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Internship Plan for The March of Dimes Foundation

Chelsea Whitfield






The March of Dimes Foundation, Triad Area
410 Brookstown Ave, Winston-Salem, NC 2710
Site Preceptor: Brenda Stubbs, Triad Regional Director
Co-Preceptor: Kweli Rashied-Henry, NC Coordinator

(Part 1)
Health Problem
Birth defects, low birthweight, and preterm labor are important factors that affect overall
infant health. Birth defects are serious health conditions that are present at birth which can change
the shape or function of one or more parts of the body. Birth defects can cause problems with
overall health over time and causes issues with the way the body is developed and how the body
functions (Birth Defects, 2015). According to The March of Dimes global report, each year an
estimated 7.9 million children are born with a serious birth defect from genetic and/or partially
genetic origins (Christianson, Howson, & Modell, 2006). This accounts for nearly 6 percent of total
births worldwide. In the Unites States, 1 in every 33 babies born are affected by birth defects. This
translates to approximately 120,000 babies affected by birth defects each year (The Centers for
Disease Control and Prevention, 2014). According to the State Center for Health Statistics, in 2010
there were 4,446 babies born with birth defects in North Carolina (NC SCHS, 2010). Birth defects
accounts for approximately 20 percent of all infant deaths in the United States, which makes it one
of the leading causes of infant mortality (Matthews & MacDorman, 2012). Some common birth
defects are heart defects, cleft lip and cleft palate, hearing loss, and spina bifida.

Additionally, in relation to birth defects posing serious health issues for babies, low

birthweight is also an important health problem. Low birthweight babies are defined as being born
weighing less than 5 pounds and 8 ounces. In the United States, low birthweight babies account for
1 in every 12 babies born (Low Birthweight, 2015). The two main causes of low birthweight are
premature birth and fetal growth restrictions (Low Birthweight, 2015). Preterm labor is labor
that begins before 37 weeks of pregnancy (Preterm Labor & Premature Birth, 2015).
Approximately 1 in 12 babies born in the United States are born prematurely (Low Birthweight,
2015). Babies born in preterm labor are at an increased risk for health problems and long term
health effects such as problems affecting the brain, lungs, and vision. Fetal growth restriction, or

growth-restricted, is defined as a baby that has not gained the weight it should during birth (Low
Birthweight, 2015). Fetal growth restriction can be due to the weight of the parents (lower
weight) or due to complications during the pregnancy which slowed or stopped the growth of the
baby such as an infection (Low Birthweight, 2015).

The risk factors that increase the chances for birth defects and low birthweight babies can

be a combination of factors including genetics, environmental, and lifestyle behaviors (Facts about
Birth Defects, 2014). The causes of some birth defects, such as genital and urinary tract defects,
remain unknown and further research is still needed in these areas. Chronic health conditions such
as hypertension and diabetes are medical risk factors that increase the chances of preterm labor
and low birthweight. Negative lifestyle behaviors such as smoking, alcohol, and drug use can
strongly increase the chances of preterm labor resulting in birth defects and/or low birthweight.
According to the American College of Obstetricians and Gynecologists, smoking can increase the
risk of a low birthweight baby by 20 percent (ACOG, 2013). Other risk factors include heredity or
having someone in the family who has a birth defect, pregnancy that occurs younger than 17 or
older than 34, and improper weight gain during pregnancy.

According to The March of Dimes website, the organization was founded during the era of

World War II in 1938 by Franklin D. Roosevelt, originally named The National Foundation for
Infantile Paralysis (NFIP). The purpose of the organization was to fight the rising polio epidemic
that, at the time did not have a cure. Basil OConnor, the organizations first president, assisted in
running the organization and creating a network of local chapters to raise funds to support polio
research and to deliver aids to those affected by the virus. During this time more than 3,100 county
chapters were established in the United States. The March of Dimes became the title for the
organizations yearly fundraising events in support of research. In 1946, Franklin D. Roosevelt was
memorialized on the United States dime (A History, 2010). In 1954, Dr. Jonas Salk created the
polio vaccine. After the Salk vaccine was licensed for use, it resulted in a rapid decline of polio (Salk

Institute for Biological Studies, 2015). After accomplishing its original mission to cure polio, the
organizations choice was to continue to focus on disabilities and disorders occurring in infancy and
childhood. Under the direction of Basil OConnor, the organization then shifted its new mission to
birth defects prevention in 1958. In 1976, the NFIP changed its name to The March of Dimes Birth
Defects Foundation. The focus of the organization then shifted to research, prevention of birth
defects, and reducing premature and low birthweight babies (A History, 2010).

