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Understanding barriers in consumer health advocacy: an improvement study

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Understanding barriers in consumer health advocacy: an improvement study

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Content Running head: UNDERSTANDING BARRIERS IN COMNSUMER HEALTH
ADVOCACY
1

Understanding Barriers in Consumer Health Advocacy:
An Improvement Study
By
Auleria S. Eakins

________________________________________________________________________
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

August 2018

UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

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Abstract

The purpose of this study is to understand the barriers that prevent consumers from effectively
advocating for health care services in a managed care system. This qualitative case study will use
individual interviews, observations and public meeting documents to assess for gaps in knowledge,
motivation, and organization influences. This study will assist organization stakeholders in
evaluating their current advocacy and leadership training programs for Medicaid consumers, as
well, inform community trainers on various modalities that support consumer advocacy education
efforts targeted to low income, low education communities. Understanding barriers in effective
advocacy is essential to stakeholder organizations nationwide. Many low-income members
continue to voice their dissatisfaction with what they believe to be substandard care and limited
access to needed services. These consumers also state that they feel that no one listens to their
concerns. To address the consumers concerns, around this continued frustration, there are
opportunities for health plans to create or recreate simplified systems and processes. These
improvements will encourage and allow consumers to provide regular feedback to stakeholders
who desire to even the playing field for consumers who are the most vulnerable and in need. The
ability for stakeholder organizations to increase their responsiveness to members is believed to
also create a higher quality member experience. Systematically, health plans can move health care
in an upward trajectory by improving and addressing customer service issues identified through
member service and consumer advisory committees. VCHP with its long history of working with
consumer’s stakeholders can position itself to be a pioneer among the nation’s largest Medicaid
health plans. This can be accomplished by incorporating sound doctrine and practices that support
the improvement of health care for those in most need.

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Dedication and Acknowledgment
“A smooth sea never made a skilled sailor.” ~Franklin D. Roosevelt

The road to victory has not been easy however the lessons learned about myself during
this journey have been more than life changing. The journey of completing my doctoral studies
could not have been done without the early lessons engrained from grandmother Esther Magee
who instilled in me the importance of education, the principles of hard work and never giving up.
This body of work is dedicated to my heavenly father who has blessed me to this point my
Husband Marvin, My son Jackson, My pup Hunter and my soon to be newborn Farris. I also
would like to thank all my friends, family for your continued prayers and encouragement from
start to finish of this program. Last, I would also like to thank Wendy Talley, LCSW and fellow
Trojan for your counseling and wisdom during the very crucial time of this program. This
journey is marked by the fact that you all were there every step of the way.
Special thanks, to Dr. Anthony Maddox, my dissertation chair for your belief in my work
and lessons of innovation. Dr. Karen Lincoln, for your attention to detail and honest feedback
ensuring my best work forward, Dr. Sudonna Moss for your calmness in the height of my
uncertainty and to Dr. Eugenia Mora-Flora for your insight and reminder that culture plays a
dominate role in how we behave as humans, professionals and consumers. Last, I would like to
thank the University of Southern California for being an institution where dreams come true and
where dedicated staff work diligently to support students ensuring that they can focus on those
things that matter the most.

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Table of Contents
Abstract ……...…………………………………………………………………………………. 2
Dedication and Acknowledgment …………...………………………………………………… 3
List of Tables ………………………………………………………………………………….. 10
List of Figures …………………………………………………………………………………. 11
Chapter One: Overview of the Study ………………………………………………………….. 12
Introduction of the Problem of Practice ……………………………………………….. 12
Background of the Problem . ………………………………………………………….. 15
Organizational Context and Mission ………………………………………………….. 16
Organizational Goal ..…………………………………………………………………. 17
Related literature …...…………………………………………………………………. 19
Importance of Effective Advocacy …………………………………………………… 21
Description of Stakeholder Groups …………………………………………………… 23
Stakeholders Performance Goals ……………………………………………………… 25
Stakeholder Group for the Study ………………………………………………………. 27
Purpose of the Study and Questions ………………………………………………….. 28
Conceptual and Methodological Framework ...……………………………………….. 29
Definition of Terms ………………………………………………………….. 30
Organization of the Study ……………………………………………………………. 31
Chapter Two: Review of the Literature…..…………………………………………………… 32
Knowledge Generation ……………………………………………………………….. 32
Community Accountability ………………………………………………………….. 33
Community Empowerment ………………………………………………………….. 34
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Community Organizing ……………………………………………………………….. 35
Marginalization ……………………………………………………………………….. 35
Theoretical Foundations needed for Effective Advocacy …………………………….. 36
Significance of the Problem ………………………………………………………….. 36
Knowledge Influences ……………………………………………………………….. 37
Declarative Knowledge Influences …………………………………………… 38
Conceptual …………………………………………………………….. 39
Procedural …………………………………………………………….. 40
Metacognitive ……………………………………………………….... 40
Motivation ……………………………………………………………………. 43
Utility Value ………………………………………………………………….. 45
Attribution ……………………………………………………………. 46
Self-Efficacy ………………………………………………………….. 37
Goal Orientation ……………………………………………………… 49
Organizational Resources …………………………………………………….. 52
Organizational Culture ……………………………………………………….. 54
Leadership …………………………………………………………….. 55
Conclusion …………………………………………………………………………….. 56
Chapter Three: Methodology………………………………………………………………….. 58
Creditability and Trustworthiness …………………………………………………….. 59
Validity and Reliability ……………………………………………………………….. 63
Ethics ………………………………………………………………………………….. 64
Document Analysis ……………………………………………………………………. 68
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Chapter Four: Analysis and Findings …..…………………………………………………….. 70
Analysis ……………………………………………………………………………….. 71
Interviews …………………………………………………………………………….. 72
Participating Stakeholders ……………………………………………..……….…………….. 74
Ms. Garcia #1 …………………………………………………………………. 75
Ms. Lakey #2 ………………………………………………………………….. 75
Ms. Munoz #3 …………………………………………………………………. 75
Ms. Jones #4 ………………………………………………………………….. 76
Mrs. Soza #5 ………………………………………………………………….. 77
Knowledge Findings ………………………………………………………………….. 83
Knowledge: Training for Advisory Members Interviews …………………….. 84
Interviews …………………………………………………………….. 84
Observations ………………………………………………………………….. 94
Site #1 ……………………………………………………………….. 95
Site #2 ……………………………………………………………….. 97
Documents Analysis …………………………………………………………………. 99
October 2016 Meeting Minutes ………………………………………………. 100
March 2017 Meeting Minutes ………………………………………………… 100
April 2017 Meeting Minutes ………………………………………………..... 101
June 2017 Meeting Minutes ………………………………………………….. 102
September 2017 Meeting Minutes …………………………………………… 105
Motivation ……………………………………………………………………. 106
Interviews …………………………………………………………….. 106
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Meeting Observations ……………………………………………………….. 110
Methods, Results, and Discussion …………………………………………… 112
April 2017 Meeting Summary ……………………………………….. 112
Organizational Gaps ………………………………………………………….. 113
Interviews ……………………………………………………………. 113
Observations …………………………………………………………………………. 115
Meeting Minutes …………………………………………………………….. 116
November 2016 Meeting Minutes ………………………………………….. 116
March 2017 Meeting Minutes ……………………………………………. 117
April 2017 Meeting Minutes ………………………………………… 118
June 2017 Meeting Minutes …………………………………………. 119
September 2017 Meeting Minutes …………………………………… 120
Chapter Five: Conclusion and Recommendations for Practice ……………………………… 121
Knowledge Influences Recommendations …………..………………………............. 123
Declarative Knowledge Influences ………………………………………….. 128
Procedural ……………………………………………………………............. 131
Metacognitive Knowledge Solutions …………………………………………. 132
Motivation …………………………………………………………………….............. 133
Self-Efficacy …………………………………………………………………...............138
Value …………………………………………………………………………...............139
Organization Influences ………………………………………………………………..140
Organization Influence and Recommendation …………………………………………140
Policies …………………………………………………………………………144
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Processes …………………………………………………………………….. 144
Cultural Models ………………………………………………………………. 145
Cultural Settings ………………………………………………………………. 146
Integrated Implementation and Evaluation Plan ……………………………………….147
New World Kirkpatrick Model ………………………………………………...147
Level Four: Results and Leading Indicators …………………………..……………….149
Level Three: Behavior …………………………………………………………………151
Critical Behaviors ……………………………………………………………...151
Required Drivers ……………………………………………………………….153
Organizational Support ………………………………………………………………...156
Level Two: Learning ………………………………………………………………..… 157
Learning Goals …………………………………………………………………157
Program ………………………………………………………………………...157
Components of Learning ……………………………………………………….158
Level One: Reaction ……………………………………………………………...…. 161
Evaluation Tools ……………………………………………………………………….163
Immediately after the Training ………………………………………………...164
Immediately Following Program Implementation ……………………………..166
Delayed for a Period after the Program Implementation ………………………167
Data Analysis and Reporting …………………………………………………………..168
Summary ……………………………………………………………………………….168
Limitations ……………………………………………………………………………..170
Conclusion ……………………………………………………………………………..170
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References …………………………………………………………………………………….. 172
Appendix A: Demographic Survey Items …………………………………………………….. 188
Appendix B: Interview Protocol ………………………………………………………………. 192
Appendix C: Observation Protocol ……………………………………………………………. 193
Appendix D: Document Analysis …………………………………………………………….. 196
Appendix E: Demographic Survey ……………………………………………………………. 197
Appendix F: CITI Certification ………………………………………………………………. 200
Appendix G: Attribution Survey ………………………………………………………………. 201

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List of Tables
Table 1.1: Organizational Mission, Global Goal, and Stakeholder Performance Goals ………. 26
Table 1.2: Knowledge Worksheet ……………………………………………………………… 41
Table 2.1: Motivational Worksheet ……………………………………………………………. 51
Table 4.1: Participant Information ……………………………………………………………....74
Table 5.1: Summary of Knowledge Influences and Recommendation …………………….….125
Table 5.2: Summary of Motivation Influences and Recommendation ……………………….. 135
Table 5.3: Summary of Organization Influences and Recommendation ……………….……...142
Table 5.4: Outcomes, Metrics, Methods for external and Internal Outcomes ………………....150
Table 5.5: Critical Behaviors, Metrics, Method, and Timing of Evaluation …………………..152
Table 5.6: Required Drivers to Support Critical Behaviors …………………………………... 154
Table 5.7: Components of Learning for the Program ……………………………………..…. 159
Table 5.8: Components to Measure Reactions to the Program ……………………………….. 162
Table 5.9: Anderson and Krathwohl Taxonomy..……………………………………………... 164
Table 5.10: Delayed Table ……………………………………………………………………. 166

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List of Figures
Figure 4.1: Understanding Barriers in Effective Advocacy: Demographics (Age) ……………..78
Figure 4.2: Understanding Barriers in Effective Advocacy: Ethnicity ………………………….79

Figure 4.3: Understanding Barriers in Effective Advocacy: Primary Language ..........................80
Figure 4.4: Understanding Barriers in Effective Advocacy: Secondary Language ……………..81
Figure 4.5: Understanding Barriers in Effective Advocacy: Level of Education ……………….82
Figure 4.6: Understanding Barriers in Effective Advocacy: Yrs. as an Advisory Member .…....83
Figure 4.7: Understanding Barriers in Effective Advocacy: Improving Advocacy Skills …….. 88
Figure 4.8: Understanding Barriers in Effective Advocacy: Acquired Leadership Skills ……... 89
Figure 4.9: Understanding Barriers in Effective Advocacy: Ability to Depend on Others ……. 90
Figure 4.10: Understanding Barriers in Effective Advocacy: VCHP Global Issues …………... 91
Figure 4.11: Understanding Barriers in Effective Advocacy: Effectiveness of CAC …………. 92
Figure 4.12: Understanding Barriers in Effective Advocacy: Issues Heard by VCHP ………... 93
Figure 4.13: Understanding Barriers in Effective Advocacy: Advisory Roles/Responsibilities.. 94
Figure 5.1: Understanding Barriers in Effective Advocacy: CAC Ethnicity …………………. 123
Figure 5.2: Understanding Barriers in Effective Advocacy: Operation Reset ………….…..… 167
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CHAPTER ONE: OVERVIEW OF THE STUDY
Introduction to the Problem of Practice
Across the United States (U.S.) low-income populations, those who fall below the
Federal Poverty Guidelines, utilize public /federally funded healthcare also known as Medicaid.
In Viking County alone, there are 11.9 million individuals served by the public healthcare
system. Due to the high number of individuals utilizing such care, a two-plan model was
developed and implemented to better serve these communities and individuals. Unfortunately,
due to high service demand and lack of effective accountability systems, the publics voice can be
lost or go unheard, causing them to become disenfranchised with their own health plan, often
disregarded, and ultimately left underserved and in need of more access to better services.
Consumer advocates are the established solution to this problem; however, there are
factors affecting the process that impede its success. Based on the expectations of VCHP’s
leadership, the current advisory committee’s ability to identify ongoing health access issues that
assist in increasing the quality of care for its members have been limited. There are several
hypotheses that support this assumption to include: increased healthcare advocacy education,
consumer members lack of awareness to their rights, roles and responsibilities, lack of
representation and feedback from all threshold groups represented by the plan, and lack of
support barriers on the part of the organization that work to impede feedback and/or changes
based on said feedback.
This dissertation is focused on consumer advocate stakeholders. Consumer advocate
stakeholders are Medicaid users who have the power to improve healthcare for themselves and
for other Medicaid consumers by participating in consumer advisory committees. These
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committees offer feedback to VCHP Board of Governors on issues related to quality of care and
member’s experiences in accessing healthcare.
Evidence-based health care recognizes the importance of incorporating consumer
viewpoints when evaluating clinical effectiveness (Edwards & Elwyn, 2009; King & Appleton,
1999; Van Wersch & Eccles, 2001). However, low-income populations have historically been
limited in their right to exercise choice especially in the sphere of public healthcare (Dixon,
2006; Grand, 2000; Mole, 2008). This means that they do not have the same options as their
counterparts as it relates to timely services, access to certain medicines, specialists, and second
opinions, to name a few. Consumers of public healthcare, such as Medicaid, are generally
comprised of low-income individuals. When low-income consumers lose or do not exercise their
voice, opportunities for feedback are often lost, leaving systems to remain broken and or unfixed.
This is harmful as these same consumers often leave with information that could help to improve
services for all (Rodin, 2007). In many instances, consumers deny their own voice by simply
withdrawing from the health plan suggested by their providers (Hirschman, 1970; Rodin, 2007).
However, ensuring that consumers are aware of opportunities to voice concerns could greatly
impact the improvement of health care for low-income populations. When the consumers leave
and seek services elsewhere health care providers often do not know the source of the
consumer’s dissatisfaction. The consumers’ voice can play a critical role in calling attention to
the deteriorating performance of America’s healthcare system (Kolarska & Aldrich, 1980). The
ability to distinguish quality service and consumer satisfaction is a key to advocacy (Iacobucci,
Ostrom, & Grayson, 2003; Kucuk, 2008).
Researchers Tyler and Lind (1992) contended that there is a link between voice and self-
esteem. Generally, middle-class patients are more articulate, more confident, and more
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persistent than less affluent patients. Those who are more affluent are often more connected,
have sharper elbows, and have a greater understanding of health terminology (Hirschman, 1970;
Braveman, 2006; Smedley, Stith, & Nelson, 2003). By utilizing their knowledge and contacts,
these individuals are more adept at using their voice to demand access to more extensive services
such as outpatient and specialist consultations, diagnostic testing, and inpatient treatments.
This dissertation utilizes the grassroots theory as a framework for understanding how to
empower consumers so that they can articulate concerns related to increasing their access to
quality care. Grassroots theory is a collective action by members of the community who work to
change problems affecting their lives (Stachowiak, 2013; Zoller, 2005). With little
understanding of the managed care landscape, many consumers are unable to navigate the
healthcare system in a way that benefits their overall wellness. Currently, there are limited
consumer feedback models that provide clear instructions to consumers on how to communicate
to healthcare decision makers and ways that they can improve access to specialized health
services for low -income consumers. This lack of practical evidence-based models in support of
the consumer’s process for input, add to the systematic unmet needs of low-income individuals.
Low-income consumers tend to be marginalized in decisions about their health. Local
leadership and continued advocacy efforts are needed to promote the value of transparency and
accountability in the healthcare industry. There must be increased opportunities for the voice of
the consumer to be heard. Organizations can support consumers by implementing systems that
are equipped to hear the problems of consumers and work to resolve them. An ideal approach to
support consumers in voicing their feedback would include a consumer -friendly option, which
also meets the state and regulatory entities documentation requirements of the health plan.
Bozeman and Scott (1996) advocated for outcomes over processes. While these are juxtaposing
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view, they demonstrate the continuous conflict between the consumers needs to be included in
policy and decision-making and the professionals desire to meet requirements of both the state
and federal government. This is important, as practitioners tend to focus on formalized systems
that tend to be confusing and difficult for low educated consumers to navigate.
Background of the Problem
As stated by key leadership personnel, consumer stakeholder committees have added
very little value to the advisory process. Consumers, on the other hand, have continued to voice
during public meetings that there is no true investment in building their knowledge so that they
can become stronger advocates for their health care needs. Evidence of this lack of support is
confirmed by VCHP lack of increased investments in support of VCHP’s consumer’s education
and trainings. Consumers also voice their desire for improved and increased consumer education
opportunities in support of their roles advocates. VCHP, a community accountable health plan,
desires to reestablish a consumer advocacy process that is collaborative as well as one that
evaluates current operations and considers new ways of approaching identified gaps that impede
effective advocacy, consumer feedback and partnership between consumers and the health plan.
VCHP is located in Viking County (local initiative health authority) and was created by
the State of Arena to provide health care services for Medicaid managed care beneficiaries
uninsured children and other vulnerable populations in Viking County. VCHP has over 2,000
employees and supports 16 Regional Community Advisory Committees (RCAC). These
committees are comprised of over 245 consumer members whose sole purpose is to provide
feedback to VCHP’s Board of Governors. The committees are organized under 12 specialists
who comprise the Community Outreach and Engagement (CO&E) department. The feedback
received advises board members about the issues impacting low-income individuals in Viking
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County who use Medicaid services. Their advisement is crucial to understanding the quality of
care Medicaid consumer members receive, as well as their direct experience with providers in a
large and complex healthcare network.
Currently, VCHP serves 2 million of the 11.9 million Medicaid managed care members
in Viking County. There are still an estimated 2,875,000 people who remain uninsured, which is
a 45% reduction of the uninsured rate from 2013 to 2015 based on those enrolled in the
Affordable Care Act otherwise known as Obamacare (Department of Health and Children
Services, 2016). Due to the high number of individuals utilizing Obamacare, it is essential to
receive feedback from the consumers to ensure that this vast number of people is being well
served. In order to receive accurate information consumer advocates are necessary so that the
information on their care can be gleaned and deciphered.
Organizational Context and Mission
VCHP is a Medicaid health plan designed to serve low-income individuals including:
seniors, persons with disabilities, children in foster care, pregnant women, and childless adults
with incomes below 138% of the federal poverty level. As published in the employee handbook,
the mission of VCHP is to provide access to quality health care for Viking County’s vulnerable
and low-income communities and residents, and to support the safety net required to achieve that
purpose. VCHP provides health insurance to residents who live in the southern parts of the
western United States through five health coverage programs including Medicaid and Medicare.
VCHP is located west of the Mississippi where approximately 12.5 million or 32.4% of state of
Arena’s residents are enrolled in Medicaid as of May 2015.
Over the past 20 years, VCHP has grown from a 100-person organization serving
200,000 Medi-Cal recipients to becoming the nation’s largest publicly-operated health plan
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serving more than two million members and employing nearly 2,000 full-time employees. The
latest US Census data lists the population of Viking County as 10.14 million. With just over
two million members, approximately one out of every five Viking County residents are currently
VCHP members.
Creating clear lines of accountability that are responsive to consumer inquires, lend
insight into bureaucracy and processes that impede VCHP consumer’s access to health care.
Addressing these barriers are imperative to improving the consumer stakeholder process. Unique
to VCHP is the opportunity consumers have to provide direct feedback to VCHPs leadership and
board of governors about their health care services.
Organizational Goal
VCHPs overall goal is to ensure that the health needs of the Medicaid populations are
met in a timely manner. Providing support for the health needs of consumers aligns with the
overall mission of the organization and is key to its success. Secondly, VCHP is charged to hear
how health proposals will impact Medicaid consumer members before the health plan makes
decisions. VCHPs leadership understands that VCHP, as the nation’s largest Medicaid Health
Maintenance Organization (HMO), has a responsibility to set a new strategic direction that
supports the performance and overall improvement of the organization while in support of its
mission.
VCHP was created in 1994 by the State of Arena legislative mandate. As result of the
legislative mandate, the CO&E was formed to ensure responsiveness to consumers and oversight
of the community advisory processes.
As stated by the organization’s Chief of Strategy, by March 2018, VCHPs, and CO&E
will implement the reform of its 12 RCACs, ensuring alignment with the organization’s strategic
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plan, mission, and vision. This improvement goal was established in October of 2015 after
review of current advisory committee operations, and meetings with key internal and external
stakeholders about the perceived effectiveness and value of the current consumer advisory
process. The achievement of this reform was measured in several stages including: (1) a member
survey of goals, which was completed prior to the start of the improvement initiative, (2) a
member survey of the process, which was completed during the initiative, and (3) a member
survey of the outcomes which was completed after the initiative was finished. The
organization’s chief of Strategy, the Senior Director of Communications and Community
Relations and VCHPs Board of Governors all championed approval for this advisory
improvement plan. The approval process includes the completion of reports to VCHP leadership
to include summative data inclusive of conducted focus groups, individual interviews and
external evaluation by the completion of the fiscal year 2018-2019.
The organizational goal of VCHPs leadership is to, “capitalize on the organization’s
community resources such as our public advisory committees to ensure responsiveness,
accountability and responsible partnership in the support of VCHP’s brand (VCHP, 2017).” The
organizational goal is used as a catalyst for improving the consumer advisory process for the
inclusion of member’s input on plan benefits and services. This organizational goal was derived
from VCHPs leadership team and the strategic initiatives department’s two session planning
meetings. Both worked together to strategically formulate and address areas within the
organization in need of continuous improvement. Additionally, these key groups were reminded
of the legislative mandate created in 1994 that formed VCHP as a community accountable health
plan with the responsibility of keeping consumers as the focal point for all decisions and
changes.
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Related Literature
According to Daniels and Sabin (1998), and Bero and Jadad (1997), establishing that
decision makers are accountable to those affected by their decisions, is the only way to show,
over time, that arguably fair decisions are being made (Bero & Jadad, 1997; Daniels & Sabin,
1998). Wallerstein (2002) argued that community capacity and community empowerment are
key interventions that change the social and political environment to improve equity and quality
of life. In a study conducted with youth advocates in New Mexico, it was found that youth who
desired to become stronger advocates were supported by the following: finding and aligning with
allies that encourage advocacy participation, creation of opportunities for dialogue that assist
youth to identify the connections between underlying issues and health symptoms, and the
measurement of personal changes in political efficacy (Wallerstein, 2002). Together these
studies show the importance of advocacy, accountability and capacity building in the areas of
civic engagement.
Rothman (2001) offers three distinct models for community advocacy: (1) locality
development, (2) social planning, and (3) social action. Together, these models incorporate
building identity and a sense of community. Community advocates must work with key experts
to build rational, empirical, problem-solving skills that increase the communities’ problem
solving abilities, and redress imbalances of power and privilege between oppressed and
disadvantaged groups in society. Organizations desiring to make a difference in their health
education and advocacy efforts, must consider comprehensive skill building programs that
connect and empower consumers to address health access and policy concerns. Thus, the
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importance of activating consumers in their healthcare outcomes is essential to improving their
awareness of their consumer rights.
Engaging consumers in their health has become a major focus for health plans and policy
makers (Coulter, Parsons, & Askham, 2008; Hibbard & Cunningham, 2008; Hibbard, Stockard,
Mahoney, & Tusler, 2004). Studies conducted by the Center for Studying Health System
Change (2007) showed that engagement levels differ considerably across socioeconomic and
health status characteristics. Activation for the purpose of this discussion is defined as the
consumer’s action based on their interaction and experience. Activation levels are linked to
important outcomes, such as seeking care, seeking information, and health behaviors, and
because activation levels are malleable attributes, they serve as a potentially important lever for
change (Lubetkin, Lu, & Gold, 2010; Ricciardi, Mostashari, Murphy, & Siminerio, 2013).
Many organizations desire to gain an understanding of how to support stakeholders but
fall short of the effective mechanisms with which to do so (Weick, Sutcliffe & Obstfeld, 2005).
Community capacity, like community development, describes a process that increases the assets
and attributes that a community is able to draw upon in order to improve their lives. Laverack
(2001) defines community capacity building as the increase in the community groups’ ability to
define, evaluate, analyze, and act upon the concerns of importance to their members, such as
health concerns and others. Studies have shown various means of addressing community
development in order to assist low-income communities in voicing their concerns (Kinney, 2012;
Laverack, 2006; Press, 2009) such as community organizing, community development, and
capacity building of community leaders. Examples of this community development include
building social capital, priority setting of community issues and allowing opportunities for face-
to-face dialogue with one another. One study in particular conducted by Chaskin (2001),
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identified four key means to building capacity: 1) a sense of community, 2) commitment to
community amongst its members, 3) the ability to solve problems, and 4) access to resources.
While these four keys vary, the study stated that solutions to this problem must include a
variation of the four capacity traits in order for consumer advisory members to meet their goals.
Importance of Effective Advocacy
Education, engagement, and empowerment are key contributions to effective advocacy
programs. Community members must build sustained knowledge, skills, and abilities in order to
be self-sufficient in addressing decision makers and advocating for equitable health services
equal to those who do not use Medicaid services (Shmueli, Warfield, & Kaufman, 2009).
According to Chin (2017), consumers must be mobilized to raise awareness, advocate for reform
and breakdown structural barriers and policies that impede health equity. Chin further argues
that in order to address health inequities constituents must focus on allocation of resources and
systematic changes.
Identifying barriers that prohibit effective advocacy is one of the single most important
contributions VCHP can make to the communities that it serves. Empowering marginalized
populations to share their experiences and use them to help improve healthcare, would have an
overall positive impact on decision makers who, in many cases, are far removed from the
communities that they serve. Addressing barriers to effective advocacy informs grassroots
practitioners as to how they can effectively and collaboratively work to empower consumer
members and address many of the social and political barriers impeding progress towards reform
and reshaping current health policies. Counter to understanding barriers in advocacy
organizations must also identify effective means to address those barriers. According to the
Bolder Institute (2017), effective advocacy can include educating the public and policy makers
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about issues of concern, attempting to influence legislation, working to shape the development of
governmental agency rules and regulations, litigating on public policy issues, educating voters
and candidates about policy issues, and ensuring that underrepresented communities have a voice
in the policy process. An increase in organizations that provide “true” investment in
communities, by connecting them to valuable resources that allow them to voice feedback to
policies that oppress and limit their access to needed services and policies can be seen as support
decision makers by assisting them to understand the impact of their decisions.
It is imperative that organizations be seen as partners in improving the healthcare system
for Medicaid users and work to ensure low-income access to quality health services which
contribute to the overall well-being of members (Freire, 1972; Minkler & Wallerstein, 2012).
Consumers must be recognized not only as end users of inadequate services but in fact, subject
matter experts on those services, trained in using their day-to-day lives to bridge the gap between
the policy makers and end users. In Turning Research into results Clark and Estes (2008) stated
that there must be efficient and effective organizational work processes along with material
resources that support the achievement of business goals. Clark and Estes (2008) further
suggested that missing and faulty processes and inadequate materials are often the cause of
barriers to achievement of performance goals, even for people with top motivation and
exceptional knowledge and skills.
VCHPs ability to effectively work with its consumer advisory stakeholders in addressing
barriers to advocacy is a key component to transforming the practice of medicine to more
effectively meet the needs of low-income consumers. Evaluation of these efforts provides a
gauge for how to improve the performance of the health plan, and the interpersonal skills needed
by consumer stakeholders to convey health access constraints. The ability of consumer advisory
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

23
stakeholders to express health access experiences can help inform health administrators of the
plethora of health advocacy competencies needed by plan providers to continuously improve the
delivery of high quality care. Continuous evaluation of these efforts support the longevity of the
organization in meeting the individual needs of VCHP consumers, as well as the quality
indicators of regulatory entities.
Description of Stakeholder Groups
VCHP stakeholders include RCAC, professional advocates such as external health
stakeholders, and VCHPs board of governors. Consumer advisory members serve at the pleasure
of VCHPs board of governors. This project focuses solely on the consumer stakeholders. These
stakeholders are essential to the advisory process. Professional advocates contribute to the
organization by serving on advisory committees and sharing professional input and feedback in
two ways. Both consumers and professional advocates advocate for the Medicaid community
and second they aid in finding solutions to problems that impede access to care. They meet bi-
monthly to engage in meaningful dialogue that further responds to the changing climates in
public policy impacting health access in Viking County. According to the University of Kansas’
Workgroup for Health and Development (2016), involving and attending to the concerns of all
stakeholders establishes your organization as fair, ethical, and transparent, as well as making it
more likely that others will work with you in other circumstances.
RCAC members are defined as persons who receive their healthcare coverage under
VCHPs health plan or persons who care for someone who does; including parents, legal
guardians or a conservator of a member. RCAC members help VCHP to understand the health
care issues that impact people who live in their community. RCAC members also provide free
health information to people in their community. RCAC members represent various areas within
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

24
Viking County and its incorporated areas. Latinos make up 94% of the RCAC membership,
leaving 2% African American, 3% Cambodian, and 1% Caucasian. The current CA committees
closely depict the current ethnic make-up of VCHPs overall consumer membership. While the
current make-up is seemingly diverse, it is not representative of all groups serviced by the plan.
With the majority of VCHPs consumer advisory identifying as immigrants, there is an apparent
knowledge deficiency of health care in the U.S. In theory these factors act as inhibitors of
effective advocacy.
Consumer members contribute to the organization’s mission by providing meaningful
feedback to VCHPs Board of Governors. While this feedback guides health care programs and
provides input on the quality of care consumers receive from providers, there has been minimal
documented success resulting from the committee’s actions. Currently, consumers are asked to
identify access issues and share with VCHP staff during their regional advisory meetings. If the
issue is deemed to be global in nature a motion is made and taken to the Executive Community
Advisory Committee. However, the realty of this process is often impeded by unclear systems
and staff obstruction based on their belief and understanding of the issue and its value. While
there have been some success from members on bringing issues forward for VCHP Board
consideration, their continues to be an disproportionate number of health access issues that
remain unaddressed by members as result of the consumers inability to hold the plan to
implementing a “true” advisory process.
VCHPs Board of Governors is comprised of 15 members. This group includes
stakeholder organizations such as hospitals, hospital associations, clinic associations, and social
services organizations. These organizations have an interest in the welfare of marginalized
communities in Viking County and their access to quality care. The Board of Governors of
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

25
VCHP strives to reflect the diversity of its members, providers and other stakeholder. VCHPs
board of governors are ultimately responsible for ensuring that the organization meets its mission
and goals and are good stewards of public funds used to care for the Medicaid and Medicare
populations.
Stakeholder Performance Goals
Currently there are no stakeholder goals by which the community advisory contributions
can be measured. Cascading goals represent best practices for strategy driven performance
measurements (Aguilar, 2003; Loch & Tapper, 2002; Risher, 2007; Pulakos, 2009; Rouse, &
Putterill, 2003). One of the problems identified in VCHP’s advocacy process is the lack of
cascading goals for the consumer advisory committees. Clearly defined goals that align with
VCHP’s board of governor’s strategic goals and the organization’s mission will serve in holding
advisory councils accountable, as well as the board accountable to the two million members
served. Additionally, these goals would allow VCHPs board of governors an opportunity to be
responsive to consumer inquires, projects, and policies that impact access and care for Viking
County’s Medicaid population.
Currently, the only means by which consumers (who are not advisory members) can
express service dissatisfaction in regards to their health care is by phone to VCHPs member
services department. The current process is to file a grievance, attend a public meeting, or Board
of Governors meeting to express concerns during the public comments time on the agenda. This
process is not customary and does not appeal to low-income and less educated consumers thus, it
is not an impactful way to engage low-income populations (Schlesinger, Mitchell & Elbel,
2002). A study conducted by Grootegoed, Bröer, and Duyvendak (2013) asserted that filing
grievances does appeal to marginalized populations. While grievances are often objectively
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

26
warranted, they challenge the moral code and trigger feelings of shame, of not being
autonomous, of demanding too much when others are worse off, and of appearing ungrateful.
Service encounters by both clinicians and non –physician health care staff can play a unified role
in the interactions between the consumer and the company (Holmqvist & Grönroos, 2012; Tajeu,
Cherrington, Andreae, Holt, & Halanych, 2015). This is primarily due to them being the first
contact for members accessing care as well as their ability to answer questions that provide
clarity to member inquiries.
Table 1.1
Organizational Mission, Global Goal, and Stakeholder Performance Goals
Organizational Mission
“Provide access to quality health care for Viking County’s vulnerable and low-income
communities and residents and to support the safety net required to achieve that purpose.”

