Changing Nappies / Changing Lives: Adjusting to Parenting Your New Baby - An Evaluation

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Changing Nappies / Changing Lives: Adjusting to Parenting Your New Baby - An Evaluation
Changing Nappies / Changing Lives:
Adjusting to Parenting Your New Baby

            An Evaluation
Changing Nappies / Changing Lives: Adjusting to Parenting Your New Baby - An Evaluation
Evaluation of the
‘Changing Nappies / Changing Lives: Adjusting to
         Parenting Your New Baby’ group
 for new parents experiencing adjustment issues
  with their babies in the first year of parenting

           Jarrod Turner                    Regina Fogarty
           Hey Dad WA, Ngala                Parent Education, Ngala

    This project was partly funded by the WA Perinatal Mental Health Unit,
  Women and Newborn Health Service and Ngala. Some materials used were
  provided by the WA Perinatal Mental Health Unit and beyondblue Australia.

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Summary

Having a new baby is a major change for most parents. Many will struggle with the
adjustment to parenting. Rates of depression and anxiety rise in the perinatal period for
both males and females. This is a community-wide concern because poor mental health and
wellbeing in parents can endure if ignored and can determine mental health outcomes for
their children well into the future. This report describes the piloting of a community-based
workshop that was aimed at helping parents adjust to parenting and improve their mental
health and wellbeing. Overall, the participants had elevated levels of depression symptoms
pre-workshop, higher in the males. Participants also rated themselves as potentially low in
parenting confidence, especially the males. At four week follow-up there was an overall
increase in parenting confidence across the participants, most notable for females; and
there was an overall decrease in depression ratings across participants, clinically significant
for males. Satisfaction ratings for different elements of the workshop were moderate to
high. This piloted workshop provides an effective model for future community efforts to
meet the needs of parents as they adjust to parenting in the first year.

Introduction

It is commonly accepted that having a baby is a significant transitional event, especially for
women and men who are experiencing their first child. The birth of the child can lead to
significant changes in possibly all of the significant life domains including but not limited to
relationships, work and finances, health, housing, recreation, and the parents’ overall
mental health and wellbeing. In Australia, it is estimated that approximately 16% of women
experience depression in the 12-month period following birth (postnatal; Buist & Bilszta,
2006; Yelland, Sutherland, & Brown, 2010). The incidence of paternal depression in the first
year following child birth may be as high as fifty percent among men whose partners were
experiencing postnatal depression (Goodman, 2004). These rates are higher than for the
general Australian adult population. For example, the general 12-month prevalence rates
for depression in women and men are 5.1% and 3.1% respectively (Australian Bureau of
Statistics, 2008). Further, the incidence of maternal anxiety in the postnatal period is

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estimated to be around 10% (Woolhouse, Brown, Krastev, Perlen, & Gunn, 2009; Yelland et
al., 2010). Nearly forty percent of women with major depression in this period may
experience a co-occurring anxiety-related disorder (Austin, Hadzi-Pavlovic, Priest, Reilly,
Wilhelm et al., 2010).

Therefore, there is an increased risk for depression and related disorders among new
parents in the first twelve months following the birth of their child. Studies and clinical
experiences have shown that poor mental health and wellbeing among parents can impair
their adjustment to parenting in the postnatal period, and poor adjustment to early
parenting can contribute to deterioration in parental mental health (National Research
Council and Institute of Medicine, 2009). Child mental health also can be affected due to the
parenting practices of the parent with depression. For example, Lovejoy, Gracyk, O’Hare,
and Neuman (2000) found that the presence of maternal depression symptoms was
associated with (maternal) hostile and negative parenting (e.g., coercive practices),
disengaged parenting (e.g., ignoring), and decreased positive parenting practices (e.g.,
engaging with less affection). In terms of infant mental health, high levels of depressive
symptoms tend to be associated with less maternal responsiveness and sensitivity, less
verbal and visual engagement with the infant, and more intrusiveness (NRCIM, 2009).

