Table of Evaluation Modules Summaries

Measures Developed for the HRSA HIV/AIDS Bureau's Special Projects of National Significance Cooperative Agreement on Innovative Treatment Models.
Funding Period: 1994-1999 by The Measurement Group


Module

Purpose

Content Domains
Module 1: Demographics- Contact Form

 

 Code major demographic characteristics of clients.

Code risk-background factors.

Code reason for form.

Code referrals provided at contacts.

 Race-ethnicity, gender, sexual orientation, age, reason for form, location, homeless status, HIV infection-retransmission risk factors, referrals to internal and external agencies and services.
Module 2: Intervention Form

 

 Code units of client services.

Code providers.

Code purpose of client services.

Code referrals provided at interventions.

Code medications ordered or provided.

 Types of service provided (outpatient medical, HIV testing/ counseling, mental health, social supports, etc.), providers (physician, social worker, peer, etc.), purpose of services, referrals made to ancillary services, medications ordered or provided.
Module 3: Presentations-Training Form

 

 Code type of presentation.

Code reason for presentation.

Code type of audience.

Code number of individuals of different demographic categories impacted.

 Type of presentation (group prevention, agency recruitment, training, advocacy, policy), type of audience (educators, community members, service agencies, etc.), number of males and females of different age groups and ethnic-racial backgrounds in the audience
Module 4: Individual Services Needed and Services Barriers Form

 

 Code services needed in the last six months and last month.

Code services received in the last six months and last month.

Code reason for not seeking-receiving needed services.

 Types of services include drug detoxification, residential drug treatment, outpatient or day treatment substance abuse treatment, shelter, food or other basic needs, dentistry, outpatient/inpatient medical, HIV-related services, mental health, self-help, counseling, pharmacy, vocational training, case management, prenatal/ pregnancy care, etc. Barriers including cost, accessibility, transportation, child care, staff disdain, language, coercion, disclosure concerns. Facilitators including caring staff, convenient location, and transportation.

Module 5: Technical Assistance Summary Form

 

 Code major aspects of technical assistance.

Code reason for technical assistance.

Code type of audience for technical assistance.

Code number of individuals of different demographic categories impacted.

 		Type of technical assistance, type of audience, number of males and females of different age groups, ethnic-racial backgrounds, and professional service groups for whom assistance was given.
Module 6: Technical Assistance Evaluation Form

 

 Code facets of satisfaction with the TA experience.

Rate value of TA for knowledge in a number of areas.

Rate pre-TA level of knowledge in a number of areas.

Rate post-TA levels of knowledge in a number of areas.

 		Overall satisfaction with the TA, specific dimensions of satisfaction (responsiveness, relevance, appropriateness, correct level, focus, efficiency), current knowledge levels, pre-TA knowledge levels, willingness to recommend TA for other projects and staff.
Module 7: Agency Capacity Interview

 

 Code services currently provided.

Code services added in the last year.

Determine service capacities.

Assess likelihood of services expansion.

 Capacity for a number of services including HIV inpatient and outpatient medical, mental health, substance abuse inpatient and outpatient treatment, shelter, basic needs, social services, family counseling, and ancillary services. Clients served. Likelihood of service expansion and barriers to expansion.
Module 8: Agency Infrastructure-Attitudes Form

 

 Assess current attitudes about the area HIV service system.

Assess belief that system is integrated and enmeshed.

Code beliefs about equity and fairness in the service system.

Assess likelihood of referral to service sources.

Determine individual priorities for the use of HIV treatment and prevention funds.

 		Determines how the individual perceives the qualities of the overall HIV service system in the area, rate how resources should be allocated.
Module 9: Agency Cohesiveness Rating Form

 Assess the degree to which agencies are connected to one another. Determines the cohesiveness of a group of service providers. Requires the use of advanced multidimensional scaling methods to analyze the data as maps of providers.
Module 10: HIV Testing History Form

 

 Code times of previous testing.

Code previous testing history.

Code assistance rendered at previous testing times.

Code client belief or non-belief in previous HIV test results.

 Develop a timeline of the HIV testing history, determine when first tested HIV-positive, services needed at time of testing, services received at time of testing, pre- and post-test counseling history.
Module 11: Satisfaction with Services: General

 

 Code major aspects of satisfaction or dissatisfaction with services: general form for use with all populations. Overall ratings of satisfaction with services, perception of service providers, importance rankings for service issues, perceived barriers, likelihood of future use and positive recommendations to family and peers.
Module 16: Standard Focus Group Characteristics Form

 

 		Code participant characteristics in focus groups; client conclusions. Covers client assessments of priorities for focus group topics. Standardized coding system for participant demographics.
Module 17: Brief Health and Functioning Questionnaire – SF-21 Form

 

 		Code participant health problems and syndromes diagnostic of, and related to, HIV disease.