Global Goal
Recognized leader in improving health outcomes for low-income and vulnerable populations
by capitalizing on community resources such as public advisory committees to ensure a
responsive, accountable, and responsible partnership in support of the Viking brand.

Organizational Performance Goal
By September 2019, Viking County Community Outreach and Engagement will implement
the reform of its 11 Regional Community Advisory Committees (RCAC) ensuring alignment
with the organizations strategic plan, mission and vision

Stakeholder 1 Goal

By October 30, 2018
Community Outreach and
Engagement will form a
consumer ad-hoc committee
comprised of Regional
Community Advisory
Committees to participate in a
Stakeholder 2 Goal
By September 30, 2018
Community Outreach and
Engagement will work with
key external advocates to
form a community advocate
ad-hoc committee to
participate in a series of focus
Stakeholder 3 Goal

By September 30, 2018
Community Outreach and
Engagement will work with
assigned Viking County’s
Board Services to appoint and
or select a minimum of two
ad-hoc committee members
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

27
series of focus groups that
assist in the design and
development of the
conceptual framework that
will assist in reforming the
current 11 advisory
committee’s civic
engagement training,
engagement processes,
consumer advocacy feedback,
and input to Viking County’s
Board of Governors on
matters impacting access to
care for Medicaid and
Medicare populations.

By April 30, 2018
Community Outreach and
Education will develop a
proactive and comprehensive
leadership and advocacy
strategy to preserve the two-
plan model, including local
and state consumer legislative
advocacy days and by
identifying and cultivating
consumer legislative
champions.

groups and surveys that assist
in the design and
development of the
conceptual framework that
will assist in reforming the
current 11 advisory
committee’s civic
engagement training,
engagement processes,
consumer advocacy feedback
and input to Viking County
Health Plan’s Board of
Governors on matters
impacting access to care for
Medicaid and Medicare
populations. This advocate
ad-hoc committee will also be
tasked with assisting Viking
County Health Plan with
input on how to strengthen
collaboration between the
plan and the advocacy
community, ensuring
increased value and co-
branding of wellness efforts.

to develop conceptual
framework for reforming the
current 11 advisory
committee’s processes,
feedback and input to VCHP
Board of Governors on
matters impacting access to
care for Medi-Cal and
Medicare populations.

This ad-hoc group will be
tasked with identifying key
areas by which they feel
consumers could aide in
providing meaningful input to
Viking County’s Board of
Governors.

Stakeholder Group for the Study
While joint stakeholders contribute to the overall organizational goal of, “capitalizing on
community resources,” the focus of this project will be on VCHPs consumer advisory
stakeholders which is comprised of VCHPs RCAC members. This stakeholder group is charged
with ensuring responsiveness, accountability, and responsible partnership in support of VCHPs
brand. In order to meet this charge, it is crucial that consumer advisroy members work with
VCHP staff assist CAs to craft strategic priorities that assist the stakeholder groups in meeting
their specified timelines and deliverables. While this should be determined by the consumer
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

28
membership, it is very difficult to execute. The inability for consumers to lead the execution of
this task is result of their lack of education and guidance
In order to address barriers impacting the CAs effectiveness, a revamp of the current
process is needed to create and implement processes that support consumer input. CO&E staff
will facilitate and work with both internal and external stakeholders to implement a strategic
development plan that will improve and reform advisory committees, increase value, and
increase global thinking (global thinking requires consumers to bring forth access issues
impacting more than one member in a region/s). This reform will assist VCHPs governing board
with input on decisions that impact Medicaid consumers. Failure to accomplish this goal will
impede consumer advisory committees from aligning with the newly adopted strategic plan and
vision. In addition, the organization will default in meeting the enabling legislation that created
VCHP. Lastly, by not adopting a new and efficient process for change, the board of governors
will not have an opportunity to incorporate meaningful feedback from consumers in their
decision-making and operations of the organization.

Purpose of the Study and Questions
The purpose of this study is to draw a mutual understanding between the needs of Viking
County as a community accountable health plan and the needs of consumer stakeholders to
provide meaningful feedback to the health plan. This can be accomplished by VCHP identifying
clear goals and priorities of the health plan and by identifying the knowledge gaps between
consumer stakeholders and the stakeholder organization goals. There are currently 245
consumer stakeholders who do not recognize their inherent power as advocates to effectively
impact policies that could improve access to care for other Medicaid users. While 245 consumer
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

29
advocate members only constitute .01% of the overall membership, VCHP deems this group has
problematic because of their ability to raise concerns that can be heard by key decision makers.
This is problematic for several reasons: 1) the homogenous input resulting from a majority
representation of one group, 2) consumers are not able to utilize learned advocacy skills to
advance the needs of their fellow consumers, and 3) organization leaders do not believe that
issues brought forth are global in nature and in fact are not representative of the larger member
base. It will also be essential moving forward that CO&E staff identify broader means for
diversifying representation in the consumer advisory committees. Consumers speak with the
authority of having used, or being prospective users of, services and therefore with have a
legitimate interest in provision of services on a personal basis (Callaghan & Wistow, 2006).
Understanding the knowledge factors impeding low-income consumers from becoming civically
literate will support VCHP in building the capacity of its consumer stakeholders in areas of
leadership, communication, professional meeting etiquette, managed care, and public policy.
The following research questions guided this study:
1. How can the consumer advocate feedback process be streamlined so that access
issues can be easily shared with the stakeholder organization?
2. What types of knowledge, motivation, and organizational influences are needed to
serve as a consumer advocate?
3. How can the stakeholder organization empower consumer advocates to become
effective members of the committee?
Conceptual and Methodological Framework
For change to occur researchers must diagnose the human causes and identify appropriate
solutions (Clark & Estes, 2008). This is a qualitative study that used triangulation to understand
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

30
performance gaps. This study utilizes a qualitative approach. The qualitative methods include
individual interviews, meeting observations, and document analysis. These approaches assist in
gaining a broad understanding of VCHP’s current consumer advocate stakeholder’s gaps in the
areas of knowledge and motivation.
The Clark and Estes (2008) Knowledge, Motivation, and Organizational (KMO)
approach provides the conceptual framework utilized to answer the proposed improvement
questions. The use of the KMO approach helps to provide a better understanding of the gaps that
impede consumer stakeholders from becoming proficient advocates. Utilizing the KMO
approach will also identify knowledge and skills needed to close the gaps that prevent consumers
from meeting their intended purpose, adding value to the organizations accountability, and
bringing alignment with the overall mission of the organization.
The results of this research will be used to assist VCHP to improve their consumer
stakeholder process, build increased and sustained capacity of their consumer advocate
committees, as well implement a improved education and empowerment program that will result
in the stakeholders ability to successfully understand health policies and advocate for or against
those policies which impact low-income Medicaid recipients. The expected outcomes are a
contrast from the current support to the advisory program. The current state of support minimally
The study will create a model for other health plans that desire to understand deficits and
implement effective and efficient models for consumer stakeholder education and engagement
through data analysis and application of individual interviews, focus groups, and document
analysis.
Definition of Terms
Advocacy-Public support for or recommendation of a particular cause or policy.
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

31
CLASS Standards- State standards for culturally, and linguistically appropriate service and
support.
ECAC- Executive Community Advisory Committee
Medicaid- Free or low cost Health Insurance for U.S. Citizens who fall below the federal poverty
guidelines
Medicare- Free health insurance for U.S. Citizens 65 years of age and older
RCAC-Regional Community Advisory Committee
Organization of the Study
Five chapters are used to organize this study. Chapter One provides the reader with key
concepts and terminology commonly found in a discussion about health care and consumer
feedback. Effective means of supporting consumers in addressing barriers to effective advocacy
are also discussed. The organization’s mission, goals, and stakeholders, as well as the initial
concepts of gap analysis are introduced. The goal for Chapter Two is to provide a review of
current literature surrounding the scope of the study. Topics of empowerment, advocacy,
engagement, health access, community organizing, and capacity building are addressed. Chapter
Three details the knowledge, motivation, and organizational elements, as well as methodology
when it comes to choice of participants, data collection, and analysis. In Chapter Four, the data
and results are assessed and analyzed. Chapter Five provides solutions; based on data and
literature, for closing the perceived gaps as well as recommendations for plan implementation
and evaluation to achieve the desired solutions.

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32
CHAPTER TWO: REVIEW OF THE LITERATURE
The review of the literature in Chapter Two of this dissertation outlines the theoretical
foundations that support ideology that consumers need basic understanding of healthcare in order
to build skills and give concise feedback on issues impacting Medicaid and the quality of care
received under its auspices. The first section focuses on specific knowledge and learning skills
needed to understand basic health care management, advocacy, and accountability concepts. The
second segment addresses varied modalities used by public decision-making entities and
community stakeholders to collaboratively address gaps in health care access, implement policies
that encourage continuous quality improvement, gather consumer feedback, and provide
advocacy to a community accountable health plan. The chapter ends with a conceptual and
organizational definition of effective advocacy which, correlates to knowledge influences and the
degree of motivation required to be an effective, strong advocate for health and social change.
This literature review focuses on the roles that motivation and knowledge-related
influences play in augmenting the value of input from consumer stakeholders. This section will
also review and correlate literatures for knowledge types and gaps, as well as categorize each
knowledge influence into a particular knowledge type that will support a, “value added global
thinking,” model for consumer engagement and advocacy (VCHP, 2016). Empowerment,
advocacy, engagement, health care access, community organization, and capacity building will
each be addressed as catalysts for a comprehensive consumer education program.
Knowledge Generation
Knowledge generation is a key factor in effective advocacy. When consumers do not
have facts, data, or background information to support their advocacy issues, it is virtually
impossible for them to justify or make claims to decision makers that will lead to realized
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

33
outcomes (Gaventa, 1995; Lubalin & Harris, 1999; West, 1996). Kiles (2002) stated that many
service and volunteer programs have failed to sufficiently address the development of
fundamental civic skills such as expressing opinions and working collectively to achieve
common interests as part of their design. Berkes (2009) recommended that organizations co-
manage as a means of introducing a problem-solving process that involves negotiation,
deliberation, knowledge generation, and joint learning with their community members. Co-
management requires organizations to value cooperation between community stakeholders and
agencies. Bridging organizations provides a forum for the interaction of different knowledge
types, and the coordination of other tasks that enable co-operation: accessing resources, bringing
together different actors, building trust, resolving conflict, and networking. Social learning is one
of these tasks, while it is essential both for the co-operation of partners, and an outcome of the
co-operation of partners (Berkes, 2009).
Community Accountability
Community accountability arguably moves beyond community participation in that it
requires the health system to be responsive to the issues raised by its participants.. In this
context, ‘responsiveness’ can be defined as changes made to the health system based on ideas or
concerns raised by, or with, community members through formally introduced decision-making
mechanisms (Molyneux, Atela, Angweny, & Goodman, 2012). In health care accountability, the
three dominate domains that serve as drivers are: professional, economic, and political
(Brinkerhoff, 2004; Emanuel & Emanuel 1996; Gamm, 1996; Magnan et al., 2012). The nexus
between quality and accountability relies heavily on the “Triple Aim” an ideation that focuses on
the containment of cost, quality of care, and the consumer’s experience while accessing care
(Gosfield, 1997; McCarthy & Klein, 2010). According to Berwick, Nolan, and Whittington
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

34
(2008), preconditions for this include the enrollment of an identified population, a commitment
to universality for its members, and the existence of an organization “integrator”- that accepts
responsibility for all three aims for that population.
Community Empowerment
Community empowerment speaks to the need for a continuous dialogue that benefits
communities, not just individuals. A renowned educator, Paulo Freire (1989) advocates
participatory education as a means of community empowerment. Freire (1989) emphasized that
people are not objects or recipients of political projects, but that the members of these
communities are actors in history; capable of naming their problems and solutions; they can
transform themselves in the midst of oppressive circumstances. Wallerstein and Bernstein
(1994) argued that there are two crucial roles that practitioners play: 1) to empower
communities, organizations must act as a resource to help create favorable conditions and
opportunities for community members to share in dialogue and improvement, and 2)
organizations must engage in the process as partners, plunging themselves deeply into the
learning process and addressing biases that may come from personal beliefs or the institution’s
influence.
Psychological empowerment is key in addressing poor health outcomes in the context of
community. According to Checkoway (1993), psychological empowerment refers to an
individual’s ability to make decisions and have control over their personal life. Psychological
empowerment shares similarities with self-efficacy, self-esteem, and its emphasis on positive
self-concept and personal confidence. The ability to advocate for one’s health relies heavily on
the consumer’s confidence in speaking about issues that directly impact his or her health
outcomes. While empowerment work can be observed at individual, community, and
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

35
organizational levels, it is the individual level where empowerment establishes an analytical
understanding of the social and political context, the cultivation of both individual and collective
resources, and the skills for social interaction (Checkoway, 1993). Empowerment at the
individual level combines: personal efficacy and competence, a sense of mastery and control,
and a process of participation in the influence of the decisions institutions make (Checkoway,
1993).
Community Organizing
Community organizing can play an integral role in effective advocacy by drawing
members of the community together into an organization that acts to improve circumstances that
effect all citizens of the population (Gutierrez, Lewis, & Minkler, 2012; Minkler, & Wallerstein,
2012). Those who are involved in their community have an opportunity to work alongside
policy makers to lead change, hold organizations more accountable through conscious raising of
issues, forming committees, and promoting political action (Ginwright & James 2002). Research
conducted by Drier (1996) stated that while many macroeconomic and social structures can
promote or inhibit grassroots mobilization, community building emphasizes the importance of
leadership development, strategic planning, and network building across neighborhoods, cities,
and regions, in the mobilization of people to solve their common problems (Smock, 2004).
Marginalization
Marginalization, according to Tucker (1990), is the complex and disputatious process by
means of which certain people and ideas are privileged over others at any given time this process
creates problematic binary notions of center and periphery inclusion and exclusion, majority and
minority as they operate in artistic and social practice. Ray (1996) described marginalization as
a process that produces individuals, social groups, and communities that are denied full
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

36
privileges, rights, access, and power within the existing political system and social structure.
Research conducted by Gutierrez (1997) stated that the ethnic-sensitive approach to multi-
cultural organization is an adequate response to the disenfranchisement and inequality
experienced by communities of color.
Theoretical Foundations Needed for Effective Advocacy
Health education comprehensively represents areas of health that provide core
foundations for clear directives on education and health promotion. According to Green and
Kreuter (2005), health promotion is defined as any planned combination of educational, political,
regulatory and organizational supports of action and conditions of living conducive to the health
of individuals, groups and communities. Health literacy according to Shim (2017), is at the helm
of the consumers ability to make appropriate health decisions. The Patient Protection and
Affordable Care Act of 2010 defines health literacy as the degree to which an individual has the
capacity to obtain, communicate, process and understand basic health information and services to
make appropriate health decisions.
Significance of the Problem
When low-income vulnerable populations have lower education, inability to express
symptoms to their providers, receive inadequate care, lack culturally competent providers, and
are not able to express their dissatisfaction with treatment, there is a likelihood that they will
experience structural barriers impacting their ability to be true advocates (Bentancourt et al.,
2016; Morales, Kington, Valdez, & Escarce, 2002; Pickett & Pearl 2001; Schlesinger, Mitchell,
& Elbel, 2002). According to Chin (2017) there must be, “movement advocacy,” or the ability
for to raise awareness of health injustices and to advocate for reform policies that impede health
equity to change systems that give marginalized group’s power to voice their concerns.
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37
Currently there are no straightforward processes for Medicaid consumers to address
issues regarding health care access at the local plan level. Many consumers lack formal
education and understanding of managed care, which impacts their ability to effectively advocate
for themselves and their family members (Christoffel, 2000). The ability to share concerns with
the decision-making authorities is often a challenge for consumers, however, this problem is
important to resolve as VCHP is recognized as the largest Medicaid program in the nation. As
an industry leader responsible for over 2 million consumers, VCHP has the ability to create a
platform that could serve as a model to effectively respond to the consumer stakeholder’s ability
to advocate for quality health care. The ability to implement a transparent, effective, and
equitable process for consumer input that improves health care for low-income consumers could
prove to be optimal for the managed health care industry.
Knowledge Influences
Knowledge influences are paramount to the way learners learn. Knowledge is recognized
as the most important resource in an organization, and a key-differentiating factor in business
today (Gurteen, 2007). It is increasingly accepted that Knowledge Management (KM) can bring
about much needed innovation and improved business performance within an organization
(Gurteen, 1999). Understanding knowledge influences is fundamental in assisting consumers to
build advocacy skills and understand barriers that prevent the same. The declarative knowledge
influences factual, conceptual, procedural, and metacognitive (Krathwohl, 2002) will be
described to articulate the education needed to achieve the stakeholder’s goals.
In Krathwohl’s “Revision of Bloom’s Taxonomy” (2002), four dimensions of learning
are defined Factual knowledge, Conceptual knowledge, Procedural knowledge and
metacognitive knowledge. These learning dimensions play a crucial role in building learning and
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

38
training curriculums. Factual knowledge is defined as “the basic elements that the learner must
know to be acquainted with a discipline or solve problems within it.” The ability to understand
consumer issues is critical to the stakeholder’s capacity to critically think and make sound policy
recommendations to VCHPs board of governors. Conceptual knowledge is defined as “the
interrelationships among the basic elements within a larger structure that enable them to function
as a whole”. This concept assists stakeholders in their ability to synthesize advocacy learning’s
and be able to apply it in other domains. Procedural knowledge is defined as knowing how to do
something; it involves making discriminations, understanding concepts, and applying rules that
govern relationships and often includes motor skills and cognitive strategies. This concept is
crucial to stakeholders as it provides the basis for connecting learning to performance this
learning dimension emphasizes the importance of knowing how to perform certain activities
(Confrey, 1990). Lastly, metacognitive knowledge is defined as “knowledge pertaining to
cognition in general, awareness of and knowledge about one’s own cognition, strategic
knowledge, and knowledge of cognitive tasks, including appropriate contextual and conditional
knowledge.
Categorizing each knowledge influence is essential in the construction of complementary
learning objectives. For success in a multitude of academic tasks, learners need to possess all
four kinds of knowledge (Mayer, 2011). Each has a distinguished role in the creation of a
methodical process for building quality curricula for research-based consumer advocacy
trainings.
Declarative Knowledge Influences
Ensuring that stakeholders have access to facts and the knowledge of how and when to
utilize those facts is imperative so that they may serve as effective advisory members. Having
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

39
comprehensive knowledge of advocacy concepts is the foundation of the stakeholder’s success.
Researchers such as Dewey (1897) made a strong case for learners to focus on more than just the
acquisition of a predetermined set of skills, but Dewey stressed the importance of the preparation
necessary to be able to use all of one’s abilities. In the endeavor to build advocacy skills among
Medicaid consumers, there is an inherent need to construct factual knowledge in areas such as
support, managed care, understanding data, social determinants of health, and the stakeholder’s
ability to influence change. Knowledge of these foundations will assist advocates in the
engagement of meaningful discussions with decision makers. Nutbeam (2000) stated that
improving consumer access to information and their capacity to use it effectively is critical to
empowerment.
Conceptual. Conceptual knowledge can be defined as, “an integrated and functional
grasp of ideas,” (Kilpatrick, Swafford, & Findell, 2001). Advocacy educators assess knowledge
by encouraging the use of skills in advisory and community meetings. Utilization of the
information will validate the knowledge of conceptual information. The development of skills
mastery is important for advocates of consumers to demonstrate their knowledge of skill
components, practice integration of said skills, and understand when to apply what they have
learned.
Alexander, Schallert, and Reynolds (2009) asserted four dimensions of learning: what,
where, who, and when. This study is crucial to the stakeholder group as it contends that
learning is both a product and a process. Educators play an important role in the transfer and
pedagogy of knowledge. Educators can support consumer advocates’ reinforcement of learning
by assisting them in the attainment of the solid mastery of advocacy principles and illustrating
multiple examples that aid in the reinforcement of learning. An educator’s role is to ensure that
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

40
he or she is able to support stakeholders by being a resource, a mentor, and someone who can
lend a helping hand. Educators must understand interdependent and fundamental issues in order
to construct cognitive, methodological, political, emotional, and interpersonal empowerment
(Herron, 1996).
Procedural. Clear knowledge of how to perform a task is essential to the success of
meeting the intended stakeholder goals. In a study conducted by Johnson et al. (2009), the
researchers suggest that tests be administered that contain questions designed to promote the
reflection of key principles. Using a style of questioning that aids in the reinforcement of
learning can greatly assist in understanding the learner’s degree of mastery. Test questions
should be designed to exemplify each of Bloom (1956) five levels of thinking: comprehension,
application, analysis, synthesis, and evaluation. Bloom’s levels of thinking support the
importance of process-oriented learning and the stakeholder’s ability to retain and recall concepts
at the proper time. In essence, consumers who are able to identify factors that impact their
learning process and performance, and are able to create a strategic plan and implement the
outcomes, would arguably have mastered procedural knowledge.
Metacognitive. Most consumer stakeholders bring to the advisory process a wealth of
experience from other community advisory boards on which they serve. According to the
information processing theory, prior knowledge can help or hinder learning. In this case, the use
of metacognitive strategies greatly assists stakeholders in becoming self-regulated in their ability
to learn new or advanced information. The ability of the educator and the learner to reflect on
their strengths and challenges greatly impacts learning opportunities for both the teacher and the
student. This often occurs when learners are given the opportunity to apply principles and share
examples based on other experiences during discussions.
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41
When learners are able to strategize and problem solve, they use tools that support the
self-awareness they need to strengthen metacognition. In an article by Kirschner and van
Merrienboer (2013) deeply analyzed the nature of the learner, learning, and teaching. The
authors asserted that it is the learner who knows best and that he or she should be the controlling
force in their own learning process. In contrast to the legend that the learners know best,
Kirschner, Sweller, and Clark (2006) asserted that guided instruction should be superior to other
styles in the context of our knowledge of human cognitive architecture, expert–novice
differences, and cognitive load. Druckman and Porter (1991) challenged this theory by stating
that learning is based on types, meaning that learners are not assigned scores based on different
dimensions, but, rather, they are classified into distinct groups. Learners may not be fully aware
of their strengths, and they may learn differently depending on the particular knowledge type that
best suits them (Druckman & Porter, 1991). Many monolingual consumer advocates have
increased their understanding of problem solving when paired with a bilingual learning partner.
This means that the educator must possess multiple means of educating and assessing the learner.
An outline showing the assumed knowledge influence, the knowledge type, and the processes to
fulfill the knowledge influence is displayed below in Table 1.2.
Table 1.2
Knowledge Worksheet
Organizational Mission
“Provide access to quality health care for Viking County’s vulnerable and low-income
communities and residents and to support the safety net required to achieve that purpose.”

Organizational Global Goal
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42
Recognized leader in the improvement of health outcomes for low income and vulnerable
populations by capitalizing on community resources such as our public advisory committees to
ensure that we are a responsive, accountable, and dependable partner in support of the VCHP
brand.
Stakeholder Goal
By September 2017, Viking County Care’s Community Outreach and Engagement
implemented the reform of its sixteen Regional Community Advisory Committees (RCAC)
ensuring alignment with the organization’s strategic plan, mission, and vision.

Assumed Knowledge
Influence
Knowledge Type Knowledge Influence Assessment

Staff must have
knowledge of basic
training skills.

• Procedural
• Metacognitive
• Engagement staff was asked to
conduct mock presentations that
would demonstrate training skills
proficiency.
• Engagement staff was asked to
reflect on their current facilitation
skills and self–select areas in
which they would like to enhance
their skills.
Using case studies,
consumer advisory
member orientation
should educate
consumers on the
VCHP processes,
managed care facts, and
guidelines. Education
must address
knowledge,
comprehension,
application, critical
thinking, synthesis, and
evaluation.
• Procedural
• Declarative
(Conceptual)
• Engagement staff updated and
produced member guidelines and a
training manual with a glossary
and resources.
Staff needed education
on learning and
motivation in order to
integrate learning
• Procedural • Staff was asked to identify
minimum of three learning
techniques and three motivation
techniques to be used when
facilitating advocacy trainings.
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43
theories in consumer
trainings.
• Staff was asked to observe each
other and assess others’ ability to
apply learning and motivation
techniques proficiently.
Board and consumer
members worked
collectively to create a
step-by-step scenario
regarding how they
would work to address
the global access issues
that impact consumers.
• Procedural • Board and consumer members
were asked to list the various
means by which consumer issues
can be resolved.
Consumer members
clearly conveyed issues
with access to care.
• Metacognitive • Consumers needed to acquire
knowledge that would help them
be more proficient in their
advocacy work.