Search strategies employed to locate this information included searching peer reviewed

journals and respected sources. Using keywords and phrases such as birth defects, low birthweight,
preterm birth, incidence/prevalence, polio, and The March of Dimes history were reviewed. These
search strategies were used to find history and evidence in identifying a health problem and non-
health problem related to The March of Dimes Foundation.
Non-Health Problem

The March of Dimes regional coordinators are responsible for conducting Provider

Education trainings in their specified region throughout the year for the North Carolina
Preconception Health Campaign. Those who participate in the Provider Trainings are doctors and
healthcare workers. Participants who complete the trainings receive free continuing education
credits. The Centers for Disease Control and Prevention (CDC) has developed 10 recommendations
aimed to improve the health of women, men, and couples, before conception of a pregnancy. The
March of Dimes Provider Education trainings are centered on 6 of the 10 CDC (2014)
recommendations. The 6 recommendations are: 1) Individual Responsibility across the Lifespan, 2)
Consumer Awareness, 3) Preventative Visits, 4) Interventions for Identified Risks, 5)
Interconception Care, and 6) Pre-Pregnancy Check-ups (Johnson, Posner, Biermann, & Cordero,
2006).

After discussion of the Provider Education Trainings with Brenda Stubbs (2015), Triad

Regional Director, she stated that participants receive an evaluation form upon completion of the

training that is used to determine strengths, weaknesses, and improvements for future training
sessions. Following the immediate evaluation, there is no formal follow up evaluation completed
with participants who received the training to determine if the information covered in the training
session is used as it was intended. Due to The March of Dimes being a fairly small organization in
North Carolina, the organization may not have the capacity to conduct an in-depth follow up
evaluation with providers. A subsequent evaluation would be critical in determining the
effectiveness of the provider training programs. The non-health problem to be addressed during
my internship is the lack of a formal evaluation of the Provider Education trainings.
Relevance to the Organization

The specified health and non-health problems, birth defects and lack of a formal evaluation,

are two very important and relevant issues to The March of Dimes organization. As mentioned
previously, the current mission and focus of The March of Dimes is preventing and decreasing birth
defects, preterm labor, low birthweight babies, and the overall prevention of infant mortality. The
goals of the March of Dimes North Carolina Preconception Health Campaign (NCPHC) are to reduce
infant mortality, birth defects, premature birth, and chronic health conditions in women, while also
aiming to increase intended pregnancies in North Carolina (About the March of Dimes, 2012). In
communication with Brenda Stubbs and Kweli Rashied-Henry (2015), NC Coordinator, both
expressed the need for a formal follow up evaluation of the Provider Education training program.
Kweli Rashied-Henry stated that concrete data from evaluations following the Provider Education
trainings would greatly benefit the organization because there is no current data supporting that
the information from the program is beneficial and useful. The SWOT analysis listed below
examines the initial thoughts and ideas for addressing the health and non-health issues.
Strengths
An evaluation tool is currently used to collect feedback from Provider Training participants.
Therefore, providing information to begin a thorough follow-up evaluation.
The current evaluation tool can be used to determine the needs for the follow-up
evaluation.

Weaknesses
There has not been a formal follow-up evaluation completed.
No one is currently addressing the follow-up evaluation issue for Provider Trainings in NC.
The current evaluation tool may not be electronic which could be a time consuming process.

Opportunities
Developing an in depth evaluation that could be used to improve the quality of the Provider
Education training program.
Developing partnerships between The March of Dimes and providers to increase
educational materials that are presented in the trainings which would potentially develop
the program and organization.
Providing a blueprint evaluation tool that could be used for future follow up evaluations.
Potential growth of the organization to hire an internal evaluator to conduct evaluations for
Provider Trainings for NC.
Threats

Failing to produce an adequate evaluation due to lack of response from Provider Training
participants.
Not receiving the initial evaluation information to determine factors that should be
addressed in the follow-up evaluation.
Lack of financial resources to conduct an evaluation for all Provider Trainings throughout
NC.
Risk of not reaching all Provider Training participants within the specified time period to
collect the data.

