YYY_Observation Forms

Appendix YYY: Observation Forms

Appendix YYY:
Observation Forms

WIC Nutrition Education Study

Phase II Nutrition Education Observations—Data Collection Forms

Contents:

• Individual Nutrition Education Assessment Form

Separate form will be completed for each session observed with each staff member who provided individual (one-on-one) nutrition education during the onsite visit.

• Group Nutrition Education Assessment Form

Separate form will be completed for each group nutrition education session observed during the onsite visit.

• Site-Level Nutrition Education Form

One form will be completed at the end of the onsite visit to summarize site-level information and overall observations.

Site and Nutrition Educator Number:

1. Each site will have a study number and each staff member in the site who conducts nutrition education within that site will be assigned a study number (same number used for Nutrition Educator Survey).

2. Staff roles and credentials will be collected for each staff member on the Nutrition Educator Survey.

Individual Nutrition Education Observation Form

Site number: _____ Observer initials: _____ Date: __ __/__ __/__ __ AM/PM

[Month] [Day] [Year] [Circle]

Nutrition educator study number: __________

1. Start time with nutrition educator __:__ End time with nutrition educator __:__

Total minutes with nutrition educator __Total minutes on nutrition education __

2. Participant category(s)  Pregnant  Postpartum woman/infant  Parent/child
[# Infants ___] [# Children ___]

3. Participant risk category  Not at high risk  High risk  Don’t know

4. Type of session  Certification  Mid-certification  Secondary education follow-up
 High-risk follow-up  Don’t know
 Other: (Specify)

5. Participant language spoken  English  Spanish  Other

6. Interpreter used?  Yes  No; not needed  No; but needed

Type of interpreter used?  Interpreter available at site

 Bilingual WIC staff member

 Language line/phone interpreter service

 Family member or friend

 Other:

7. Nutrition education topic(s) discussed

 Breastfeeding  Calcium intake  Child feeding practices  Fruit and vegetables  Having enough to eat  Healthy meals  Healthy snacking  Healthy weight for child  Healthy weight for mother  Infant feeding practices

 Introduction of solid foods  Iron/anemia  Medical issues (e.g., blood pressure, gestational diabetes)  Milk choices/consumption  Physical activity  Picky eaters  Prenatal nutrition/diet  Protein intake

 Shopping for and preparing healthy foods  Sugar-sweetened beverages  Vitamin and mineral supplements  Water consumption  Weaning from the bottle  Whole grains

 Other

8. Written nutrition education materials provided (e.g., brochure)? Yes No

9. Comments on written nutrition education materials provided (e.g., photocopy or printed, in appropriate language, up to date). Obtain copies of materials.

10. Other reinforcers used

 Bulletin board/poster  Circle charts  Computer, tablet, or kiosk  Display table

 Educational props (e.g., breastfeeding dolls, physical activity items)

 Food models  Self-study sheet/module  Video/DVD

 Other:

11. Referral provided?  Yes  No

If yes, describe:

Individual Nutrition Education Characteristics

For each feature listed, check the description that most closely describes the nutrition education session observed. Check one item for each row; check NA if the feature is not applicable.

12. Approach to Education Topics							NA
Little or no nutrition education provided		Several nutrition topics addressed with no prioritization of topic areas			Small number of nutrition topics addressed participant’s interests and priorities
							
13. Focus of Nutrition Education Topics
Nutrition educator did not ask about needs and interests of participant		Participant’s needs and interests were not the focus of nutrition education discussion			Participant’s needs and interests determined focus of nutrition education discussion
							
14. Seating Arrangement
Seating arrangement/ computer placement did not facilitate conversation (e.g., educator turned away from participant while entering data)		Participant seated across desk or table without access to computer screen			Seating arrangement/ computer placement allowed for direct eye contact and participant access to computer screen
							
15. Talk Time Distribution (Estimated Time Participant Speaks During Appointment)
Less than 20% of time	Less than half (20–39%)		About half (40–59%)	More than half (60–79%)		80% of time or more
						