Code general health levels and issues.

Code physical symptoms and problems.

Measure Health-Related Quality of Life

 		Health items of major relevance to HIV disease. Includes CDC indicators of stage of HIV disease. May be used for repeatedly assessing progression of HIV disease.
Module 18: Abbreviated HIV/AIDS Health Form – SF-21 Form only

 

 		Code follow-up/repeated assessments of client health, progression of disease, and Health-Related Quality of Life. Health items as above in an abbreviated format. Changes since last assessment.
Module 19: HIV/AIDS Health Form: Women

 

 Code women-specific health issues.

Code issues such as child-rearing, birth control, pregnancy, etc. of particular relevance to a woman’s health and functioning.

 		Items particularly related to women’s health including reproductive history and medical syndromes and symptoms, STDs, other medical issues.
Module 20. HIV/AIDS Risk Behaviors Form

 

 Code major issues of HIV risk and retransmission risk due to sexual contact.

Code major issues of HIV risk and retransmission risk due to injection drug use.

Code major issues of HIV risk and retransmission risk due to other means.

 		Number of sexual partners, sex acts with and without latex protection, injection drug use, hemophilia and other blood transfers, tendency to have sex while intoxicated or high, sex trade, sexual history of sex partners.
Module 21: Weekly Program Census Form

 

 Method for capturing the weekly census on functional service units. Weekly total census, demographic characteristics of census, method of collecting census.
Module 22: Quality of Life Form

 

 Objective indicator of ability to engage in life activities such as being a partner, employment, attending recreational activities, etc.

Objective indicator of presence of sufficient resources to provide adequate standard of living.

Subjective indicator of self-perceived satisfaction with domain areas identified for objective indicators.

 		Rated ability to fully participate in and enjoy a large number of domains of activities including employment, being a partner, sexual relationships, recreation, travel, strenuous activity – exercise, enmeshment in the community. Checklist of activities participated in during the past month.
Module 24: Substance Abuse History Form

 

 Standardized measure of lifetime and current substance abuse including both injection and non-injection routes of administration. Ever used, use in last 6 months, use in last month of: alcohol, marijuana, cocaine, heroin, crack, speedballs, amphetamines, PCP, LSD, other hallucinogens, barbiturates, other drugs. Injection drug use. Needle sharing/cleaning behaviors.
Module 25: Activities of Daily Living Form

 

 Standardized measure to assess current ability to conduct standard living activities including meal preparation, use of telephone, handling finances, taking medication, etc. Checklist of clients’ ability to do daily life activities: dressing, preparing meals, driving an automobile, attending work, etc. Designed for repeated assessments, possibly daily.
Module 26: Current Psychological Distress Form

 

 Standardized measure of psychological distress comparable to major studies conducted over 15 years throughout the US: Center for Epidemiological Studies Depression Scale (CES-D). In last seven days: depressed, moody, blue, lonely, etc.
Module 29: Standardized Focus Group Instructions

 

 Standardized specifications for conducting focus groups.

Suggested format for reporting focus group results.

Suggested qualitative and quantitative questions for focus groups.

 Standard grid for eliciting focus group free-responses, demographic items to code focus group participants, facilitator form to code reason for focus group and major dynamics, standardized methods for ranking alternatives.
Module 31: Sexual Behaviors Form

 

 Code current sexual practices including partners. Number of current partners of both sexes, total sexual partners in past years, sexual partners of both sexes who were injection drug users, sex with male and female partners with and without latex protection, types of sexual practices.
Module 32: Abuse History

 

 Code history of physical abuse.

Code levels of physical abuse.

Code history of sexual abuse.

Code current levels of sexual abuse.

Code admitted behaviors as abuser.

 		Lifetime and current indicators of physical and sexual abuse from parents, other family, and strangers. Admitted abuse against others.
Module 33: Self Esteem

 

 Code current levels of self-esteem. Use major, multidimensional self-esteem scale. (Rosenberg)
Module 34: Partner Disclosure Risk Form

 

 Code likelihood of being recipient of partner violence if HIV status is disclosed. Indicators of potential partner psychological, verbal, and physical violence at disclosure of HIV status.
Module 35: Homelessness Index

 

 Code stability of current housing situations.