Ethical Analysis
Ethical concerns associated with this evaluation are cultural and socioeconomic barriers
which would affect patients. CDC preconception health recommendations such as individual
responsibility across the lifespan and preventative visits may be an underlying issue for
patients. Cultural barriers could interfere with the dietary consumption of Folic Acid but this
issue may not be addressed through providers. Socioeconomic factors such as transportation
and income could prevent patients from making preventative visits. Other ethical issues may
become apparent after conducting the in-depth evaluation. If ethical concerns are discovered
during the internship evaluation, it will be presented through the evaluation presentation.

(Part 2)
This section will be used to further analyze the health problem and non-health problem.
The approach to analyzing the health problems of birth defects, low birth weight, and premature
birth is to look at the issues in a broad sense. Analyzing the non-health problem, lack of evaluation,
will provide a link between the health problems and non-health problem to provide a more in-
depth understanding of the follow up evaluation when beginning the internship. A conceptual
model was developed to create a graphic representation of these issues, which forms the
connections and relationships of these causal factors affecting the health and non-health problems.
The first three phases of PRECEDE-PROCEED was used as a guide to analyze the health problem.
The conceptual model is seen below.

Problem Analysis
The first phase of PRECEDE consists of social assessment and situational analysis. These
components involve assessing the overall high priority problems and an overall scan of
determinants and resources (Cottrell, 2012).The conceptual model is read by beginning on the far

right with birth defects and low birth weight, which are the overall health problems that are
covered within the mission of The March of Dimes.
Phase two consists of epidemiological assessment which is an assessment of the extent and
causes of the health problems (Cottrell, 2012). As previously mentioned, the causes of some birth
defects result from genetics and heredity (Centers for Disease Control and Prevention, 2015).
According to the CDC (2015), having someone in the family who has a birth defect could increase
the risk during pregnancy. Age is also a factor because the risk of birth defects and low birth weight
are increased when pregnancy occurs in women younger than age 17 and older than age 34 (CDC,
2015). As seen in the conceptual model, genetics and heredity can directly lead to birth defects and
low birth weight. Additionally, age which is a genetic factor, can increase the risks of preterm labor
which results in premature birth. Preterm labor is labor that begins before 37 weeks of pregnancy
(Preterm Labor & Premature Birth, 2015). Babies born in preterm labor are at an increased risk
for health problems and long term health effects. Thus, as seen on the conceptual model, preterm
labor has a direct connection to low birth weight which in turn could also result in birth defects.
These factors are important to consider when analyzing the overall health problems, but will not be
addressed during the internship.

Phase three of the PRECEDE planning model is educational and ecological assessment. This

phase assesses factors that predispose, enable, and reinforce behaviors as well as assessing social
and physical environment factors that influence behaviors to produce health effects (Cottrell,
2012). As illustrated on the conceptual model, barriers to prenatal care have a direct connection to
birth defects and low birth weight. Barriers to prenatal care are also linked to premature birth. One
of the most important steps in ensuring a healthy pregnancy is obtaining early and accurate
prenatal care. According to the Maternal and Child Health Bureau (2013), in 2009-2010 within a
thirty state area 17.2 percent of pregnant women reported that they were not able to receive early
prenatal care.

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Factors that result in delayed prenatal care are listed to the left of barriers to prenatal care

on the conceptual model. These factors include: failure to adhere to doctors visits, unintended
pregnancy, transportation, and health insurance. Unintended pregnancy accounts for about 51
percent of the 6.6 million pregnancies in the United States each year (Guttmacher Institute, 2015).
In 2008, it was reported that unintended pregnancy rates were lower for women with more years
of education and higher for women who had not obtained a high school degree (Guttmacher
Institute, 2015). When pregnancy is unintended and if the mother is uninsured, it could pose
difficulty in receiving recommended prenatal care visits. According to the US Institute of Medicine
Committee on the Consequences of Uninsurance (2002), uninsured women receive fewer prenatal
visits than women who are insured. Additionally, uninsured newborns are more likely to suffer
from adverse outcomes such as birth defects and low birth weight babies. In North Carolina,
Community Care Network contracts with practices and clinics across the state to serve as a
Pregnancy Medical Home (Module 15: The Pregnancy Medical Home, 2015). Medicaid patients are
eligible to receive ongoing prenatal care services at the designated Pregnancy Medical Home.
Additionally, participating practices receive financial incentives such as rewards for quality
improvement and engagement in preterm birth prevention among Medicaid patients.
Continuing with Phase 3 of the PRECEDE planning model, assessment of predisposing
factors aids in determining factors that contribute to a health problem. Chronic health conditions
are illustrated on the conceptual model linking to low birth weight. Negative lifestyle behaviors
related to diet and obesity can strongly increase the risks of preterm labor resulting in birth defects
and/or low birth weight (CDC, 2015). According to the National Institute of Health (2013),
management of blood glucose levels prior to pregnancy is important because high blood glucose
levels can cause birth defects during the first few weeks of pregnancy. Furthermore, factors such as
obesity and being overweight can increase the risks of developing diabetes during pregnancy
(gestational diabetes) and preeclampsia. Income and socioeconomic status also have links to

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chronic health conditions on the conceptual model. Low income results in a low socioeconomic
status, which in turn can impact the same factors that are listed for barriers to prenatal care. In
addition to these factors including diet, alcohol and drug use, and obesity can all be affected by
socioeconomic status.
Current Programs to Address the Health Problem
The North Carolina Center for Birth Defects Research and Prevention is a research center
funded by the CDC that currently conducts research in 33 counties in North Carolina (About the
North Carolina Center, 2015). The purpose of the research center is to reduce the incidence of
birth defects by identifying maternal exposures that may occur during the early phases of
pregnancy and to provide information to the public about birth defects prevention (Centers for
Birth Defects Research, 2015).
The March of Dimes currently works to advocate and address factors included in the
category of barriers to prenatal care. The Pregnancy and Newborn Health Education Center located
on the March of Dimes website has Health Education Specialists available to answer questions
related to finding prenatal care, health insurance options with the Affordable Care Act, and
scheduling prenatal visits (March of Dimes Foundation, 2015). As it was previously mentioned in
Part 1, the curriculum of the Provider Education trainings is centered on 6 of 10 CDC (2014)
recommendations for conception health. One of the six recommendations, interventions for
identified risks, encompasses the category of lifestyle behaviors within the Provider Education
training. The March of Dimes currently addresses the factors of chronic health conditions,
obesity/overweight, poor diet, and alcohol/drug use through the Provider Education trainings.
Additionally, The March of Dimes currently works to increase the education promoting the benefits
of folic acid intake among women of childbearing age. Folic acid and unintended pregnancy are
factors that are also related to adherence to recommended prenatal doctors visits. In the past,
these factors have been addressed during the Provider Education training but a formal follow up

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evaluation has not been completed to determine if these factors are used by trainees as it is
intended.

Impact/Outcome Objectives
The Provider Education trainings curriculum currently addresses the issues of reducing
unintended pregnancies, the importance of folic acid intake, and reinforcing the importance of
recommended prenatal visits. There is a lack in data to determine if the information the providers
receive in the trainings is being discussed with their patients. The first objective for the evaluation
is to identify the current program model used for the Provider Trainings. If no program model is
currently in place, then the next step is to develop a program model. The second objective is to
create baseline data from the current evaluation forms that are completed immediately after the
Provider Training session to assess the current data that the organization has collected. The third
and fourth objectives are to identify questions to be answered from the follow up evaluation by the
March of Dimes Triad director and assess current data in order to create follow up evaluation
materials. The final objectives are to create the follow up evaluation tool and create a plan to
deliver the evaluation to participants.
By the use of the conceptual model, The March of Dimes overall broad health problems and
factors contributing to birth defects and low birth weight were assessed using the first three phases
of PRECEDE-PROCEED. The factors of genetics/heredity are less related to the Provider Education
trainings and will not be addressed during the internship. There does appear to be more room for
growth within the organization in advocating and addressing factors associated with barriers to
prenatal care. The evaluation will assist in providing data to support that the Provider Education
trainings are making an impact in addressing the overall broad goal and mission of The March of
Dimes.
(Part 3)

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The following section pertains to the activities and methodology of the internship. The

purpose is to provide a step-by-step description of the process and plans. A logic model is used to
summarize the processes of completing the internship. According to Knowlton and Phillips (2009),
the pieces of a program logic model consist of the recipe for a specified result. As seen below, the
logic model has four different categories: inputs, activities, outputs, and outcomes. The model is
read from left to right. The outcomes column is the overall goals to be achieved during the
internship by completing the items that are listed in the three subsequent columns.
Inputs
Triad Director

State
Coordinator

Time spent by
intern

Triad Director

Provider
Education
training
curriculum

Time spent by
intern

Curriculum
materials
Triad Director

Past
evaluation
forms

Time spent by
intern

Evaluation
forms

Activities
Communicate with
Triad Director and
State Coordinator to
determine a plan for
the evaluation

