Kaczmarekb ph1120 Final Proposal

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
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.
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
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
INTRODUCTION
Dehydration is a serious health problem defined as an individual consuming an
inadequate amount of water and therefore not meeting their bodys 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
programs 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 bodys 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 and
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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 elses 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).
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 cant provide the means to have a home (DHUD, 2012).
However, homelessness doesnt 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.
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
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
to the shelter partners in Houston is the Houston Food Bank. Houston Food Bank plays a key
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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
homeless individuals who lack a basic necessity of life. Ms. Davis acknowledges that struggling
11
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
as Healthcare for the Homeless, receive year round water delivery. This access is actually only an
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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
go towards funding the program. IAW is looking to further diversify their source of revenue in
the future.
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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 individuals 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.
Information Sources
14
Information about IAW was obtained using the foundations website, the 2014 IAW
Annual Report, the 2013 IAW Financial Report, and interviews with Elena Davis and Angela
Ambers-Henderson.
15
Figure 1. Logic Model for the I Am Waters Water Program

Inputs
Activities
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
Outputs
Number of
staff and
volunteers to
execute
activities
Number of
water bottles
distributed by
site
Number of
homeless
individuals
who receive
water bottles
Short-Term
Outcomes
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 selfesteem among
homeless
Intermediate
Outcomes
Increased
access to
potable water
among
homeless
Increased
hydration
among
homeless
Long-Term
Outcomes
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 individuals 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 populations 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 populations 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 11C 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 individuals lack of knowledge of clean water sources, lack of
communication about hydration with individuals who are not homeless, perceived barriers to
19
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
21
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 individuals 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 groups 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 arent 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 (OSullivan
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 individuals 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 Banduras Social Cognitive Theory
(SCT) (McAlister, Perry, & Parcel, 2008). Self-efficacy deals with an individuals confidence to
perform a behavior (McAlister et al., 2008). An individuals confidence commonly stems from
feelings of self-worth and a high self-esteem. Self-esteem is also related to the SelfDetermination 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 individuals 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 (RaleighDuRoff, 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 (RaleighDuRoff, 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 (LavizzoMourey et al., 1988). The study concluded that an individuals 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 bodys 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 individuals 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 individuals 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 was also a significant
28
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 (GrahamJones 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 drinking
30
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 arent 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 stakeholders 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?
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?
verbally to program
participants
-Expert opinion
What enabled the homeless

individuals to participate in
verbally to program
participants
-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?
verbally to program
participants
Why did aware homeless

individuals not participate in
-Expert opinion
Are there barriers to

homeless individuals
participating in the IAW
water program?
-Expert opinion
What are the sociodemographic characteristics

of the homeless individuals
who do not participate in the
IAW water program?
verbally to program
participants
- 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?

shelter partners

What proportion of homeless

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

shelter partners

Differences Across Sites

Is there a variation in
coverage between the sites
implementing the IAW water
program?
-Records from participating -Program staff expectations

shelter partners
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)?

shelter partners

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
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
-Records from shelter

partners

partners
verbally to program
participants


-Needs of target population

-Performance of similar
programs
Duration
Did program implementers
allot enough time for IAW
water bottles to be
distributed?

partners
Does the distribution of IAW

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

partners


implementers

implementers
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


implementers
38
Are the workers

knowledgeable in addressing
dehydration?
-Observation of program
implementation by evaluator
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?

implementers

Are the shelter workers

readily available?
verbally to program
participants

What is a shelter workers

typical length of service?

partners
programs

implementers
-Expert opinion
verbally to program
participants
Facilities, Resources, Materials, and Supplies

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

implementers

verbally to program
participants
What assets support the

delivery the IAW water
bottles compared to what
was intended?