Therefore, in line with parent-child attachment models and clinical studies (e.g., Bowlby,
1988), there is the potential for a detrimental effect on the parent’s ability for the
establishment of a positive social and emotional connection with the infant. Further,
exposure to the types of negative parenting behaviours outlined above can represent a
chronically stressful environment for the infant, leading to poor mental health outcomes.
For example, infants of mothers with depression symptoms are considered to have more
‘difficult’ temperaments, are more bothersome, and are rated as being more difficult to care
for than infants of mothers without depressive symptoms (Whiffen & Gotlib, 1989). These
infants tend to show more negative affect (e.g., crying, fussing) and less seeking of
emotional support from their parents at critical times (Field, 1992; Tronick & Gianino, 1986).
Further, there has been a suggestion that there may be increased stress responses from
infants in their underlying psychobiological systems with elevated autonomic activity (e.g.,
higher heart rate, increased respiration) and increased stress hormonal levels (e.g., cortisol)
in response to the parenting behaviours associated with parental depression (Field, 1992).

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There is an obvious community-wide need for early intervention services for women, men
and their families struggling during the perinatal period. Access to, and the effective
provision of, focused services that provide support, education, and helpful techniques to
assist parents in the perinatal period has been identified as a clear priority in Australia.
Attention also has been given to potential barriers to services for mothers, including costs,
childcare arrangements, and long waiting times (Beyondblue, 2011). Fathers might be
unintentionally marginalised from services that lack well formed father-inclusive practices
(Fletcher, Matthey, & Marley, 2006).

This evaluation reports on the effectiveness of a pilot workshop, ‘Changing
Nappies/Changing Lives: Adjusting to Parenting Your New Baby’ (CNCL), for parents who
were experiencing adjustment issues within the first year of their child’s life. The workshop
was designed and constructed based on the outcomes required for the project for the WA
Perinatal Mental Health Unit. The workshop was also informed by contemporary
understandings of adjustment to parenting and depression and related disorders (e.g.,
anxiety) within the perinatal period. The workshop was designed and piloted by the Hey Dad
WA program at Ngala with support from Ngala’s Parent Education Services.

Method
Participants
Eighteen parents agreed to attend the CNCL workshop, 10 females (m = 30.4 yrs) and 8
males (m = 33.75 yrs). The average age within the entire group was 32 years. Parents were
recruited via an advertised flyer distributed through early parenting services, including
Ngala, within the Perth metropolitan area.

Procedure
There were two identical workshops facilitated. Each was located in a comfortable, well-
equipped (chairs, tables, kitchen, toilets, parking, crèche) community-based parenting
centre in North and South regions of the Perth metropolitan area. Parents were selected for
either workshop based on proximity to their home address. The workshops were facilitated
in the evenings (6.00 to 8.30 pm) by a male Hey Dad WA staff member and a female Ngala
Parent Education staff member. Each workshop was facilitated over two week-day evenings

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for a total of five hours (2.5 hrs per evening). Parents were required to attend both
evenings. Upon arrival on the first evening, once informed consent was obtained, each
participant was required to complete the Edinburgh Postnatal Depression Scale (EPDS; Cox,
Holden, & Sagovsky, 1987) and the Karitane Parenting Confidence Scale (KPCS; Črnčec,
Barnett, & Matthey, 2008). These instruments along with a specially constructed workshop
evaluation and feedback questionnaire (Appendix A) were also completed by the
participants at four weeks follow-up and returned by mail/email for inclusion in this report.