16. Goal Setting Strategy
16a.Participant was not engaged in discussion about behavioral goals		Behavioral goals primarily determined by nutrition educator based on assessment			Behavioral goals primarily determined by participant
							
16b.Participant was not engaged in discussion about ideas and strategies to achieve behavioral goals		Nutrition educator provided ideas and strategies to change behavior and achieve goals			Nutrition educator asked participant for ideas and strategies to change behavior and achieve goals
							
16c.Goal(s) set at previous visits not mentioned		Nutrition educator stated goal(s) set previously and asked if participant met goal(s)			Nutrition educator asked participant about progress or challenges in meeting goal(s) set previously
							
17. Information Gathering							NA
Used few or no open-ended questions		Used open-ended questions frequently
							
18. Participant Autonomy (Explore-Offer-Explore)
Did not ask permission before sharing information or strategies		Asked permission occasionally before sharing information or strategies			Asked permission consistently before sharing information and strategies
							
19. Affirming Positive Behaviors
Provided no affirmations		Provided affirmations not tied to specific participant strengths, behaviors or efforts			Provided affirmations related to specific participant strengths, behaviors, and efforts
							
20. Sharing Nutrition Education Materials
Did not offer nutrition education materials		Did not incorporate materials offered into education discussion			Incorporated materials into education discussion
							
21. Follow-Up on Use of Reinforcers
Did not mention reinforcers provided at previous visits		Asked if participant recalled reinforcers from previous visits			Asked participant about if/how they used reinforcers from previous visits
							
22. Comments about Process and Style of Nutrition Education Provided

Group Nutrition Education Assessment Form

Site number: _____ Observer initials: _____ Date: __ __/__ __/__ __ AM/PM

[Month] [Day] [Year] [Circle]

Nutrition educator study number: _________

1. Group start time __:____ Group end time __:____Total time (minutes) _______

1a. Time watching video or in a didactic presentation (minutes) ________ [ ] NA

1b. Time in group discussion or interactive exercises (minutes) ________ [ ] NA

2. Participant categories targeted  Pregnant  Postpartum woman/infant
 Parent/child  Not category specific

3. No. of participants scheduled __________  Not applicable (walk-in)

No. of participants present __________

4. Participant language spoken  English  Spanish  Other ________________

5. Session presented in appropriate language?  Yes  No

6. Interpreter used?  Yes  No; not needed  No; but needed

7. Topic(s) addressed

 Breastfeeding  Calcium intake  Child feeding practices  Fruit and vegetables  Having enough to eat  Healthy meals  Healthy snacking  Healthy weight for child  Healthy weight for mother  Infant feeding practices

 Introduction of solid foods  Iron/anemia  Medical issues (e.g., blood pressure, gestational diabetes)  Milk choices/consumption  Physical activity  Picky eaters  Prenatal nutrition/diet  Protein intake

 Shopping for and preparing healthy foods  Sugar-sweetened beverages  Vitamin and mineral supplements  Water consumption  Weaning from the bottle  Whole grains

 Other

8. Focus of group nutrition education:  Child focused  Adult/parent focused

9. Group elements included

 Discussion between pairs/partners  Flip charts

 Food sampling/ demonstrations  Hands on activity or game  Icebreakers

 Physical activity  PowerPoint presentation  Video/DVD

 Other

10. Reinforcers used

 Circle charts  Cooking demonstration  Display table  Educational props (e.g., breastfeeding dolls, physical activity items)

 Food models  Food tasting  Nutrition education pamphlets or handouts

 Posters  Quizzes/surveys

 Other

Group Nutrition Education Characteristics

For each feature listed, check the description that most closely matches the characteristics of the group nutrition education session observed. Check one item for each row; check NA if the feature is not applicable.