implementers
Is funding for the program

adequate to implement
distribution of IAW water
bottles?
-Interviews with
implementers
program -IAW budget
Is there enough time given to

implement distribution of
-Interviews
program -Program staff expectations
with

programs
39
IAW water bottles?
implementers

programs
Are there enough IAW water

bottles available for
distribution?
-Interviews with
implementers
program -Staff expectations based on

program goals
-Shelter inventory
Consistency
Is delivery of the IAW water
program consistent across
the different shelters? Why
or why not?

implementers
Is the IAW water program

delivered at each shelter the
same way every time?

implementers

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

implementers

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?
verbally to program
participants

Do participants engage more

with particular workers as
compared to others?

verbally to program
participants
40
verbally to program
participants
Satisfaction
How satisfied are
participants with the IAW
water program as a whole?
verbally to program
participants

programs
-Participant preferences
How satisfied are

participants with the workers
who implement the IAW
water program at the shelter?
verbally to program
participants

programs
-Participant preferences
Coordination
Does the program staff
coordinate with the workers
implementing the IAW water
program at the shelter?
-Interviews with program -Program staff expectations

implementers and IAW staff based on established goals
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)

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?

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 pre42
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:
NR
X O1
----------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 mission of
45
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
47
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
Rosenberg Self-Esteem Scale, 10-item

Likert scale questionnaire
Time
Reliability
/Measurement
Primary Reference Article/Survey
Validity Information
Internal consistency =
At
0.77; minimum
Self-esteem among
Example item: I feel I do not have
follow- Coefficient of
homeless individuals much to be proud of. Choose: strongly
Reproducibility at
up
least 0.90
disagree, disagree, agree, strongly agree
Type of
Variable
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 Ordinal
variable
for homeless, cocaine-using, African-American Women.
Journal of Substance Abuse Treatment 28, 171179.
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.
48
Table 4. Proposed Measurement of the Communication Outcome for the IAW Water Program
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
Time
Reliability
/Measurement Validity Primary Reference Article/Survey
Information
In-depth interviews conducted

individually with both participants
(homeless individuals) and
facilitators (housed individuals)
Communication between
homeless and housed
individuals about
hydration
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
At
Interview schedule
follow- pretested
up
Type of
Variable
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 Qualitative
Health Care, 52(5), 449-66.
data
Example item for facilitator: Has

communication with the homeless
improved since distribution of the
water began?
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 tenitem 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
individuals 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 SelfEsteem 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 dont 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 interviewees 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. Lastly,
54
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 programs 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 programs 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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Kaczmarekb ph1120 Final Proposal

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Kaczmarekb ph1120 Final Proposal

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Evaluation Proposal for the I Am Waters Water Program

By: Brittany Kaczmarek

Methods: A nonrandomized two-group quasi-experimental design is proposed for the evaluation

PART ONE: PROGRAM DESCRIPTION

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

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

PART TWO: PROGRAM CRITIQUE

Support for Intervention Hypothesis

PART III: PROCESS EVALUATION

-Program staff expectations

How did program

-Program staff expectations

-Records from participating

-Data from previous studies

Why did homeless

What enabled the homeless

Are there specific subgroups

-Demographic records from

-Data from previous studies

What percent of the aware

-Data from previous studies

Why did aware homeless

Are there barriers to

What are the sociodemographic characteristics

- Data from previous

-Records from participating

-Program staff expectations

What proportion of homeless

-Records from participating

-Program staff expectations

Differences Across Sites

-Records from participating -Program staff expectations

-Records from participating

-Program staff expectations

Table 2. Evaluation of Program Delivery

Quality and Accuracy

Are the IAW water bottles

Is the speed of the delivery of

-Interviews with program

-Records from shelter

-Records from shelter

-Program staff expectations

-Program staff expectations

-Needs of target population

-Records from shelter

Does the distribution of IAW

-Records from shelter

-Program staff expectations

-Interviews with program

-Interviews with program

Is there an adequate amount

-Staffing records from

-Program staff expectations

-Interviews with program

Are the workers

Are the workers at the

Are the workers at the

-Interviews with program

-Program staff expectations

Are the shelter workers

-Program staff expectations

What is a shelter workers