Motivation
Motivation and knowledge influence work in concert to offer support to consumer
stakeholders. Motivation also adds value to the consumer input processes and assists consumers
in the attainment of their advocacy goals. Collectively, they impact the goal of producing well-
trained and integrated consumer advocates. Some stakeholders are what Bandura (2000) calls
“shapers” of events. True advocates work to make things better for themselves and their
community. Bandura (2000) argued that people are partly the products of their environments,
but, by selecting, creating, and transforming their environmental circumstances, they are
producers of environments. Working collectively to address barriers cannot be done alone. It is
imperative that advocates work together to meet their intended goals and serve their purpose. In
Bandura’s Exercise of human agency through collective efficacy, he notes that perceived
collective efficacy fosters groups’ motivational commitment to their mission and resilience to
adversity and performance accomplishments.
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44
According to Wigfield and Eccles (2000), the expectancy value and motivation theories
can be a strong predictor of persistence and mental effort. In the endeavor to build advocacy
skills among Medicaid consumers, it is important to understand the baseline motivation factors
associated with the stakeholder’s desire to participate in long-term advocacy and skills building.
To implement a true learning experience, the VCHP Community Outreach and Engagement staff
must be introduced to learning and motivation theories that integrate key learning concepts and
support effective consumer trainings. Given the importance of knowledge transfer to
disenfranchised community members, acquisition of advocacy skills is important to the
development of strong advocates.
Principles associated with the Information Process Theory (IPT) (Miller, 2003), and the
Expectancy Value Theory (EVT) (Wiggfield & Eccles, 2000) are important to motivation efforts.
The IPT suggests that when information learned is meaningful and connected to prior
knowledge, it is stored and retained more accurately because it is associated with prior
knowledge. Perhaps this may explain why community stakeholders who have participated in
other advocacy efforts adapt at a faster rate than their counterparts who have not participated in
other advocacy efforts to understand their role as an advocate for VCHP.
Based on the EVP, the four influences that play a major role in motivation and influence
on a learner are: utility value, attribution, self–efficacy, and goal setting (Wigfield & Eccles,
2000). Utility value is defined as the usefulness of meeting future goals. Heider (1958) defined
attribution as the process by which individuals explain the causes of behavior. According to
Bandura (1994), self-efficacy is the process by which an individual’s belief in his or her capacity
to execute essential knowledge that produces specific performance attainments. Lastly, goal
orientation falls into two categories: mastery and performance. When learners work to master
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45
information as opposed to comparing their performance to that of their peers, they tend to use
themselves as a comparison and not their counterparts. Observation of stakeholder participants
yields several types of learners: those who desire to retain information for basic recall, those who
desire complete mastery of advocacy information, and those who aspire to use the information
for a bigger goal. This is also described as a growth mindset vs. a fixed mindset. Dweck (2000)
noted that students who hold incremental beliefs about intelligence tend to adopt mastery goals,
and those that hold entity theories of intelligence tend to adopt performance goals.
Utility Value
Utility value, according to Eccles (2009), is associated with a set of beliefs that impact
short and long term goals. Studies conducted by Eccles correlate achievement-related choices to
two sets of beliefs: 1) The individual’s expectations for success, and 2) The importance or value
the individual attaches to the various options perceived by the individual as available. Consumer
stakeholders must perceive the value of expanding and retaining their knowledge of advocacy
and social justice issues in order to transfer knowledge when addressing VCHPs board of
governors and other policy influencers.
According to researchers Hidi and Renninger (2006), interest plays a powerful role in the
level of a person’s learning. Learning and interest play an important role in building consumer
advocacy education, it also opens doors in other areas of advocacy that further support an
advocate’s growth and success. Examples of utility value can be identified when consumer
members who have successfully completed advocacy trainings are able to transfer their
knowledge and skills to serve in leadership roles regionally and at board of governor’s level.
High confidence in one’s ability to successfully master material and the ability to understand the
utility value of learning for future options builds confidence in one’s ability to place high value
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46
on their potential (Wigfield, Schiefele, Roeser, & Davis-Kean, 2006). Activists and disease-
based organizations (i.e. cancer, AIDS, and diabetes) have demonstrated that the lay public can
learn and participate in scientific, medical dialogue and contribute to setting research and policy
agendas (Zarcadoolas, Pleasant, & Greer, 2009).
Eccles (2009) stated that being fully engaged while completing the learning task is the
construct for success. Utility value is increased by how well a task fits into an individual’s goals
and plans, or how well it fulfills other basic psychological needs. Consumer advocates, who are
able to connect their choice to become advocates, participate in learning opportunities, and
become proficient in their advocacy skills, can efficiently exercise utility value. The ability to
utilize advocacy skills assists consumers to champion for themselves, their families, and
community. In contrast, if consumer advocates do not see the value of completing the task
associated with learning, they may not be motivated in their effort. According to an executive
leadership training evaluation conducted by the VCHP (Leadership Training Survey, February,
2015), consumer advocates reported the usefulness of the training they received stating that,
before the training they were afraid to speak up, but now they are assertive enough to address
issues when they present.
Attribution. Attribution according to Harvey and Martinko (2009) is vital for adapting to
changing environments and overcoming challenges we are confronted with in our daily lives.
Attribution and its correlation to behavior outcomes was originally studied by Fritz Heider
(1958) and later evolved by Bernard Weiner (2001). The work of attribution is useful in
understanding how learners form causal beliefs about their abilities and link those beliefs to
motivation. Weiner’s attribution model draws attention to three dimensions: Locus, Stability,
and Controllability. Acknowledgement of internal (contingent on behaviors controlled by the
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47
individual) or external factors (those out of the individual’s control) and their impact on success
or failure is defined as the locus of attribution. Assisting stakeholders in their understanding of
the power they possess in making changes that lead to successful outcomes is a crucial aspect of
process learning. Educators must encourage learners to move beyond maladaptive behaviors that
negatively impact progression along the performance spectrum.
Weiner (2006) also stated that feedback must be specific and not general. Specific
feedback assists students in the development of adaptive, attributional beliefs about their
capabilities. This is important because it aids the learner in his or her ability to focus on areas
where improvement is most needed. Some consumer advocates in leadership roles labeled
themselves as self-doubters and increased confidence in their abilities as result of timely
feedback. Brophy (1981) suggested that being able to administer proper feedback and motivation
is paramount to assisting learners. Educators have the power to shape student attribution in
comments to students, feedback given on assignments and examinations, and the types of praise
offered during instruction. Studies conducted by Weiner, (2006) suggested that the way in which
attribution is communicated to the learner directly affects the continued motivation of the
student. In teaching advocacy skills, it is imperative that staff facilitators be made aware of the
proper ways that feedback should be provided to participants.
According to Shute (2008), feedback should be timely and accurate. Shute (2008) also
affirms that the earlier corrective information is provided, the more likely it is that efficient
retention will result. This theory was also studied by Phye and Andre (1989). Together these
researchers found that when students were not required to provide feedback, a substantial delay
in retention occurred. Likewise, when students were required to provide feedback, delayed
retention was virtually eliminated. The superiority of immediate over delayed feedback has been
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48
demonstrated for the acquisition of verbal materials, procedural skills, and some motor skills
(Anderson, Magill, & Sekiya, 2001; Brosvic & Cohen, 1988; Dihoff, Brosvic, Epstein, & Cook,
2003).
A preliminary conclusion derived from both Schroth (1992) and Corbett and Anderson
(2001) findings is that delayed feedback may be superior for promoting the transfer of learning,
especially in relation to concept-formation tasks, whereas immediate feedback may be more
efficient, particularly in the short term and for procedural skills (i.e., programming and
mathematics). Based on the numerous studies conducted, timely feedback can have both positive
and negative effects. However, it is widely accepted that timely feedback greatly enhances the
learner’s ability to perform.
Self-efficacy. Self-efficacy, according to psychologist Albert Bandura (2000), is defined
as one's belief in his or her own ability to succeed in specific situations. One's sense of self-
efficacy can play a major role in how one approaches goals, tasks, and challenges. When self–
efficacy is used as a model of behavioral change, there is proof that strengthening positive
attitude and adoption of healthier choices occurs (Bandura & Cervone, 1983; Maibach & Parrot,
1995). Self-Efficacy is used to set realistic learning and behavioral goals. It ensures follow up
to ascertain the accomplishment or failure of goals set. This reciprocated check-in is effective in
reinforcing self-efficacy, ensuring support and accountability. There is a general belief among
researchers that community-based participatory research is an effective approach to studying and
addressing health disparity issues (Minkler, Blackwell, Thompson, & Tamirand, 2003).
The transference of skills to community members proved successful in a study conducted
by Minkler et al. (2003). In this study, high profile foundations supported three community-
based intermediary organizations as they conducted trainings for twenty community members.
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49
These participants received training on how to properly conduct and analyze data from a massive
door–to-door survey campaign undertaken as part of the city’s Enhanced Enterprise Community
Project. Additionally, participants underwent training that helped them work with
representatives of government agencies, health departments, and academic institutions to develop
new approaches to the problems identified in the survey.
After seven years, many of the participants who were originally trained were still
involved in research and action in their respective communities. This type of collaboration is
what Bandura identified as individual and collective self-efficacy. Individuals and organizations
with high self-efficacy tend to choose difficult tasks, expend greater effort, persist longer, and
use more complex learning strategies. Knowing how to do a job inevitably leads to increased
self-efficacy; being able to attain self-efficacy can positively influence motivation.
In the support of self-efficacy, VCHP consumer advocates are taught to use motivational
interviewing. Motivational Interviewing (MI) is a technique created by William Miller, Ph.D.
MI is a method that works on facilitating and engaging intrinsic motivation in order to change
behavior. Consumer advocates utilize MI when working with each other to promote health and
build advocacy skills. In contrast to Miller’s MI, Deci and Ryan (2000) argued that simply
feeling competent to engage in a behavior is not enough to promote optimal motivation. An
increase in perceived competence will only lead to optimal motivation for action when it takes
place within the context of a degree of self–determination. The authors concluded that a
motivationally supportive environment will provide reinforcement for both autonomy and
competence.
Goal orientation. Goal Orientation falls into two categories: mastery and performance.
Consumer advocates that master information tend to be more proficient, able to think critically,
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50
transfer information efficiently, and apply specific skills to different scenarios. According to
Locke and Latham (2002), self-efficacy is important in goal setting. The researchers state that
people with high self-efficacy are more committed to assigned goals. Likewise, researchers
Kruger and Dunning (1999) stated that when learner’s work to master information as opposed to
comparing their performance to that of their peers, they tend to use themselves as a comparison
and not their counterparts. According to Kruger and Dunning (1999) it is better for learners to
master knowledge than to focus on performance. Recognizing one's own incompetence leads to
inflated self-assessments (Kruger & Dunning, 1999). Many consumer advocates aspired to
become leaders within their advisory committees where they were able to use all of their learned
advocacy skills to represent fellow consumer members on VCHPs executive advisory committee.
Additionally, there were opportunities for promotion to VCHPs board of governors as a
consumer board representative.
In contrast to one’s desire to master advocacy skills, mastery avoidance can transpire.
Mastery avoidance occurs when consumer advocates work diligently to avoid any
misunderstanding or corrections by the educator. In part, this may have been due to a desire to
avoid looking incompetent (Van, Elliot, and Anseel 2009). Van et al. (2009) note that this can be
damaging to performance improvement relative to the mastery approach. The second category
of goal orientation is the performance approach. Performance approach occurs when consumer
advisory members “hijack” learning opportunities by dominating the learning session impeding
others’ participation. Likewise, performance avoidance occurred when consumer advocates did
not ask questions and avoided participating in learning activities that would have otherwise
validated their learning. Table 2.1 summarizes motivational influences and their uses for this
research.
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51
Table 2.1
Motivational Worksheet
Assumed Motivation
Influences

How Will It Be
Assessed?
Motivational Solution Principle
Expectancy–Value

Utility Value

Attribution

Self-Efficacy

Interview Survey
Item
“How much do you
value being able to
advocate quality
health care? Do you
expect to succeed?”

Interview Survey
Item
What leadership
skills have you
mastered from being
a part of the Regional
Community Advisory
Committee?

Written Survey Item
Consumer advocates
ability to recall the
procedural steps for
creating a motion on
health access issues,
to be heard by the
board of governors.

Interview Survey
Item
“How confident do
you feel about your
ability to recall
specific advocacy
skills in meetings
Rationales that include a discussion
of the importance and utility value
of the work or learning can help
learners develop positive values
(Eccles, 2006; Pintrich, 2003).

Eccles et al. (1983) define task
values as the perceived importance
of the task because: it is useful or
relevant for other tasks or aspects
of an individual’s life

Learning and motivation are
enhanced when individuals
attribute success or failures to
effort rather than ability.
(Anderman & Anderman, 2009).

Learning and motivation are
enhanced when learners have
positive expectancies for success
(Pajares, 2006).

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52

Goal Orientation
.
with decision
makers?

Interview Item
Name three areas of
advocacy that in
which you would like
to improve your
skills.
What is your
motivation for
learning about
advocacy? and, How
will you use the
information ?

Focusing on mastery, individual
improvement, learning, and
progress promotes positive
motivation (Yough & Anderman,
2006).

Organizational Resources
Adding to knowledge and motivation barriers of consumer advocates, there are also
organizational barriers that factor into the performance gap of VCHP. Maintaining continuous
monitoring of identified organizational culture gaps is essential to sustaining change. Clark and
Estes (2008) stated that developing and changing the culture of an organization can change its
performance. The improvement of consumer performance relies on the support of the
stakeholder organization. All organizational goals are achieved by a system of interacting
processes that require specialized knowledge, skills, and motivation to operate successfully
(Clark and Estes, 2008). An organizational that strengthens work processes, culture in the
environment, groups, and in individuals, collectively works to advance consumer advocacy and
lessens overall performance gaps. In Turning Research into Results, Clark and Estes (2008)
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53
stated the importance of “value chains” as an organizational resource. Value chains identify the
way that divisional or team processes achieve goals for internal and external customers. They
rely heavily on effective work processes which according to Clark and Estes (2008), tell groups
of individuals how to combine their separate work procedures into a smooth functioning unit.
Consumers innately rely on VCHP to have clear processes in place that support the overall
feedback loop used to address quality of care and member access issues.
Accountability in health care continues to shift between managed care organizations and
regulatory entities. As a result of this continuous shift, the disenfranchised consumer’s ability to
hold entities accountable is often challenged. Bozeman and Scott (1996) write that the existence
of red tape implies an unnecessary and counter-productive obsession with rules, rather than
results and processes. Red tape often delays accountability by upholding systems that encourage
formalization and stagnation. Additional research by Sabin, O'Brien, and Daniels (2001), states
that accountability for practicality requires three elements: transparency of organizational
policies and decisions, deliberation that recognizes the needs of both the individuals and the
population served, and the opportunity for appeals and revision of limit-setting policies.
Gaventa (1995) stated consumer advocacy has little to do with incapacity or disinterest,
but more to do with the construction of power in which consumers find themselves. According
to Gaventa (1995), understanding power, powerlessness, and empowerment strategy is key to
building political efficacy and advocacy skills. Empowerment comes from encouraging the
disenfranchised to bring their grievances into the political process (Gaventa, 1995).
Empowerment is extremely important to consumers as their participation in shaping policy is
critical to decision makers and their understanding of the true experience of a Medicaid
consumer. Organizations must operate with transparency by creating a clearly defined landscape
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54
that supports consumers in the resolving of issues and repairing systems that hinder consumers’
ability to access quality health care.
Organizational Culture
Organizational culture is defined as the set of shared values that help organizational
members understand organizational functioning, and thus guide their thinking and behavior
(Desphande & Webster, 1989). Organizations that leverage diversity improve their overall
business performance (Glick, Miller, & Huber, 1993). Creating a culture within an organization
that embraces diversity lends to the cultures’ success. According to Angeline (2011), effective
leaders demonstrate a commitment to valuing diversity through inclusive action. An example of
this occurs when leaders promote an organizational culture that promotes equity and inclusion as
well cultivates an atmosphere where diversity is viewed as an asset to the organization and its
stakeholders. The make-up of an organization’s upper echelon is a critical determinant of the
organization’s performance. This is further supported by Ditomaso, Post, and Parks-Yancy
(2007) who stated, “effective leaders promote diversity at the highest levels of the organization”.
A firm’s culture can be a source of sustainable, competitive advantage if the culture is valuable,
rare, and imperfectly imitable (Barney, 1986).
Leaders of organizations have an opportunity to enhance health care for low-income
consumer stakeholders by creating an internal culture that values its consumers and readily
aligns its operations with the overall mission of the organization. Organizations develop
different cultures over time. Clark and Estes (2008) stated that there are three common
approaches to comprehending culture in organizations: culture in the environment, culture in
groups, and culture in individuals. Culture in the environment describes how an organization’s
culture can change its performance. It is also believed that the work environment can change
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55
cultural patterns. Culture in groups is described as the cultural property of a group: it is the “I”
vs. “We” that focuses on groups instead of individuals or environments. Lastly, culture in
individuals can be described as a person’s core knowledge and motivational patterns.
Organizations sometimes suffer when there are clashes between different cultural beliefs and the
expectations of its members. Understanding organizational culture can guide decisions about
goal selection and the processes used to achieve them.
Organizations can build patterns of response to challenges. Clark and Estes (2008) assert
that when employees fail to get the necessary resources for a high priority work goal, or when a
policy is not supported by effective work processes, it is presumed that a conflict between an
aspect of organizational culture and current performance goals exists.
Leadership. Leadership plays an essential role in the shaping of organizational culture.
However, according to Clark and Estes (2008) there are no best practices, for all organizations
vary at all stages of development. Clark and Estes (2008) suggested that organizational
development is more likely to succeed when stakeholders are equipped to handle its unique
challenges. Leaders can help develop, shape, and maintain desired organizational culture and
may affect organizational innovation by creating new sets of shared values (Conger & Kanungo,
1987; Schein, 1990; Trice & Beyer, 1993). Enz, O’Reilley, and Roussea, (1991) acknowledged
the guiding and directing role of values as the primary component of an organization’s culture
and employees’ behavior. Accountability, organizational culture, and leadership are key factors
in the success of a changing organization. Additionally, innovation, stability, teamwork, shared
vision, and enabling others to act positively all impact the cultural landscape of an organization
(Jaskyte, 2004).

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Conclusion
The purpose of this project was to understand the needs of VCHP and its consumer
stakeholders used to hold the health plan accountable. The primary goal of this project was to
increase the value of consumer input to the board of governors by implementing clear processes
for consumer engagement and feedback regarding issues of access and quality of care. This will
be accomplished by ensuring the implementation of a streamlined process that documents tracks
and trends all access issues experienced by members. The secondary goal of this project was to:
increase consumer knowledge, outline motivating factors for current participants and assess the
organizational culture that is needed to support changes. This will be measured by conducting a
post survey inclusive of consumer-identified barriers experienced when working with internal
stakeholders. This is important to the framework of the advisory program as it assists members
to critically think and consider solutions to consumer issues that they identify. In conclusion,
this project is expected to identify findings during the stakeholder interviews and highlight gaps
that hinder the performance of advocates that contribute to the overall improvement of care for
Medicaid consumers.
The overall goal of this project was to increase the value of consumer input to the board
of governors by implementing clear processes for consumer engagement and feedback regarding
issues of access and quality of care. The questions this project sought to answer were the
following: 1) What knowledge is needed to be proficient at the basic level of advocacy?,
2) What processes are in place that support consumer advocacy?, 3) Do consumer members
understand their roles and responsibilities as advisory members? 4) What skillset is needed by
staff to support the increase in knowledge of consumer advocates? 5) What are the basic skills
needed for civic engagement? 6) How many consumers are aware of the social determinants of
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57
health? 7) Based on the number of consumers, how many advocates are needed per region to
represent the total member base? 8) What does diversity look like from the consumer
perspective to ensure equitable representation of the total membership? 9) What defines
“increased value” to the board of governors? 10)What type of data currently exists that supports
the need for consumer input? 11) Is there any conceptual knowledge about the consumer input
process? 12) Are consumer advocates fully supported to identify and address barriers to
accessing care? 13) Do members understand the importance of the stakeholder process and
power they possess to change processes and policies that impact the services they receive? 14)
15) What are the short, medium, and long-term impacts of consumer engagement and advocacy?
While this questionnaire was believed to support the overall research questions, it was limiting in
that it minimally was able to answer questions related to this research project.

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CHAPTER THREE: METHODOLOGY
Clark and Estes (2008) KMO approach will be utilized to evaluate the proposed
improvement model. The use of the KMO approach assists in providing an analysis of the gaps
that impede consumers from becoming proficient in their basic understanding of healthcare
systems, and assists in focusing consumer advocates in areas needed to build knowledge and
skills in basic healthcare comprehension aimed at preventing consumers from meeting their
intended purpose. Learning how to close these gaps adds value to the organization’s
accountability and helps it to come into a stronger alignment with the overall organizational
mission.
The methodological approach used was primarily qualitative in nature and utilized one -
on -one interviews, meeting observations and document analysis. These approaches assist in
gaining a better understanding of the consumer advocate stakeholders’ current healthcare
knowledge, gaps in their knowledge healthcare systems and operations their motivation, and
their perception of support from VCHP. Gaining insight into these aspects contribute to the
organization’s ability to educate and create engaged and empowered consumer advocates who
successfully understand health care rights and can advocate for or against policies that impact
low-income Medicaid recipients. Currently, knowledge around these policies can be requested
through VCHPs Government Affairs department, and other community collaborative’s working
to inform consumers and increase advocacy around important health access topics. Addressing
issues of quality of care and overall member experience is the responsibility of the advocates.
CAs are made aware of this role upon their initial onboarding and orientation as consumer
advocate representative. In the event that members cannot accomplish the said goals,
opportunities to implement change are greatly diminished for the Medicaid users they represent.
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Credibility and Trustworthiness
Credibility and trustworthiness is key to successful research. As the researcher, I worked
diligently to maintain the credibility and trustworthiness of this study. I maintained sole
responsibility by ensuring the research was conducted in a respectful and ethical manner and
without bias. Eisner (1991) concluded that while qualitative and quantitative studies require
objectivity and truthfulness, the criteria for qualitative studies differ. Qualitative studies seek
believability, based on coherence, insight, instrumental utility, and trustworthiness (Lincoln &
Guba, 1985). According to Merriam (2014), the qualitative investigator’s equivalent concept,
i.e. credibility, deals with the question, “How congruent are the findings with reality?” Lincoln
and Guba (1985) supported this concept by arguing that ensuring credibility is one of most
important factors in establishing trustworthiness.
Shenton (2014) offered a step-by-step approach to realizing credibility. The first step
requires adopting well-established qualitative research practices by taking notice of how
questions are asked and how data is gathered. Understanding how data are analyzed is important
in maintaining credibility in research and should be based on comparable projects. The second
step is the development of an early familiarity with the culture of participating organizations.
Lincoln and Guba (1985) and Erlandson, Harris, Skipper, and Allen (1993) suggested, that focus
groups should not be the first encounter with research participants. They further recommended,
“prolonged engagement” between the investigator and the participants so that both gain an
adequate understanding of the organization and it establishes a relationship built upon trust
between the parties. The third step in establishing credibility is to conduct random sampling. By
conducting a random sampling, Shenton (2014) noted that the researcher may negate charges of
researcher bias in the selection of participants. Stakes (1994) claimed that in random sampling,
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60
multiple voices exhibiting characteristics of similarity, dissimilarity, redundancy, and variety
allow the researcher to gain a greater knowledge of a wider group, such as a more general
population, rather than simply the individual informants who are contributing data.
The scientific method by which the participants were chosen is a random single stage
sampling of current consumer advisory members. These consumer advisory members are
representative of VCHPs 11 consumer advisory committees. Babbie (2007) noted that single
stage sampling is conducted when the researcher has access to the population and can sample the
people directly. The researcher conducted randomized sampling of the participants. This
ensures diverse participation as well eliminates bias that could occur by using a purposeful
sampling technique.
Triangulation uses multiple research strategies to address all aspects of a project, with the
understanding that not all strategies work as a standalone, but together provide a comprehensive
understanding (Brewer & Hunter, 2006; Guba, 1989). Triangulation for this study involved the
use of individual interviews, document analysis and observations to help understand barriers to
effective advocacy. In triangulation, each research method has its own strength; however,
together they complement each other and can be very useful as they work in concert to support
corroboration or convergence; or divergence when the research information is not in agreement.
An example of how triangulation assists credibility in this study is the comparing of data sources
by committee member’s individual interviews, focus group responses, and document analysis.
This comparison supports the credibility of the study outcomes and the data collected. The data
are representative of a wide range of consumer members and their responses in comparison to
other consumers in other regions.
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Tactics to ensure credibility were employed in interactions with participants. To support
the voluntary nature of the project (human subjects), participants were encouraged to be honest
and had the right to answer, or not answer questions that might have made them feel
uncomfortable. Participants were made aware of the right to withdraw from the study at any time
without fear (Shenton, 2014). Iterative questioning also plays a role in credibility. This is done
by way of asking questions for clarification based on the participant’s response or by noting in
the final research report any discrepancies and offering possible explanations. Peer scrutiny is
also useful in increasing credibility. Peer scrutiny was applied from both my VCHP collogues
and my OCL peers. According to Shenton (2014), peer scrutiny provides a fresh perspective that
allows them to challenge assumptions made by the investigator, whose closeness to the project
frequently inhibits his or her ability to view it with real detachment. Questions and observations
from peers may well enable the researcher to refine his or her methods, develop a greater
explanation of the research design, and strengthen his or her arguments in the light of the
comments made (Shenton, 2014).
Furthermore, the background, qualifications, and experience of the investigator help to
establish credibility. According to Patton (1990), the credibility of the researcher is especially
important in qualitative research, as it is the researcher who is the major instrument of the data
collection and analysis. According to Maxwell (2013), to check internal validity is through,
“member checks.” Member checks allow the researcher to solicit feedback on preliminary or
emerging findings from study participants. During this process, the researcher can share some
preliminary findings with study participants and ascertain if the findings are valid. Another
validity measure is adequate engagement in data collection. The researcher should collect data
until they reach a point of “saturation” (Maxwell, 2013).
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Creswell (2013) took the position that while there is no specific answer as to how many
surveys one should include in as his or her study, the sample size should depend on the
qualitative design being used. Charmz (2006) offered another thought on data collection
procedures by stating that the researcher should stop collecting data when the categories become
saturated. Given the small sample size, I will review focus group responses for saturation until it
is clear that no new information or insights appear. Understanding the problem of practice is key
to the goal of the project. Ensuring validity ensures that the processes used to meet the goals of
the project are not put in jeopardy. Outcome validity is the extent to which outcomes occur,
which leads to a resolution of the problem that led to the study (Herr & Anderson, 2015).
Ensuring credibility is a continuous process from beginning to end. Qualitative studies
can be excellent if they address a worthy topic, are rich in rigor, transparent, credible, resonate
with a variety of audiences, make significant contributions to the field, attend to ethical
considerations, and show meaningful coherence to literature, research, questions and findings,
and interpretations with each other (Tracy, 2013). This triangulation study requires a clear
understanding of the studies’ purpose and the insurability of its alignment with credibility and
trustworthiness standards.
As the researcher, I have ensured that the focus group and interview questions used with
participants directly measures what was intended for the problem of practice. This is measured
by using questions from like improvement study models. Secondly, I shared the goal and
purpose of the study with the executive consumer committee. The intent of this presentation will
be to build transparency and to answer any questions regarding the purpose, outcomes, and plans
for study findings. Ensuring participants confidentiality, as well assuring them that their
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insurance benefits would not be jeopardized as result of their participation in this study also
support this.
Qualitative researchers can check to determine if their research approach is reliable by
documenting as many of the steps of the procedure as possible and by setting up a detailed case
study protocol and database so that others can follow the procedures. Gibbs (2007) suggested
the following reliability procedures: check written transcripts to ensure they do not contain
obvious mistakes made during transcription, and make sure there are no drifts in codes used for
the coding the process. Miles and Huberman (1994) recommended that the consistency of
coding be in agreement at least 80% of the time for good qualitative reliability. To account for
internal validity checks, I will solicit feedback on the preliminary findings from participants on
their individual transcripts. Using a triangulation of research methods yields a report that is in
support of the advocacy practitioner’s understanding of the skills needed for improving
consumer advocate trainings, as well as contributes to the body of knowledge that supports
health advocacy.
Validity and Reliability
To ensure validity and reliability is increased and maintained, the researcher used an
abbreviated survey to determine the accuracy of the study’s findings. The following questions
served as a guide for ensuring validity: Do survey results correlate with other results?, Do
survey items measure hypothetical constructs or concepts (Creswell, 2014)? Reliability indicates
that the researcher’s approach be consistent across different researchers (Gibbs, 2007) Questions
used to ensue reliability included: Are the item responses consistent across constructs?, Are
scores stable over time when the instrument is administered a second time?, Can the researcher
determine whether there was consistency in test administration and scoring (Creswell, 2014)?
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Study participants were all asked to complete short questionnaire that included concepts that
participants encounter in their advocacy efforts. Each participant was asked questioned in a
standardized format insuring continuity for each question and unbiased input.
Denzin (1978) identified four types of validity measures that are incorporated into the
study: (1) the use of multiple methods, (2) multiple data sources, (3) multiple investigators, and
(4) multiple theories to confirm emerging findings. Of the four types of validity measures
mentioned the use of multiple methods was used as a strategy to support this study. Merriam and
Tisdale (2016) identified additional strategies that promote validity and reliability. The
researcher points to usage of a multiple methods approach using the triangulation of data. This
allows the researcher to compare and cross check data collected through observations at different
times or in different places, or allow interviews to be collected from different people with
different perspectives.
The ability of the researcher to check for inherent biases in non-responses must be
predetermined and is crucial to the quality and outcomes of the study. Fowler (2009) described
response bias as the effect of nonresponses on survey estimates. This research project utilizes
respondent and non-respondent analysis. For this study, I have kept a record of the number of
returned versus surveys not returned. I have also used a respondent and non-respondent
approach by contacting a few non-respondents by phone and determining if their responses differ
substantially from respondents. This information will be shared in a table with graphs that depict
survey outcomes.
Ethics
Researchers must always anticipate ethical issues that may arise during their studies
(Punch, 2005). Researchers need to protect their research participants, develop trust with them,
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promote integrity of research, guard against misconduct and impropriety that might reflect on
their organizations or institutions, and cope with new challenging problems (Israel & Hay, 2006).
Participants were protected through all phases of the study including: reporting, sharing,
presentation of findings, and storing of data.
Participants for the study were recruited from VCHPs current consumer advisory
committees. These committees are comprised of 11 committees with a total of 245 members.
Members were notified during their regional meetings of the opportunity and basic criteria to
participate in the study. Members who met the basic criteria were asked to add their names to a
list of potential study participants. Using basic information provided, staff verified member’s
info using the VCHP member database. VCHP staff was able to qualify potential participants
based on language and tenure requirements of the study. Participants who met the requirements
were placed in a pool for selection.
A simple random sample from seventy self -identified monolingual and bi- lingual
English-speaking consumers were chose. Using Microsoft Excel software, five names were
randomly drawn from the perspective pool. Participants were notified by phone and asked of
their continued availability. The five interview participants were chose as a means to initiate
groundwork for this project and to raise awareness around the need for further investigation.
Given the magnitude of the project, the population size of consumer participants on the
committees (245) the traditional sample size with a 95% confidence interval would need to be no
less than 244. However, because of time, needed to complete this projects requirement, the
researcher was limited to the number of study participants. Consumer members were scheduled
and interviewed within a two- week time span in a location of their choice (local coffee and
sandwich shops). Participants were provided with the purpose, written explanations of the study,
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as well as how the findings will be used for future improvement of the consumer advisory
committees using instruments submitted for IRB approval
To further address the ethics of this study all research participants were asked to read and
sign an informed consent form. There were no refusal for participating in the study however;
participants were not pressured to sign the form. Tracy (2013) suggested that guidelines
“prescribed by certain organizational or Institutional Review Boards (IRB) as being universally
necessary” be employed, such as “do no harm” and “informed consent”. Informed consent is a
process that includes the following steps: participants are told about any risks related to the
study, participants are told about benefits of their participation, participants are given a chance to
ask questions and receive answers to their comfort and satisfaction.
The proposed study was submitted to the University of Southern California’s IRB and
follows all written guidelines to protect participants from harm. All participation in this research
project is considered voluntary, meaning that participants can withdraw from participation at any
time. The researcher has a duty to ensure that participants are comfortable and are not subject to
the use of offensive, discriminatory, or other unacceptable language. Such language was avoided
in the formulation of the questionnaire, interview, and focus groups questions.
Unique identifiers were assigned to each participant. The researcher is the only person
who had access to the code names, which were maintained, solely for use in instances where
follow-up was needed by the researcher to responses provided by focus group participants.
Identifiers were used during interviews, and observations. Identifiers were used throughout the
transcript to maintain anonymity. All information was disassociated with study participants
(Creswell, 2014) this form of confidentiality was important to participants, as they wanted to be
ensured that there was no retaliation for their feedback on the current advisory operation. This
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also ensures another level of security for participants. Data will be kept in a locked storage
located at Viking County Health Plan’s headquarters for a period of five years and then
discarded by Viking County Health Plan’s professional document disposal service. All
participants received light snacks, $10 Starbucks gift card and a thank you note for their
participation. All participants were informed that upon their request, a copy of the summary
findings and recommendations could be obtained from the researcher.
As a full-time employee of VCHP and manager of engagement efforts there are potential
conflicts of interest as I am a member of VCHPs management team. Glesne and Peshkin (1992)
define “backyard” research as studying one’s own organization, or immediate work setting. The
researchers stated that this often leads to compromises in the researcher’s ability to disclose
information and raises issues of an imbalance of power between the inquirers and the
participants. Results from this study could potentially implicate my department, their skills or
lack thereof to conduct the adequate training consumers may need to improve advocacy
proficiently. In addition, I could also be biased in favor of the consumers based on my passion
for grassroots advocacy work. This could inevitably create bias related to the project and shape
interpretations I make during the study.
Acknowledging bias could also influence outcomes that support management and their
definition of “member added value”. Additionally, members of the advisory committees may be
confused by my role as employee and researcher. To address this issue, the researcher has
written memos that capture my biases and the researcher will not facilitate any of the focus
groups interviews. The researcher will train key department staff to conduct focus groups. To
further reiterate the study’s purpose and my role, the researcher will include an educational
opportunity that will disclose the full background on the project to participants and address any
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questions related to my involvement in the study, and provide additional contact information to
reach my committee chair.
According to Creswell (2014), researchers must clarify their personal biases. This self-
reflection creates an open and honest narrative that resonates well with readers. This is important
to this problem of practice as the researcher is employed by the stakeholder organization and is
very close to the issues experienced by members. Creswell (2014) further stated that good
qualitative research contains comments by the researcher about how their interpretation of the
findings is shaped by their background, gender, culture, history, and socio-economic origin. The
following reflection points to biases that could impact the studies outcome: as a longtime
advocate working in the community: I have over twenty plus years of public policy, advocacy,
and grassroots education. I volunteer countless hours in the areas of healthcare, reproductive
justice, and community empowerment. I am a member of several community boards in the
communities most impacted by the social determinants of health (Solar & Irwin, 2007). I am
classified as a minority woman; this is significant as over ninety percent of participants are
minority women. Additionally, I live in an area that mirrors the areas where many of the study
participants reside. My cultural background and work experience allows me to understand
marginalized groups and the barriers they face living in low socioeconomic areas. I am aware of
the many negative factors impacting education, food access, poor health outcomes, lack of
resources, lack of jobs, and cultural isolations. These biases will be addressed as appropriate to
sustain the integrity of the project.
Document Analysis
To complete the triangulation process for this project document analysis was used to review
meeting summaries from the consumer stakeholder bi-monthly meetings. Meeting summaries
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69
serve as the primary source of information as the originator of the meeting is recounting
firsthand experience with the phenomena of interest (Merriam & Tisdell, 2016). Data from this
analysis were used to identify knowledge, themes, and opportunities for additional learning in
support of the committee’s advocacy efforts.

