NURS 6720 Week 11 reflection example

The Phone Number I Never Questioned: Reflecting on the Assumption My Catch-Up Program Trusts Least

Student Name

College of Nursing, Walden University

NURS 6720: Population-Based Public Health Nursing Interventions

Instructor Name

Month Day, Year

The Phone Number I Never Questioned: Reflecting on the Assumption My Catch-Up Program Trusts Least

The Assumption

The assumption I trust least in the program I designed this term is that the state immunization registry holds contact details for resettled families that are current enough for reminders to reach them. Every component of the program leans on it. When I began the course, I did not see it as an assumption at all. A registry record has a phone number and an address, and I treated those fields as facts in the same way I treated the dates of doses. Only when I tried to write the stopping rule in Week 9 did I realize that a low result could mean the program was failing families, or simply that it had never reached them, and that I had no way to tell the two apart.

Where It Hid

Looking back, the assumption appears in every week's work, usually in a sentence I wrote quickly. In the aggregate profile, I sized the group by matching screening records to registry records on name, date of birth and sex. I noticed that placeholder birth dates and different spellings could create duplicate records, but I never asked about the contact fields on those same records, which were entered at the same screening visit and are likely to be older than anything else in the file.

In the evidence review, I set aside text reminders because of language and script, and noted in passing that numbers change. I then carried forward registry recall as transferring with adaptation, and the adaptation I named for contact details was to refresh them through the resettlement agency. I did not ask how current the agency's details would be for a family that arrived two or three years ago, when the agency's formal services have ended.

In the objectives, Process Objective 1 aimed to reach four in five households from the opening quarterly list by midyear. I justified the 80% by allowing for families who had left the city. I did not allow for families who are still here but whose numbers no longer work. That group could be large, and it would look, in the log, exactly like a family who chose not to answer. A worker making the third unanswered call has no way to know whether the phone rings in an empty room or in a home where the parent is on a shift. In the implementation plan, the community health workers' first task is to call. And in the evaluation, the reach measure depends on the same contact log, so if contact details are poor, both reach and effectiveness will look weak, and the evaluation will not say why.

What I Should Have Written Down

The W.K. Kellogg Foundation's guide to logic models treats assumptions as part of a program's logic: the beliefs about how and why the program will work, which should be stated alongside the inputs, activities and outcomes so that they can be examined (W.K. Kellogg Foundation, 2004). My logic model in Week 9 listed the registry list as an input. It did not list the assumption that the list could be used to reach people. If I had written that assumption down in Week 5, when I set the objectives, I would have seen that Process Objective 1 depended on it and that no objective measured it directly.

This is the change in my thinking that I can point to. I used to read a program design as a set of activities and targets. I now read it first for the conditions it takes for granted, and ask which of those conditions I have evidence for. Of all of them, the registry's contact details were the one I had the least evidence for and relied on most.

What I Would Test First

Before launch, I would propose a small audit of the contact fields. With authorization from the state immunization program and under whatever data agreement its rules require, the registry analyst would draw a random sample of about 40 records from the open-series list. A community health worker would attempt to reach each family using only the registry's contact details, and record whether the number worked, whether it reached the right family and whether the address was current. The same sample would then be checked against the resettlement agency's records, with the agency's permission, to see whether its details were more current.

The audit would take a few weeks and would answer the question the evaluation cannot. If most registry numbers work, the program can proceed as planned. If they do not, the program needs a different first phase: perhaps outreach through the mutual assistance association's meetings and the schools the children attend, which do not depend on a phone number at all. I would also add a measure to the evaluation: the share of contact attempts that fail because the details are wrong, so that low reach can be explained rather than guessed at.

A Second Assumption

There is a second assumption I trust only slightly more: that the mutual assistance association will have the capacity to lead outreach in year two. I argued in Week 8 that the partner families built is the one most likely to keep reaching them, and I still believe that. But building community capacity takes time and support, and it can fail if an organization is asked to take on more than it can manage (Shediac-Rizkallah & Bone, 1998). I have no evidence yet about the association's staffing, its finances or its experience supervising employees. I would ask its leaders directly, early in year one, what they would need, rather than assuming that willingness is the same as capacity.

What I Carry Forward

The most useful habit I take from this course is to read my own plans for their weakest dependency before anyone else does. Evaluations such as RE-AIM exist to find out whether a program reaches the people it intends to (Glasgow et al., 1999), but a designer can find some of the answer earlier, and more cheaply, by asking what the program assumes about how it will reach them.

References

Glasgow, R. E., Vogt, T. M., & Boles, S. M. (1999). Evaluating the public health impact of health promotion interventions: The RE-AIM framework. American Journal of Public Health, 89(9), 1322-1327. https://doi.org/10.2105/AJPH.89.9.1322

Shediac-Rizkallah, M. C., & Bone, L. R. (1998). Planning for the sustainability of community-based health programs: Conceptual frameworks and future directions for research, practice and policy. Health Education Research, 13(1), 87-108. https://doi.org/10.1093/her/13.1.87

W.K. Kellogg Foundation. (2004). Logic model development guide.