek to determine whether changes in health behavior have produced anticipated changes in health status” (Sharma & Petosa, 2014, p. 19).

Process Evaluation

As part of our comprehensive analysis, the process evaluation will be performed simultaneously while implementing the WRAP IT program. This will be accomplished by checking the advancement of the program against the process evaluation checklist. Evaluation will be conducted by our Program Manager and Program Assistants. The quality of the program will be evaluated. Evaluation will take place at different sites. For example, part of the evaluation will take place at designated public high schools in Baltimore City to collect contact information from program participants and to distribute the Pre-Test before students attend assemblies and the health fair. Another site will include the office where the program administrative assistant will ensure signed consent from the school board and each participating high school. The evaluation checklist will ensure program implementers reach a certain amount of students per health fair, proper materials are created, acquired, and distributed, and the proper software needed for analysis of the evaluation is available. (Sample checklist in Appendix A)

Impact Evaluation

Our target population are Baltimore City adolescents, ages 14-18, who attend public high school. The instrument we use will measure the beliefs and attitudes of the target population towards contraceptive use. In the impact evaluation we will be evaluating the target population’s attitudes as it has been proven that attitudes altered by health intervention can accurately predict intentions and therefore health behaviors (Sheeran et al, 2016). Impact evaluation is vital in particular to ensure the program will produce a positive result. The pre-test will help to identify their attitudes towards preventative sexual methods, condom use, perceived risks of acquiring STIs, and utilizing health services. It will be distributed at the beginning of our program. The program manager will be conducting the evaluation. It will take place at different public schools located in Baltimore City.

As the pre-test is important and is the first step in conducting the impact evaluation. Therefore it is imperative that the target population complete both Likert tests. As an incentive for students to complete the test, gift baskets will be raffled off at each high school for students who attend the health fairs and complete both the pre-test and post-test. The winning raffle ticket will receive a prize basket of gift cards, a laptop, shirts, backpack and school supplies.

The same Likert test that is distributed to participants before the implementation of the health intervention program will again be administered at the end of the program as a post-test. Comparison of the pre- and post-tests will aid in evaluating the effect of the health intervention program on the attitudes and beliefs of program participants. (Sample Pre-/Post- Test Questions Appendix B)

Outcome Evaluation

A year after the ending of the implementation of the STD/STI education program, program implementers will use the outcome evaluation to follow up with the participants and evaluate if their attitudes about STDs and contraception has changed. This questionnaire will measure attitudes on STIs. This evaluation will monitor long term attitude changes amongst the students and measures long term success of the program. A web developer will be hired to develop the web page that will have this questionnaire. Students will be emailed a modified Likert questionnaire and will be incentivised to complete it by the possibility of winning gift cards, laptops,t-shirt, and school supplies.

Recommendations

Based on our comprehensive evaluation, we hope to get strong feedback on our process, impact, and outcome evaluations. Our goal through the process evaluation is to collect appropriate pre-test information, likert questionnaire data, and attendance slips. Using this information, we can track if we are targeting our intended participants along with the success of the program. The impact evaluation will present data on our pre and post test comparison data to identify attitudes of high school students before and after 6 months into the program . The compared pre and post test data will reveal a potential change in attitudes toward STD’s and ways to prevent STD rates. Lastly, the outcome evaluation will have students that participated follow up a year later on a web based questionnaire to show long term attitude changes in high school students towards STD’s.

APPENDIX A

SAMPLE CHECKLIST (PROCESS EVALUATION)

· Signed consent of program compliance with school administration (legal standards)

· Signed consent of STD/STI education signed from each target high school administrator

· Student permission slips for STD/STI prevention education sent to target high schools

· Assembly Attendance slips created

· Health fair Attendance slips created

· Contact information for each participant has been created

· Pre Tests have been administered

· Pre Tests have been scored

· Post Tests have been administered

Appendix B

SAMPLE PRE- AND POST- LIKERT TEST (IMPACT EVALUATION)