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CHAPTER FOUR: DATA ANALYSIS AND FINDINGS
The purpose of this study was to conduct a gap analysis that would examine the
knowledge, motivation and organizational barriers that impede effective advocacy among low-
income Medicaid stakeholders (Clark & Este, 2008). While VCHP could ultimately benefit from
a comprehensive study that would focus on all stakeholders to include staff and organization
leaders, this study focuses on consumer stakeholders. It is the researcher’s belief that this group
would most readily benefit from the outcomes and recommendations of this evaluation. With the
belief that the current efforts are inadequate these recommendations will also support their quest
to prepare consumers to be equipped to advocate for access to quality healthcare.
Data collection efforts for this study included triangulation of three data sources which
included five interviews with current consumer advisory members, observation of two
community advisory meetings, and document analysis of five documents from the monthly
Executive Community Advisory Committee (ECAC) meeting minutes. According to Patton
(2015) triangulation in any form, increases credibility and quality by countering the concern that
a study’s findings are simply an artifact of a single method, a single source or a single
investigators blinders. Interview participants were selected based upon current membership
demographics ensuring that interview participants closely resembled the overall advisory
member population. The make-up of participants included two African Americans and three
Latina members. While Latinas make up the majority of the current advisory membership it was
important to have representation from other groups in this study. A purposive sampling of
consumer advisory participants with a minimum of one year participation across advisory
regions were selected as interview participants for the study (Palays, 2008). All interviews were
conducted in a meeting place selected by participants. While I had prepared for a maximum of
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60 minutes for each interview, each interview took an average of 120 minutes to complete. This
time included 45-60 minutes of participants sharing personal background information prior to
the start of their interview and 60 minutes of responding to interview questions which would
lend insight as to their involvement in VCHPs consumer advisory process. Using Excel, to assist
in the second means of data collection was through existing meeting minutes taken from five
randomly selected months within a twelve month period. Meeting minutes are public documents
that are captured by the stakeholder organization’s board services department during monthly
ECAC. These meetings are comprised of consumer chairs (presidents) of each regional advisory
committee. Meeting minutes are produced to capture any actionable items in need of a vote,
request for follow-up from consumers, investigations related to the health access issues, quality
of care and consumer experience. Finally, the researcher participated as a participant observer in
two RCAC. Data collected from these meetings were scribed and transcribed by the researcher.
This allowed the researcher first hand interaction with the consumers of which this study seeks
to understand as it relates to their knowledge, motivation and the organizations influence on
change. The researcher was the sole person responsible for the development of the interview
protocol. The series of questions were reviewed during inquiry studies and the researchers
assigned accountability partners. This review was for soundness and applicability to the study.
All interview participants were provided an overview of the type of questions that were going to
be asked. The rationale for this method was so to decrease bias related to responses given by
study participants.
Analysis
The researcher utilized the triangulation approach. Data collected from stakeholder
individual interviews, focus groups, and document analysis, was used for analyzing data
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72
associated with this project. For time management, the researcher began this process upon
completion of my first round of interviews. Thorough data collection, analysis, and report
writing, of interview findings were documented immediately. This was done to help increase the
validity and or trustworthiness of findings and so that information was not lost over time.
Interviews
Interviews are categorized as qualitative research. The analysis of interview data for this
study, is guided by Clark and Estes (2008) conceptual framework KMO. The KMO premise
begins with the understanding that, research based and tested performance improvement
strategies work and are more cost effective. In conducting interviews with the study participants,
there were ample opportunities to gain a understanding from the advocates view on the support
and investment from VCHP into their advisory committees. Interview analysis, according to
Creswell (2014), involves segmenting and taking apart the data, as well as putting it back
together. All interviews were recorded by the researcher and transcribed by Rev.com software
application. Rev.com provides accurate and affordable audio and video transcription for $1 per
minute of content. This transcription included field notes, and categorization of data from
stakeholder respondents that depict common themes and tones across all interviewees Creswell
(2014) suggested that in qualitative research the researcher should aggregate data into a small
number of themes of no more than five to seven. Upon review of collected data, I reviewed
interview data and coded all collected data. During the coding process, I engaged in open
coding. I strongly believe that it allowed me the opportunity to learn things about the
stakeholders that I many not have considered in my initial hypothesis. Merriam and Tisdell
(2016) stated that when you begin analysis you can be as expansive as you want in identifying
any segment of data that may be useful. Based on my current knowledge and the direction of my
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study I also used axial coding. Axial coding allowed me to group my open codes. As I only
conducted a small number of interviews (5), I hand coded all data from interview participants.
To address this, I made sure that all participants’ feedback was included. This ensured that there
was a broad spectrum of input by consumer’s stakeholders. Addressing typicality is important
for this study as it allowed me to determine what is normal for my stakeholders and be able to
convey to internal stakeholders who are unfamiliar with consumer advocacy how the program
typically impacts consumer stakeholders. I engaged in multiple phases of coding. This was done
by organizing and assigning a word to the segment in order to develop a general pattern. During
each phase I codes were added to my master list. The continuous updating of my codebook
ensured that all segments were accounted for. Proper coding ensured the richness my results
section as well unsuspected themes resulting from conversations with consumer participants.
Bogdan and Biklen (2011) stated that quoting your subjects and presenting short sections
from your field notes and other data helps to get closer to the people you have studied. Lastly, is
the final write up of the data, as a triangulated project my research will be built on qualitative
insights and finding. These findings play an important role in the overall defense and
recommendations gleaned from the study. I described lessons learned, my personal
interpretation of the data outcomes, the comparison of data among two groups (monolingual
English, and bi-lingual English/ Spanish speaking participants), as well confirmed or rejected
current research or ideas of building community capacity and advocacy assets that improve
barriers to effective advocacy. Figure 3 & 4 provide description of both primary and secondary
language spoken by study participants.

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Participating Stakeholders
Interviews were conducted with five consumer advisory members. Table 1 summarizes
the consumer advisory members interviewed. For anonymity and confidentiality of participants
pseudonyms were used. All participants are currently active in the stakeholder advisory process.
This study yield 100% participation rate. Of the 245 active members on the RCAC roster, five
members met the study participant criteria and were interviewed. The age of participants
interviewed ranged from 25 years of age to over 65 years of age. Three participants completed
high school and two of five were educated at the Masters level. Two study participants self-
identified as African American and three of Latin decent. Tenure of interview participants as
members of an advisory committee ranged from 1 to 12 years. All interviews were conducted in
English with three of five participants self -identifying themselves as bilingual English/Spanish
speaking. Table 4.1 summarizes participant’s information.
Table 4.1
Participant Information
Pseudonym Age Ed. Ethnicity Bilingual CT* IL*
Ms. Garcia1
35-44
HS Latina Yes
9-12 yrs. English
Ms. Lakey2
65 and Over Masters
African Am No
2-4 yrs. English
Ms. Munoz3
25-34 HS
Latina Yes
1yr or less English
Ms. Jones4
45-54 Masters
African Am No
2-4 yrs. English
Ms. Soza5
35-44 HS
Latina Yes
9-12 yrs. English
CT*= Committee Tenure IL*=Interview Language

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Ms. Garcia #1
Eager to share, Ms. Garcia noted that, it means a lot to her to be able to advocate in the
US. She came here undocumented to find a better life, and has found through advocacy, that she
is able to use her voice to help her children and friends. Ms. Garcia sees herself as a role model
for her children in that she is avidly involved in her community and helps others to advocate for
what they need. Ms. Garcia feels that she has gotten far because she is bi-lingual and is able to
communicate well. Ms. Garcia defeats cultural norms of Latina women as she is outspoken, very
opinionated, and does not mind taking necessary risks to get to where she needs to be.
Ms. Lakey # 2
Ms. Lakey, an 86-year-old feisty African American woman, was happy to share her
advocacy journey growing up during segregation, a time where African Americans were not able
to voice their opinions. Ms. Lakey is a 1954 graduate of Howard University, the first historical
Black college, a veteran of the US Air Force, and has served on countless boards and community
advisory committees. A strong proponent for education Ms. Lakey, shared about 45 minutes of
her background and history prior to the start of her interview. Social justice in nature, Ms. Lakey
does not take no for an answer and is a firm believer that you have to know the history of a
particular topic in order to solve the problem. Ms. Lakey in physical appearance is frail and uses
a motor chair however, she clearly stated, “I may have physical limitations but I am mentally
strong for my age.”
Ms. Munoz #3
A 30 year old, Latina American, single mom, domestic violence survivor, educator,
accountant, recent divorcee, and parent to a special needs child. Ms. Munoz has found liberation
through her advocacy efforts. Ms. Munoz feels that being a domestic violence survivor and
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Latina American has greatly impacted her ability to speak up. When asked to share examples of
this she stated: “my mom was a housekeeper for a Caucasian family while I was growing up”. “I
would spend countless hours with her at work. The family had children my age and often invited
me with them to all sorts of outings”. “I became very much a part of their family”. “To this day
the daughter is my best friend” “Because of my schooling, environment and associations my
ability to voice my opinion was enhanced and never inhibited by my Latin culture”. “I say what
I got to say”. “When I got married my voice was taken away, the relationship was extremely
abusive”, “I’m happy to say that finally, one day I got strong enough to leave”. Ms. Munoz also
stated that because she has a child with a learning disability, she has also become a stronger
advocate for her child to ensure that the school district honors her daughters Individual
Education Plan. Ms. Munoz is extremely dedicated to the advisory purpose. To this end, she
worked out a plan with her current employer that allows her to attend bi-monthly meetings
without pay. She feels that being a part of the advisory empowers her work, as well as, keeps her
informed of changes to Medicaid, which positively impacts her daughter. Lastly, Ms. Munoz
makes reference to her current health problem stating that she has had to spend countless hours
on the phone in addition to writing letters in order to access needed services. When asked has it
worked she says, “I don’t stop till I get what I need.” Ms. Munoz repeatedly contends, “I have no
problem speaking up.”
Ms. Jones #4
A 54-year-old, disabled, African American woman was ready to share how she overcame
feeling sorry for herself and began using her education to learn more about disability rights.
With a very serious look she stated, “Why is it that every time a black woman speaks people
think we’re angry? I’ve been working on my tone so that people don’t use it against me when I
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speak. I’m not angry, but I am passionate about my advocacy work”. Ms. Jones stated that she
forced herself to become knowledgeable about disability rights so that when she would speak to
decision makers she was using factual information to justify her request. Ms. Jones feels that
without her education and membership on other advocacy committees she would not be a strong
advocate for the disabled community. Ms. Jones understands the importance of collaboration in
order to be an effective advocate. Ms. Jones feels that she is still learning but proclaims that it
was her early experiences of unfair treatment and being disabled that contributes to the
advocated she is today.
Mrs. Soza #5
A 36-year-old Latina woman, married with three children, Mrs. Soza presented flustered
but eager to share her opinions and views in hopes that her participation in the interview session
would make a difference in the future of the advisory committees. Ms. Soza stated that she
spends a lot of time driving from place to place, city-to-city, just to get health services and
medical prescriptions that she so desperately needs. Ms. Soza stated that she is actively involved
in other community groups in support of her children who has documented disability that
requires much of her attention. Ms. Soza said she spends quite a bit of time with VCHP trying to
get help accessing needed doctors, specialists, appointments, and referrals. Ms. Soza, despite
life’s hiccups, is dedicated to advocacy and tries to be a part of any group she feels she can learn
from. Ms. Soza is currently a member of several groups that she believes enhances her ability to
connect and share community resources. Figure 4.1. Provides a overview of study participants
by age.
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Figure 4.1. Participants demographics.
0%
20%
40%
20%
0%
20%
18-24 25-34 35-44 45-54 54-64 65 AND OVER
UNDERSTANDING BARRIERS IN EFFECTIVE ADVOCACY
DEMOGRAPHICS AGE
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Figure 4.2. Participants ethnic make-up

40%
0%
60%
0%
0%
0%
0% 10% 20% 30% 40% 50% 60% 70%
African American
Asian
Latino
Native American
White of Latino Descent
Other
UNDERSTANDING BARRIERS IN EFFECTIVE
ADVOCACY
ETHNICITY
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Figure 4.3. Study participants by primary language spoken.
80%
20%
0% 0%
English Spanish Khmer Other
UNDERSTANDING BARRIERS IN EFFECTIVE
ADVOCACY
PRIMARY LANGUAGE
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Figure 4.4. Secondary language spoken by study participants.
20%
40%
0% 0%
English Spanish Khmer Other
UNDERSTANDING BARRIERS IN EFFECTIVE
ADVOCACY
SECONDARY LANGUAGE
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Figure 4.5. Participants education level.
0
1 1
0
1
0
2
0%
20% 20%
0%
20%
0%
40%
0
0.5
1
1.5
2
2.5
3
8th grade and
under
High School
(9th-12th grade)
Associates
Degree (2 years
college)
Bachelor's
Degree (4 years
college)
Started College
but did not
finish
Trade or
Technical
College
Gradutate
Degree (Master
Doctorate
Degree)
UNDERSTANDING BARRIERS IN EFFECTIVE
ADVOCACY
LEVEL OF EDUCATION
Series1 Series2
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Figure 4.6. Number of years as a consumer advisory member.
Knowledge Findings
Knowledge gaps can have a substantial impact on the effectiveness of those charged with
implementation of training and education programs. At VCHP, it is imperative for staff to have
knowledge of best training and evaluation models in support of the organizations advocacy
efforts. Based on interviews, meeting observations, and document analysis, the following three
knowledge findings were identified during the research study: 1) Training for advisory members,
2) Education that assist advisory members in understanding managed care systems, and 3)
Improvement of communication skills. This section will examine research findings and their
nexus to the research questions of how to improve the consumer input process and how the
1
2 2
0 0
20%
40% 40%
0% 0% 0
0.5
1
1.5
2
2.5
3
1 year or less 2-4 years 5-8 years 9-12 years 13 years and more
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YEARS AS AN ADVISORY MEMBER
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stakeholder organization can empower consumers to be effective members of their advisory
committee.
Knowledge: Training for Advisory Members
Interviews. To support advisory members in being more effective it is important that
they receive comprehensive training in Managed Care and Advocacy. Data collected from
individual interviews, validate the assumed cause that consumers stakeholders must have
knowledge of basic leadership procedures and performance measures in order to facilitate their
meetings. To further validate this assumption, interview participants were asked to complete a
demographic survey which included key questions used to determine their level of advisory
knowledge. The demographic survey included questions about age, race, education, advisory
tenure,
These findings are consistent with literature from Clark and Estes (2008) as it relates to
training to address knowledge and skill gaps. These findings are also consistent with Krathwohl
(2002) as it relates to conceptual and procedural knowledge. To gain more insight into the
participants knowledge about VCHP advocacy process, participants were asked to first identify
and circle the best process for getting health access issues heard by VCHP. Only four of the five
interview participants answered correctly. They were then asked to answer the following
question: Can you identify the role of an advisory member? All five participants answered the
second question correctly. Using a Likert scale, the third question asked participants to rank
advisory priorities (improved advocacy training, improved meeting agenda, and improved
orientation) in order of importance. Three participants believed that advocacy training is most
important and one participants believed that improved orientation is somewhat important. Only
one participants believed that an improved meeting agenda should be a priority. Both training
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and new member orientation could provide an opportunity for advisory members to increase
their knowledge of underlying principles, structure, theory of managed care and advocacy.
This section reviews survey results and provides a baseline for further inquiry into the
role of an advisory member. The survey also confirmed that advocacy training, knowledge of
managed care, and communication skills are needed to be effective advocates. During participant
interviews, there were several themes around training that were deemed worthy of mentioning.
Among all five interviews conducted, the need for training was mentioned over 26 times.
Interview participants believe that training for committee members not in leadership positions
would greatly enhance overall engagement of members (See appendix).
Interview participant Ms. Garcia, felt strongly stating that, “members should be guided
by staff with very clear language of what the expectations are and what to do.” She further stated
that, “…training at the advisory meetings could help. We should be trained on things like access
to care, Medi-Cal eligibility, the Medi-Cal re-determination process, how not to lose your
benefits and how to be a part of an advisory committee.” Ms. Soza stated, “Maybe, if you all
would give us more tools and training, more direction and guidance, maybe we would be better.
You guys give us training and never follow-up.” The common theme identified from these
participants were that trainings conducted separate from their monthly meetings would assist
them in building stronger advocacy skills. Based on interview participants feedback, three
participants felt that they were only able to depend on other advisory members to answer
questions that they have in, “some cases,” the other two stated that, “rarely,” are they able to
depend on other advisory members to answer questions that they pose. Ms. Garcia stated that,
“Viking County Staff needs to take a look at the advisory meetings and make them more
understandable for members. Maybe, if members got more training they would not just sit there
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and agree with everything.” This lack of dependability from fellow advisory members validates
the lack of knowledge skills in the advisory role of members which could be demonstrated by
participants being able to respond to questions that require them to demonstrate knowledge of
basic facts and information related to inquires of their peers. As part of the advisory committee,
members must be able to not only engage each other in discussions related to health access
issues, but they must also be able to work together as a committee to bring health access issues
forward to the VCHP Board of Governors.
Given the participants tenure in their individual advisory committees and experience,
when asked how effective they believe the advisory committee is with addressing issues and
forwarding them through the advisory process, two of five interview participants believed that
the committee is, “not effective,” the other two stated that, they believe that the advisory
committees are, “somewhat effective.” On the other hand, one of five respondents believed that
advisory committees are effective. Knowledge of how to have access issues resolved or
addressed by Viking County’s Board of Governors, is essential to being and advisory member.
According to Krathwohl (2002), knowledge of the skills and procedures involved with the task,
including techniques, methods are necessary steps. Without knowledge of basic meeting
techniques and Medicaid principles, advisory members will find it difficult to recall, analyze and
apply procedural concepts conducive to being an effective advocate. Addressing this finding
further validates the assumption that in order for advisory members to be competent and able to
depend on their fellow advisory members for guidance, all advisory members must have a strong
knowledge base. When members possess knowledge that support them in being effective
advocates, their ability to process and comprehend health access issues, assert correct inquiry
from decision makers and apply critical thinking in support of solid recommendations and
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solutions increases. Strong knowledge base is important to advocates confidence and ability to
speak up and increase engagement.
Consumer advisory members must receive comprehensive education in all areas of
managed care and advocacy. In support of Ms. Garcia suggestion, VCHP advisory member
orientation and trainings must be extended and include declarative and procedural training that
supports advisory members to increase their knowledge in areas of managed care, the role of an
advocate, meeting procedures, and patient rights. This assumption was further validated during
the interview with Ms. Garcia who when asked, “What would make you a stronger advocate,”
simply responded, “self- education of course, but also, advocate trainings.” Ms. Garcia further
explained that, “members need proper training on the proper rules of order ( Roberts Rule of
Order), how to conduct meetings, and how to speak in public.”
Ms. Soza responded by stating, “consumer members need more detailed trainings on key
advocacy topics, more direction, more tools, more training and a clear plan on what to do with
the information we learn.” This request is validated by researchers Clark and Estes (2008) who
state that when we tell people something about their jobs they need to know to succeed on their
own, we are giving them information. This is also key when people do not need help practicing
in order to apply the information successfully. In this instance, Clark and Estes (2008) asserted
that information is all that is needed to reduce uncertainty about how to achieve a performance
goal. Based on this, interviewees who attained higher education have ample opportunities to
transfer knowledge and practice usage of declarative and procedural knowledge needed to be
successful as advisory member. According to Clark and Estes (2008) training is required for
those who require “how to” knowledge and skills and need practice and corrective feedback to
help them achieve specific work goals. For those interviewees categorized as having less
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education and little to no experience in an advisory capacity it is imperative that VCHP staff
conduct a skills assessment to gain insight into their areas of strength and weakness. This
assessment will aide in building a training that will support them in their continuous learning and
role as an advocate.

Figure 4.7. Understanding barriers in effective advocacy.
0
1
2
3
4
5
6
30 minute advacy
training during RCAC
meetings
Training separate
from my meeting
More detailed
consumer advocacy
orientation
None of them
3
4
5
1
60%
80%
100%
20%
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ADVOCACY
AREAS YOU BELIEVE WOULD HELP BUILD STRONGER ADVOCACY
SKILLS
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Figure 4.8. Acquired leadership skills.
MEETING FACILITATION
ROBERT RULES OF ORDER
GROUP FACILITATION
CONFLICT RESOLUTION
HMO?MANAGED CARE
NONE OF THE ABOVE
3
4
2
4
3
0
60%
80%
40%
80%
60%
0%
UNDERSTANDING BARRIERS IN EFFECTIVE
ADVOCACY
LEADERSHIP SKILL YOU HAVE AQUIRE AS
MEMBER OF THE COMMITTEE (ALL THAT
APPLY)
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Figure 4.9. Participants self-reporting of comfortableness depending on peers
0
2
3
0 0 0%
40%
60%
0% 0%
NEVER RARELY IN SOME CASES MOST OF THE
TIME
ALWAYS
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Do you feel able to depend on other members to
answer questions you may have
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Figure 4.10. Understanding of VCHP’s definition of global health access issues.
1
4
0
20%
80%
0%
ISSUES REGARDING ACCESS FOR
AN INDIVIDUAL CONSUMER
MEMBER
ISSUES REGARDING ACCESS FOR
AN MULTIPLE CONSUMER
MEMBERS
ISSUES REGARDING ACCESS FOR
CONSUMERS NATIONWIDE
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ADVOCACY
HOW DO YOU UNDERSTAND HOW VCHP
DEFINES "GLOBAL HEALTH" ACCESS ISSUES
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Figure 4.11. Effectiveness at addressing issues.

0
2 2
1
0 0%
40% 40%
20%
0%
NOT AT ALL
EFFECTIVE
NOT EFFECTIVE SOMEWHAT
EFFECTIVE
EFFECTIVE EXTREMELY
EFFECTIVE
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ADVOCACY
HOW EFFECTIVE IS THE CONSUMER
ADVISORY COMMITTEE AT MEETINGS AND
ADDRESSING ISSUES BROUGHT FORTH
THROUGH THE ADVISORY PROCESS
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Figure 4.12. Superior process for presenting issues to VCHP.