11. Greeting							N/A
Facilitator did not introduce herself or explain what will happen during session		Facilitator welcomed group and mentioned topic of session			Facilitator greeted attendees warmly, introduced herself by name, and explained what will happen during session
							
12. Seating Arrangement
Inadequate seating for attendees		Adequate seating with chairs arranged in rows (classroom style)			Adequate seating with chairs arranged so that attendees can look at one another
							
13. Occupying Children
No activities/resources to occupy children during group sessions		Limited activities/resources to occupy children during group sessions			Adequate activities/ resources to occupy children during group sessions
							
14. Attendee Engagement (Estimated Time Participants Speak During Session)
Less than 20% of time	Less than half (20–39%)		About half (40–59%)	More than half (60–79%)		80% of time or more
						
15. Facilitation Style
15a. Facilitator presented information or played video with minimal discussion or group interaction		Facilitator presented information with some opportunity for discussion or involvement from attendees			Facilitator engaged group with adult learner techniques (e.g., partner sharing, small group discussion, learning activities, games, guided discussion, or storytelling)
							
15b. Used few or no open-ended questions to elicit participation, ideas and strategies from attendees		Used open-ended questions frequently to elicit participation, ideas and strategies from attendees
							
16. Affirming Positive Behaviors
Provided no affirmations		Provided affirmations not tied to specific participant strengths, behaviors or efforts			Provided affirmations related to specific participant strengths, behaviors, and efforts
							
17. Sharing Nutrition Materials
Did not offer nutrition education materials		Did not incorporate materials offered into session			Incorporated materials into session
							
18. Comments about process and style of nutrition education provided

Site-Level Nutrition Education Form

Site number: _____ Observer initials: _____ Date: __ __/__ __/__ __ AM/PM

[Month] [Day] [Year] [Circle]

1. Types of nutrition education modes observed (Check all that apply.)

 One on one

 Group education

 Independent learning (e.g., worksheet, self-study guide)

 Nutrition reinforcer (e.g., bulletin board, education pamphlet)

 Onsite computer, tablet, or kiosk

 Other (describe):

2. Nutrition Education Materials: Collect five of the most frequently used nutrition education materials

3. Number of Participants Served

	Number of participants served:	How did volume of participants compare to typical day?
Day 1		 Less than typical  Typical  More than typical
Day 2		 Less than typical  Typical  More than typical
Day 3		 Less than typical  Typical  More than typical

4. Site environment factors that may affect participant experience	Yes	No
There is a greeter or receptionist who welcomed participants as they entered clinic
Waiting room has items to occupy children
The site has posters, photos, or bulletin boards with positive nutrition and breastfeeding messages
Offices for individual counseling provide privacy
Offices for Individual counseling have items to occupy children
There is a designated space for group education that is not used for other activities during sessions
Other (describe)

5. Nutrition reinforcers for participants to view or take home	Yes	No
Display rack with nutrition-related information (newsletters, referrals, etc.)
Display tables with nutrition-related information
Newsletters or games/activities
Nutrition education DVDs/videos played in waiting area or space set aside for viewing
Nutrition posters
Nutrition-related bulletin boards
Other (describe)

6. Use of stationary computer system/kiosk/tablet

Is there a computer/ tablet/kiosk onsite for participants to use?  Yes  No

How is it used?  Nutrition education contact  Nutrition education reinforce  Both

Observed frequency of use  Often  Sometimes  Seldom  Never

Describe how the computer/kiosk/tablet is integrated into nutrition education at this site. [Include items such as how staff members discuss the technology with participants, placement in clinic, signage]

Provide any additional comments necessary to describe overall style and quality of nutrition education provided at this site. Comments may address:

• Counseling style (e.g., participant centered, directive, guiding)

• Prominent counseling skills used

• Overall participant engagement

• Summary of common strengths and challenges of nutrition educators

• Overall comments about process of nutrition education at this site

7. Overall comments about individual nutrition education provided

8. Overall comments about group education provided

9. Comments about ways nutrition reinforcers are integrated into nutrition education

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