Workshop Description
The CNCL workshop was designed to provide participants with information, strategies, and
support on 1) improving the adjustment to early parenting, 2) increasing confidence around
day to day parenting, 3) identifying and meeting theirs’ and their infant’s social and
emotional needs. The workshop also attempted to address mental health and wellbeing
issues in the perinatal period. The workshop was comprised of two 2.5 hour interactive
group presentations using Microsoft PowerPoint. The first evening’s content focused on the
initial three aims outlined above. The second focused exclusively on perinatal mental health
and wellbeing issues. The facilitators strictly adhered to the workshop protocol as outlined
in the PowerPoint presentation. Materials were provided to participants including fact
sheets, pamphlets, booklets, and other resources from the West Australian Perinatal Mental
Health Unit beyondblue Australia, and Ngala (including Hey Dad WA). Overall, the workshop
was informed by literature and guidelines consistent with best clinical practices within early
parenting services and perinatal mental health services (e.g., beyondblue, 2011; Bowlby,
1988; Fletcher, 2011; Parker & Hunter, 2011). The approach taken was to present
information and then to facilitate discussion in the form of questions, comments, and
sharing of concerns from individual members of the group. The conversation could be
directed either to the facilitators directly or through other group members (i.e., group
discussion). Participants were provided with supplementary resources including a list of
recommended community supports available to parents and writing materials for note
taking. The use of a male and female facilitator was deliberate and aimed to provide an
across-gender experience for the participants. Both facilitators were trained and
experienced in father-inclusive practices (FaHCSIA, 2009) and in the delivery of education
modules to new parents.

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Measurement
The Edinburgh Postnatal Depression Scale (EPDS; Cox et al., 1987) is a 10-item self-report
questionnaire designed to identify symptoms of depression in the perinatal period and is
one of the most widely used measures of postnatal depression in clinical practice and
research. The EPDS has strong, well-established psychometric properties (Cox et al., 1987,
1996; Leverton & Elliot, 2000). It has been used across clinical, non-clinical and community
populations. Scores above nine are considered indicative of ‘possible depression’ with
maximum sensitivity (‘probable depression’) occurring at scores of 12 or above. Others have
suggested a score of seven or eight may be more appropriate to decrease the likelihood of
false-negative results, with a male cut-off point two points lower due to males being less
likely to endorse certain items (e.g., “I have been so unhappy that I have been crying”)
compared to females (Matthey, Barnett, Kavanagh, & Howie, 2001). For the purposes of this
evaluation, the authors have chosen to apply a clinical cut-off point of nine for female
participants, and seven for males.

The Karitane Parenting Confidence Scale (KPCS; Crncec et al., 2008) is a 15-item self-report
questionnaire designed to measure parents’ subjective confidence in their parenting
abilities, or ‘perceived parenting self-efficacy’. The KPCS was developed within the
Australian context and is developed for use with mothers and fathers of infants aged 0 to 12
months. The KPCS has strong psychometric properties (see Crncec et al., 2008). To the best
of our knowledge there has been no published evidence of any attempt to validate the scale
exclusively among fathers. For the purposes of this evaluation, the authors have chosen to
apply the recommended clinical cut-off point of 39 or less for both female and male
participants (Crncec et al., 2008, p. 14).

The Changing Nappies – Changing Lives Workshop Evaluation Form (CNCL-WEF; Appendix A)
is an unpublished questionnaire developed by the authors. It utilises a subjective rating
scale (1 = low satisfaction to 5 = high satisfaction) with the participants rating the completed
CNCL workshop across a range of items (e.g., “How do you rate your satisfaction with this
workshop?”). The CNCL-WEF also included items that required qualitative information from
the respondents (e.g., “Which parts of the workshop were the most helpful?”). The
questionnaire was based on typical workshop evaluation forms utilised within parent
education services at Ngala.

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Results

                     10
                      9
                      8
                      7
                      6
                      5
                      4
                      3
                      2
                      1
                      0

                          Pre-Female   F/Up Female   Pre-Male   F/Up Male

Figure 1: Participants’ EPDS mean scores at pre-workshop and four week follow-up. Note:
Female scores above nine = possible depression. Male scores above seven = possible
depression.

The participants’ pre-workshop and four week follow-up EPDS mean scores are presented in
Figure 1. Fifteen participants attended both evenings of the CNCL workshops and their data
were grouped for analysis. The pre-workshop data of the three non-completers (of the
original 18) were excluded from the analysis to preserve the integrity of the presented data.
The data in Figure 1 show a clinically significant difference between males and females such
that the male pre- scores, on average, exceeded the clinical-cut off point for ‘possible
depression’. The female scores were elevated yet, on average, within the non-clinical range.
Further analysis of individual scores revealed that pre-workshop 85.7% of male participants
exceeded the clinical cut-off point, compared to 25% of female participants. Overall, there
were reductions in average scores for both females and males at follow-up. In particular the
change in male scores, on average, was clinically significant such that as a group their scores
showed a move to below the clinical-cut off point for ‘possible depression’.