CALL MEMBER
SERVICES AND
REPORT TO L.A.
CARE HEALTH
NAVIGATOR
ISSUE BROGHT UP
AT REGIONAL
COMMUNITY
ADVISORY
COMMITTEE
(RCAC)
MEETINGS,
VOTED BY RCAC
MEMBERS, AND
MOTIONED AT
EXECUTIVE
COMMUNITY
ADVISORY
COMMITTEE AND
ADDED TO THE
BOARD AGENDA
SOMEWHAT
EFFECTIVE
EFFECTIVE
0
4
0
1
0%
80%
0%
20%
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THE BEST PROCESS FOR GETTING HEALTH ACCESS
ISSUES TO BE HEARD BY VCHP BOARD OF
GOVERNORS
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Figure 4.13. Self -awareness of advisory member role.
Observations
Application of knowledge is key to addressing barriers that prevent consumers from
effective advocacy. According to Krathwohl (2002) observations can be validated by observing
participants doing the task and by looking for evidence of necessary methods, techniques and
steps. During my observation of two of VCHP Regional Advisory Meetings, I was able to
TO BRING
LATEST
COMMUNITY
EVENT TO THE
ATTENTION OF
THEIR
COMMITTEE
ADVISE ON
ISSUES
RELATED TO
ACCESS T
OCARE FOR THE
MEDICAL
COMMUNITY
ACT AS A
LIAISON
BETWEEN L.A.
CARE AND THE
COMMUNITY
PARTICIPATE IN
ADVOCACY
EFFORTS AND
SHARE
INFORMATION
WITH FELLOW
COMMUNITY
MEMBERS
ALL OF THE
ANSWERS
0 0 0 0
5
0% 0%
0%
0%
100%
UNDERSTANDING BARRIERS IN EFFECTIVE
ADVOCACY
WHAT DO YOU BELIEVE IS THE JOB OF THE
ADVISORY MEMBER
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identify knowledge gaps in consumer advisory members participating in the structured 2.5 hour
meetings.
Site #1. Meeting #1 took place 9:00 a.m. in a local community center known to
community residents. The meeting was conducted in three languages English, Spanish, and
Khmer. There were 18 members in attendance. The committee chair conducted the meeting in
English. The Vice-Chair monolingual Spanish speaking communicated only in Spanish. While
the committee is multi-ethnic, Cambodians represent the majority of the membership. To assist
with language differences, interpreters were present to provide simultaneous interpretation
services for committee members and the public in attendance. Observation data collected from
my attendance to RCAC meetings allowed me to observe member interactions and their ability to
transfer basic knowledge learned in new member orientation and leadership trainings. Based on
my observation, I was able to validate the assumption that consumer’s stakeholders must have
knowledge of basic leadership procedures and performance measures in order to facilitate their
meetings. This also validates comments made from members who stated, “we need more
training,” and, “sometimes I feel uncomfortable and don’t want to say the wrong thing.” The
researcher observed that the committee chair read a written report provided to her word-for-
word. The chair was not able to effectively transfer knowledge to committee members using her
own notes nor was she able to summarize information in a way that assisted members to
understand information and take action. The ability to take notes and summarize for fellow
committee members is an expectation for all chairs and is expressed in their roles and
responsibilities. During the bi-monthly advisory meeting, it was also observed that during key
sections of the agenda, meeting participants were not engaged. Examples of low engagement
occurred during the approval of the agenda. It was observed that members were not verbally
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interacting during key portions of the meeting, members recused themselves during important
votes that took place during the meeting and last when called upon to paraphrase discussions
they were not able to do so. Other examples included the new business section of the agenda
where there was a call for motion to approve the meeting agenda. It appeared that they were lost,
for some members there was a blank stare and for others they said nothing. It could not be
confirmed that all meeting participants understood what was happening during this portion of the
meeting. Secondly, during the approval of the minutes, there was a call for a motion twice, once
by a Spanish speaking member, this time the motion was properly second by a member of the
Cambodian community.
The chair in the moment, acknowledged the, “energy,” in the room by asking, “if
everyone was sad because no one was saying anything?” The chair recognized that there was
minimal engagement from members present. It was later mentioned during the meeting that the
Cambodian members experienced a death of a fellow committee member. During this meeting a
woman presenting herself as the consumer advocate on Viking County’s board of governors
asked to address the committee with a few words. She first acknowledged the loss experienced
by committee members, she then reminded members that they, “could make their friend proud by
continuing to be good advocates.” The representative also reminded members that, “it’s our job
to bring issues of the community to Viking County Health Plan. Sharing information with
Viking County Health Plan makes a difference for our entire community.” The next agenda item
was listed as, “Change in Operating Rules,” and was presented by Viking County’s Community
Outreach and Engagement staff. This section of the agenda also supports assumption that not
having access to ongoing trainings greatly impact the long term knowledge and effectiveness of
the consumer advocate process. Having access to key knowledge and information is believed to
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address barriers in effective advocacy. When conducting interviews with participants, and when
listening to consumers voice areas of support in their meeting they continuously state that, “ You
all (VCHP staff) should educate consumers on Viking County’s Health Plans processes,
managed care facts, guidelines, and that education should address knowledge, and help us apply
what we learned, and think things through (aka critical thinking, synthesis and evaluation)”. It
was expected for consumer advisory members to have knowledge of the purpose and goals of the
advisory committee’s operating rules. To better understand things from the members perspective
and where more education is needed, staff proceeded to ask committee members to define their
understanding of operating rules. Of members present, the advisory chair was the only member
who was able to respond. This further validates the lack of knowledge for advisory members in
non- leadership roles.
Site #2. Meeting took place at 10:00 a.m. in a local children’s service center for low-
income families. The meeting was conducted in two languages English and Spanish. There
were 15 members in attendance. The Committee Chair conducted the meeting in English. The
Vice- Chair monolingual Spanish speaking communicated only in Spanish. Five of the fifteen
members were of Latino decent. The committee was comprised primarily of Spanish speaking
members. To assist with language differences, interpreters were present to provide simultaneous
interpreter service for committee members and public in attendance. Data collected from meeting
observations further support the assumption that consumer’s stakeholders must have knowledge
of basic leadership procedures, meeting facilitation and performance measures in order to
facilitate their meetings. It was observed that many members do not know when to apply
meeting principles during their meetings. According to Clark and Estes (2008), “Training” is
defined as information plus guided practice and corrective feedback. This method according to
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Clark and Estes can result in high impact learning in any context. Examples of areas where
knowledge is needed was identified during the consumer advisory meeting when members were
not aware of basic information such as existing programs, voting procedures and basic health
terminology when questioned by staff during the stakeholder meeting. This lack of knowledge
further implied the need for training and posed an impediment for members and their ability to
have meaningful participation in the meeting, another example observed by the researcher during
the meeting observation occurred with the overuse of acronyms during updates. Many members
were clueless as to what was being addressed. Evidence of this claim could were evident in the
follow-up questions asked by members and the members inability draw concrete conclusions
from the information they received Upon completion of the presentation, Viking County staff
ask the member to repeat what she understood and the member could not give a clear response
and then stated, “I’m not really sure”. This was another indicator that supports low -engagement
and further validates that the member had minimal understanding and could have perhaps
benefited from the use of visual aids opposed to all written materials. Usage of adult learning
theories would assist to increase learning effectiveness and long term memory of the key
information. Clear concise information serves as a knowledge building opportunity for this
group. Opposite of this, the overuse of acronyms did not support knowledge building as there
was no explanation or visual tools to assist meeting participants to follow along effectively. The
researcher observed members falling asleep, not asking questions and using cell phone which
insinuated low engagement. The ability to ask questions as a means to gain knowledge and
understanding about a phenomena is crucial to the learning process. During the meeting, staff
continued to defer member questions to another department opposed to stating they would get
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the information for the member. VCHPs staff’s inability to answer knowledge based questions
greatly impacts learning and reinforcement opportunities of consumer advisory members.
Document Analysis
According to Fear (2012) public records can assist in examining how local organizations
deal with competing discourses (local, national and international), construct and reconstruct their
social reality through public records. To understand barriers impacting effective advocacy, a
lottery method from 2016-2017 fiscal year was used. Five meeting minutes of the Executive
Community Advisory Committee (ECAC) were retrieved from Viking County’s website.
Meeting minutes are located under the community meetings section of the health plans web
portal. As a public entity, meeting minutes are posted monthly to ensure transparency and
accountability to the public on the health plans operations. The purpose of using meeting
minutes were to further validate assumptions around knowledge, and the application of
knowledge in addressing learning gaps during consumer meetings. Many advisory members
who participate at this level have a median tenure of 5 plus years and have served in leadership
roles internal and external to VCHP.
In review of the health plans public meetings records, findings were consistent with
comments made by members during the interview section of the data collection. However, the
findings did not completely validate knowledge assumptions identified in chapter three regarding
the consumer stakeholders need for basic leadership skills in order to facilitate their meetings.
In this regard meeting facilitation is defined in a comprehensive manner and is anything that
supports the effective participation of advisory members.

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October 2016 Meeting Minutes
In review of the October 2017 meeting minutes, a consumer member advocate asked staff
to identify which health access related bills were being advocated by Viking County. The staff
responded by stating she was not sure. The member advocate proposed, that it would be a good
practice moving forward to indicate the bills that Viking County is taking position on so that
advisory members can also advocate. Other committee members showed approval of this
suggestion by stating, “ECAC is a community committee whose members will be able to inform
their communities of bills that will impact them and can encourage them to advocate.”
Additionally, there was another member who reported that members brought forward an issue
stating that Viking County takes too long to authorize speech, physical, occupational and
behavioral therapy services for children 0-3 years of age. The members stated that currently
authorizations are taking from six to twelve months even after it has been referred by the primary
physician. Members of the committee asked for VCHP to provide education to all of its county
members. Statements made by members validate the assumed knowledge influence that
consumer stakeholders must be educated on Viking County’s processes, managed care facts and
guidelines. Training people effectively, requires giving them accurate procedures, practice and
corrective feedback that permits them to gradually automate the knowledge (Checkoway, 1993;
Christoffel, 2000).
March 2017 Meeting Minutes
In review of the March 2017 meeting minutes, advisory members asked for an update on
motions brought forth. There were several opportunities for advisory members to be provided
procedural instruction on how Viking County addresses member complaints regarding long wait
times at contracted clinics. Opposed to educating advisory members on clear processes used to
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investigate reports, the response given to advisory committee members by Viking County staff
was, “Those clinics have informed us that they have added staff, more training and are meeting
our standards.” There was no declarative education provided to advisory members on how to
further address issues should the problem continue. Additionally, during this meeting a member
of the public noted that the meeting agenda was too long and that staff should consider limiting
the items presented to allow more time for public participation. Allowing more time is believed
by members to be an opportunity for further inquiry associated with access issues experienced by
Medicaid consumers.
April 2017 Meeting Minutes
In review of the April 2017 meeting minutes, advisory members made inquiries
regarding, the Affordable Care Act (ACA), contractual agreements with providers, and the salary
of the CEO. The CEO himself provided conceptual and declarative knowledge about Viking
County’s role in educating and monitoring the repeal of the ACA, and the impact to Medicaid
consumers if such laws were put into place. The CEO also provided a brief explanation to
consumers on progress to add teaching hospitals to the health plans network and the pressure for
other major universities to follow the path as set by the universities who have agreed to
collaborate by signing contracts. Last, the CEO responded to inquiries regarding the amount of
his pay. He explained to consumers how his salary is determined, who determines it and his role
in the process. Based on the committees response there was varying knowledge of how much the
average CEO makes per year. A member jokingly expressed, ”that she is happy to pay the CEO
anything less than two million dollars.” The member further expressed her opinion to the
committee by stating, “I have worked in corporate America and I am aware of how much CEOs
usually get paid.” The member further challenged her fellow members to, “go look at how much
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other CEO’s of other public insurance companies are making.” Another knowledge gap was
identified when a member brought forth an issue identified with seniors who live in her building,
the member stated that, “about fifteen Viking County members who live in my building were cut
off from Viking County and were not notified that they had to be re-determined in order to
continue benefits.” The response to the consumer advocate from the CEO was that, “a staff will
be assigned to contact those fifteen people to help them fill out their re-determination forms.”
This represented yet another learning opportunity for members to be educated on the
redetermination process so that consumer advocates understand the process and can further
educate community members in order to assist them in not losing access to medical coverage.
Additionally, an inquiry to senior management on long wait times for approval of medication
and inability to access urgent care was brought up by consumer advocate members. Based on
meeting minutes, consumer advocate members while able to bring their initial problems to the
attention of the Executive Committee and Viking County staff, seemingly lack the procedural
knowledge on how to follow-up and hold staff accountable for responding to identified access
issues. According to recorded meeting minutes, Viking County staff on more than one member
issue tend to defer consumer members to the members service department and to use the formal
grievance process. There was no stated procedural process provided to members that would
assist them to visually or verbally understand steps necessary to report and resolve global issues
experienced by consumers throughout Viking County.
June 2017 Meeting Minutes
The ability of consumer members to identify key departments and their responsibilities
for addressing access issues identified in their communities is key to effective advocacy. In
review of the June 14, 2017 meeting minutes, it is documented that consumer members asked
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questions that could be concluded as knowledge building questions. According to Anderson and
Krathwohl (2001), the cognitive process dimension represents a continuum of increasing
cognitive complexity. Based on Krathwohl (2001) the ability to ask questions that confirm
understanding is representative of higher order thinking. Examples of this level of cognitive
process were identified in questions asked by consumer members to Viking County’s Chief
Medical Officer (CMO). The questions asked were, “What are your priorities in reference to
prevention programs going forward?” The CMO’s response was that, “Viking County’s goal is
to improve the health for all Viking communities. We are working hard to improve our customer
service. A few of our goals are to improve timely access, quality of care and outcomes with
higher member satisfaction ratings.” The second knowledge related question asked by a
committee member to the CMO was, “what is the organization doing to incentivize the
physicians to provide the same level of quality service to Medi-Cal consumers that they provide
to those with private insurance?” Questions asked by members further validate the assumed
knowledge that consumer stakeholders must have knowledge of basic leadership procedures, and
performance measures in order to facilitate their meetings.
Additionally, members expressed that they were experiencing access issues at a local
contracted provider. As with previous months documented meeting minutes, Viking County
Staff instructed members to file a grievance to insure that information gets recorded in Viking
Health Plans system. Consumer advocates were told that this was the only way that the health
plan could track information reported while monitoring the clinic.
In review of the June 2017 meeting minutes, members also identified the homelessness
epidemic as a global issue impacting Viking County members. This area of focus and inquiry
while not assumed by the researcher as an area of importance was further validated by consumer
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advocate member. In respect to the $ 20,000,000 in funding provided directly to the “Start New”
Program, the consumer member requested that further oversight be put in place to ensure that
services t to address homelessness are met. Viking County staff responded by stating that the
County health department is responsible for establishing protocol for this type of request.
Consumer members asked for an update on the inability to access urgent care, an issue
that according to meeting minutes has been brought up in previous meetings. Viking County’s
senior staff responded that “an update will be provided at a future meeting. This issue is a global
issue and is being addressed by multiple health plans. There were no further investigative
questions asked by the consumer member. Educating consumer advocates on how to ask the
right questions may be an effective solution to closing the gaps in conceptual knowledge (Clark
& Estes, 2008). Knowledge generation is key to effective advocacy. Consumer advocates must
be able to connect claims to decisions makers. The degree to which there are opportunities to
create relevance for participants to use the information learned is the best use of resources
(Berkes, 2009; Kiles, 2002).
Last, during the June meeting, questions asked under the Community Benefits section of
the meeting agenda provide a clear example of a consumer related questions and the appropriate
and comprehensive response to the consumer advocate. The questions asked of Viking County
staff was “how do initiatives get to the Community Benefits Department for consideration?”
The department’s director responded, “We get a lot of information via different Viking
departments. The Communications department for example, helps by relaying information about
the community’s needs. We also get information through the ECAC and the RCACs as well as
through focus groups that are made up of some community clinics. Funding is then allocated by
the Board of Governors based on what we learn. The budget approved for initiatives has
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increased throughout the years.” This level of response further validates that conceptual
knowledge happens when one understands the interrelationships among basic elements of a
larger structure that enables those elements to function together (Anderson & Krathwohl, 2001).
September 2017 Meeting Minutes
Liken to previous months, the September 2017 meeting minutes further validate the
assumption that consumer’s members will be able to identify key departments and the
responsibilities of those departments for addressing identified key health access issues. During
the global member issues section of the agenda members were asked to share issues that were
discussed at their RCAC meetings. To validate this assumption a member expressed during the
Executive Community Advisory Meeting that “three members of my committee had to wait a
long time for their follow up appointments” There were four documented issues presented to the
Executive Committee with contracted transportation offered by Viking County. While these
issues do not fully represent a full spectrum of health access issues, they do represent a sub -
category of impediments preventing consumers from accessing care. Upon further analysis of the
September 2017 meeting minutes, it was further validated that while members can successfully
identify health access issues, they lack proper education and process on how to further excavate
issues beyond their surface manifestation, make necessary connections, ask staff for follow-up to
issues brought forth, and make recommendations that work collectively with Viking County’s
Board of Governors to address global issues impacting consumer members. According to Clark
and Estes (2001) the only way to equip people to handle the novel and unexpected is with
education. The researchers also contend that educating people provides organizations with the
capacity to generate new conceptual knowledge that will solve novel problems and handle novel
job challenges when they occur.
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Motivation
Interviews. Consumer Advocacy members cannot see the value of their advocacy efforts
if they are not able to utilize their skills when they believe they are needed. Understanding
barriers that discourage the outcomes of ones advocacy efforts is crucial to understanding what
keeps motivation high and the consumer members actively engaged in the outcomes and success
of their advisory committee. According to Rueda (2011) the higher an individual values an
activity the more likely he or she chooses, persist and engages in it. In conducting interviews it
was apparent that all interview participants were self-motivated, possessed an intrinsic value
towards helping others and being an advocate as well as a sense of self- efficacy. This was
measured by comments “ I feel good when I have answers”, common words used such as “I love
to help people” and response to questions that asked members to describe in their own words
their role as a consumer advocate? “ I always share information I get from meetings with other
people” based on your role as an advocate, how they felt they were able to effectively carry out
their role?
The individual’s belief in his or her capacity to execute behaviors necessary produces
specific performance attainments (Rueda, 2011). This inherent attitude was validated when
interviewing Ms. Garcia who stated:
“In this last year, I was able to attend a conference”. “It was probably one of the few
times that I felt that all of the knowledge that I've gained throughout the years of being an
advocate have allowed me to be a better person in how I handle situations”. “I know how
to navigate the system”. “I know what to do, who to talk to and how to document issues now”.
“Before I used to just focus on the complaining part, and say that there is a problem instead of
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seeing the solutions to it”. “I'm able to articulate more of my words and try to focus more on the
issue that I want to talk about”.
Ms. Garcia also stated that she is also able to use her advocacy skills to help her family.
She said, “I've applied this knowledge at home. “When I go to the doctor, I know who to talk to,
I know what to say”. I know how to be more concrete on my questions. I know how to advocate
for my rights. I had to learn my responsibilities as well. I think I've gained so much knowledge
that I'm a better person for my family.” When asked, are there other areas that your advocacy
knowledge is transferrable to, Ms. Garcia responded, “I've also gained confidence and patience
when working with large organizations because there is so many steps you have to go through in
order to get things done.” When asked about instances where she may become discouraged, Ms.
Garcia replied, “I do get discouraged, a lot of times. Sometimes I want to quit. What I do is, I
revisit my commitment to why I'm here in the first place.” In contrast, Ms. Soza does not see the
value of her advocacy efforts, as she believes she gets no help from Viking County staff. Ms.
Soza believes that staff should play an integral role in the effectiveness of consumer members by
the way in which they support member in seeking answers to their health access issues. Ms.
Soza stated, “I've had to learn my own way. Not by help from you guys (Viking County) or
anything. I had to do it on my own, because every time I would bring up a point or a problem,
they'll be like, Call member services.” This series of comments further confirm researchers Clark
and Estes (2008) who stated that individuals and groups can have very different beliefs about the
different ways they can achieve effectiveness.
Consumer members must have confidence in their advocacy skills and abilities in order
to be strong advocates. An assumed motivation cause is the consumer member’s lack of
confidence in their ability to impact organizational change. This assumption was validated by
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Ms. Garcia who shared an example of a time when she was most proud to be an advisory
member, and had confidence in her abilities as part of a collaborative effort. Ms. Garcia shared:
It was when the consumer advisory committee voted on a motion that was forwarded to
Viking County board of governors regarding the need for more providers with accessible
exam tables. This motion in itself increased accountability, access and member
experience. When I saw the results of the advisory committee coming together and using
our advocacy skills to advocate for monies that would assist health plan providers to
purchase elevated exam tables for seniors and disabled. I was nervous that it would not
pass, but it did and I could see we we're making a difference and saving lives.
Another example came from Ms. Munoz who stated:
I had a situation where I bumped into somebody that needed help with a child who
needed surgery for hemorrhaging, actually that was a day that everything went well. I
supported that person got them help so fast by working with everybody in Viking County
Health Plan, and by working with member service navigators. I was just so amazed, it
took, I think like, three days. It felt great. It felt like I was doing what I was supposed to.
This is why I do this, you know? It felt amazing.
In the interview with Ms. Lakey, she provided a clear metaphoric response to
member’s confidence related to their advocacy skills. Ms. Lakey stated:
One does not understand a system until your caught in it. It’s like a spider being caught
in a web. You think you understand a spiders web as a fly when you’re on the other side
of the window, but when you come into a health system for more than just minimal care,
it is there where you begin to understand how the health care system works. You have to
have a need to be in it. “I don’t mean accessing care by choice for example when you
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want to get a physical or annual exam” “that’s a want to be”. “Need to be in a system occurs
when something happens to you”. For example “You get a disease or medical process that
forces you into the health system that makes you have to go look for care”. There is a major
difference between things we want and things we need.”
Building confidence through lived experience motivates consumers in their role as
advocates. Another motivation assumption was that consumer members lack confidence in their
ability to impact organizational change that essentially, holds the health plan accountable for
their experience as a Viking County consumer member. In this instance, confidence is the nexus
between understanding barriers that impede consumers from being effective advocates and
creating safe spaces that allow members to engage the health plan in dialogue that assist decision
makers in their role to ensure quality healthcare and increased member experience. Consumer’s
ability to utilize their advocacy skills when needed is paramount to effective advocacy.
According to Reuda (2011), attributions that focus on effort are seen as leading to
different outcomes in the future. Interview participants made reference to how advocacy
education and trainings could play a larger role in their being an effective advocate if more were
offered. Additionally, interview participants also believe that there is a need for additional
training for consumer members who have not served in a leadership capacity. Interview
participants strongly believe that this will impact member’s confidence to engage in meaningful
conversations with decision makers in support of decision makers and in the improvement of
their overall access to care. Examples of this were validated by Ms. Garcia who stated:
Staff could really help us if they would train me or educate me more on what an advisory
committee is, what is the expectations of and advocate, how to structure ideas into a
proposal or a suggestion, how to ask for follow-up issues brought forth, how to educate
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others about an issue, how to have a strong plan. I think education is the key. This also
helps when we are asked to be a part of legislative office visits. You need guidance in
order to help you get the results you want”.
In support of this assumption, Ms. Munoz stated, “many in the Hispanic community are not well
informed. They need help. Viking County staff could help us be effective by, supporting us,
mentoring us, helping us to navigate meetings and to actually train us.” Ms. Jones stated, “having
more education with refreshers is important. We also need the staff to listen more and to train
and help us to bring more clarity when things are cloudy and when we don’t understand. Staff
could help us to be stronger instead of discouraging us by questioning ‘why do you want to do
that,’ or ‘why do you want to say that.’ Staff needs to be more open –minded to our concerns
and support us more.”
Meeting Observations
Motivation is defined as the reason or reasons one has for acting a certain way.
Motivation according to Clark and Estes (2008) is comprised of active choice, persistence and
mental effort. These three motivational indexes are most commonly seen in work environments.
When validating the motivation of consumer members to Viking County’s community advisory
committee, the researcher was able to focus on the research assumption that advocate
participant’s lack clear reasoning for joining the consumer advisory committees beyond the
monetary incentive provided by Viking County and the perceived status from the community
from being an advisory member. Goal orientation focuses on the purpose and reasons for
engaging in achievement behaviors (Pintrich, 2003). This assumption could not be validated as
all five interview participants were able to clearly validate their rationale for joining Viking
County’s consumer advisory committee and their commitment to be fully engaged whether an
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incentive was present or not. In interviewing Ms. Soza, the member was asked how is her role as
an advocate affected by the presence of an incentive. Ms. Soza stated, “Nobody is just going to
give you seventy bucks, the seventy dollars is a help…. I’m not going to lie, but giving me
seventy dollars is not to keep me quiet and keep on taking everybody’s $%& and not voice how I
feel? I would still participate because if I’m doing something I like, why stop? I’m getting
something out of it because I’m still helping other people.”
In interviewing Ms. Jones, the researcher asked the same question regarding the $70 stipend and
its influence on her as an advocate. Ms. Jones responded by saying, “for me personally, I do what
I do because I really want to make a difference. It ain’t about a stipend. I’m not going to lie and
say that the stipend is not an addition. I volunteer on other boards and don’t get paid a dime. I do
it because I want to.” In interviewing Ms. Lakey, her response to whether or not her role as an
advocate is affected by the presence of an incentive, she stated:
“When I started I didn’t know VCHP gave money. I had no clue. It had to do with the
way the law went. I had been rolled over in to Medicaid and I had to get my medical
from somewhere. I looked at what my choices were then I found out that ARP Care
Network had and memorandum of understanding with VCHP so I said okay….so it
wasn’t about the money, I wanted to see how the money was being used. If you’re taking
charge of my medical benefits I want to know where the money is going, how it’s being
used, and what’s going on with it. I learned from a friend that the way you learn and
voice your concerns is by going to the consumer advisory meetings.”
These combined comments further validate that member overall participation has little to do with
monetary incentives or perceived prestige from membership in Viking County’s advisory
committees.
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Understanding times in which motivation is high and when it is low is important as
provides insight into the members psyche as it relates to continued engagement. To better
understand the phenomenon as it relates to motivation and persistence the question asked to
participants was when you become discouraged with your advocacy efforts, describe what you
do to stay active and engaged with your committee? What motivates you to stay involved? Ms.
Lakey responded by saying, “Think about how bad things can be if I don’t show up. I ask
myself, ‘what are we doing today? Somebody wants to hear your voice today.’ Even when I
show up and the other members go like, ‘Oh, God, she’s here again.’ I tell myself that somebody
at the meeting knows you care about what happens to them. That’s how I function with my
advisory committee, ‘I say somebody wants to hear.’ The members know I’m here to help them,
I stay motivated by speaking up for them.” When learners both value what they are learning and
have positive expectations for success they are more likely to experience success in the task
(Clark, 1999; Clark & Estes, 2008; Pintrich, 2003).
Methods, Results, and Discussion
April 2017 meeting summary. The ability for consumer Advocacy members to discern
the value of their advocacy efforts and utilize their skills when they believe they are needed
could only be validated in one of five meeting summaries reviewed for this study. During the
April 2017 Executive Community Advisory Meeting, the committee brought forth a motion that
would require Viking County Health Plan do the following to provide education to all members
on how to access assigned urgent care centers, consider placement of urgent care phone numbers
on consumer ID cards and that a 24 hour live agent service be put in place that connects
members to appropriate urgent care centers. While this validation is less than what is needed in
order to fully support the assertion, it implies that more work is needed to assist member to
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identify gaps that circumvent their advocacy efforts. This lack of education also impacts the
motivation and confidence required to impact comprehensive organizational change while
holding Viking County accountable for quality care and improved member experience. Based on
review of the five meeting minutes for this research, there was only one motion proposed in
support of improving consumer member access. From this review, it is assumed that because
staff generates the meeting agenda, the agenda is, “Pro” Viking County Health Plan. There is
little time for educating members, nor is there time for member input or meaningful dialogue in
areas most impacted on members. ECAC meetings based on meeting minutes are being
facilitated in a professional businesslike manner leaving members with little time to give
feedback on key agenda items. During the April 2017 meeting, it was noted during the
Community Outreach & Engagement section of the agenda by a member that, the agenda is too
long and that staff should consider limiting items so that it allows more public participation.
Organizational Gaps
Interviews. Incorporating clearly defined systems is paramount when working within
large complex organizations. To better understand organizational gaps, VCHP must differentiate
between procedures and processes barriers impacting effective advocacy. Viking County Health
Plan lacks clearly defined internal processes that support staff and members with effective means
to resolve health access issues of consumer members with complex issues. According to Clark
and Estes (2008) all organizational goals are achieved by a system of interacting processes that
require specialized knowledge, skills and motivation to operate successfully. This assumption
was validated through the participant’s questionnaire conducted during their individual
interviews. This organizational assumption was further validated by responses to the following
question: Do you think that VCHP makes it harder or easier for members to get issues resolved?
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Ms. Garcia believes that VCHP makes it harder, she proceeded by stating, “I think VCH puts
effort into it, but I also know that there’s a lot of things that could be done differently. Members
should be able to bring issues to the staff, that’s what staff are for. This is the reason we have
consumer committees, and advisory groups, so you can help us address situations going on in our
community. We get a lot of push back when we bring up issues.” When asked the same
question regarding the participant’s opinion towards clearly defined system that supports staff to
resolve health access issues of consumers members with complex issues, Ms. Lakey responded
by saying, “the problem is that the process for members to bring issues forward takes too long”.
“I have studied how long it takes Viking County to address a problem once a member brings a
health access issue to the committee”. “I sat down and figured it out, it takes about 18 months
from the time the issue is discussed”. “The process that we have takes too long.” To get Ms.
Lakey to expand on her comments, the researcher asked, have you ever thought of what an
expedited process would look like? Ms. Lakey responded by saying, “First, committee chairs
need to understand how to properly vote”. “Next, committee members and community
advocates need to know how to put things on the ECAC agenda and the Boards agenda for
consideration”. Ms. Lakey in a frustrated tone stated, “it takes too long to address any issue that
is valid and brought up by a consumer”. Perhaps the consumer chair or the members needs to be
invited to meet with Viking County staff to talk about consumer access issues. “This time will
be an open and free space that allows more time to address and discuss issues outside of the
regular meeting.” When interviewing Ms. Soza, the researcher asked if she thought the process
Viking County has in place assist consumers in identifying health issues is effective. Ms. Soza
responded by saying, “I feel not really. I feel it’s something that could start people talking.
Members need to know that during their meetings that it’s their time to speak up”. From the
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participants stance they seem to think that committee meetings are only about the issues brought
up by the health plan. Consumers think you can’t bring anything else up.” When asked about her
ideas to create a more effective system her response was:
“Being able to connect with a live person that walks you through the process is helpful as
they are able to call the doctor and advocate for you. This is better than what you guys
always tell members…call member services, “you don’t know who your talking to,” “the
call drops and your left in the middle”, “you have to call back and tell the story all over,”
“you guys should have a number that you can call staff directly and say,” listen I’m
having a problem what should I do? That person just stays with you the whole way until
you get the problem resolved.” Having clear lines of communication with members
when they are experiencing access issues is believed to improve customer services as
well as patient outcomes.
Observations
Understanding your stakeholder member population is crucial to building effective
advocacy programs. The organizations assumptions about their consumer stakeholders level of
education and socioeconomic status impedes their ability to value consumer input. This
assumption could not be validated in any of the five interviews conducted. As there were no
obvious written or verbal comments that would justify this assumption. Viking County’s
mission does not align with the expectations, unspoken culture and operation of the organization.
This assumption was validated by the organizations staff’s lack of response, lack of information,
and lack of follow-up and to members in their quest to bring forth health access issues
warranting timely response from VCHP. According to Sabin, O’Brien, and Daniels (2001),
accountability for reasonableness requires three elements: transparency of organizational
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policies and decisions, deliberation that recognizes the needs of both the individuals and the
populations served and the opportunity for appeals and revisions of limit-setting policies. To
validate these assumptions the following was identified:
Meeting Minutes
November 2016 meeting minutes. Standing items on the agenda included the Executive
Community Advisory Committee Chair report. During this agenda item key leadership staff
provided reports on future business plans that included the opening of a new Viking County
resource center in one of the most needed areas of the county. While information on the center
was provided it was very vague as to the operations and involvement of advisory members to
ensure that the new center is representative of services desired by the immediate community,
This assumption regarding VCHPs cultural model was further validated during the
Viking County board member report. During this section of the agenda, Consumer Board
member Garcia asked for Viking County to continue to work on the lack of exam tables with lifts
for Viking County members who are not physically able to get on an exam table at their providers
office. The response by staff was that VCHP is working with other health plans in Viking County
to develop a list of providers with the lift tables and ways to help members get the services they
need at their provider office. While this information is responsive there is a clear lack of
accountability from Viking County to ensure that they are responsive to the needs of consumers
assigned to them for care. According to Clark and Estes (2008) when people fail to get the
necessary resources that were promised for a high priority work goal or when a policy is not
supported by effective work processes or procedures, one of the possible causes is a conflict
between some aspect of organizational culture and current performance goals. This assumption
was further validated during the Global member issues section of the agenda. In this section,
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members share access issues with Viking County. Issues brought up that can be linked to the
unspoken cultural norms of the organization are to refer members to member services when
answers cannot be provided. An example of this is noted when a members inquires from staff
about providing education to providers regarding balanced billing. The response was training has
been provided to providers and that the member should contact member services, another issue
brought up at the advisory meeting was related to pharmacy denials and lack of response to a
request, staff responded that member should speak to a health navigator or call member services.
Another example occurred when a member expressed that she feels discriminated against because
of language barrier. She added that translation services are not available in all languages that are
spoken in her community. The member stated that she is the voice of those that are unable to
communicate with Viking County due to language barrier. These series of incidents impact
diversity, equity and accountability as a community accountable health plan.
March 2017 meeting minutes. Under the Communication and Community Relations
update, this assumption was further validated by the proposal of additional rules that impede
members from becoming a full consumer advisory member immediately after new member
orientation (1 month) to six months opposed to twelve months. These proposed changes were
not followed by any justification or benefits to new members. There was no apparent alignment
between this suggested change and the overall mission of the organization. Additionally, a
member inquired about follow-up to an access issue regarding long wait times at a contracted
provider office. Staff responded by stating, that the clinic has informed VCHP that they have
added additional staff, conducted trainings and is now meeting Viking County Standards. Staff
then encouraged members to contact member services and file a grievance if they are continuing
to experience issues getting an appointment. A final example of this assumption took place
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during the public comment section of the agenda where comments made by consumer members
alluded to Viking County’s limiting members in subtle ways from participation in key meetings
that allow member to hold the health plan accountable as well voice concerns regarding access to
care. Examples of this were noted when the member asked for clarification as to changes made to
Vice Chairs participation at ECAC meetings. The staff’s response to this inquiry was that staff
will contact each Vice Chair to clarify. However, the question was not answered. This again
according to Clark and Estes (2008) addresses one of the three elements required for
accountability for reasonableness related to transparency.
April 2017 meeting minutes. To validate this assumption, examples were found under
the Global Member Section of the agenda. A member shared that during his area consumer
meeting members discussed long wait times for medication approval. Following the process
proposed by Viking County staff the member filed a grievance and brought the issue to the
executive committee for review. The member believes that this process is ineffective as when a
grievance is filed the follow-up takes a long time and members have reported not getting
medicine until one month later. This process seemingly is an operation issue as filing a grievance
should not slow down the process for accessing care.
Another example that validates this assumption is the lack of information to members
regarding urgent care. As documented in meeting minutes, not being able to access urgent care
impacts the community by forcing members to go to the emergency room, which are normally
very busy and tend to be very expensive. Member stated that when she asked her doctor where
the closest urgent care was, she was referred to one that did not accept Viking County health plan.
This lack of access does not align with Viking County’s mission, consumer expectations as well
conflicts with presumed quality and effective operations.
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Last example, is of VCHPs culture and how its responsiveness to issues brought forth by
members regarding long wait times at two local clinics that service a large Viking County
member population. Staff provided the same response as in previous month’s member issues,
“Viking County has reviewed all the clinics policies and procedures and have determined that
they have all the right policies in place and that if members continue to have problems accessing
care at this facility they should call member services and file a grievance. This recommendation
was rebutted by a consumer member who stated that there is a problem with wait time when
calling Viking County’s member service department. The member further stated that when you
are able to get a member service representative on the phone they are not trained to help you and
do not know how to respond to your call. Member concluded by stating that Viking County
should look into their contracted urgent care centers as some of them do not provide urgent care
but in fact are rehabilitation centers. The member further suggested that staff shadow her as a
member when she calls member services to see the type of interaction she has with the
representative. Members further addressed this assumption in the New business Section that
Viking County does not truly understand cultural competency and most often focuses on language
an very little on diversity, quality and culturally competent care and services. This issue
regarding cultural competence has presented itself in multiple instances and further validates the
there is an unspoken culture related to diversifying its services to be culturally relevant to its
member population and the county as a whole.
June 2017 meeting minutes. To further validate this assumption, during the Global
Member Issue Section, a member expressed that she remains concerned for people who live in the
dry desert part of Viking County. These members continue to have issues with long wait times
for appointments. Staff responded that members who are experiencing this issue should in fact
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file a grievance to insure that information is recorded in the system. The member was told that
this is the only way that Viking County can began monitoring that clinic. Staff precluded saying
that he would look into the issue to see if other grievances have been filed and to see what action
have been taken. A report will then be provided at future advisory meeting.
Another member requested an update on a previous motion regarding urgent care. Staff
response was the update will be provided at a future meeting. Viking County staff stated that this
is a global issue and is being addressed by multiple health plans. While the member issue section
captures the response of how member related access issues are handled in the moment, it does not
provide a clear path for how bringing the issues forth will inform the health plans decision makers
on poor access issues experienced by its members.
September 2017 meeting minutes. The September meeting minutes do not validate the
original assumption that VCHPs mission does not align with the expectations, unspoken culture
and operation of the organization. This in part could be that the majority of the meeting discussion
focused on the educating, voting and implementation strategies of newly proposed operating rules
opposed to addressing member issues which is the sole purpose of consumer advisory meetings.