Code history of housing stability.

 Time history of places lived and with whom, log of places slept in the last year and month, use of shelters, ability to support a permanent home.
Module 36: Family Composition Form

 

 Code current and past family members.

Code major aspects of family functioning including cohesiveness, support, stability.

 		History of children, partners, siblings, parents, extended family. Ratings of current family problems and strengths.
Module 41: Standardized Nutrition Schedule

 

 Standardized nutrition recording form permitting an estimate of calories consumed. Overall schedule of food consumed, total calorie estimate, hunger, desire to eat.
Module 42: Psychosocial Observations Form

 

 Code perceived level of cognitive, social, intellectual functioning.

Code appearance, obvious behavior problems, emotional state.

Code manner of speaking.

 		Ratings of functioning levels; behavioral descriptions of emotional state, appearance, stated problems, inferred problems, manner of speaking, possible intoxication, disorganization.
Module 43: Clinical Observations Form

 

 Code levels of behavioral, mental, and health problems.

Code unusual incidents.

Code changes in status.

 Ratings of clinical problem levels conducted by clinical staff. Goes beyond psychosocial observations by requiring trained clinical inference.
Module 44: Progress Ratings Form

 

 Code progress of deterioration, HIV disease, or adherence to treatment regimens.

Code barriers to progress.

Code client satisfaction with progress.

 		Ratings of overall progress including changes.
Module 45: Life Stressors Form

 

 Standard measure of the presence of significant sources of life stress Checklist of major life stressors and valence associated with each.
Module 46: Social Supports Form

 

 Standard measure of the presence and importance of sources for social support. Ratings of support from partner, children, parents, other family, HIV-positive individuals, church, employer, male friends, female friends, etc.
Module 47: Coping

 

 Standard indicators of modes of coping with stress and illness. Assessment of coping through denial, projection, discounting, emotional leveling, and other methods. Coping will be assessed both as a general theme and in terms of coping with HIV disease.
Module 49: Staff Characteristics Form

 

 Major demographic characteristics of staff service provider.

Experiential background of service provider.

Educational background of service provider.

Major "treatment philosophy" of service provider.

 		Staff race-ethnicity, age, gender, sexual orientation, similarity to target groups (HIV-positive, drug abuser, mental health diagnosis), educational background, ratings of agreement with treatment practices and philosophy items.
Module 51: Referral Form

 

 Codes referrals made to participating social service agencies. Tracking of referrals for social services, mental health, substance abuse treatment, basic needs services.
Module 53: Trainee Characteristics Form

 

 Code major demographic characteristics of trainees.

Code professional background.

Code prior experience/knowledge of HIV/AIDS issues.

 Ethnic-racial, age, types of professional training and degrees, professional identification and licensure, experience with clinical aspects of HIV/AIDS, experience with HIV/AIDS prevention techniques.
Module 54: Trainee Reactions to Training Form

 

 Code major facets of satisfaction with the training experience.

Code satisfaction with trainers.

Rate value of training for knowledge in a number of HIV/AIDS-related areas.

 		Satisfaction with training, connection with trainers, perceived utility of information-skills presented, value of training and relevance for own job.
Module 55: Trainee Reactions to Training Follow-up Form

 

 Short version of above used for temporal follow-up. Satisfaction with training, connection with trainers, perceived utility of information-skills presented, value of training and relevance for own job.
Module 56: Trainer Characteristics Form

 

 Major demographic characteristics of trainer.

Experiential background of  trainer.

Educational background of trainer.

Major "philosophy" of trainer.

 Trainer race-ethnicity, age, gender, sexual orientation, similarity to target groups (HIV-positive, drug abuser, mental health diagnosis), educational background, ratings of agreement with practices and philosophy items.
Module 57: Training Evaluation Form: Knowledge, Attitudes, Comfort

 

 Code major areas of HIV/AIDS knowledge.

Code attitudes toward HIV/AIDS and related conditions.

Code self-perceived comfort dealing with topics related to HIV/AIDS.

 Standardized scale of HIV/AIDS knowledge for health care professionals.

Standardized scale of attitudes toward HIV/AIDS and related conditions.

Standardized scale of degree of comfort in addressing HIV/AIDS topics.
Module 61: Hotline Client Background and Referral Form

 

 Codes client calls to a hotline or agency when such calls constitute a service.