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40

                     35

                     30

                     25

                     20

                     15

                     10

                      5

                      0

                          Pre-Female   F/Up Female   Pre-Male   F/Up Male

Figure 2: Participants’ KPCS mean scores at pre-workshop and four week follow-up. Note:
Scores 39 or less = possible low levels of parenting confidence.

The participants’ pre-workshop and follow-up KPCS mean scores are presented in Figure 2.
The data show that the pre- male and pre- female scores, on average, were below the
clinical cut-off point possibly indicating low levels of parenting confidence. Pre-workshop,
the female participants, on average, rated themselves higher in parenting confidence than
the males. Further analysis of individual scores revealed that 100% of male participants
were below the clinical cut-off point pre-workshop, compared to 33.3% of female
participants. At follow-up, the average female scores had improved to within the non-
clinical range. There was a slight improvement for males, pre-workshop to follow-up.

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5

                         4

                         3

                         2

                         1

                         0

                                     1   2   3   4   5   9   10

Figure 3: Participants’ mean scores on the individual CNCL-WEF items at 4-week follow-up.
Note: Scores range from 1 = low to 5 = high (the higher the rating, the more positive the
evaluation).

The participants’ responses to the individual CNCL-WEF items (see Appendix A for
descriptions) are shown in Figure 3. Converted to percentages, ratings ranged from 69%
(Item 2, workshop helping with adjustment) to 91% (Item 10, satisfaction with the setting).
Overall, the participants rated their satisfaction with the workshop at 78% (Item 1). In terms
of providing support and education around mental health issues (Item 5), the overall rating
was 83%.

Post-Workshop Participant Feedback
The following quotes are samples from the participants’ workshop evaluation forms.
Can you identify any changes that occurred after your attendance in this workshop?
‘Yes, acknowledging that I can only change things that are in my control and loving and
enjoying my baby now rather than wanting to change him or wishing that he’s older’.
‘I’ve become a lot more ‘in the moment’ and mindful and I’ve also started looking at the big
picture of parenting’.
‘Somewhat easier to keep an in-the-moment perspective’.
‘I’m learning to relax more’.
‘More discussion with my partner’.
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Which parts of the workshop were most helpful?
‘The discussion on self care was helpful’.
‘Values. This was something we had never thought about’.
‘Discussion with other parents. It was nice to hear that we are in the same boat and that our
stresses are common’.
‘Information about where to get help and postnatal depression information’.
‘Validating what my husband and I are experiencing as common to others’ experiences’.
‘The information-pack regarding information on depression and how to get appropriate
help’.
‘Talking to fellow parents and the presenters regarding issues, how people dealt with them
and the feelings involved’.
Which parts of the workshop were the most enjoyable?
‘Discussion around the group – good to hear other’s experiences and hearing that we’re not
alone’.
‘Discussion with other parents’. ‘Sharing stories and experiences’.
‘Question and answer and discussions’. ‘Interactions with other parents’.
‘The second week. Learning to organise and the issues regarding mental health’.
‘I enjoyed the slow pace of it. It was a pleasant change from the fast pace of caring for our
baby’.
How could this workshop be improved in the future?
‘More examples and techniques for improving situations’.
‘Focus less on postnatal depression and add more parenting skills’.
‘Role plays and good/bad case studies and examples would be fun’.
‘More information on routine, sleeping, etc.’. ‘More (baby) age-specific information’.
‘Provide a more basic explanation of attachment’.

Discussion
This report described an evaluation of a piloted community workshop aimed at helping
parents adjust to their first year of parenting. The results support a successful piloting of the
workshop. Eighteen participants started and fifteen completed both evenings of the
workshop. There was a reduction in average EPDS scores for the group pre-workshop to

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follow-up. Changes in EPDS scores were clinically significant for males because their scores
moved from above the clinical cut-off point to within the normal range. Importantly, the
male participants rated themselves as experiencing higher levels of depressive symptoms
pre-workshop and at four week follow-up. Females were within the non-clinical range at
both points, yet still reported elevated levels of symptoms.

There was a slight improvement in the average level of parenting confidence for both the
female and male participants pre-workshop to follow-up, more so for females for whom
average parenting confidence scores improved to move to the non-clinical range. Overall,
follow-up satisfaction ratings for six of the seven items relating to the workshop content and
facilitation were above 70%. In particular, the overall workshop satisfaction rating for the
group was high. In terms of helping with mental health issues, the satisfaction rating was
very high. Qualitative feedback was thoughtful and encouraging, with many participants
endorsing various components of the workshop.

The only slight improvement in parenting confidence for parents was not entirely
unexpected, given that others have found that effect sizes across the range of factors (e.g.,
parent self-efficacy) examined in the large scale meta-analysis of early parenting programs
tend to be quite small (Pinquart & Teubert, 2010). However, the point has been made that
with early parenting programs, small improvements in outcome measurement may still
reflect meaningful change for the participant (Parker & Hunter, 2011). This point
notwithstanding, integration of participant feedback from this pilot can be used to assist
future efforts to modify the current workshop to increase the likelihood of significant
improvements in the area of parenting confidence.

There are limitations that need to be considered. First, caution must be taken before
generalising to wider populations and clinical practitioners as only a relatively small group
was involved with the workshops and evaluations were conducted by the same two
practitioners. Secondly, there was no opportunity to randomise allocation of participants to
the workshop or a comparison group. Changes may not be uniquely attributable to the CNCL
workshop. Finally, the time period between the workshop and follow-up evaluation was
relatively brief at four weeks.

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There were notable strengths to this evaluation. Multiple measurement instruments were
used, some with strong psychometric properties (e.g., EPDS, KPCS). The workshop was
clearly defined through its administration in PowerPoint and associated materials.
Participants met criteria for poor adjustment to parenting. Some were experiencing
clinically significant levels of PND-related symptoms. Efforts were made to ensure a period
of time had elapsed before the participants were administered follow-up evaluations.

The outcomes of this piloted CNCL workshop have important implications for community
organisations seeking to provide an effective workshop or program for mothers and fathers
adjusting to parenting. These findings suggest that PND symptoms might be at worrying
levels for new parents, regardless of gender. Levels of parenting confidence might be low.
The workshop model provided here represented a relatively straight-forward, easily
accessible, community-based intervention for these types of parents. The fact that there
was an overall improvement for the group as measured using standardised instruments is
encouraging. Future efforts could include attempts to replicate the pilot while also
integrating the findings here, especially the participants’ qualitative feedback, into what
might be an improved workshop. The challenge for practitioners will be in satisfying the
unique needs of each parenting dyad, without necessarily excluding the other members of
the group at each point and failing to include other important aspects of content as
suggested by the existing body of research. As was the aim with the current pilot, future
efforts need to maintain a workable balance between client-centered and evidence-based
practices.

Author Information
Dr Jarrod Turner has a background in Clinical Psychology and works in Ngala’s Hey Dad WA
program providing support and education to fathers in the early parenting period.
Regina Fogarty has a background in Child Health Nursing and works in Ngala’s Parent
Education program providing support and education to parents in all areas of early
parenting.

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References
Austin, M.P.V., Hadzi-Pavlovic, D., Priest, S. R., Reilly, N., Wilhelm, K., Saint, K., & Parker, G.

        (2010). Depressive and anxiety disorders in the postpartum period: how prevalent

        are they and can we improve their detection? Archives of Women's Mental Health,

        13(5), 395-401.

Australian Bureau of Statistics. (2008). National survey of mental health and wellbeing:

        Summary of results: 4326.0. Canberra: Australian Bureau of Statistics.

Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development.

        New York: Basic Books.

Buist, A., & Bliszta, J. (2006). The beyondblue national postnatal screening program,

        prevention and early intervention 2001-2005, Final report. Vol 1: National Screening

        Program. Melbourne: beyondblue: the national depression initiative.