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CHAPTER FIVE: CONCLUSION AND RECOMMENDATIONS FOR PRACTICE

In order for Viking County to meet its intended purpose and to improve its state
mandated consumer stakeholder process, it is crucial for VCHP to look at various dimensions
that combined will work to create improved and sustain performance in areas that impact
improvement gaps. Equally clear lines of accountability will be important to this improvement
process in order to provide a baseline for organizations to measure and compare themselves to
common improvement standards. In most cases these improvement standards are established by
regulatory entities that, value consumer input on services funded by state and federal
government. Being responsive to consumer inquiries, and creating processes that assist
consumers to use their voice as collaborators opposed to enemies is believed to increase the
added value of their mere existence.
Currently, there are three means for consumers to express service dissatisfaction with
regards to their health care services. According to internal stakeholder documents, consumers
can phone to VCHP member services department, file a grievance and or attend a public meeting
and or Board of Governors meeting to express concerns during public comments on the agenda.
While these seemingly offer multiple options for consumers to express dissatisfaction, these
means of expressing dissatisfaction are not customary to low- income, less educated consumers.
In fact these means actually poses a problem for an impactful way to engage low-income,
vulnerable populations. Studies conducted by Grootegoed, Bröer, and Duyvendak (2013) assert
that filing grievances does appeal to marginalized populations. While grievances are often
objectively warranted, they often challenge the moral code, trigger feelings of shame – of not
being autonomous, of demanding too much when others are worse off, and of appearing
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ungrateful. Service encounters by both clinicians and non –physician health care staff can play a
unified role in the interactions between the consumer and the company (Holmqvist & Grönroos,
2012; Tajeu, Cherrington, Andreae, Holt & Halanych, 2015).
In order for VCHP to meet its original mission, consumers must have a streamlined
process for voicing their health access needs. Understanding the strengths and weaknesses of the
current process and business operations is crucial to the longevity of the organization. The
impact of not addressing this goal deprives marginalized consumers from using their voice to
improve services impacting their overall health. This act of non-inclusion of consumers could
greatly diminish the stakeholder’s mission, values and outcomes as a community accountable
entity. There is an expectation from the State and Federal government that the stakeholder
organization works collaboratively with its consumer stakeholders to continuously improve
access for its Medicaid population. Other negative outcomes resulting from not creating clear
means for consumer input and feedback could be: delayed resolutions of key access issues, loss
of competitive edge, missed opportunities to learn from the end user, loss of accreditation, and
worst case, becomes extinct.
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Figure 5.1. Consumer advisory demographic summary.
Knowledge Influences Recommendations
Building knowledge to improve the performance of consumer advocates requires
stakeholder staff to evaluate what advocates need to know in order for them to meet the goals of
their intended purpose. Knowledge is an aspect of learning that relies not solely on the learner
but also those in charge. Leaders must have clearly defined goals that funnel to the educator and
then to the end user. To assist with a framework for outlining knowledge influences, Table 5
represents the initial list of assumed knowledge influences and their probability of being
validated based on my observation and by current literature on knowledge. Checkoway, (1993)
and Christoffel, (2000) both suggested that training people effectively requires giving them
accurate procedures; practice and corrective feedback that permit them to gradually automate
144 members …
22 members =
10%
14 members 6%
15members =7%
3 members …
3 members =1%
24 undetermined =
UNDERSTANDING BARRIERS IN EFFECTIVE
ADVOCACY
COSUMER ADVISORY ETHNICITY
Latino African American Caucasian
Cambodian Asian Japanese
Filipino Armenian Other
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knowledge. As such, and as indicated in Table 1.1, it is anticipated that the following influences
have a high probability of being validated and have a high priority for achieving the overall
stakeholder goal: Consumers stakeholders must have knowledge of basic leadership procedures,
performance measures etc. in order to facilitate their meetings. The second stakeholder goal
would require using case studies, and consumer advisory member orientation to educate
consumers on the VCHP processes, managed care facts and guidelines. The third stakeholder
goal states that staff will need education on learning and motivation in order to integrate learning
theories in consumer stakeholder trainings. The fourth knowledge influence goal would be to
ensure that consumer members are able to clearly convey issues they have regarding access to
care. Interviewees shared that they often need help from staff to communicate to VCHP’s
leadership. Consumers believe that this is currently the only effective means to have their
issues and concerns addressed. They repeatedly stated that they it would greatly assist them to
have a “real” system in place to support those them in accessing services.
Education should address knowledge, comprehension, application, critical thinking,
synthesis and evaluation. Rueda (2011) stated the danger to learning is that one has to move
beyond the what and how to the why and when is that the learner then is subject to hit and miss,
trial and error and does not meet the learners needs. Clark and Estes (2008) suggested that
declarative knowledge about something is often necessary to know before applying it to classify
or identify, as in the case of understanding basic performance measures so that feedback is in
alignment with the initial framework. Table 1.1 also shows the recommendations for these
highly probable influences based on theoretical principles and findings. Additionally, literature
reviewed from Kiles, (2002), Berkes, (2009), Wallerstein and Bernstein,(1994), Paulo Freire,
(1989), Dewey (1897), and Kilpatrick, (2016) further supported the assumptions by stating that
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125
knowledge generation is key to effective advocacy. Consumers must be able to connect claims to
VCHP decision makers. The degree to which the trainer is able to create relevance for the
participant to use the information learned is the best use of resources.
Organizational effectiveness is said to increase when leaders identify, articulate, focus the
organization's effort on and reinforce the organization's vision; they lead from the why. The goal
oriented theory was chose for this project because it best exemplifies principles that supports the
need for consumer stakeholders to attain knowledge of basic leadership procedures and
performance measures in order to facilitate their meetings and conversations with VCHP
leadership. Knowles (1980) stated that adults are more motivated to participate when the see the
relevance of information, a request or task to their own circumstance. For this problem of
practice the framework used to guide discussion for knowledge will be Clark and Estes (2008).
Table 5.1
Summary of Knowledge Influences and Recommendations
Assumed Knowledge
Influence: Cause,
Need, or Asset*

Validated
Yes, High
Probability, or No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Consumers
stakeholders must
have knowledge of
basic leadership
procedures,
performance
measures etc. in
order to facilitate
their meetings. (D)

Using case studies,
Consumer Advisory
Member orientation
should educate
consumers on the
Validated
High probability

High Probability

Yes

Yes
(Conceptual,
declarative)
Training people
effectively, requires
giving them
accurate
procedures,
practice and
corrective feedback
that permits them
to gradually
automate the
knowledge

(Procedural)
Checkoway,1993;
Conduct in
depth training
on meeting
facilitation,
Robert’s Rules
of Order, Ralph
Brown Act and
Communication
skills.

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126
Heart of L.A.
processes, managed
care facts and
guidelines.
Education should
address knowledge,
comprehension,
application, critical
thinking, synthesis and
evaluation. (P,M))
Christoffel, 2000;
Conduct a 2-3
three day
training that
orients
consumers to
their advisory
role, managed
care,
compliance,
Health
Information
Portability Act,
meeting
procedure,
accountability,
advocacy 101
and patient
rights.
Staff will need
education on learning
and motivation in
order to integrate
learning theories in
consumer stakeholder
trainings. (D)
Validated
High Probability
Yes Sound background
of learning and
motivation
techniques can
enhance the
delivery of
information during
trainings. Training
and follow-up
leading to
improved job
performance that
positively
contributes to key
organizational
results positively
contributes to
organizational
results.
(Procedural)
Checkoway,1998;
Mayer, 2011;
Kilpatrick et al,
2016;
Herron, 1996
In response to
consumer response,
VCHP must
conduct
professional
development and
train the trainer
exercises for staff.
This is important to
assist with
transferring
knowledge to
consumer
stakeholders.

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127

Staff will need
education on learning
and motivation in
order to integrate
learning theories in
consumer stakeholder
trainings. (D)
Not Validated
High Priority
Yes Conceptual
knowledge is
defined as an
integrated and
functional grasp of
ideas (Kilpatrick,
Swafford &
Findell, 2011)
Advocacy
Educators can
assess knowledge
by encouraging the
use of skills in
advisory and
community
meetings.
Staff should facilitate a
learning process that
aligns Board and
consumer members
work collectively to
create an step-by-step
scenario on how they
will work to address
global access issues
impacting consumers.
(M)

Consumer Advisory
orientations consumers
should be able to
categorize the Heart of
L.A. lines of business
and be able to identify
the population those
products target
(seniors, children,
disabled) (P).

Consumer members
will be able to identify
key departments and
their responsibilities
for addressing key
access issues identified
in metaphoric
scenarios (P)

No Yes Well received
training that
provides relevant
knowledge and
skills to the
participants and the
confidence to apply
them on the job

(Procedural)
Molyneux et
al,2012;
Krathwohl, 2002;
Alex et. Al, 2009

Key staff to conduct
one day strategic
planning retreat
with Consumer
Board and
Advocate Board
Representatives to
create annual work
plans that address
health access issues
and align efforts
with consumer
advisory
committees.
Consumer members
can clearly convey
issues they have with
access to care. (D)
High Probability Yes Knowledge
generation is key to
effective advocacy.
Consumers must be
able to connect
claims to decision
makers. The
degree to which the
Staff will include a
section in the
consumer
leadership training
that addresses
effective
communication as
well as instructions
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128
trainer is able to
create relevance for
the participant to
use the information
learned is the best
use of resources.
(Metacognitive)
Kiles, 2002
Berkes, 2009;
Wallerstein and
Bernstein, 1994;
Paulo Freire,
1989;Dewey,1897;
Kilpatrick, 2016
Increasing
knowledge, skills
and motivation and
focusing those
assets on
organizational
goals are keys to
the success
(Metacognitive)
Clark and Estes
(2008)

on how to address
health access issues
when addressing
organization
leaders.

This will be
achieved by using
skills learned in
trainings to assist
consumers to
effectively make
formal request
related to their
health access as
well follow-up on
previous unresolved
requests.
*Indicate knowledge type for each influence listed using these abbreviations: (D)
Declarative; (P) Procedural; (M) Metacognitive

Declarative Knowledge Influences
Performance requires knowledge of basic facts, information and terminology related to a
topic (Krathwohl, 2002). To close the declarative knowledge gaps, it is imperative that
consumer advocates are able to depend on themselves when advocating for policies that support
the improvement of their health care. Knowing how to be an effective advocate is crucial to the
value added dimension of improving the consumer stakeholder process and for being a effective
consumer advocate. The key to addressing this issue is being able to identify the knowledge gap
and having the right tools to address identified deficiencies. While this project focuses on the
consumer, it will be incumbent upon the stakeholder organization to also look at staff knowledge
gaps that support consumers. I am proposing that staff be educated on learning and motivation
theories in order to convey key leadership concepts in consumer stakeholder trainings. When
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129
conducting consumer interviews many of the participants did not have 100% confidence in the
support that they receive from staff. This lack of trust greatly impacts the consumers trust in
information and guidance when applying key advocacy principles. Additionally, stakeholders
should be knowledgeable about basic leadership procedures, managed care, and how health plans
measure performance. While knowledge of managed care is essential component to the learning
goals, consumers must also be resourceful areas outside of managed care that impact the overall
health outcomes of low income communities such as those of social determinants (i.e., food
insecurities , housing, education, safety, financial literacy, mental health etc.) health equity. This
source of knowledge supports and improves consumer’s abilities to be strong advocates in their
communities. This information is essential in assisting them to engage decision makers and
understand how decisions are made. This two-way dialogue will also aid consumer members; to
clearly convey issues they have accessing care.
Ensuring that stakeholders have access to factual information and knowledge of when to
utilize it is critical to their ability to be effective advisory members. Having comprehensive
knowledge of advocacy concepts is the foundation to the stakeholder’s success. Researcher such
as Dewey (1897) made a strong case for learners to focus on more than acquiring a
predetermined set of skills, but also to prepare to use all their capacities. To this end building
advocacy skills among Medicaid consumers, will require factual knowledge in areas such as
advocacy, managed care, understanding data, social determinants of health, and the stakeholders
ability to influence change. Knowledge of these foundations will assist advocates to engage in
meaningful discussions with decision makers. Nutbeam (2000) stated that improving consumer
access to information and their capacity to use it effectively is critical to empowerment.
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130
Members are empowered when they can autonomously seek information and resources as well
understand how to utilize information when needed.
Conceptual knowledge can be defined as, “an integrated and functional grasp of ideas,”
(Kilpatrick, Swafford, & Findell, 2001). Advocacy educators can assess knowledge by
encouraging the use of skills in advisory and community meetings. Utility of the information
will validate the knowledge of conceptual information. The development of skills mastery is
important for consumer advocates to demonstrate their knowledge of skill components, practice
integration of those skills, and know when to apply what they have learned. This will be
validated by asking participants to observe their meeting, review meeting summaries and by
completing a comprehensive meeting questionnaire that evaluates their understanding of meeting
processes, and their ability to act based on provided during their meetings. Alexander, Schallert,
and Reynolds (2009) asserted four dimensions of learning (what, where, who, and when) that
map the product and process of learning. This study is crucial to the stakeholder group as it
contends that learning is both a process and a product. Educators play an important role in the
transfer and pedagogy of knowledge. Educators can support consumer advocates reinforcement
of learning by assisting them with attaining solid mastery of advocacy principles and illustrating
multiple examples that aid in reinforcement of learning. The educator’s role is to ensure that
they are able to support stakeholders by being a resource, support, mentor, helping hand, and
learner. Educators must understand interdependent and fundamental issues in order to construct
cognitive and methodological empowerment, political empowerment, and emotional and
interpersonal empowerment (Herron, 1996).

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131
Procedural
According to Krathwohl (2002), knowledge of the skills and procedures involved with
the task, including techniques, methods and necessary steps are critical to the knowledge factor.
As stated in Table 5.1, using case studies, during the initial Consumer Advisory orientations
consumers should be able to categorize the Viking County’s lines of business and be able to
identify the population those products target (seniors, children, disabled). Consumer members
will be able to identify key departments and their responsibilities for addressing key access
issues identified in metaphoric scenarios. These procedural schemes are detrimental in increasing
knowledge and linking barriers to advocacy to improved access and outcomes.
Clear knowledge of how to perform a task is essential to the success of meeting the intended
stakeholder goals. In a study conducted by Johnson et al. (2009) the researchers suggested that
tests should be administered with questions designed to promote reflection on key principles.
This style of questioning reinforces learning. Test questions should be designed to exemplify
each of Bloom’s five levels of thinking (comprehension, application, analysis, synthesis, and
evaluation) (Bloom, 1956). Bloom’s levels of thinking, supports the importance of process
oriented learning and the stakeholder’s ability to retain and recall concepts at the proper time.
Other means for validating procedural knowledge are asking participants to articulate or
demonstrate the steps necessary to participate in advocacy processes and to observe participation
in role plays where the group along with facilitator will look for evidence of the necessary
methods, techniques or steps. To master this knowledge factor, consumers advocate stakeholders
must be able to identify factors that impact their learning process and performance, and be able
to create a strategic plan and implement the outcomes. This essentially would measure their
mastery of procedural knowledge. This was validated by observing the participants doing the
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132
task and by looking for evidence of necessary methods, techniques or steps. Last, each interview
participant being able to demonstrate the necessary steps to perform the task validated this.
Metacognitive Knowledge Solutions
Building metacognitive knowledge can greatly strengthen and reinforce critical thinking
that supports consumer stakeholders to be solution oriented. According to Krathwohl (2002), the
ability to reflect on and adjust necessary skills and knowledge including general strategies, assess
demands, plan one's approach and monitor progress is paramount to effective learning.
Participants must be able to reflect and transfer what they have learned during trainings to their
meetings, confirms knowledge increase and knowledge of how to appropriately handle and
report access issues. In support of this theory, staff will facilitate a learning process that aligns
board and consumer members work goals collectively, and create step-by-step scenarios on how
they will work to be responsive to stakeholders and address global access issues impacting
consumers.
Most consumers’ stakeholders bring to the advisory process a wealth of experience from
other community advisory boards in which they participate. In many cases this knowledge is
helpful in helping them to assert themselves in similar environments. According to the
information processing theory, prior knowledge can help or hinder learning. In this case, the use
of metacognitive strategies greatly assists stakeholders in becoming self- regulated in their ability
to learn new or advanced information. The ability of the educator and the learner to reflect on
their strengths and challenges will greatly impact learning opportunities for both the “help” and
“helper.” This often occurs when learners can apply principles and share examples during
discussion based on other experiences with knowledge.
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133
Additionally, the ability to strategize and problem solve supports the self-awareness
needed to strengthen metacognition. In the article “Do learners really know best?” Kirschner
and van Merrienboer (2013) looked critically at the nature of the learner, learning, and teaching.
The authors assert that it is the learner who knows best and that she or he should be the
controlling force in their or his learning. This theory is challenged by Druckman and Porter
(1991) who stated that learning is based on types, meaning that learners are not assigned scores
based on different dimensions but classify people into distinct groups. Learners may not be fully
aware of their strengths and may learn differently depending on the knowledge type (Druckman
& Porter, 1991). Many monolingual consumer advocates have increased understanding of
problem solving when paired with a bilingual learning partner. What this means for knowledge
influences is that the educator must possess multiple means of educating and assessing the
learner. An outline showing the assumed knowledge influence, the knowledge type, and the
processes to fulfill the knowledge influence is displayed above in Table 5.1.
Motivation
Motivation according to Clark and Estes (2008) can be measured by active choice,
persistence and mental effort. Motivation for this study was validated by the surveys and
interview conducted on each interview participants. Each participant expressed an intrinsic
value towards being a part of their advisory group and the fulfillment (extrinsic value) it brings
to be a resource of information for their peers. Interview participants state that while they
appreciate the monetary stipend they receive (for the 2.5 hours of time dedicated to attending
meetings), the benefits of being connected to resources outweighs the time spent. An outline
showing the assumed knowledge influences, the knowledge type, and the processes to fulfill the
knowledge influence is displayed in Table 5.1.
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134
It is paramount for the facilitator to be aware of the stakeholder’s motivation for
participating in the training academy According to Clark and Estes (2008) increased motivation
combined with effective knowledge skills and work processes result in goal achievement.
Stakeholder organizations can increase motivation by understanding how consumers value
learning and knowledge tasks. Staff will need to disseminate a civic engagement survey to
ascertain where on the motivation spectrum consumer stakeholders are placed and ask key
questions that validate those motivation factors. Consumers answered questions that provided
insight on the reason they are involved in the advisory committees, their opinion of the value for
their participation, and how important it is to be a member of VCHPs advisory committee. Other
examples of validating the motivation of consumer advocate included tasking new consumer
advisory members to identify learning expectations as an individual and group learning
assessment.
Motivation influences in Table 5.2 represent the complete list of assumed motivation
influences and their probability of being validated based on the most frequently mentioned
motivation influences.to achieve the stakeholder’s goal Rueda, (2011) suggested, that the
individual's belief in his or her capacity to execute behaviors necessary produces specific
performance attainments. Further, Bandura (1977) suggested that people who are positive and
believe they are capable and effective will achieve significantly more than those who are just as
capable but doubt their own abilities. As indicted in Table 5.2, some motivational influences
have a high probability of being validated and have a high priority for achieving the
stakeholder’s goal. There is a clear alignment between the influence, principle and
recommendation. Evidence of this became apparent when study participants stated that they
believed that they were expected to know things that they were never taught. It is assumed that
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135
consumer advocates are able to self-assess their motivation and build goals for themselves. This
form of evaluation is not realistic and requires broader evaluation and technical expertise to align
motivation with the groups goals. Table 5.2 also shows the recommendations for these
influences based on theoretical principles.
Table 5.2
Summary of Motivation Influences and Recommendations
Assumed Motivation
Influence: Cause, Need,
or Asset*

Validated
Yes, High
Probability,
No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Expectancy Value
Cause
Consumer advocates are
not able to self assess
advocacy skills and
abilities to help build
short, intermediate and
long term learning goals.
(SE).

V Yes In order to
address the gap
analysis, there
must be short,
intermediate and
performance
goals set (Rueda,
2011)

Once goals have
been determined
it is necessary to
see how far from
achieving them
current
performance is
(Rueda, 2011),

Staff will
disseminate a civic
engagement survey
to ascertain where on
the motivation
spectrum consumer
stakeholders are
placed and ask key
questions that
validate those
motivation factors.

Consumers will be
answer questions that
provided insight on
“the reason they are
involved in the
advisory
committees”, “ what
they see as a value
for their
participation” and “
how important it is to
be a member of
THOLA’s advisory
committee”.

Task new
consumer advisory
members to
identify learning
expectations as
individual and
group learning
assessments.

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136
New consumer
advisory need to be
able to self-
identify their
individual learning
gaps. This self-
identification will
improve their
advocacy efforts in
support of their
overall learning
goals.

Utility Value Need
Consumer Advocacy
Members cannot see
the value of their
advocacy efforts if they
are not able to utilize
their skills when they
believe they are
needed. (V)
HP No The higher an
individual values
an activity the
more likely he or
she chooses,
persists and
engages in it
(Rueda, 2011)

People value
what they believe
helps them and
reject what they
believe stands in
their way (Clark
and Estes, 2008)

Advocacy training
participants are
asked to provide
examples of how
new learning’s will
support future
advocacy efforts.

Attribution Asset
Consumer members
lack confidence in their
ability to impact
organizational change
that essentially holds
the health plan
HP Yes Attribution
supports the
ability to adapt to
changing
environments
and overcoming
challenges
Consumer
participants will
utilize leadership
skills by
transferring
knowledge during
role plays and by
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

137
accountable for their
member experience.
(SE)

(Harvey and
Martinko, 2009)
Providing
feedback that
stresses process
nature of
learning,
including the
nature of
learning,
importance of
effort, strategies
and potential
self-control of
learning
(Pintrich, 2003)

Attributions that
focus on effort
are seen as
leading to
different
outcomes in the
future ( Rueda,
2011)
using skills in their
advisory meetings
and other
Organizational
business meetings
where consumer
input is needed.
Self-Efficacy Need
Newly immigrant and
other minority
consumers lack
confidence in their
ability to voice
concerns regarding
their health benefits.
(SE)

HP Yes The individual's
belief in his or
her capacity to
execute
behaviors
necessary
produces specific
performance
attainments
(Rueda,2011)

People who are
positive and
believe they are
capable and
effective will
achieve
significantly
more than those
who are just as
capable but
doubt their own
abilities
(Bandura, 1977)

Different
individuals and
groups can have
very different
beliefs about the
different way
Members will
participate in mock
board meetings
and legislative
office visits that
allow them to build
confidence in
utilizing their
advocacy skills.
Upon completion
consumer members
will complete a
self -efficacy
assessment to
gauge their ability
to advocate on key
health access
issues.