Codes referrals made to participating social service agencies.

 Tracking of client characteristics and nature of the call. Tracking of referrals for social services, mental health, substance abuse treatment, basic needs services, etc.
Module 63: HIV Status Report, AIDS Related Variables

 

 Codes major HIV disease related variables on a single form.

Items taken from HRSA Uniform Reporting System (URS).

 		CDC-defined disease stage, CD4 count, source of status, exposure category, TB status.
Module 64: Self Efficacy Scale

 

 Codes feelings of mastery Standardized scale with known reliability and validity.
Module 65: Acceptance of Disease Scale

 

 Codes acceptance of HIV disease.

Codes ability to view the successes and positive impact of one’s life.

Codes feelings that previously unresolved issues related to family and friends have been resolved.

 		To be determined.
Module 67: General Well Being Scale

 

 Codes feelings of well being in a number of different areas of life. Standardized scale by Andrews and Withey and used in General Social Survey since 1976. National data available. Used in hundreds of studies.
Module 68: Program Discharge Form

 

 Codes discharge date.

Codes reasons for program discharge.

 Reasons for discharge including voluntary and involuntary withdrawal from the program, movement from service area, death.
Module 71: Medical Health Form

 

 The purpose of this module is to assess medical health conditions that are related to HIV disease. Items are adapted from Adolescent SPNS National Evaluation; Codes HIV-related conditions such as PCP, MAI, TB, and other health problems.
Module 72: Missed Visit/ Appointment Form

 

 The purpose of this module is to record missed appointments or office visits by a client. This is a key issue in tracking adherence to program advice. Codes type of appointment missed and reason missed.
Module 73: Karnofsky and Disease Stage Scale

 

 The purpose of this form is to code stage of disease, CD4 count, and Karnofsky ratings for a client. Graphically represents stage of disease as a function of CD4 count; includes annotated Karnofsky rating scale.
Module 74: Urinalysis Report Form

 

 The purpose of this form is to record the results of urinalysis that may be conducted as part of monitoring for use of alcohol or other drugs. Codes substances detected and confirmed via urinalysis. Does not specify which assay method is used in the urinalysis.
Module 75: Disclosure Questionnaire

 

 The purpose of this module is to record which close friend and service providers the individual has informed about his/her HIV. Codes individuals who are close to the person, individuals who were told about client HIV, reasons for not disclosing, and whether or not service providers have been told.
Module 80: Collaborative Agencies Evaluation Form

 

 The purpose of this form is to assess how well collaborating agencies work with one another. Codes information about agency involvement, professional background, usefulness of agency’s trainings, collaboration/referral network improvements, changes/improvement in services provided, overall satisfaction with agency.
Module 81: Nutrition Clinic Evaluation Form

 

 The purpose of this interview is to gather information about the experiences and services received by clients at a HIV nutrition clinic. Codes information about client background, health ratings, ratings of perceived importance of various nutrition services, barriers to receiving nutrition services, involvement in nutrition visits.
Module 82: Training Impact Follow-Up Interview

 

 The purpose of this interview is to obtain information about the effectiveness of trainings on systems change and changes in patient care. Codes information about trainees’: major demographic characteristics, professional background, satisfaction with training, perceived effect of trainings on changes in patient care and systems change.
Module 83: Training Evaluation Form for National AIDS Update

 

 The purpose of this form is to evaluate the youth component of the National AIDS Update Conference workshops. Codes educational background, types of professional training and degrees, comfort and knowledge with workshop topics, satisfaction with workshop, usefulness of information presented, quality of workshop and relevance for own job.
Module 84: Key Informant Interviews, Comprehensive Healthcare Projects

 

 The purpose of this interview is to elicit feedback from stakeholders in each of three comprehensive healthcare service delivery programs for persons living with HIV/AIDS. Codes information about the progress of these projects in areas such as patient recruitment and retention, accessibility, quality of care, education and training, consumer involvement, development of service networks, and information dissemination.
Module P1: Adherence to Protease Inhibitor Therapy

 

 The purpose of this interview is to gauge a patient’s overall adherence to protease inhibitor therapy. Codes information about the number of medications a patient is taking, provider-patient interactions, protease inhibitor history, participation in clinical trials, medication side effects experienced, attitudes about medication, social interactions.

 

Related Information:

Modules and Instruments Developed by The Measurement Group
 The Measurement Group Evaluation & Research Tools

© Copyright 1996-2005 by The Measurement Group LLC. All rights reserved.