Cox, J.L., Chapman, G., Murray, D., & Jones, P. (1996). Validation of the Edinburgh Postnatal

        Depression Scale (EPDS) in non postnatal women. Journal of Affective Disorders, 39,

        185-189.

Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of postnatal depression:

        Development of the 10 item Edinburgh postnatal depression scale. British Journal of

        Psychiatry, 150, 782-786.

Črnčec, R., Barnett, B., & Matthey, S. (2008). Karitane Parenting Confidence Scale: Manual.

        Sydney South West Area Health Service. Sydney: Australia.

Families, Housing, Community Services, and Indigenous Affairs (FaHCSIA). (2009). Father-

        inclusive practice guide. Canberra: Commonwealth Government.

Field, T. (1992). Infants of depressed mothers. Development and Psychopathology, 4, 49-66.

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Fletcher, R. (2011). The dad factor: How the father-baby bonding helps a child for life. NSW:

       Finch Publishing.

Fletcher, R.J., Matthey, S., & Marley, C.G. (2006). Addressing depression and anxiety among

       new fathers. Medical Journal of Australia, 185, 461-463.

Goodman, J. H. (2004). Paternal postpartum depression: Its relationship to maternal

       postpartum depression, and implications for family health. Journal of Advanced

       Nursing, 45(1), 26–35.

Leverton, T.J. & Elliott, S.A. (2000). Is the EPDS a magic wand: A comparison of the

       Edinburgh Postnatal Depression Scale and health visitor report as predictors of

       diagnosis on the Present State Examination. Journal of Reproductive and Infant

       Psychology, 18, 279-296.

Lovejoy, M.C., Graczyk, P.A., O’Hare, E., & Neuman, G. (2000). Maternal depression and

       parenting behaviour: A meta-analytic review. Clinical Psychology Review, 20, 561-

       592.

Matthey, S., Barnett, B., Kavanagh, D.J., & Howie, P. (2001). Validation of the Edinburgh

       Postnatal Depression Scale for men, and comparison of item endorsement with their

       partners. Journal of Affective Disorders, 64, 175-184.

National Research Council and Institute of Medicine. (2009). Depression in parents,

       parenting, and children: Opportunities to improve identification, treatment, and

       prevention. Washington, DC: The National Academies Press.

Parker, R., & Hunter, C. (2011). Supporting couples across the transition to parenthood.

       (Briefing No. 20). Australian Institute of Family Studies, 1-9.

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Tronick, E.Z., & Gianino, A.F. (1986). The transmission of maternal disturbance to the infant.

       In E.Z. Tronick and T.Field (Eds.), Maternal depression and infant disturbance (pp. 5-

       11). San Francisco: Jossey-Bass.

Whiffen, V.E., & Gotlib, I.H. (1989). Infants of postpartum depressed mothers:

       Temperament and cognitive status. Journal of Abnormal Psychology, 98, 274-279.

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Appendix A

  Changing Nappies – Changing Lives: Adjusting to parenting your new baby

Workshop Evaluation:
Completion of this form does not require personal information, just your gender
Male / Female (please circle)
               Please circle the appropriate number: 1 = low, 5 = high
1. How do you rate your satisfaction with this workshop?

                                1    2     3     4     5

2. How do you rate this workshop as a means of helping your adjustment to
   parenting?

                                1    2     3     4     5

3. How do you rate this workshop in helping you understand yours and your
   child’s needs?

                                1    2     3     4     5

4. How do you rate this workshop as information around day to day parenting?

                                1    2     3     4     5

5. How do you rate this workshop as a means of helping you understand
   mental health issues?

                                1    2     3     4     5

6. Can you identify any changes that occurred after your attendance in this
   workshop?

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Appendix A

7. Which parts of the workshop were the most helpful?
Why?

8. Which parts of the workshop were the most enjoyable?
Why?

9. How satisfied were you with the presenters of this workshop?

                             1     2     3     4     5

10. How satisfied were you with the setting and facilities for the workshop?

                             1     2     3     4     5

11. How could this workshop be improved in the future?

12. Can we use your comments in future CNCL promotions?

                              Yes No (Please circle)

Date you completed this form:__________

THANK YOU FOR COMPLETING THIS FORM

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