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138
they can achieve
”effectiveness”
(Clark and Estes,
2008)

Cultural
stereotypes and
mishandling
cultural
differences are
only a couple of
the ways that
people in
organizations can
discourage
performance
(Clark and Estes,
2008)

Goal Orientation
Need
Advocacy

Participants lack clear
reasoning for joining
advisory committees
beyond the monetary
incentive and or
perceived status.(V)

V No Goal orientation
focuses on the
purpose and
reasons for
engaging in
achievement
behaviors
(Pintrich, 2003)

Participants will
participate in a pre
and post survey
that will assess
their readiness for
advocacy work as
well assess where
support is most
needed in order to
recall skills during
advocacy and
leadership training
efforts.
Participants will be
asked to complete
both individual and
group presentation
on key advocacy
topics

Self-Efficacy
According to psychologist Bandura (2000), is defined as one's belief in his or her ability
to succeed in specific situations or accomplish a task. One's sense of self-efficacy can play a
major role in how the goals, tasks, and challenges are approached. Self–efficacy used as a
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139
model of behavior change has been proven to strengthen positive health attitudes and behaviors
as well encourage the adoption of healthier choices (Bandura & Cervone, 1983; Maibach &
Parrot, 1995). Self-Efficacy is used to set realistic learning and behavior goals for each other. It
ensures follow up to see if a partner was able to meet the goals set. This reciprocated check-in is
effective in reinforcing self-efficacy, ensuring support and accountability to goals. There is a
general belief from community researchers that community based participatory research is an
effective approach to studying and taking action to addressing health disparities (Minkler,
Blackwell, Thompson, & Tamirand, 2003). The members ability to see themselves utilize key
information in support of their advocacy efforts, paly a major role in their ability to effectively
address barriers that prevent them sharing their experiences accessing care.
Value
According to Eccles (2009) is associated with a set of beliefs that impact short and long
term goals. Studies conducted by Eccles correlate achievement related choices to two sets of
beliefs: 1) The individual’s expectations for success, and 2) The importance or value the
individual attaches to the various options perceived by the individual as available. Consumer
stakeholders must perceive the value of expanding and retaining their knowledge of advocacy
and social justice issues in order to transfer knowledge when addressing Viking County’s board
of governors and other policy influencers.
According to researchers Hidi and Renninger (2006) interest plays a powerful role in the
level of a person’s learning. Learning and interest play an important role in building consumer
advocacy education, it also opens doors in other areas of advocacy that further support an
advocate’s growth and success. Examples of utility value can be identified when consumer
members who have successfully completed advocacy trainings are able to transfer their
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140
knowledge and skills to serve in leadership roles regionally and at board of governor’s level.
High confidence in one’s ability to successfully master material and the ability to understand the
utility value of learning for future options builds confidence in one’s ability to place high value
on their potential (Wigfield, Schiefele, Roeser, & Davis-Kean, 2006).
Organization Influences
Understanding the organizations influences are paramount to understanding the root
cause of performance barriers. To address this problem it is imperative for the organization's
division of labor to be clear to employees so that they are able to address the health concerns of
consumer stakeholder members. Currently the Organization's leadership underestimates the
capacity and abilities of the consumer members to hold them accountable. This essentially
promotes negative behavior towards adopting solutions that support the consumer advocacy
process. In order to address this concerns the organization's mission must align with the mission,
expectations, unspoken culture and operations of the organization.
Organization Influence and Recommendations
Organizational influences are sometimes very difficult to diagnose. While not all
symptoms to this problem are visual, they nonetheless can impact the effectiveness, quality and
overall efficacy of programs. In order to address organizational influences there must be
included in this improvement model an opportunity to address social and cultural influences that
impact consumer advocates and their interaction with the stakeholder organization. VCHP must
take into account the consumer as an individual, the consumer as a part of the community. This
complex perspective is key to improving processes that support consumers in the plight to
untangle barriers that impact their ability to be effective advocates. Based on the cited principles
and recommendations, there will need to be clear alignment with the assumed influences that
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141
speaks to the stakeholder organization not having clear structure, policies and processes in place
to continuously address complex issues brought forth by consumers. It will be essential to the
consumer process that an investment in be made in support of improving the system to one that
is culturally aligned and understood by VCHP consumer base and addresses member access
issues in a timely manner.
Organizational influences in Table 5.3 represents the complete list of assumed
organization influences and their validity based on the most frequently mentioned organization
influences to achieve the stakeholders’ goal. This data was captured during informal interviews
and literature reviews that provide insight on the impact of organization influence and culture.
The stakeholder organizations ability to successfully implement change is crucial to future
success of the consumer advocacy program. The consumer training and advocacy program is
dependent on VCHP monetarily, for staff support and for policy implementation. The result of
VCHP not supporting their consumer advocacy groups could mean the following: They do not
meet their legislative mandate, no added value to the community accountability, uniformed
consumers, low engagement loose direct connection to member feedback on service delivery and
disempowered members. As such, as indicated in Table 5.3, some organizational influences
have high probability and can be validated and should be considered high priority for achieving
the stakeholder goal. Table 5.3 also shows the recommendations for these influences based on
theoretical principles.

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142
Table 5.3
Summary of Organization Influences and Recommendations
Assumed Organization
Influence: Cause, Need,
or Asset*

Validated
Yes, High
Probability, No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and Citation

Context-
Specific
Recommen
dation
(CS)
The organization lacks
clearly defined systems
that support key staff to
resolve health access
issues of consumer
members with complex
issues
HP Y All organizational goals are
achieved by a system of
interacting processes that
require specialized
knowledge, skills, and
motivation to operate
successfully (Clark and
Estes, 2008).

Organizational structures,
policies and practices can
influences whether the
performance goals of
individuals groups, or
entire school or
organizational units are
met Reuda, (2011)

Institutionalizing New
Approaches
Articulating the
connection between the
new behaviors and
corporate success.
Developing the means to
ensure leadership
development and
succession Kotter,
(1995).

VCHP will
create clear
business
processes
that support
the
resolution of
identified
member
issues
reported
through the
consumer
advisory
process.

Cultural Setting Influence 2:
The organization's
assumptions about their
consumer stakeholders
level of education and
socioeconomic status
impedes their ability to

HP

Y

Cultural models can be
used to characterize
organizations , business
settings and classrooms
as well as individuals
Gallimore and
Goldenberg(2001),

VCHP staff
will
participate in
cultural
competency
and member
sensitivity
training that
support the
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value consumer input
(CS)
A pattern of shared
assumptions that is
learned by a group as it
solve its problems of
external adaptation and
internal integration that
has worked well enough
to be considered valid
and to be taught to new
members as the correct
way to perceive, think
and feel in relation to
those problems Schien,
(2004)

A strong organizational
culture controls
organizational behavior
and can block an
organization from
making necessary
changes for adapting to a
changing environment
Schien, (2004).

Knowing what people
actually do in their daily
lives helps preclude
making inaccurate
judgments about
individual or group
characteristics based on
factors such as ethnicity,
race gender,
socioeconomic status
(Gutierrez & Rogoff,
2003)
overall
consumer
advisory
feedback
process.

Cultural Model Influence
3:
Organization's mission
does not align with the
expectations, unspoken
culture and operations of
the organization (CM)
HP N Accountability for
reasonableness requires
three elements: transparency
of organizational policies
and decisions, deliberation
that recognizes the needs of
both the individuals and the
population served, and
opportunity for appeals and
revision of limit-setting
policies Sabin, O'Brien and
Daniels (2001)

When people fail to get the
necessary resources that
were promised for a high
priority work goal or when a
policy is not supported by
effective work processes or
Leadership
will
participate in
a series of
trainings that
address
organization
cultural
norms that
impede the
goals of
being a
community
accountable
health plan.

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procedures, one of the
possible causes is a conflict
between some aspect of
organizational culture and
current performance goals
Clark and Estes (2008)

Systems of accountability
should address equity,
diversity and access in
various sectors (Lim,
Haddad & Daugherty
(2013); Trenerry &
Paradies (2012).

Leadership
will task
staff to
implement a
process for
resolving
member
issues and
support
findings
outcomes to
the
organization'
s board of
governors

Policies
In addressing barriers to effective advocacy, there must be policies created that support
Viking County’s administration to implement clear lines of accountability that are: 1)
transparent, 2) evolve as the consumer needs evolve, and 3) create continuity for internal
stakeholders to measure the effectiveness of policies that support member feedback and
navigation of their health care benefits. According to Hentschke and Wohlstetter (2004)
accountability is contextually defined. Leaders are more accountable when accountability is
framed both internally and externally and takes on many forms; including bureaucratic
accountability, professional accountability, and market accountability.
Processes
Understanding the organizations cultural processes are of great benefit to those tasked to
implement change. Currently the stakeholder processes for sharing feedback to the organization
is complex and requires multiple steps that deter stakeholders from engaging in the process.
Creating a streamlined process that is clear, user friendly, and accessible would greatly support
consumer stakeholders and the staff required to support them. Examples of clear processes
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145
include but is not limited to a user friendly reporting of access issues, time bound, does not
require bureaucratic approval, inclusive of a clearly defined grievance process, documented for
board discussion one that is inclusive of a continuous process improvement which includes
consumer input.
Cultural Models
Cultural changes must be visible and concrete in the consumer stakeholders meeting
environment. To achieve this factor VCHP staff will share meeting goals and expected outcomes
with meeting participants. Additionally, members will participate in setting goals prior to the
start of their annual fiscal year to ensure that they create optimum environment for effectiveness.
Goals will be specific, measurable, attainable realistic, and time bound. By proactively setting
these goals it is assumed that members will shift to attitudes that align with improved cultural
acculturation. Cultural models are often invisible and often go unnoticed by those who hold
them (Reuda, 2011). A strong organizational culture controls organizational behavior and can
block an organization from making necessary changes from adapting to a changing environment
(Schien, 2004).
When interviewing Latina consumer stakeholders, there was clear inner conflicts that
exist between what is expected of them as advocates, their traditional culture, and their ability to
challenge men they perceived as dominate and in charge. Much of this attitude is enabled by
result what is termed as a Marianismo. A Marianismo is defined as a pattern of behavior that is
regarded as conforming to a traditional or archetypal female role. While this type of behavior has
a large cultural undertone it creates complexity when there is a need to challenge policies, status
quo and organizational change. Given that the majority of the stakeholders are Latina women
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this presents a problem for addressing long term systemic change in an organization that is
dominated by men.
According to Gallimore and Goldenberg (2001), Cultural models are shared mental
schema or normative understandings of how the world work or ought to work. Using empirical
data from other successful models to support the implementation of strategies is an example of
model-based implementation. Organizational effectiveness increases when leaders facilitate
creative and collaborative problem solving. Leaders should not focus on cultural change
however they should focus on the business problem: what isn't working. The key to problem
identification is to become very specific (Schein, 2004).
Cultural Settings
Understanding the cultural setting of the stakeholder organization is key to answering
questions related to the organizational gaps. With VCHPs upper management and governing
leadership being primarily male, there is an unspoken tone that exists in who and how decisions
are made. This setting is of concern as women are the primary consumer stakeholders of the
organization. Many studies have shown that women are key decision makers in their household
when it comes to major decisions and large purchases. Contrary to the socioeconomic and
cultural experience of VCHPs member population, decisions are made by primarily by VCHPs
leadership who by majority identify as Caucasian men. These leaders lack association with the
member population and often make decisions based bottom line that lack community interest.
These decision makers also lack knowledge about key cultural issues impacting the VCHPs
member base. In order to address the polarity that is present in the organization it will be
essential to integrate and diversify the leadership team to incorporate broader perspectives and
innovative ways to address access issues.
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Cultural settings according to Gallimore and Goldenberg (2001), Cultural settings can be
helpful in thinking about the more visible aspects of an organizations settings. In addition to
what is customary and what is normal. Cultural settings can be seen as the who, what, where,
when, why and how of the routine which constitute everyday life also known as social context
(Cole, 1996; Engestrom, Miettinen & Punamaki, 1999; Tharpe & Gallimore, 1988). Cultural
settings are where policies and practices are enacted (Rueda, 2011). To address influences
identified as impacting the cultural setting, the organization will need to implement meetings that
empower members, encourage dialogue and creates an intentional marriage between policies,
access realties and health outcomes.
Integrated Implementation and Evaluation Plan
New World Kirkpatrick Model
The new world Kirkpatrick model will be used to support the integrated implementation
and evaluation efforts for this improvement project. The new world Kirkpatrick model
(Kirkpatrick & Kirkpatrick, 2016) is adapted from the original Kirkpatrick model (2006), which
suggested four levels for evaluating trainings. The new world Kirkpatrick model (NWKM)
evolves the “Four Levels” by reversing the order from levels 1-4 to levels 4-1. According to
Kirkpatrick this is done to keep the focus on what is most important. The NWKM premise
stated, “The end is the beginning.” Kirkpatrick and Kirkpatrick (2016), stated that in order to
bridge the gap between individual initiatives and organizational results leading indicators must
be used. Leading indicators are defined as short-term observations and measurements that
suggest that critical behaviors are on track to create a positive impact on the desired results.
Leading indicators are crucial to connecting the organization's mission to targeted outcomes
which should focus on the highest-level result.
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Keeping in mind the mission of VCHP being to promote accessible, high quality health
care that reflects a commitment to cultural diversity, and the knowledge necessary to serve our
members with respect and competence. The project examined VCHP as a community
accountable health plan as well it examined barriers both visible and hidden that impact the
outcomes of effective consumer advocacy. Feedback from the consumer advisory board to the
stakeholder organization on the quality of care and their overall experience accessing health care
services is crucial to the stakeholder’s board of governors as it assist with program planning,
decision-making and proper resource allocation. In addition to identifying access issues, the
ability of consumers to address systemic barriers that impede them from providing effective
feedback is equally important to addressing health access barriers. Addressing this goal will
greatly align to the organizations mission, and work to improve the care provided to Viking
County’s vulnerable populations. The desired outcomes for this project was to provide the
stakeholder organization with key recommendations on how to improve its consumer advisory
process based on current research and to increase the value of consumer input through the
organizations vetted and agreed upon consumer feedback process.
The expectations for use of the recommendations is that the stakeholder organization
consider a multi-pronged approached to improving and understanding barriers that impede
effective advocacy. The first recommendation is that consumer advisory meetings are
reformatted to allow for increased opportunities for consumers to receive foundational education
on managed care and advocacy, create more opportunities for consumers to participate in
dialogue that aligns the original intended purpose of consumer advisory committees, create
opportunities for consumer input on the improvement of low scores attained from the health
effectiveness information and data. Secondly, that the stakeholder organization invest in
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trainings beyond training for consumers in leadership roles. Increased training is believed to
assist consumers in becoming stronger advocates as well prepare them for leadership roles.
Third, recommendation is for the stakeholder organization to increase opportunities for
consumers to conduct outreach in their immediate communities. The opportunity to conduct
outreach is believed to empower consumers to recruit other consumer advisory members as well
it allows them to utilize learning’s by educating fellow community members on access to care
issues and basic health information. This essentially strengthens the relationship between the
stakeholder organization and its consumer advisory members as well brands the organization
countywide. Last is the implementation of evaluation in all engagement efforts. Evaluation of
efforts is key to understanding increase in knowledge and to determine the connections between
gaps, improvement of programs and the cost associated with those programs. Evaluations of
programs will assist VCHP with knowledge of how their monetary investments in consumers
support the overall goals and mission of the organization.
Level Four: Results and Leading Indicators
Table 5.4 shows the proposed Level 4: Results and Leading Indicators in the form of
outcomes, metrics and methods for both external and internal outcomes for VCHP. If the
internal outcomes are met as expected and as result of the training and organizational support,
there will be increased levels of self -efficacy exemplified by continuous member input and
feedback to the stakeholder organizations board of governors. This feedback will act in support
of the stakeholders charter as a community accountable health plan.

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Table 5.4
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metric(s) Method(s)
External Outcomes
Increased KSA’s of
consumer stakeholders in
areas of managed care, access
to care and health advocacy.
Increase the number of consumer
leadership trainings from 3 times a
year to bi-monthly meetings.
Conduct pre and post testing of all
curriculums and incorporation of program
specific evaluations.
“No wrong door policy” that
encourages consumers
advocates to share health
access issues with
stakeholder via formal and
informal settings.
Implement Clear policies and
systems that support consumer
feedback.

Successful creation and implementation of
reporting logs, policy creation,
interdisciplinary committee. (Prior to the
start of the fiscal year on or before
September 30, 2018)
Align consumer feedback
with HEDIS data and
outcomes
Conduct annual HEDIS education
for strategy implementation.
HEDIS education (Annually in
September)

Increase opportunities for
community partnerships.
Conduct community meet and greet
opportunities and manage key
relationships minimum 3 in each
region.
Co-branding opportunities,
Sponsorships and grants
(Monthly, ongoing)
Conduct consumer advocate
recruitment for underserved
groups in key regions to
increase diversity of
consumer advocacy
members.

Increase outreach to
underrepresented groups for
recruitment into the advisory groups
Use the organizations threshold data
as indicators for outreach to diverse
populations.
Seek outreach opportunities and approval
for Participation. Use event for branding
and visibility at community events and
locations in concentrated areas of the
communities served. Document
participation by sign in sheet (monthly,
ongoing)
Recruit for Quality consumer
member opposed to quantity
Increase the number of consumer
advisory members who are motivated
to improve healthcare access in their
community.
Staff will conduct pre-screening
interviews to identify knowledge and
motivation.

Multicultural recruitment strategy,
Calendaring of countywide community
events, recruitment presentations at local
cbo’s, provide a recruitment incentive.

Based on the level of participation sign-
ups, and attendance to community
events(ongoing).
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Internal Outcomes
Increased responsiveness to
member dissatisfaction
Reduce the number of months in
which the stakeholder organization
responds to member dissatisfaction
reported during consumer advisory
meetings.
Create universal processes for handling
member inquiries regarding dissatisfaction,
increased opportunities for member voice
and feedback, responsible department
attendance to ECAC,(ongoing)
Alignment of patient
outcomes with the mission
Use of member feedback and other
data sets for guidance in building
effective interventions and programs
Assign quality indicators to enterprise
goals in alignment with the stakeholders
organization's mission. (Minimum 6)
Implementation of a clear,
user friendly and Valuable
consumer advisory process.
Increased number of global issues
brought forth to the stakeholder
board for consideration
Track and trend of member issues at both
the Executive advisory level with
outcomes and completion of an annual
report(monthly)

Level Three: Behavior
Critical Behaviors
The stakeholders of focus are the consumer advisory committee members. Critical
behaviors are those behaviors, according to Kirkpatrick and Kirkpatrick (2016), are the few
specific actions, which if performed consistently on the job will have the biggest impact on the
desired results. The first critical behavior is that that will be implemented and observed is
the consumer advisory members ability to correctly convey the mission of the stakeholder
organization during planning, and improvement processes. The second critical behavior is that
consumers will be able to identify and share health care access issues experienced by Medicaid
consumers during consumer advisory and board of governor meetings. The third critical
behavior requires VCHP to distribute and review health disparities data with consumer advocates
to aide in educating them on health disparities and poor health outcomes in their individualized
communities. The fourth critical behavior is that consumers can identify the “3 pillars” of
community engagement when asked. The fifth critical behavior is that consumers will apply
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152
advocacy training and principles to instances that require them to inform and voice concerns
relating to the quality of care 1) practice with accessing member services, and 2) to share
member experience with customer service agents. The specific metrics, methods and timing for
each of these outcomes and behaviors appears in Table 5.5.
Table 5.5
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical
Behavior
Metric(s) Method(s) Timing
1. Consumer
advisory
members will
be able to
correctly
convey the
mission of the
stakeholder
organization.

Participants will score
minimum of 80% on
learning test.
1) Pre and post test conducted
during trainings and
meetings.
2) Staff will conduct various
Learning and engagement activities
during trainings to assist with
reinforcement of information.
3) Activities in support of overall
knowledge increase, advocacy and
managed care.
During the first 60 days and
c completion of new member or
orientation & ongoing (bi-
monthly)

2. Consumers
will Identify
and share
health care
access issues
experienced by
Medicaid
consumers
during
consumer
advisory and
board of
governor
meetings.

Attendance sheets By attending bi-monthly
meetings

During the member section of
Bi-monthly meetings. ( 6x per
year)
3. VCHP will
review and
distribute
health
disparities data
Consumer members
will work with their
staff specialist to
create 20 leave behind
packets to be
Attendance to local legislative
office visits, and board
meetings.
Annually 33 meetings (3 x
11 regions)

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to consumer
advocates to
aide in
educating
decision
makers of
health
disparities and
poor health
outcomes in
their
individualized
communities.

disseminated to
legislative office staff
during 100% of
scheduled office visits.
4. Consumers
can Identify the
“3 pillars” of
community
engagement
when asked?
Participants will score
minimum of 80% on
Pre and post test
conducted during
trainings and
meetings.
Staff will conduct various
learning and engagement
activities for information
reinforcement.

By the completion of new
Member orientation or first 60
days of committee
membership.
5. 1. Practice
with accessing
member
services 2. To
share member
experience with
customer
service agents.

Participants will
participate in a
minimum of one
phone call to VCHP
customer service,
Members will share their
experience during scheduled
meetings
During bi-monthly meetings
(every 60 days)
During members service focus
group and feedback
opportunities
6. Ability to
attend and
network with
other cbo’s for
collaboration
Participants will be
assigned networking
opportunities to attend
with instruction on
how to 2 way
communication and
sharing of information
Members will share their
experience during
scheduled meetings
During bi-monthly
meetings (every 60
day

Required Drivers
New consumer members require the support of their Field Specialist, Liaison and their
committee chair to attain crucial advocacy knowledge and be able to apply during public
meetings. The ability to utilize knowledge during Board of Governors, and other internal and
external community meetings where decisions are made, can greatly impact decisions related to
the care of Medicaid users. Understanding rules and regulations as it relates to managed care is
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154
crucial in forming arguments that support Medicaid access and services. Table 5.6 shows the
recommended drivers to support critical behaviors of new reviewers.
Table 5.6
Required Drivers to Support Critical Behaviors
Method(s) Timing Critical Behaviors Supported
1, 2, 3,4,5.
Reinforcing
Participate in new
member orientation
1 once per
o onboarding
11,2,3
Advocacy training to
establish key goals.
Monthly 1,2,3
Participate in mock board
of governors meetings.
Minimum of
3 times per
year
1,2,3
Health Technology Training Bi-Monthly 1,2,3
Understanding and
interpreting data for
decision making
Bi-Monthly 1,2,3
Meeting preparation and
communication
Bi-Monthly 1,2,3
Encouraging
Participate in leadership
trainings
Bi-Monthly 1,2,3
Provide opportunities for
each consumer advisory
chair to share medical
access issues from their
region and ascertain if
other areas share same
Monthly 1,2,3
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155
experience to report as
global issue
Rewarding
Consumer members who
actively participate in
their advisory committees
and who also attend
trainings, community
events and agency
sponsored meetings
representing Medicaid
consumers will advance
in leadership
opportunities
Annually 1,2,3

Monitoring
Consumer Chair and Vice
Chair will be required to
complete meeting
evaluations in support of
understanding gaps in
knowledge and
motivation of consumer
participants
Bi-Monthly
consumer
meetings and
Monthly
Chair
meetings
1,2,3
Staff lead will complete
observation notes of all
consumer advisory
meetings to ensure
transfer of knowledge
from staff to community
advisory members related
to meeting effectiveness
and dissemination of
knowledge information.
Monthly and
during all
meetings and
trainings.
1,2,3
Staff will conduct pre
meeting phone calls with
consumer advisory chairs
to confirm understanding
Monthly 11,2,3
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156
of information and
support the ability to
transfer information
during advisory meetings

In support of the consumer advisory committees the stakeholder organization will be
held accountable to support the collection of data that aides staff in understanding areas of
knowledge growth as well as gaps in knowledge that impede the consumers stakeholder in their
ability to effectively advocate for their health access and wellness. The stakeholder organization
will approve the use of a SharePoint drive that will be utilized to support the collection of data
accessible to department who work directly with consumer advisory member. Stakeholder
organization will also be accountable for producing an annual report that encourages and
reinforce the importance of health advocacy and the compilation of consumer contributions to
advocacy. The stakeholder organization will also commit to attaining professional consultants
that address areas of deficiency that impact knowledge, motivation and collaboration with the
health plan and its consumers. To ensure that drivers are implements on a continuous basis,
assigned staff will monitor and “check-in” with updated during Executive advisory and tam
meetings. Data will be essential to the success of these efforts. By not implementing these
activities the organization will not have data to drive continuous improvement likewise consumer
advocates will not have info in which hold the organization accountable for the improvement of
care.
Organizational Support
The stakeholder organization can greatly support critical behaviors by providing
financial, and staff support to do the following: host multiple opportunities for new members to
participate in orientation and other skills building opportunities that provide them with
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157
foundational skills needed to become effective advocates. The stakeholder organization will also
provide consumers with a annual calendar with dates of ongoing trainings that assist members to
build knowledge areas that they have identified as needing support to increase advocacy
effectiveness.
Level Two: Learning
Learning goals
Following the completion of the recommended solutions, most notably the consumer
leadership training will support stakeholders to:
1. Recite the organization's mission and goals
2. Apply “Robert's Rules of Order” to maintain meeting effectiveness
3. Organization's mission does not align with the expectations, unspoken culture and
operations of the organization
4. Reference the Ralph Brown Act and its guarantees the public’s right to attend and
participate in public meetings.
5. Place a motion in support of policies and change needed to support consumer advocacy.
6. Communicate health access barriers to stakeholder organizations board of governors.
7. Communicate the impacts of varied policies on the Medicaid population.
Program
The learning goals listed in the previous section, will be achieved by implementing a
training program that is culturally and linguistically appropriate for the stakeholder participant
group. All materials will be translated into the learner's language of choice to encourage
meaningful dialogue in support of the programs goals and objectives. This will be done by
utilizing learning strategies that build on the cognitive load and that focuses on the stakeholders
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158
desire to effectively advocate for themselves and other Medicaid consumers. A multi-pronged
approach must be utilized. Each bi-monthly advisory meeting should occur six times per year
for 2.5 hrs. each, during the assigned training portion of the meeting agenda and will include
opportunities to engage and model skills needed when attending and communicating to the
stakeholders board, elected officials and other key decision makers. Trainings for committee
chairs will take place once a month for six months with each session totaling six hours each
along with training for non-leadership consumer members, to occur bi-monthly for six hours
each training session.
Components of Learning
Learning goals will be measured by the consumer advocate's participation and retention
of key knowledge and information that supports them to be effective advocates that add value to
the stakeholder process. By the end of the leadership training, participants will be able to recite
and or summarize the organization's mission and goals when representing the organization
during various community affairs. Consumer advocates will also be able to apply “Robert's
Rules of Order” to maintain meeting effectiveness as well reference the Ralph Brown Act as
necessary to ensure public meeting compliance. Consumer advocate members should also be
able to place motions in support of policies and changes needed to support consumer advocacy
efforts.
Consumer stakeholders should also be able to communicate health access barriers to the
stakeholder organizations board of governors and communicate the impacts of proposed policies
on the Medicaid population. These learning goals will be measured by the following: Pre- and
post-test, program evaluations quarterly and annual progress reports listing accomplishments of
member access issues by consumer advocate members. As such, Table 5.6 list the evaluation
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159
methods and timing for these components of learning. Evaluation of learning activities is crucial
as it provides a data dashboard that support revamping, re-thinking, and opportunities for
improvement in support of increased accountability, effective and efficient outcomes.
Table 5.7
Components of Learning for the Program
Method(s) or Activity(ies) Timing
Declarative Knowledge “I
know it.”
During each key section of the leadership
training
Knowledge checks through use
of pre and post test
During each key section of the leadership
training
Knowledge checks through
group assignments and report
outs to the larger group of
training participants.
During leadership workshops.
Procedural Skills “I can do it
right now.”

Consumer Advocate Member will
be able to effectively use the correct
Robert’s Rules of Order to
effectively participate in meetings.
Observation modeling and utilization of RRO
During trainings and monthly meetings
Consumer advocates will utilize the
proper procedures for properly
documenting and addressing
member access issues with VHP
leaders during public meetings.
Consumers will complete a basic assessment to
identify knowledge in areas of placing items on
the agenda per the Ralph Brown Act.
Using the “triple aim” as the health
care indicator method, consumer
advocates will be able to identify
health access issues and categorize
Through use and review of case studies analyzed
with other learners and multiple choice exams.
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160
them by cost, care and member
experience
Attitude “I believe this is
worthwhile.”

Discuss how information will
be used in support of fellow
advisory meetings.
During training workshops.
Share success stories with
stakeholder organizations
leadership
Annual report dissemination

Confidence “I think I can do
it on the job.”