1. It is difficult to suggest contraceptive use to each sexual encounter

A- Strongly Agree

B- Agree

C- Neutral

D- Disagree

E- Strongly Disagree

2. I trust my partner and do not feel we need to use condoms

A- Strongly Agree

B- Agree

C- Neutral

D- Disagree

E- Strongly Disagree

3. Using female condoms are easy

A- Strongly Agree

B- Agree

C- Neutral

D- Disagree

E- Strongly Disagree

4. I feel comfortable going to the health center or doctor

A- Strongly Agree

B- Agree

C- Neutral

D- Disagree

E- Strongly Disagree

5. I feel comfortable getting condoms from the school health center

A- Strongly Agree

B- Agree

C- Neutral

D- Disagree

E- Strongly Disagree

Appendix C

SAMPLE LIKERT TEST (OUTCOME EVALUATION)

1. I feel comfortable using a condom or asking my partner to use a condom

A- Strongly Agree

B- Agree

C- Neutral

D- Disagree

E- Strongly Disagree

2. I have used a condom with my sexual partner(s) every time I have had sex.

A- Strongly Agree

B- Agree

C- Neutral

D- Disagree

E- Strongly Disagree

3. I know (without any doubt) that sexual partner does not have/has never had a STD/STI

A- Strongly Agree

B- Agree

C- Neutral

D- Disagree

E- Strongly Disagree

4. Only people who are sexually promiscuous get STDs.

A- Strongly Agree

B- Agree

C- Neutral

D- Disagree

E- Strongly Disagree

5. If I have unprotected sex with a partner, I feel it is the right choice to get tested.

A- Strongly Agree

B- Agree

C- Neutral

D- Disagree

E- Strongly Disagree

Appendix D

Budget

Process Evaluation Budget:

-Raffles($15,000): Shirts,gift cards(visa, itunes, food, starbucks, etc…), laptops, backpacks, and school supplies

-Data analyst ($64,000): File and record all of the high school’s attendance records/sheets for the Health fair and assembly slips.Students who attended the fair and assembly will receive attendance slips that will be given to the program coordinators.Data analyst will be responsible for this data (see that we are reaching our intended audience)

-Pre-test supplies ($2,500): Paper, Ink , and printing cost associated with the pre-test

-Health promotion specialist($46,796): Create the pre and post test questionnaire. Additionally later on will create the outcome questionnaire.

-Assistant($33,910): assist the health promotion specialist as well as the program manager with workload regarding the comprehensive evaluation portion of the program

-Program manager($125,000): monitors that the program is in compliance with legal standards, public school administration , and meets professional standards . Keep records documenting health program delivery(services,attendance,resources) .

-Consultant($85,000): Decide whether we are targeting the correct audience, using resources correctly, avoiding potential failures of interpretation

Impact Evaluation Budget:

-Paper supplies for the Likert Test ($2,500)

-Biostatician($80,000): Pre/post test comparison

-Assistant(34,000): Gather pre and post test data and input data

-Assistant($34,000): Distribute and collect pre and post tests to the schools and students

-Incentives($15,000)

-Evaluation Consultant($70,000): review programming and analyze strengths within the programs. Recommend methods for improvement.

Outcome Evaluation Budget:

-Web developer ($65,000-based on median annual income) : create Web page where we create a modified post test questionnaire to measure attitudes

-Assistant($34,000): Get all the students emails and responsible to send out the email alerting students to take questionaire

-Health promotion specialist ($47,000):Create the outcome evaluation likert questionnaire and compute the results from all of the Baltimore City public high schools data.Collect data from the questionnaire and evaluate the results

-Epidemiologist($70,000): assist the health promotion specialist in collecting the data from the outcome evaluation and computing the results from the conclusions of the WRAP IT program

-incentives($15,000): to take the likert test questionnaire

Other:

Travel expenses to deliver and gather resources and materials ( pre and post test, incentives, attendance information): $5,000

-Home base office to conduct evaluation at and work from when not visiting schools-(5,000/Month) 12 months= $60,000

-Evaluation meetings that will require resources such as time,food,paper material -$5,000

-IBM SPSS program = $178/ month. Will use program for two years = $4,272

-Miscellaneous: $15,000

-Indirect costs: $50,000

Total: $977,978

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