Identify previous
evaluation materials
Review Provider
Education training
curriculum

Determine the
evidence based
strategies and
methods within the
current curriculum

Outputs
Completed final
evaluation plan

Outcomes
An evaluation plan
and blueprint for
future evaluations

Program model
developed for
evaluation of Provider
Education training
program based on the
current curriculum

Knowledge of an
evidence based
program model for
program personnel
identified for future
evaluations for the
organization

Collect past
evaluation forms from
in-person Provider
Trainings

Compile data in
spreadsheet

Determine statistical
tests to be used and
analyze data using

Compiled data from

current evaluation
tool

Document containing
list of questions that
are to be included in
the evaluation tool

Greater
understanding for the
Triad Director and
State Coordinator of
program data from
the current
evaluations

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Computer/stat
istical
software

Triad Director

State
Coordinator

Time spent by
intern

Computer

statistical software

Generate informal
report with
data/findings from
evaluation forms

Determine the
questions to be
answered from the
follow-up evaluation
Collaborate with staff
to determine the best
method for the
evaluation

Develop follow up
evaluation tool

Evaluation delivery
plan

Increased knowledge
and understanding for
the intern and for the
organization
personnel about
completing the follow
up evaluation

Internship Activities and Methods
The first row of the logic model shows the initial portion of the internship evaluation. The
first step of the evaluation is to create a plan to follow for completing an evaluation. This will be
done through meetings with the Triad Director and State Coordinator to collaborate and
brainstorm on the pieces that need to be included in the evaluation process. The activities in this
section also include identifying previous evaluation materials that have been used for Provider
Trainings. The overall outcome of this section is the development of an evaluation plan which will
create the blueprint for executing the actual evaluation when the internship is complete and
provides a plan for future evaluations that can be used by the organization.

The second input is to identify or create a program model that is used for the Provider

Trainings. It is not currently known whether the Provider Trainings are centered on an existing
evidence based program model. If there is not a program model in place, the next step is to review
the Provider Training curriculum to help determine the best program model that correlates with

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the information in the curriculum. Also within this step, another activity listed in the logic model is
to assess the evidence based strategies and methods used in the Provider Trainings. This
assessment will be done to further understand which program model is most relevant to the
trainings. The output for this section is the development of a program model for the Provider
Trainings. The overall outcome is the knowledge of an evidence based program model identified for
program personnel for the development of the evaluation and for future evaluations with this
organization.

The next input listed in the logic model is to obtain information from data of the past

evaluations. As it was mentioned in parts one and two, there has not been a follow-up evaluation
for the Provider Trainings. Immediately after a training session, participants complete an
evaluation form about the session, but there has not been a follow up evaluation completed to
determine if the information from the sessions are being used as intended. The information from
the immediate evaluation forms has also not been analyzed. Therefore, in this section the first
activity is to collect the past evaluation forms from the in-person Provider Trainings. After all the
forms are collected, the data will be compiled into a spreadsheet and analyzed using SPSS, a
statistical software. The exact data collection plan and data testing analyses are to be determined.
Once the data is analyzed, it will be presented to the Triad Director and State Coordinator and
information about questions to be answered for the follow up evaluation tool will be decided. The
outputs of this section are a collection of data from the immediate evaluations. Also, a list of
questions to be answered during the evaluation tool will be a result of these activities. The overall
goal in this section is greater understanding for the Triad Director and State Coordinator of the
program data from the immediate evaluations.

The final input is to create an evaluation tool in either the form of paper, mail, electronic

survey, or in-person. The activities for this section include collaborating with The March of Dimes
staff to determine the best method of evaluation and use information gathered from evaluation data

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to create the follow up evaluation tool. This will include suggestions made from the analysis of the
immediate evaluation. The output for this section is to have a plan in place to deliver the evaluation
once the internship is complete. The overall outcome of this section is increased knowledge and
understanding about completing an evaluation for the intern as well as having an actual evaluation
ready for dissemination upon completion of the internship for the organization. If the organization
chooses to deliver the evaluation upon completion of the internship it will provide concrete
documentation of progress on program goals and effectiveness (CDC, 2012).
Project Timeline

A Gantt chart is used to illustrate the sequencing of the project timeline in which the goals

and objectives are to be accomplished (What is a Gantt Chart, 2012). The activities are listed on
the left of the chart and along the top is the project timeline.

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