Consumer advocate members
will be able to transfer skills
from leadership training to their
regional meetings
Ongoing
Engage in predetermined
talking points that reinforces
learning objectives
During their training
Commitment “I will do it on
the job.”

Consumer stakeholders: I will be
able to use the information learned
during my next meeting.
Monthly
Participants will solicit peer
feedback from meeting
participants related to meeting
effectiveness.
Monthly
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Level One: Reaction
To ensure participants feedback to the leadership program, facilitators will disseminate a
workshop evaluation form inclusive of Likert scale questions regarding location, time, quality of
information, usefulness of information and brief summaries. Using the PDSA quality indicator
model, information from the participant evaluation will be considered by leadership trainers to
revamp and increase the effectiveness of the consumer leadership trainings to include addressing
any identified gaps. Inclusion of participant’s feedback is crucial to the overall improvement and
effectiveness of the program. Likewise, it is imperative that consumer education and ability for
consumer advocates to recall information during advocacy efforts during: 1) Member issue
section of the consumer advisory meetings, 2) member issue section during the Executive
Community Advisory Meeting. and 3) Community Outreach & Engagement section of VCHP
Board of Governor Meetings. Failure to implement these key-learning’s and engagement
strategies will gravely impact the stakeholders organization to continue qualify as a true
community accountable health plan. This failure could also result in lack of value added for the
consumer program and loss of motivation for consumer involvement.
The table below lists the methods and timing that will be used to measure the
participant’s engagement, relevance, and reaction to the information. Equally this table shows
the consumer participants desire to actively participate in leadership trainings, and their ability to
transfer information during their attendance at community forums, public meetings and
legislative office visits in support of continuous access to care.
Complete a pledge card self-
addressed to be reminded of the
agreed commitments.
Upon completion of each training module.
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Table 5.8
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Facilitators will use role
plays to engage consumers
in learning activities.
During scheduled leadership
trainings
Consumer Advocates will
act in role as secret
shoppers to practice
accessing information
from member services.
Ongoing in conjunction with
trainings and business inquiries
initiated by the BOG
Consumer advocates will
participate in scheduled
local and state office visits
to lobby for various health
and community issues.
As scheduled by staff
stakeholders.
Consumer Advocates will
participate in assigned
community outreach
events where they will
engage and share health
advocacy information with
other community
members.
As Scheduled
Relevance
Consumer Advocate
members will share
situational examples of
how learning’s will be
used to support access
issues. experienced as
individuals and as
community members
During leadership trainings
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Consumer Advocates will
review access issues and
connect the terms with
correct resolution,
During leadership trainings
Customer Satisfaction
Consumers will complete
training evaluation
Upon completion of leadership
trainings
Consumer will complete
meeting evaluation survey
Upon completion of monthly
meetings
Consumers will conduct
post outreach survey with
questions related to their
ability to share learned
advocacy information
Upon completion of assigned
outreach activities

Evaluation Tools
Evaluation is essential to monitoring the effectiveness of the said learning intervention.
Evaluation will take place during and immediately following the leadership trainings. This
evaluation will require the use of verbal assessment, written quiz, and Questions & Answer
opportunities. Participants will be asked to complete as series of questions that provide a pulse
on the how well the learning objectives were met. When scores fall below 80% participant will
be invited to attend future trainings in key areas to support their overall learning success. Level
one reaction works to increase overall engagement from members and applicableness of the
education to their role as consumer advocate. Level two provides consumer members an
opportunity to participate in revamped and refocused advocacy education. Level two directly
supports staff to facilitate an evidence-based curriculum supported with clear concise
engagement activities that reinforce learning’s and monitors outcomes.

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164
Immediately After the Training
Immediately following the program implementation training facilitators will implement
both knowledge evaluation and a participation survey. The knowledge (L2) survey will be used
to indicate the increase in knowledge and opportunities for additional training in support of the
learning to continuously evolve as an effective consumer advocate. Separately, consumer will
complete a participation survey (L1, L3, and L4) that will serve as the pulse for the overall
experience of the training program. This survey will gauge the increase in positive attitudes and
behaviors towards new learning, their ability to use the information learned and their belief that
the new information will lead to mutually beneficial outcomes for the stakeholder organization
and its consumers.
Table 5.9
Anderson and Krathwohl Taxonomy for Teaching Learning and Assessing
Declaration Knowledge Item
Knowledge consumer participation during
board of governor meetings in “multiple
choice form”
Consumers who desire to speak to the board
must:
a) Wait in line to speak
b) Raise hand to speak
c) Complete a comment card
(Multiple Choice)
Consumers will answer a broad spectrum of
questions related to advocacy to declare what
they know.
● How are legislative bills passed?
● What is the mission of VCHP?
● Contrast the difference between the 3
types of advocate stakeholders
Discussion
Consumer will be able convey why healthcare
moved from fee for service to managed care.
Describe why manage care exists

Discussion
Procedural knowledge
Scenarios in which consumers utilize
knowledge to support health access solutions.
Arrange the steps needed to having issues
addressed during public meetings:
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165
Open -ended
1. Complete a comment card for the
section you wish to speak
2. Read the meeting packet
3. Request a meeting packet to be mailed

Categorize by order
Attitude
Training Facilitator check-in:
Using color cards in your packet:

● Hold up Green if the training section
was a good use of your time and you
learned one new thing
● Hold up Yellow if there are
opportunities for improvement
● Hold up Red if the training was not a
good use of your time and you learned
nothing new.
● Attitude related questions
administered through written
evaluation.

During training

Discussion
Confident
Discussion about the impact of the program
on participants.
Describe how has the leadership training
empowered you to be a better advocate.
Discussion and written evaluation
When I return to my regional committee I feel
competent in applying meeting concepts
learned during my meeting.
After each training course
To what extent did you gain confidence in the
following areas:
Using Low, Medium, High, Master

A. Facilitating effective meetings
B. Negotiating conflict during meetings
C. Asking the right questions

After the completion of all 6 leadership
workshops.
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166
Commitment
On a scale of 1-10 To what degree are you
committed to applying what you learned?
Upon completion of each session

Table 5.10
Delayed Table
Evaluation Item
L1: Reaction I felt the training was worthwhile

L2: Learning What I learned in the leadership training will
be useful when I participate in regional and
community meetings.
L3: Behavior I will use the information to advocate for my
family, myself and my community.
L4: Results (Impact of training) I am able to use and share information I
learned in the leadership training.

Immediately Following the Program Implementation
Consumer stakeholders will complete post- test with scoring of 80 % or higher in all
advocacy categories (meeting facilitations, Managed Care 101, Effective communication and
Roberts Rules of Order). Consumer stakeholders will also be asked to complete a training
evaluation that will include questions from levels 1-4. The question will gauge their level of
engagement (did the training meet their expectations, relevance to their role as consumer
advocates and the overall satisfaction with the quality of information), Level 2: Learning
Experience (increase in knowledge, skills to recall advocacy information during public meetings
, attitude and confidence to apply knowledge and commitment to apply knowledge), Level 3:
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167
Behavior ( does the stakeholder feel supported, does the level of on the job learning meet
expectations), and Level 4: Results ( will the stakeholder be able to use and share information
learned with others). Additionally, upon Completion of training consumer stakeholders will be
acknowledged by receipt of a certificate of completion as well acknowledged by the VCHP
Board of Governors as having completed consumer leadership training program. See.Table 14.
Kirkpatricks reporting implementation

Figure 5.2. Operation Reset: Accountability, Value, and Collaboration.

Delayed for a Period After the Program Implementation
Delayed reporting will take place in two intervals approximately six months post the
implementation of the program and one year post the implementation of the program. The
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168
purpose of this timing and reporting will be to evaluate sustained engagement, member feedback,
increase in knowledge, confidence, commitment and effective advocacy. Further, this evaluation
will measure the four key levels as outlined in Kilpatrick (2016) training and evaluation. The
evaluation tool assess the training from a blended approach which will provide comprehensive
feedback that measures the stakeholder participant's perspective, satisfaction and relevance of the
training (Level 1), confidence and value of applying their training (Level 2), application of the
training to the expectations of being an effective advocate (Level 3) and the extent to which
consumer stakeholders are able to utilize information as result of the training. Level 3 is key to
performing critical behaviors and holding consumers accountable (see Appendix Training,
Outcomes Dashboard X)
Data Analysis and Reporting Summary
The level four goals of consumer advocacy is to ensure that the consumer stakeholder is
able to address barriers in their ability be effective advocates. The researcher will train and
review with staff the Kirkpatrick (2016) model to ensure program goals align with expected
outcomes. A consumer friendly dashboard will also be included to report both qualitative and
quantitative programmatic outcomes. Both graphics used will report data for all levels of
evaluation (1-4).
Summary
The New World Kirkpatrick Model (NWKM) will be used as framework to guide the
planning of each learning category identified as crucial to being an effective advocate. The
NWKM model is useful to convey learning principles to staff in support of their ability to be
adaptable and to identify the most effective means to engage adult monolingual and bilingual
learners. The NWKM also provides a concise way to comprehensively evaluate the training
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169
program. Effective evaluation assist to streamline processes, justify effectiveness, and future
cost allocation for training implementation. These positive attributes support the stakeholder
organization to create an evidence-based program for engaging consumers and for being a true
community accountable entity. Utilizing the NWKM supports the stakeholder organization
expectations by providing clear qualitative and quantitative evidence based data that measures
the target groups engagement in the leadership training. Strengthened engagement is key to the
leadership training outcomes. Engagement, according to Kilpatrick (2016) is the degree to
which the participants favorably rate their experience. Engagement is vital to the evaluation of a
program as it assesses the cognitive vigilance participants have towards the learning opportunity.
The program will also be measured by the learning objectives and outcomes. Using the
participant's pre-test scores as the baseline assessment, it is expected that there be an overall 70%
increase in knowledge scores. This increase in knowledge is representative of the successful
facilitation of level 2 learning’s. Other means that serve as indicators for having implemented a
successful program is self-reported behavior change. Participants reported during their initial
assessment that they were not able to use information learned in the program as, “it was too
much information at one time,” and, “I don’t feel competent enough to advocate on my own.”
The goal for the final assessment is to increase consumer confidence and the participant’s belief
that they could autonomously utilize the information outside of the training and recall advocacy
principles to effectively advocate for themselves. The overall results of this study, further
validate the importance of crafting a comprehensive training that identifies and leverages
indicators (Kilpatrick, 2016). Utilizing the NWKM will keep the initiatives on track and
provide a vehicle for providing stakeholders interim updates during their monthly meetings.
These updates will serve the following three purposes: 1) information updates for the committee,
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170
2) motivators for the participants to complete the training program, and 3) connecting data from
Levels 1-3, so that we were able to demonstrate that the desired results of increasing knowledge
of stakeholders ultimately reduced barriers in effective advocacy.
Limitations
While this project sought to provide a basis for understanding internal hygiene factors
that impact consumer training programs, there were limitations such as access to the larger
member population that prohibited the size of the study. As result of time required to complete
this study, the researchers language capacity and access to interpreters, the number of
participants were limited. Other limitations to this project included being able to only evaluate
input from the consumer’s perspective. Future research that would be beneficial to a
comprehensive understanding of the issue would be to integrate both staff and leadership
perspectives on their perceived barriers to effective advocacy efforts. As the researcher, I would
also like to interview other community stakeholder to gauge their impression on VCHP advisory
process, its value and effectiveness.
Conclusion
In conclusion an investment from the stakeholder organization to “Understand Barriers in
Effective Advocacy” could prove to enhance VCHPs overall health plans rating and consumer
satisfaction. As the researcher, I chose to research and focus on the consumer stakeholder, as
they are the group most widely impacted by the organizations true investment to identify an
effective solution to a ongoing problem in support of their consumer members. Constructive
feedback from consumer stakeholders that is focused and deliberate is greatly needed. VCHP
must move beyond its existing processes and adopt a desire for continuous quality improvement
with the overall benefit of supporting consumers who find themselves with no safe space to
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171
voice concerns about the health care that they receive. If we as practitioners believe that
healthcare is a right and not a privilege, it will be well worth our time and efforts to investigate
ways to implement and evaluate efforts that support health, wellness and authentic advocacy
from health agencies desiring to assist the most vulnerable in our county. Moving forward there
should be a concerted effort to follow-up this initial research with a study that looks deeper into
resolving this issue. Resolving this issue would not only help VCHP but also other organizations
mandated to be include consumers in their ongoing consumer involvement process.

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Appendix A: Demographic Survey Items
The following demographic information will be conducted on all interview and focus
group participants.
Demographic questions:
Age Range:
a) 18-24
b) 25-34
c) 35-44
d) 45-54
e) 54-64
f) 65 and over

Ethnicity:
a) African American
b) Asian
c) Latino
d) Native American
e) White (not of Latino Descent
f) Other________________________________________________________

Primary Language (What language do you feel most comfortable speaking, please
check one):
a) English
b) Spanish
c) Khmer _
d) Other_______________________________________________

Secondary Language (Do you speak any other language, Check one):

e) English
f) Spanish
g) Khmer
h) Other_____________________________________________

Survey:
1. What is the highest level of education that you have attained?

a) 8
th
grade and under
b) High school (9
th
-12
th
grade)
c) Associates Degree (2 year college)
d) Bachelor’s Degree (4 year college)
e) Started College but did not finish
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189
f) Trade or technical degree
g) Graduate Degree (Masters or Doctorate Degree)

2. Best describe how long have you been a member of the L.A. Care’s Regional
Community Advisory Committee?

a) 1 year or less
b) 2-4 years
c) 5-8 years
d) 9-12 years
e) 13 years and over

3. Please circle all the areas that you believe would help build stronger advocacy skills
for you:

a) Dedicate 30 minutes of advocacy training during my RCAC meetings
b) Trainings conducted separate from my meetings
c) More detailed consumer advocacy orientation
d) None of the above

4. Please circle all that apply. What leadership skills have you mastered from being a
part of the Regional Community Advisory Committee?

a) Meeting Facilitation
b) Roberts Rules of Order
c) Group Facilitation
d) Conflict Resolution
e) HMO/ Managed Care
f) None of the above

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190
5. Do you feel you are able to depend on other members to answer questions that you
may have?

1 2 3 4 5
Never Rarely In some cases Most of the time Always

6. Which definition best fits your understanding how L.A. Care defines “Global health”
access issue? Choose one.

a) Issues related to accessing health care experienced by an individual consumer
member.
b) Issues related to accessing care experienced by multiple consumer members
all over the county.
c) Health access Issues experienced by consumer members all over the nation.

7. In your opinion on a scale of 1-5 with 1 being the lowest, how effective is the
Consumer Advisory Committee at meeting and addressing issues brought forth through
the advisory process?
1 2 3 4 5
Not at all
effective
Not effective Somewhat
effective
Effective Extremely
Effective

8. Circle the best process for getting health access issues to be heard by L.A. Care’s
Board of Governors. Choose one.
a) Call member services and report to L.A. Care Health Navigator.
b) Issue brought up at Regional Community Advisory Committee (RCAC)
meeting, voted on by RCAC members, and motioned at Executive
Community Advisory Committee (ECAC) meeting to be added to the Boards
Agenda.
c) Issue addressed during the public comments at Board meetings.
d) Call staff and ask them add to the Board of Governors Agenda.

9. What do you believe is the job of the advisory members?
a) To bring latest community events to the attention of their committee
b) Advise on issues related to access to care for the Medicaid community
c) Act as a liaison between L.A. Care and the community
d) Participate in advocacy efforts and share information with fellow community
members
e) All of the above

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191
10. Please rank the following priorities in order of importance using the scale from Most
Important, Somewhat Important and Least Important.
1. Improved Advocacy training
2. Improved meeting agenda
3. Improved orientation

Most Important Somewhat Important Least Important

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192
Appendix B: Interview Protocol
Research Questions:
1. How can we improve the consumer advocate process of identifying health access issues?
2. What types of knowledge, motivation, and organizational influences are needed to serve as
a consumer advocate?
3. What are the recommendations for improving the consumer advocate process?
Interviewer: The purpose of this study is to understand how “The Heart of L.A.” can
improve its consumer advocacy process. You will be asked eleven one-on-one interview
questions. As a participant you have the right to not participate and to withdraw at any
time. To ensure that the information you provide is captured correctly, I will be using a
tape recorder to record our conversation. The information you provide will be held in strict
confidence and will only be used for the purpose of this study.
Mission and Knowledge related questions
2) In your own words tell me what is your role as a consumer advocate?

3) Based on your role as an advocate, how do you feel you effectively carry out your role?

4) In your opinion what do you think would make you a stronger advocate?

5) What do you believe is the staff’s role in supporting you to be an effective advocate?

6) Do you feel that they are capable in helping you to resolve your issues?

7) Can you share examples of when you have observed advocacy work for yourself, your
family and or in your community?

8) I want to share a problem with you. Let’s say you are a wheelchair user, you make an
appointment with your provider and learn that your provider office does not have exam
tables with lifts. How would you identify this access issue in your region?

9) Using the same example, how would you bring the issue to L.A. Care for solution/s?

Motivation related questions
10) When you become discouraged with the outcomes of your advocacy efforts, describe
what you do to stay active and engaged with your committee?

Organization Influence related questions
11) What can the “Heart of L.A.’s” leadership do to support and build a working relationship
with its advisory members?

12) ******Bonus Questions: How is your role as an advocate affected by the presence of an
incentive?
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193
Appendix C: Observation Protocol
The purpose of this observation tool is to triangulate emerging findings (Patton, 2015). This
protocol is not a stand-alone but to be used in conjunction with interviewing and survey studies.
PRE-MEETING
PROFICIENCY SCORE
Poor Fair Good Excellent
Staff developed a results-focused agenda and facilitation guide. ¨ ¨ ¨ ¨
Staff prepared talking points and/or facilitation guide for Chair. ¨ ¨ ¨ ¨
Staff and Chair met to review agenda and facilitation guide. ¨ ¨ ¨ ¨
ARRIVAL
Chair/staff greeted members upon arrival. ¨ ¨ ¨ ¨
Agenda/meeting materials distributed to members. ¨ ¨ ¨ ¨
Health Navigators seated in a visible area. ¨ ¨ ¨ ¨
Liaison set up check-in table with all meeting materials/resources
displayed in an organized manner.
¨ ¨ ¨ ¨
Audio/visual equipment set up and viewed easily for all. ¨ ¨ ¨ ¨
Liaison set up refreshment area before members arrived. ¨ ¨ ¨ ¨
Refreshments provided are of healthy variety. ¨ ¨ ¨ ¨
Meeting location provided plenty of parking and easily found. ¨ ¨ ¨ ¨
Ground rules/meeting arrangements pre-charted or written on a
PowerPoint/handout.
¨ ¨ ¨ ¨

1. Please write down anything you observed prior to the start of the meeting that needs
to be address:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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194
The section below refers to staff (mainly the Field Specialist) facilitating the meeting.

DURING MEETING
PROFICIENCY SCORE
Poor Fair Good Excellent
Reviewed the agenda and meeting results. ¨ ¨ ¨ ¨
Reviewed the ground rules. ¨ ¨ ¨ ¨
Enforced the ground rules. ¨ ¨ ¨ ¨
Used varied facilitation techniques. ¨ ¨ ¨ ¨
Used varied participation methods. ¨ ¨ ¨ ¨
Managed agenda and time allocated for each topic. ¨ ¨ ¨ ¨
Adjusted activities, time, pace, content, and sequencing to
accommodate group needs and explained changes as necessary.
¨ ¨ ¨ ¨
Handled the member issues section efficiently and created areas for
members to raise global issues.
¨ ¨ ¨ ¨
Clear and to the point when facilitating sections. ¨ ¨ ¨ ¨
Had adequate knowledge of the topic/content. ¨ ¨ ¨ ¨
DURING MEETING (CONTINUED)
PROFICIENCY SCORE
Poor Fair Good Excellent
Felt well-prepared and organized. ¨ ¨ ¨ ¨
Created a comfortable meeting environment. ¨ ¨ ¨ ¨
Spoke in easily understandable language. ¨ ¨ ¨ ¨
Diffused unruly and unproductive members. ¨ ¨ ¨ ¨
AFTER MEETING
Chair/staff debriefed after the meeting. ¨ ¨ ¨ ¨

2. Please describe what went very well during the meeting:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

195
______________________________________________________________________________
______________________________________________________________________________

3. Please describe what needs to be improve during the meeting:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

The section below refers mainly to the Chair in the meeting.
DURING THE MEETING
PROFICIENCY SCORE
Poor Fair Good Excellent
Showed leadership abilities. ¨ ¨ ¨ ¨
Took control of the meeting and its membership. ¨ ¨ ¨ ¨
Had support from Field Specialist when it came to discussions. ¨ ¨ ¨ ¨
RCAC/CCI members were engaged and actively participated in
meeting.
¨ ¨ ¨ ¨

4. Please describe what the Chair needs to improve on (if any) come next meeting:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

196
______________________________________________________________________________
______________________________________________________________________________
Appendix D: Document Analysis
The purpose of this document analysis tool is to triangulate emerging findings (Patton,
2015). This protocol is not a stand-alone but to be used in conjunction with interviewing and
focus studies.
To conduct document analysis I obtained written request from the stakeholder
organization. Upon approval from the stakeholder organization, one year of meeting minutes
from Regional Community Meetings were reviewed. Meeting minutes were chose for analysis
as they memorialize meeting actions that took place and those that did not. Meeting minutes are
recorded by staff and uploaded to the stakeholder’s webpage within two weeks of the meeting as
per the Ralph Brown Act rules for public meetings. For continuity, all meeting minutes follow
the same written construction. Meeting minutes have a direct correlation to the focus of this
study, which is to understand barriers in effective advocacy. According to McCulloch (2004), the
author, place and the date of writing all need to be assessed. Additionally, The use of the
Executive Community Advisory Committee meeting minutes were used to validate progress of
the regional committees and their ability to have their issues addressed or not addressed at the
executive level.

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197
Appendix E: Demographic Survey
University of Southern California
Rossier School of Education –Organizational Change and Leadership
3740 Trousdale Pkwy, Los Angeles, CA, 90089

INFORMATION/FACTS SHEET FOR EXEMPT NON-MEDICAL RESEARCH

INFORMED CONSENT FOR NON-MEDICAL RESEARCH
Knowledge, Motivation and Organizational Influences that aid in Understanding
Barriers To Effective Advocacy Processes

You are invited to participate in a research study. Research studies include only people who
voluntarily choose to take part. This document explains information about this study. You should
ask questions about anything that is unclear to you. Your participation is voluntary. You should
read the information below and ask any questions that you may have related to the goals and
purpose of this study before you decide on participating. If you decide to participate you will be
asked to sign a consent form. You will also be provided with a copy of this document for your
reference.

PURPOSE OF THE STUDY
The purpose of this study is to gain a better understanding of how to improve Medicaid consumer
advisory groups who work with public health leaders to continuously improve access to care. This
research study aims to understand how advisory members share feedback with their health plan
and the process for having key concerns addressed in a manner that supports the overall
improvement of care for all members.
The benefits of this study will assist healthcare leaders to build and implement processes that
support education, training and advocacy skills of MediCal consumers. These improvements are
believed to increase the overall value of consumer input, quality of care and member experience
as a Medicaid user.

To support this research the questions that guide this study are as follows:
1. How can the consumer advocate feedback process be streamlined so that access
issues can be easily shared with the stakeholder organization?
2. What types of knowledge, motivation, and organizational influences are needed to
serve as a consumer advocate?
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

198
3. How can the stakeholder organization empower consumer advocates to become
effective members of the committee?

Example:

PARTICIPANT INVOLVEMENT
If you agree to participate in this study you will be asked to participate in a one hour focus group
with other Medicaid members and respond to series of questions that address issues of their
knowledge of advisory and other decision making processes that are used to make decisions in
governmental business like settings, motivation for becoming a community advisory member and
their opinion of the type of training and support needed to be a successful advocate.

PAYMENT/COMPENSATION FOR PARTICIPATION
You will receive $10 visa gift card for your time. You do not have to answer all of the questions
in order to receive the card. The card will be given to you at the end of the focus group.

Whether you participate or not in this study your relationship with your health plan will not be
affected

CONFIDENTIALITY

There will be no identifiable information obtained in connection with this study. Your name,
address or other identifiable information will not be collected.

Information from the focus groups will be recorded and transcribed for research purposes only. No
“real” names will be used to identify study participants. You will be provided a pseudo name prior
to the start of the focus group. Upon completion of the study recordings of the focus group will
be disposed of according to IRB protocols ( a copy can be provided upon request)and to ensure
confidentiality.

Your total contributions to this study will be no more than 1.5 hours. You have the right to decline
if you do not wish to be recorded however, you will be excused from the group and offered an
opportunity for an individual interview to capture their response in which handwritten notes will
be taken. Additionally, You do not have to answer any questions you don’t want to; if you don’t
want to be taped, you cannot participate in this study.

PARTICIPATION AND WITHDRAWAL
Your participation is voluntary. Your refusal to participate will involve no penalty or loss of
benefits to which you are otherwise entitled. You may withdraw your consent at any time and
discontinue participation without penalty. You are not waiving any legal claims, rights or remedies
because of your participation in this research study.

UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

199
Required language:
The members of the research team, the funding agency and the University of Southern
California’s Human Subjects Protection Program (HSPP) may access the data. The HSPP reviews
and monitors research studies to protect the rights and welfare of research subjects.

INVESTIGATOR CONTACT INFORMATION

If you have any questions or concerns regarding this research, please feel free to contact Principal
Investigator Auleria Eakins or phone at (213) 694-1250 ext. 4280 or by email: aeakins@usc.edu,
L.A. Care Health Plan, 1055 West 7
th
Street 10th Floor, Los Angeles, Ca 90017or Faculty Advisor
Dr. Anthony Maddox @ amaddox@usc.edu
IRB CONTACT INFORMATION
If you have any questions or concerns, or complaints about your rights as a research participant
or the research in general and are unable to contact the research team, or if you want to talk to
someone independent of the research team, please contact the University Park Institutional
Review Board (UPIRB), 3720 South Flower Street #301, Los Angeles, CA 90089-0702, (213)
821-5272 or upirb@usc.edu

Signature of Research Participant
I have read the information provided above. I have been given a chance to ask questions. My
questions have been answered to my satisfaction, and I agree to participate in this study. I have
been given a copy of this form.

SIGNATURE OF INVESTIGATOR
I have explained the research to the participant and answered all his/her questions. I believe that
he/she understands the information described in this document and freely consent to participate.

_________________________________________
Name of Person Obtaining Consent (Please Print)

________________________________________

Signature of Person Obtaining Consent

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200
Appendix F: CITI Certification

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201
Appendix G: Attribution Survey

Directions: Please indicate your opinion about each of the statements below. There is no right or
wrong answer. Your answers are confidential.
1. How interested are you in identifying health access issues?
Not at all Slightly Somewhat Very Extremely
1 2 3 4 5

2. How easy is it for you to understand health access issues?
Not at all Slightly Somewhat Very Extremely
1 2 3 4 5

3. How confident are you in your ability to learn about health access?
Not at all Slightly Somewhat Very Extremely
1 2 3 4 5

4. How much does your mood affect learning about health access?
Not at all Slightly Somewhat Very Extremely
1 2 3 4 5

5. How motivated are you to learn about health access?
Not at all Slightly Somewhat Very Extremely
1 2 3 4 5

6. How many hours do you spend studying health access in a day?
None 30mins-1hour 2-3hours 4-5 hours Over 5 hours
1 2 3 4 5
UNDERSTANDING BARRIERS IN COMNSUMER HEALTH ADVOCACY

202
7. How much does your Field Specialist help you do better in identifying health access I
ssues?
Not at all Slightly Somewhat Very Extremely
1 2 3 4 5

8. How much does your peers help you do better in identifying health access issues?
Not at all Slightly Somewhat Very Extremely
1 2 3 4 5

9. How often do you use strategies to help you do better in identifying health access issues?
Not at all Slightly Somewhat Very Extremely
1 2 3 4 5

10. How interested are you in the tasks you must do in identifying health access issues?
Not at all Slightly Somewhat Very Extremely
1 2 3 4 5

11. How often do you misbehave in meetings?
Never Rarely Sometimes Often Always
1 2 3 4 5

12. How much support do you need to do tasks as a consumer advocate?
None Little Neutral Moderate A lot
1 2 3 4 5

13. How much do you prepare before a meeting?
Not at all Slightly Somewhat Very Extremely
1 2 3 4 5

Abstract (if available)

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Asset Metadata

Creator Eakins, Auleria S. (author)

Core Title Understanding barriers in consumer health advocacy: an improvement study

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 08/09/2018

Defense Date 05/30/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag advocacy,community accountable,consumer advisory,consumer education,consumer engagement,consumer feedback,consumer health,consumer stakeholder,health advocacy,health plan,healthcare,managed care,Medicaid,OAI-PMH Harvest

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Maddox, Anthony (committee chair), Lincoln, Karen (committee member), Mora-Flores, Eugenia (committee member), Moss, Sudonna (committee member)

Creator Email auleriaeakins@yahoo.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-64328

Unique identifier UC11671674

Identifier etd-EakinsAule-6711.pdf (filename),usctheses-c89-64328 (legacy record id)

Legacy Identifier etd-EakinsAule-6711.pdf

Dmrecord 64328

Document Type Dissertation

Format application/pdf (imt)

Rights Eakins, Auleria S.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA