THE APPLICATION OF SMALL GROUP TECHNIQUES T0 7 TRAINING IN COMMUNITY PARTICIPATION: A FIELD EXPERIMENT Dissertation for the Degree of Ph. ,D. MICHIGAN STATE UNIVERSITY AMANDA ANN BECK 1973 (we LIBRARY lllllllllllllm L if; H ,a'~,: ~ad—.~—~ao ~~MW a. VHWU‘I‘. ._‘. 51-22 W11 aver" ;,.-;..-. u": .' ‘.‘~ - . ‘ 4 t" " 'v e I “‘ ~' 0‘; .;:-‘r1:-'('- " "192‘ S J “P; " I - It; . This, 15:10 Eertfithat the ' . ‘ l 'i‘ 7 ’ " thesis entitled \"t‘- A C 1‘ . " \ lhé- Application Of Small Group Techniques To ‘3' ‘ Training in Commity Participation: A iFiéld 3: Experiment 1.. I), L ptésented by " Amanda A. Beck ‘ 3'; I in; _ , ' .3 has been accepted towards fulfillment ‘: l "I (of the requirements for ‘3“ Ph. D. degree in' Psvcholoa ‘1 \ Major professor :- I’ .‘ 'Dz'lte 10/30/73 George W. Fairweather, Ph.‘ D. . «£4559 ABSTRACT THE APPLICATION OF SMALL GROUP TECHNIQUES TO TRAINING IN COMMUNITY PARTICIPATION: A FIELD EXPERIMENT The status of as reported in the tus consumers in a mented in previous BY Amanda Ann Beck citizen participation in governmental decision-making literature was reviewed. The problems of marginal sta- regional comprehensive health planning agency as docu- research on the authoress were also reviewed. The re- lative advantages and disadvantages of an autonomous small group alterna- Q tive for consumer training versus the traditional workshop approach were discussed. A description was then presented of an innovative experiment designed to increase the information and perceived legitimacy of partici- pants and thereby increase their participation and alter their role in agency decision-making activities. Results demonstrated that an autonomous task-oriented, problem-solving cohesive group did mechanisms for the tion, and provided Comparison of group participants significant 1y more factors reflecting making activities, develop which generated its own information, established reinforcement of the legitimacy of consumer participa- opportunities to practice decision-making skills. small group training participants with traditional , demonstrated that the experimental program resulted in information, significantly higher rankings on the the legitimacy of their participation in the decision- and significantly greater formal and informal partici- pation for participants. THE APPLICATION OF SMALL GROUP TECHNIQUES TO TRAINING IN COMMUNITY PARTICIPATION: A FIELD EXPERIMENT BY Amanda Ann Beck A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1973 Copyright by AMANDA ANN BECK 1973 Dedicated to Dr. Peter C. Bishop, Ph.D. my friend and colleague without whom the success of this effort would not have been possible ii ACKNOWLEDGMENTS Grateful appreciation is expressed to the following for helping a dream come true: My Louisiana State University professor, Jack Lappe Ph.D. for having the courage to take a chance on beginning a dream; My father, Charles J. Beck for his unfailing faith in my ability to succeed; My friend Nancy Foltz, for her constant support in being happy; My friends Diane Singh and Jasbir Singh Ph.D., for always being there when I needed them; My friend and research secretary, Tami Lowrey for work above and beyond the call of duty; My Chairman, George W. Fairweather Ph.D., for his moral and intellectual support in completing this research; My committee members, Lawrence W. O'Kelly Ph.D., Louis Tornatsky Ph.D., and Ralph Levine for their guidance in the preparation of this document; Training and Studies Division, 314C of Health Services and Mental Health Administration, DREW, for grant # CS-P (D01) 552005-01-72 for the financial support of this research. iii Table of Contents Chapter I Introduction . . . . . . . . . . Citizen Participation . . . . . . . . . . . Background Information on Consumers and Providers Alternative Solutions-Individual Contrasted with 8m 1 Group 0 O O O O O I O O 0 O I O O O H”°th€.€. O O O O O O O O O O O 0 O O O 0 Chapter II Methods . . . . . . . Designeeeeeeeeeoeee Sampling . . . . . . . . . . . . General Plan of the Experiment . Chapter III Measurement . . . . . . . . . . Autonomous Small Group Development . . . . Effects of Autonomous Small Group Training Chapter IV Results . . . . . . . . . . . . Autonomous Small Group Development . . . . Effects of Autonomous Small Group Training Description of the Post-Experimental Period Discussion . . . . . . . . . . . Chapter V Bib 11° graphy O O O O O O O O O O O O O O O O 0 Appendix A Operational Measures, Autonomous Small Group Development . . . . . . . . . . Appendix B Operational Measures, Effects of Autonomous Small Group Training . . . Appendix C Non-Significant Results of Participation in the Small Group Training Program . . . . . iv 12 22 24 24 43 55 56 56 59 65 65 78 88 98 113 117 124 132 Table Table Table Table Table Table Table Table Table Table Table 10 11 List of Tables Pre-Experimsntal Comparison of Providers and Consumers . . . . . . . . . . . . . . . Pro-Experimental Comparison of volunteers and Non-Volunteers . . . . . . . . . . . . Pre-Experimental Comparison Between Training Group and Traditional Participation Group . Rank Order of Comment Type by Phase of CSG Developmentesssssssssssssss Rank Order of Comment Content by Phase of CSGDevelopment.............. Problem Solving Ability and Cohesiveness by Phase of CSG Development . . . . . . . . . Information and Legitimacy by Phase of CSG Development . . . . . . . . . . . . . . Post—Experimental Information Level . . . . . Post-Experimental Legitimacy of Participation Attendance-Autonomously Trained Consumer Support Group vs. Traditional Participant Group . . . . Post-Experimental Informal Participation . . . . 44 50 73 74 76 78 79 81 86 88 Figure Figure Figure Figure Figure Figure Figure Figure Figure List of Figures Agencymdelsesssssssssssss Consumer Workshop Model . . . . . . . . . ConsumerGroupModel. .. . ... . .. . Mean Attendance Frequency by Phase of CSG Development . . . . . . . . . . . . Average Speaker Frequency by Phase of CSG Development . . . . . . . . . . . . Comment Frequency by Interaction Category- Members 0 O O O O O C O O O O O I O O 0 Comment Frequency by Interaction Category- NOD-Membersssssssssesssss Comment Frequency by Interaction Category- Coordinator and Secretary . . . . . . . Roles fulfilled by Phase of CSG Development ‘vi 11 13 19 66 69 7O 71 71 75 Chapter I Introduction Citigen Participation Research has demonstrated that participation in the decisiondmaking process by the recipients of the decision often leads to greater acceptance of the decision, and hence, more successful implementation (Coch and French, 1948; French, et a1., 1959; Gilmer, 1961; Tannenbaum, 1968). In governmental planning agencies, the basic task is decision-making, and the recipients of such decisions are the consumers of the programs planned. In such agencies, citizen participation in the decision-making process plays a vital and powerful role in "monitoring" professional plans and making sure that the planning professionals and technical experts do not design programs with either disregard for citizen interest or simply for the interests of certain power groups (Altschuler, 1970; Dubey, 1970). \{ij’ While the concept of citizen participation as a valuable contribution “t a to the decision-making process may have been accepted by many, incor- poration as an operating concept in most planning agencies has been, on the whole, slow and ineffective. Some voluntary efforts to encourage low income participants in I; O s I " .-.. \ menus..- m N i‘er) \‘ neighborhood social action were begun in the 1890's, 1900's, and 1930's. It was not, however, until the early 1960's that the requirements for Ford Foundation grants and government regulations of O.E.O. and H.U.D. programs forced a more active role on community representatives in social, reform decisionemaking. The funding of Model Cities programs, for example, required that policy making boards consist of a majority of citizen representatives. The greatest attempt to expand the domain of citizen participation and provide for "maximum feasible participation of the poor" was incorporated in the Economic Opportunity Act of 1964 (Moynihan, 1970). Unfortunately, the confusion surrounding the definition of the term "maximum feasible participation" and the methods by which this was imple- mented in various areas led to the development of Community Action Programs ranging from complete policy control and major political power afforded the citizens to mere source of employment for the participants. As Sherry Arnstein (1969) explained citizen participation has ranged from: A) token states of informing the citizen, consulting his opinion, or placating his desires, b) through a condition of partnership or delegated power in decision-making, and rarely, c) to effective citizen control. In concluding remarks she agreed with the Organization for Social and Technical Innovations' conclusions that "in general, citizens are finding it impossible to have significant impact on the comprehensive planning that is going on." (p. 240). Thus professionals have traditionally acted upon the assumption that only they possess sufficient expertise to plan and they have continued to plan "benevolently" for the public (Fairweather, 1969; Struauss, 1972). A recent effort has been made to involve citizens in decisions affecting their health care. In 1966 Congress recognized the problems of multiple health care delivery mechanisms and soaring costs by creating Public Law 89-749, the "Partnership for Health" Act. Section 314 estab- lished a mechanism for resolution of some of these difficulties-comprehensive health planning (CHP), at the federal, state, and local level. Recent years have also brought a heightened social awareness of equal rights; among them, that health care is a right of all people and not a privilege of the fortunate. Congress also recognized this right as shown in community participation in health planning decisions, and, therefore mandated that health care consumers be included in all policy making and advisory board in comprehensive health planning (National Commission on Community Health Services, 1967; Ready, 1972). The Secretary of the 0.8. Department of Health, Education, and Welfare in promulgating the guidelines for Section 314 further stipulated that consumers be the majority on these boards. Thus a planned mechanism was established for partnership between health consumers and providers where providers were specifically prevented from numerical domination (Andryezewski, 1972). Formal membership does not, however, automatically lead to effective participation. Many have complained that, like other social action agencies in the past, CHP has basic problems in consumer participation, prdmarily little participation by a relatively uninformed, ineffective citizen group (Andryezewski, 1972). Citizens themselves have also complained of being marginal rather than central to the decisiondmaking process (Strauss, 1972). Background Information on Consumers and Providers An opportunity for an empirical investigation of the position of the citizen participants in the decisiondmaking process of planning was afforded by a Comprehensive Health Planning "b" agency established in 1968 as a result of the "Partnership for Health" Act. It was a regional agency planning and coordinating health delivery services in a tri-county area of lower Michigan with financial resources consisting of Federal H.E.W. funds matched 1 to 1 with local contributions. Its personnel consisted of a full-time professional planning staff and volunteer part-time members of two types: providers of health services (anyone who earns his livelihood in teaching, delivery, or administration of health services), and consumer representatives (anyone who does not earn his livelihood in health teaching, delivery, or administration). The internal organization of the agency was composed of the staff just mentioned, a Board of Trustees, and Executive Committee (acting between Board meetings), and five planning committees. The Board of Trustees met quarterly. It consisted of 45 members, and at least 51 percent of them were supposed to be consumers. Planning committees met monthly, ranged in size from 12 to 43 members, and generally reflected the same consumer to provider ratio as the Board. The marginal status of consumer participants in this agency was documented in previous research (Beck, 1972) by analysis of attendance rates at agency meetings and data derived from interviews with the members. The documentation was based on the attendance of all members and interviews with 52 consumers (722 of possible) and 54 providers (75! of possible) and 5 staff (1002 of possible). The marginal status of consumers was shown by comparing consumers with providers on the basic components of effective participation. If a parity between consumers and providers was suggested by the "Partnership" Act then there should have been no significant differ- ences between the two groups in these areas. These results on marginality may be viewed from three perspectives: (1) those specifying the infor-} mation about health planning processes possessed by consumers, (2) those reflecting the legitimacy of their participation in decision-making activities of the Agency, and (3) those indicating the extent of their behavioral participation in these activities. Information was collected to measure the extent to which consumers were adequately informed and sufficiently knowledgeable to consider and resolve key decisiondmaking points (Palmer, 1972). A series of questions were collected concerning: 1) CHP in general, 2) the organizational structure of the Agency, 3) the Agency staff, 4) the voluntary formal leadership of the Agency, and 5) the Agency work program i.e., the budgeted plan of operation for the organization. Analysis of these questions presented in Table 1 show that consumers were significantly less informed than providers on all categories except the last. 0n work program items, only a small percentage of either group could name the Agency‘s programs. Legitimacy is considered as the rightful participation of a group in Agency decision-making activities and the likelihood that it and its decisions will be accepted by the parties at interest (Palmer, 1972). ‘While it is a somewhat less tangible concept than information it may be measured by indices of socio-economic status, effective constituency, power. psychological membership, and social or institutional roles. Table 1 Pre-Experimental Comparison of Providers and Consumers ‘ITest Of VARIABLE PROVIDERS CONSUMERS df Significance INFORMATION General 1.60 1.31 102 t- 4.87c Committee Names 1.51 1.34 97 c- 2.91b Agency Staff 1.60 1.47 102 c- 2.10 Committee Chairmen 1.22 1.14 97 t- 1.83a Work Program 1.20 1.14 96 t' 1.23 LEGITIMACY Socio-Economic Status Formal health education none 2 21 little 0 13 some 9 9 4 x2 - 57.16c quite a bit 11 8 great deal 28 0 Formal general education grammar school 0 1 high school 1 12 para prof. 3 5 2 c Bachelor degree 8 20 6 x I 29.17 Master's degree 19 9 Ph.D. 6 4 Medical Professional 12 1 Family Income 47,000 0 11 7-12,000 4 4 12-2o,ooo 13 26 4 x2 - 12.27a 20-30,000 18 12 > 30,000 12 5 Constituency no formal represent- ation 11 16 l x2 - 1.71 formal representation 41 33 constituency identi- fication 40.58 16.24 100 t C 1.238 constituency effect 3.60 3.31 100 t - 2.35 Table 1 (Continued) Test of VARIABLE PROVIDERS CONSUMERS df Significance Power/Influence Tannenbaum actual own 2.52 2.19 50 t I 1.42 actual consumer .v2.05'1 c actual provider 3.98="'3',___gg t : lg'ggc actual staff 4.43' ' c actual consumer 2.12- t - 13.42 actual provider 3.56 _ _ _ _ _ _ _51 t _ 6 86c actual staff 4.50- ° Psychological Membership Attraction to group 3.68 3.33 90 t I 1.83 to members 3.83 3 82 88 t - 0.21 Acceptance (standardized) 0.09 -0.15 100 t I 3.00b task assignment (staff) included 3 1 8 g 2 c random 6 2 3 8 X I 18.70 excluded 4 10 1 BEHAVIORAL PARTICIPATION Attendance 2 a frequency non attendance 265 275.5 1 X - 6.25 frequency attendance 236 176.5 Informal Communicator number contacts made 20.76 17.37 90 t = 1.12 number contacts received 18.98 16.17 90 t I 0.93 frequency contacts made 1.77 1 58 90 t - 2.13a frequency contacts received 1.77 1.69 90 t - 0.54 P<.05 P<.01 P(.001 The first major characteristic of socio-economic status considered was the profession of the participants themselves. By definition, providers were professionals in the matters on which decisions were made and consumers were only part-time volunteers. This in itself provided an automatic legitimacy advantage to providers (Strauss, 1972). As Table 1 shows, education, measured both as formal health education and formal general education, was consistent with the information deficit just reported. Consumers had significantly less education in both respects. Measures of family income as displayed in Table 1 also showed that consumers had signi- ficantly less income than providers. These results about socio-economic status demonstrated a consistent pattern of subordinate status for consumers. Because the Agency followed the format of a mediating group (Cartwright and Zander, 1968) membership was generally restricted to those representing a group or organization upon which health planning had an impact. Palmer (1972) considered the legitimacy of such representation to be a critical factor in decision-making. Legitimacy of representation can be operation- ally defined as: (l) the simple existence of an organized constituency; (2) the type of organization which formed the constituency; (3) the effect of the constituency upon the behavior of the representative; and (4) the recognition of the constituency by other members. Results based on these concepts as shown in Table 1 demonstrated no difference between the percentage of providers and consumers who reported themselves as formally representing a group. Powever, since consumer constituencies are by definition non-health professionals they would automatically tend to occupy a less legitimate position in this hierarchy. No differences were found on the extent to which other members could correctly identify the con- stituencies of consumers and providers. As Table 1 shows, however, consumers, reported that their constituencies had much less effect on their participation in the Agency than providers did. A constituency which can be named but is not in Operation is unlikely to be a legitimate factor in decision-making. Palmer (1972) reported that in lacking an effective constituency, consumers also lack an effective power base. Power was therefore the next variable examined. Since it has multiple meanings, it was examined from several perspectives. The first approach (Arnstein, 1968) determined the position consumers occupied on a ladder of power types which ranged from merely being informed of decisions to control over such decisions. Analysis of such measures showed that consumers were consulted before decisions were made but that, on the whole, they did not vote on decisions nor did they as a group share in final resource allocation, have delegated power to make' decisions, or have control over decisions. The relative influence of the three major participant groups (consumer, provider, staff) was examined from the zero-sum perspective (Tannenbaum, 1968) which assumes a limited amount of power possible in an organization or in decision-making. Power distribution was also measured under the assumption that it could be an unlimited sum (Tannenbaum, 1968). Documentation as shown in Table 1 con- firmed the report of Mott (1972) that consumers were significantly less powerful in the Agency than providers. The amount of influence each individual attributed to himself was also examined and Table 1 shows that consumers perceived themselves as more powerless than providers ‘perceived themselves as being. To the extent that individuals are accepted by fellow members and iritegrated as full legitimate members into decision-making processes, 10 they possess "psychological membership" in contrast to formal membership (Jackson, 1959). Results on the attraction to psychological membership showed that both consumers and providers were moderately attracted to their committees with no significant difference between them. Consumers, however, were significantly less accepted by their committees than providers were. The final aspect of legitimacy of participation considered was the extent to which consumers participated in roles necessary to Agency func- tioning. Results in Table 1 show that of the thirteen possible roles that consumers could have been fulfilling, they were assigned only one and were excluded from ten others. "Representing community opinion" could be a significant role for consumers. Simultaneous exclusion from more specific tasks, however, would make this role either irrelevant or theoretical. The most important characteristic of consumer participation examined was their behavioral participation in the formal and informal decision- making activities of the Agency. Attendance records for all Agency meetings held during a 12 month period were examined and results in Table 1 show that consumers attended meetings significantly less frequently than providers did. Analysis of inclusion in the informal channels of communication revealed as shown in Table 1 that providers indicated that they contacted other members significantly more frequently than consumers did, but were contacted with about the same frequency. Thus while consumers appeared to have been included in the network, the value of remembering informal contacts may have been more valuable to providers than consumers. In summary the empirical evidence in the particular Agency under study (unafirmed reported concerns that community representatives were less infcnnned, less legitimate, and participated less in planning than providers. 11 It likewise supported the reports of Strauss (1972) that consumers did in fact occupy in Agency proceedings what Fairweather (1967) has classified as "marginal status." Finally it supported other findings (Bloomberg, 1969) that while the letter of the law had been complied with, the spirit had not. The empirical results in combination with observations of the resear- chers indicated that the internal organization of the Agency could be illustrated by Figure 1 (Agency Model). messages Consumers actions Providers 51% 492 Axecommendation J [ Agency Decisions] Figure 1. Agency Model 12 In addition to the empirical results already reported between consumers and providers, observation showed that instead of the staff merely providing a support service it was in fact an active participant in the manner and outcomes of Agency decision-making. As a filter to all information coming into the Agency, the staff could selectively disperse it. If information is power, then the staff was indeed a powerful factor in participation. Instead of the staff perceiving themselves as powerful, however, re- sults showed that they perceived providers as the focus of Agency power and saw them as an adversary in control of Agency decisions. Providers saw staff as more powerful than themselves and in turn viewed them as adversaries in decisions. Consumers were a quite diverse group but empiri- cal results showed that in general they viewed the staff as the most powerful group and as an ally, with providers being the competitors in resource allocation. As a result there were three theoritical possibilities for direct change staff, consumers, and providers, In reality, however, the psycho- logical and political climate of the organization made direct interven- tions for change possible only for consumers at the time of the experiment. Alternative Solutionstlndizidgal_§ontrasted With Small Group Individual solutions as shown in workshops The most common approach to the problems of citizen participation has ‘been to ignore them. When efforts have been made to assist citizens in overcoming their handicaps to effective participation they have generally 13 been oriented toward alleviating the most chronic complaint of providers- consumers ignorance of professional matters. The format of these educa- tional programs has been that of traditional workshops using traditional classroom methodology (Hart, 1970; RCHP, 1971) to teach individual con- sumers what providers want them to know (Andrejewski, 1972). In this method a teacher generally teaches basic health terminology, general organization of the health delivery system and occasionally con- ducts some role playing exercises. In its basic form then the model for this approach (Figure 2, Consumer Workshop Model) shows a flow of infor- mation only from staff teacher to student with implied translation of this information into more effective participation. Teacher information Student participation facts Agency Figure 2. Consumer Workshop Model Shortcomings of this approach seem immediately apparent. The basic underlying assumption of this model is that increased information is 14 sufficient to increase the quantity of the group product, Agency partici- pation. Collins and Guetzkow (1964), however, caution that this is gene- rally true only when there is a single best answer to a proposed problem. There are times, which are the usual in comprehensive health planning, when the important task is to reach agreement or consensus on any one of a large number of equally "correct" alternative solutions. They further state that the "simple availability of information does not mean it will be effectively used" (p. 30). The evidence reported by Beck (1972) de- monstrated that, in fact, both information and legitimacy were lacking in consumer participation. Given its necessity, whatever information is conveyed is determined by the staff teacher. Limited by her expertise and filtered through her before the student receives it. Even the most conscientious teacher cannot avoid bias in selecting and transmitting information. Because the workshops is primarily a classroom approach, it rarely approximates the actual decision-making conditions in which the information is to be utilized, and therefore, lessens the transfer of what is learned (Ellis, 1965; Fair- weather, 1964). Because most information is generated by the staff teacher, no mechanism is developed for the student's eventual self-generation of information or perpetuation of the learning experience after the withdrawal of the staff. Additionally, the teacher-student relationship tends to perpetuate the superior—subordinate relationship evidenced in the health planning Agency rather than elevating the low social status of consumers (Fairweather, 1969). Finally, because it is essentially an individual approach it ignores the multiple benefits which can be derived from learning and working in a group (Collins and Guetzkow, 1964) . 15 Small grogp approach Even though legitimacy is given some attention in the traditional workshop model, it is still a quantity derived from an external source, the staff, rather than from the members themselves. The social status differential between student and teacher is still maintained. The subordinate student role is encouraged instead of the development of independent thought and critical analysis skills which could lead to a new behavioral role in the decision-making process. For alleviating the multiple difficulties of marginal consumer status, the most advantageous alternative to the typical workshop method of individual interaction might be an autonomous small group training approach. According to Palmer et al., (1972) Didatic presentation of rational planning issues is not likely to reach and modify the personal barriers to group function- ing. The contribution of behaviorists in structural techniques of group process to achieve full participation as well as ability in problem analysis and decision-making offers a valuable approach which may be used both in initial orientation and continuing development of participatory skill (p. 21). Collins and Guetzkow (1964), after an extensive review of the literature, summarized the major advantages of group products over that of individuals. They report that, in general, group members may achieve collectively more than the most superior members could alone and that face-to-face groups have a profound impact on the motivations, knowledge, and persons alities of the participants. They further state that the critical demand for group superiority is the complexity of the task and report three major factors differentiating the productivity of an individual working alone versus the productivity of the same individual working in a face-to-face group: (1) resources, (2) social motivation, (3) and social influence. 16 Collins and Guetzkow also point out that a group will have access to more extensive resources than an individual; that they are advantageous in allowing for division of labor, duplication of effort, and reducting the random error by pooling estimates, and for tasks involving creation of ideas or remembrance of information, there is greater probability that one of a group will produce the Optimal suggestion rather than a single individual. Even though group deliberation may take longer than that of an individual, groups will selectively use information often improving the quality of the group product. In discussing social motivation, they report that the presence of other people in face-to-face decision-making groups creates new motiva- tional implications for each group member which may be irrelevant when he works in isolation and to the extent that productivity is rewarded by the group, motivation for productivity and productivity itself will be increased. With regard to social influence Collins and Guetzkow (1964) state that once one member has gone to the effort of learning information or acquiring a skill, other group members can benefit from the efforts of this person. A group member is likely to accept social influence in areas of his ignorance or from an expert and this generally speaking improves the quality of the group product. They further report that in many cases evidence exists that group decisions will exhibit greater risk-taking than an isolated individual would. They caution however, that the social influence can decrease effectiveness when: (1) an expert continues to be influential outside of his own area of expert knowledge; (2) a group member conforms in order to buy social approval; 17 (3) conformity and agreement set in so quickly that the full resources of the group are not brought to bear; and (4) group members can become dependent on others and this can impede individual learning. Integration individual and small groupjapproaches The traditional workshop model has only one of these group benefits to a limited extent - social motivation. Students do learn in the presence of others. However, since the workshop is typically not a cohesive group the reward is often for being a good student rather than consumer advocate. Thus the workshop model probably reduces the time spent in deliberation but the deliberation process may be essential not only in producing a better group product but in giving persons an opportunity to learn decision-making skills. Additionally, the workshop approach generally utilizes only one of the information sources reported by Campbell (1961, and 1963) - verbal reports and ignores the other twq,direct personal investigation and observation of another members investigation. Evidence exists that the traditional workshop method is superior to a small group approach for the simple learning of factual material (Spence, 1928, Asch, 1951). If more than informational deficit is to be overcome then the problem of consumer participation qualifies as a complex task to which a small group approach would appear to be more desirable. The creation of a group could allow for more varied inform- ation, more creative suggestions on the promotion of consumer legitimacy and division and duplication of effort in solving consumer problems. Social motivation could come from other consumers so that the participants might become effective consumers rather than merely well-informed ones. 18 As a group, consumers could take valuable risks which they as indivi- duals might have been afraid to do. If, in the past, they had conformed toom quickly to the professional experts opinion, they could learn that this was not only not unnecessary but unproductive. They might realize that they have their own unique expertise as community representatives which providers do not have. Such a group could also utilize all three information sources: (1) verbal reports, (2) personal investigation, and (3) observation of other members' investigation. Most importantly, howb ever, group members might overcome a major problem which Collins and Guetzkow (1964) caution against - dependency on others rather than thinking or learning on their own. Therefore, to prevent the superior-subordinate relationship of the typical workshOp from being perpetuated it would be necessary for the staff teacher to encourage autonomous group development and withdraw from group leadership (Fairweather, 1964). Finally to fully implement the goal of more effective consumer participation in planning decisions versus continuous orientation it would be necessary for the staff teacher to remove herself from the group and allow it to operate autono- mously. Figure 3 (Consumer Group Model) illustrates that after a teacher has conveyed information and messages of legitimacy to a group of consumers she can discontinue such control and the group can operate autonomously, participating in the Agency and interacting with the community and having these in turn interact with the group. Fairweather's (1969) research on the reduction of marginal status for mental patients reported that advantages of small groups are that they 19 coauomom huwssfiaoo momeuHmo; sowumEHOMsH sowuomom omeOum sowumewofiuume Hopes moose possmsou .m ouswam macsOuse wow um>om _ b wsw>o>coo hoJWfiuwuoH mommmmoe mhzers did have increased informal participation in Agency activities by the fact that they communicated with more members rather than more frequently with fewer members . 88 Table 11 Post-Experimental Informal Participation -Traditional . Autonomous Group Group if e if s df t Number contacts 18.80 11.03 36.60 17.02 18 2.78b made Number contacts 13.60 13.03 30.80 22.10 18 2.12‘ received Frequency contacts 2.09 1.15 1.86 0.52 18 0.55 made Frequency contacts 1.88 0.38 1.86 0.54 18 0.05 received ‘ K .05 b 92:.01 Description 9; The Post-Experimental Period In accordance with the program plan for group autonomy, the CSG be- came independent of all program staff intervention after the termination of the 6 month experimental period. CSG meetings were not, therefore, monitored and strict records of their activities were not maintained by the program staff. It appeared from attendance results, however, that the major effects of the experiment were not evidenced until the post- experimental period. The following brief description of the post-experi- mental period is drawn from review of agency files and interviews with CSG members active during that period. 89 There were seven formal Consumer Support Group meetings held during the six month post-experimental period. The mean attendance frequency at these meetings was 4.4, 2.7 of those being original small group members and 1.7 being members of the traditional participant group who joined during the post-experimental period. The analysis also showed that on the average 242 of the original small group members and traditional parti- cipant group members attended meetings. 68% of the opportunities for attendance by the original training group members were utilised and 102 of the opportunities for traditional participant group members were utilized. Five members of the original training group attended at least one post-experimental CSG meeting. Four members of the original tradi- tional participant group attended at least one post-experimental CSG meeting. In the later part of Phase III of the experimental period, open con- troversy began to develop with the Agency concerning the policies and pro- cedures of the Executive Director. The first Board of Trsutees meeting of the post-experimental period was concluded in Executive session during which the resignation of the Executive Director was requested. The members of the Consumer Support Group became concerned that consumers had not been properly involved in the decision for this request. They called a special CSG meeting for the purpose of discussing this concern and invited all consumer members of the Agency to attend. The results of this CSG meeting was a resolution requesting delay of the Board's decision regarding the Executive Director's resignation. Because the original request had been made without a quorum being present, a Board meeting to confirm the 90 action was held two weeks later. The Board moved immediately into Execu- tive session. Aymotion for delay was not presented by the CSG members present and after discussion the Executive Director submitted his resig- nation effective in two months. The CSG members were still concerned about the procedures of Board decisions and had some doubt about the legal constitution of the Board of Trustees at the time the request for resig- nation was made. They then sought legal counsel in that regard. Upon counsel's advice, they considered requesting a judicial injunction against further Board of Trustees actions until the legality of Board membership was confirmed. This consideration was informally conveyed to agency officers. It was not activated by the CSG and no formal action was taken with regard to the resignation of the Executive Director. Part of the advice obtained from their legal counsel was for more CSG members to be elected to the Board of Trustees so that they could directly participate in its decision-making. The CSG later learned that only one of their members was to be placed on the list of nominees presented by the nominating committee at the Agency annual meeting. They therefore formulated and presented at the annual meeting their own list of 15 nomi- nees which included the original core group of the CSG and other interested consumers and providers from.the community. Five active members of the CSG were elected to Board membership following this nomination. Also during this meeting the By-law changes proposed by the CSG regarding meeting absences was adopted. In the latter part of the summer the CSG began intensive efforts to expand its membership. All consumer members on Agency committees were 91 invited to join by letter and by personal phone call from one of the CSG members. At the first CSG meeting after the invitation seven new Agency consumers attended. As a result of the CSG meeting just mentioned, three members, who were also Agency Trustees, requested the agency President to hold a spcial meeting of the Board of Trustees to discuss the screening com- mittee which was currently in the process of selecting a new agency Executive DIrector. The special meeting was called and one of the active CSG members was choosen as an additional consumer member on the committee so that it would have a majority of consumers. One of the prime interests of the CSG became the current status of out-patient care in the tri—county area. Investigation was conducted in this area by CSG members. At the group's invitation, representatives of the Community Medicine Divisions of the two local medical schools attended a meeting and discussed the role of the schools in the community and in the Agency. An outreach effort was conducted to bring into the CSG consumers who were not already members of the Agency. Seven new community members at- tended this recruitment meeting. Major concerns discussed at this time were the current role of the CSG and its relationship to the Agency, Hedi- care guidelines, and the financial plight of the local voluntary associa- tion for In-home care. The CSG adopted the motion that they "consider themselves a consumer's lobby for health" and that "...any statement, idea, or report that any member of the group feels has significance, will be brought to the floor for a vote and, if passed, a copy of the report will be forwarded to the Agency Board of Trustees with copies sent to the 92 Federal, State, and County representative." As a result of this same CSG meeting a resolution was presented to the next regular Board of Trustees meeting requesting a staff investigation and report on the following cir- cumstances of the In-home association: 1) current financial status, 2) community effectiveness, and 3) alternatives for additional funding. The resolution was adopted by the Board at that meeting. A resolution sup- porting the In—home association was adopted by the Board and published but the requested staff report was not subsequently submitted for Board approval. At this time the Grant Application Committee was in the pro- cess of developing the 1973-74 Work Program.Application. A motion was, therefore, adopted to have the Grant Application committee review the possibility of having the 1973-74 Work Program include a long range plan to assist the In-home association. This item.has not been subsequently included in the 1973-74 application. Following a report from the CSG chairman of the motions adopted at the last CSG meeting, the Trustees adopted the motion "that the Board of Trustees express confidence in the Consumer Support Group and that the Consumer Support Group respond by demonstrating their trust in the Agency Board." During the following month the CSG became concerned that because the Consumer Participation Grant would be terminating shortly, provisions for staff support for consumer participation be included in the 1973-74 work Program.Application. At the CSG's invitation, the Agency Associate Director attended a CSG meeting and discussed at length the current prac- tices and policies of the agency and its relation to the CSG. 93 At the next regular meeting of the Board of Trustees the CSG Chair- 'woman presented the CSG report. She conveyed that the Executive Director of the Inrhome association had met with the CSG to discuss the current status of the organization. She expressed the CSG's disappointment "that no one has ever responded to this Board's direction that staff prepare information on the In-home association". She then reported that the CSG believed that the agency staff time allocated in the 1972-73 work program to consumer education had not been devoted to consumers as intended. She made the following statements which were included in the minutes of the meeting as part of the CSG report. If the _ggggz truly wants consumers who are‘ggggz.to_ be involved Ln the_planning activities Lf such a program and not ‘glgazg.critics_ on the then Lt .must.give staff support to consumers. This staf support, time, money, and most in- port ant Interest committment to the importance Lf the role Lf budget Lr the work_ program for 1973-74. Therefore the Con- sumer Support Group recommends that this Board take two steps: (1) fulfill the committment to the Consumer Support Group pro- ject Ln staff time Lr free the money for the Consumer Support Group_ to hire its own staff this summer; (2) to hire staff Ln behalf_ Lf the consumers Ln a permanent basis.“ She then introduced a resolution that the 1973-74 work program be enlarged to include staff time and resources necessary to have "definite emphasis on out-patient needs and positive solutions geared for satis- fying preventative health care needs in the near future..." Minutes of the meeting reported that the "Consumer Support Group feels that the 'needs of the community' are not being met in the proposed 1973-74 work program." It was agreed that a data base must be established first and then, if necessary, an amendment to the work program could be made at a later date. 94 The following motion was then passed in this regard, "that staff, working with a committee of the Consumer Support Group, develop an amendment to the work Program for 1973-74 to implement the concerns of the Consumer Support Group." The proposed 1973-74 Work Programnwas approved at that meeting of the Board. The amendment regarding the CSG had not been developed four months subsequent to the motion for its development. The chairwoman of the CSG had a staff member from a statedwide con- sumer research group as her guest at the next Board of Trustees meeting. The staff member gave a presentation to the Trustees on their research of physician participation in the Medicaid Program. Two active members of the CSG, who were also Trustees,‘were appointed to the nominating committee charged with recommending new Agency Trustees for the coming year. At the request of the CSG co-chairwoman several citizens interested in physician access for medicaid recipients were introduced at the Board meeting. The Board then discussed their concerns with them. The Agency President in- structed the chairmen of each of the major standing committees to "discuss the problem'within the coming month and to propose a specific direction for the Agency to pursue." The screening committee recommended appointment of one of the candi- dates interviewed for the vacant position of Executive Director, and he was subsequently hired. Summary In summation, two sets of hypotheses were tested in this study-one set relating to the formation of an autonomous task-oriented small group 95 of consumers and one set relating to the effects of participation in such a group. The first hypothesis tested relative to group formation was simply that _a_p autonomous task-oriented m p_f_ consumers 39951 p; _f_o_r_me_d_. verbal description of group development demonstrated that this could occur. Quantitative description of small group attendance, verbal participation, role/task distribution, problem solving ability, and cohesiveness confirmed this finding. The second hypothesis tested relative to group formation was that members 35 the autonomous task-oriented 92.1.]; 59223313 perceive M M _erp receiving informational support _ip _t_l_1_e_ m. Verbal description of information exchange during gorup development demonstrated that this had occurred. Quantitative description of perceived information measured confirmed this finding. The final hypothesis tested relative to group formation was that members pf the autonomous task-oriented small group would pgrceive that thez were receiviug group §EP29rt for the legitimacz pf their participa- tion gg_consumers ip the Agency. Verbal description of legitimacy pro- motion and reinforcement during_group development demonstrated that this had occurred. Quantitative description of perceived legitimacy support confirmed this finding. The first hypothesis tested relative to the effects of participation in the small group was that these participants would when contrasted with traditional_participants increase the information they possessed about health_planning activities. Results confirmed this hypothesis on all measures of information utilized. 96 The second hypothesis tested relative to the effects of participation in the small group was that M participants _w_h_gp_ cgpared 3321M 5329.9}. participants would increase _t_h_e_ legitimacz 33 £99.93. participation _ifl 9.8.9351 activities. This was measured by l) the effect that the partici- pants constituency had upon him, 2) the power he possessed in Agency acti- vities, 3) the roles he fulfilled in Agency activities, A) psychological membership in his committee and, 5) his perception of his importance in Agency activities. This hypothesis was confirmed on all measure except constituency effect. Results on the measures of constituency effect did not confirm this prediciton. This was attributed to improper wording of the measure. The third hypothesis relative to the effects of participation in the small group was that these participants M 39.9.9. contrasted gig; 5552.; _t_i_._op_a_l_ participants increase _t_l_1_e_i_r_ participation _i_p 3293...]- decision-making activitiLs p_f_ 3315 535351. This hypothesis was not confirmed during the six months of the experimental period. It was, however, confirmed during the post-experimental period. Even though some traditional participant group members attended small group meetings during the post-experimental period, they were maintained in the entire traditional participant group for comparison with the original training group participants and the in- creased attendance reported was therefore due to a'delayed effect upon the original participants only. The final hypothesis tested relative to participation in the small group was that participants would when contrasted with traditional pa: ticipants increase their participation L1 informal decision-making acti- vities 3_f_ the Aggncy. 97 Results confirmed this hypothesis both for the numbers of fellow member participants spoken to and the number who spoke to the participants. Chapter V Discussion The most common approach to the problems of citizen participation in _ planning has been to ignore them. If an attempt has been made it has typically been a workshop teaching consumers what providers want them to know (Andrejewski et al., 1972). According to Andrejewski et a1. (1972) such attempts "will not be very successful without concurrent attention to techniques that can equalize consumer-provider effectiveness in group settings and to organizational arrangements that facilitate consumer input” (p. 27). The verbal and quantitative description of the develop-' ment of the training program reported here demonstrated that an autonomous small group of consumers could be formed. It showed that a staff leader can initiate autonomous group formation, information flow and reinforcement of the legitimacy of consumer participation. It described the fact that a staff leader can gradually withdraw from.group direction and that the group will assume leadership responsibilities, begin generating its own information, reinforcing its own legitimacy, practicing decisiondmaking skills, and delineating a new behavioral role for themselves. 98 99 The description reported that with the complete withdrawal of staff support, the group autonomously continued, developing and practicing the behaviors and attitudes initiated during the initial phases of the program. The description did then demonstrate that a viable alternative to doing nothing and traditional education exists and that it can address both basic prerequisites for effective participation - information and legitimacy. According to Collins and Guetzkow (1964) "group members may collectively achieve more than the most superior members are capable of achieving alone." (p. 55). The results on the effects of participation in the autonomous small group training program documented that this in fact did occur. Results supported the first predicted outcome - small group .ppgticipants did become more informed_ip_hea1th plannipg activities. According to Guetzkow and Collins (1964) "information alone is not enough." It must also be presented persuasively and documented legitimately before group members are likely to accept it (p.50 ). The second major hypothesis then tested the ability of the small group program to increase the legitimacy of participants in decision-making activities of the Agency. Evidence supported that this had resulted. The first component of legitimacy - existence of an effective constituency was critical because such a constituency could serve as both a reference group (Cartwright and Zander, 1968; Gerard, 1952; Kelly, 1954), and as a power base (French and Raven, 1959). Unfortunately the measure of constituency effect was so worded as to prohibit the direct quantification of the Consumer Support Group (CSG) as an effective constituency. However, description of the post-eXperimcntal period did 100 indicate that the CSG served as a reference group for active members fulfilling both a comparison function and normation function (Cartwright and Zander, 1968; Gerard, 1952; Kelly, 1954). The presence of a normative group was additionally important in providing a mechanism for reducing the normlessness component of alienation and marginal status (Bloomberg, 1969) documented in Beck's (1972) research. Results on power redistribution were especially gratifying because they also indicated a reduction in marginal status of training group consumers, ie. that the powerlessness component of consumer alienation had been reduced (Bloomberg, 1969). Even though power of small group participants was not measured from an external perspective, results did show that these participants perceived themselves as having significantly more power than comparison members did. The CSG did then serve as a supportive power base for participants (French and Raven, 1959). CSG members apparently operationalized their theo- retical legitimate power by means of both eXpert and reward power (Collins and Guetzkow, 1964). The post-experimental description in fact shows that small group participants participate to the extent of delineating identi- fiable consumer goals. In some cases to obtain their wishes, they also changed the goal structure of consumers and providers from contriently interdependent ones to promotively interdependent ones (Deutsch, 1949) so that providers could not botain goals with consumers also doing so. Results regarding the role fulfillment reflected the gain in power 101 for training participants. After participation in the autonomous small group program, consumers who had originally been assigned only a theoretical role in Agency activities were recognized as fulfilling significantly more operational roles. This achievement was important because previous research (Fairweather, 1969) had indicated that fulfillment of partici- pating roles in the actual setting is critical to creating participating status rather than marginal status. Psychological membership was described by Jackson (1959) as comprised of attraction to the group and acceptance by it. Fairweather (1969) found acceptance to be most closely related to group performance and leadership, role delineation and attraction most closely related to group cohesiveness. Hollander and Webb (1955) Hurwitz, Zander, and Hymovitch (1968) substantiated an association between interpersonal attraction and the exercise of power. Acceptance of the consumer by his committee was considered one of the prime reflections of the legitimacy of his role in its activities. The results of the present investigation demonstrated that participation in the small group training program resulted in higher acceptance by fellow committee members. Acceptance as measured here was essentially a measure of interpersonal attraction of the committee to the consumer. Power and acceptance were measured independently in this study but their simultaneous rise follows the reports of Hollander and Webb (1955) and Hurwitz, Zander, and Hymovitch (1968) who substantiated an association between interpersonal attraction and the exercise of power. Results showed that attraction of small group participants to the Agency committee as a whole increased but not that of attraction to the individual participants. This could have been an artifact of measurement or a legitimate difference, if as 102 participants became more familar with their fellow committee members they began to realize feelings that could not realize from a distance. However, because the primary normative goal of the group (Fairweather, 1964) was effective participation in their respective committees, increased attraction to that committee would be a logical consequence. The final component of legitimacy was a direct measure of each participant's perception of his own importance in the health planning decision-making process. This was designed to cut across all other legitimacy components. One of the main goals of the legitimacy manipulation was to convince consumer participants of their importance in the health planning process so that their self-esteem and level of aspiration for involvement in Agency decision-making would rise and consequent to that their participation in these (Cartwright and Zander, 1968). Results showed that this goal was achieved and description of the post-experimental period indicates that these self-expectations did rise and were translated into behavior. The results supported the predicted effects for participants in the small group training program - legitimacy in_§gency decision-making was increased and marginal status decreased. The ultimate objective of the training program was to increase effective participation of the participants in health planning decision- making. This was quantified by their participation in formal and informal decision-making activities of the Agency. Results demonstrated a signi- ficant increase in participation in the informal communication network during the six month experimental period. Increased formal participation of the original and small group participants however, was apparently a delayed effect not being statisgally significant until the post-experimental 103 period. This may have been characteristic of the nature of this program or due to the artifact that some training group members had very few opportunities to attend meetings during the experimental period. If a participant missed one meeting during the period, and only one was held, then zero attendance rate resulted. In sum, the results demonstrated that a viable alternative does exist to do nothing about the problems of consumer participation and also a traditional workshOp approach to alleviate them. They demonstrated that an autonomous small group training program can transmit information to its members and reinforce the legitimacy of their participation in Agency decision-making. Most importantly they demonstrated that participation in this program resulted in greater, more effective participation in Agency decision-making activities. The implications of these findings are two fold for the training of citizen participants and the structure of citizen participation itself. The first is essentially a question of the primary objective of citizen training, and as a consequence of the answer, to determine the most apprOpriate format. The primary objective of the autonomous small group training program described here was to increase effective consumer participation in health planning decision—making. It attempted not only to change the information and attitudes of participants but also to change their structural position in the Agency, i.e. to actually decrease the marginal status of marginal participants and move them into the mainstream of "real" decision-making activities. While information was a necessary condition for this to occur it was not in itself sufficient to bring about the desired change. The fact that mere CSG participants had been 104 involved in a traditional workshop training program prior to volunteering showed not that this previous training was responsible for the success of the CSG but that without specific relevant information, perceived legitimacy relevant to the current setting and operational skills, the motivation originally exhibited was not translated into meaningful participation. The methodology employed was also quite different in that it was not intended to produce so called "good" consumers as defined by profes- sionals. It was not designed to produce informed consumers who could apprOpriately appreciate the remarks of the professionals. It was instead designed to provide skills to numbers and to allow them to utilize them as they decided. It was designed to remove impediments to parity with professionals, to establish a functional role for consumers, to produce an effective constituency, to increase their psychological membership and to increase their power. t was therefore designed as an advocacy group. To have done otherwise, would have traded "benevolent planning" (Strauss, 1972) for "benevolent training." If the primary objective of citizen training is to relieve their ignorance or improve their competence in professional health matters (Palmer et al., 1972) then the standard workshop is the recommended method (Asch, 1951, Spence, 1929). If, however, the real objective is to more fully implement the SpiT:t cf the "Partnershin Law" rather than a facade of consumer participation, then the method described here is more appropriate. Of the two, it offers the post h0pe for reversing the self-confirming circularity of alienation (Blccmberg, 1959) and utili- zing it to reduce marginal status of consumers rather than perpetuating it. 105 The choice of training goal is most closely aligned with understanding the structure of consumer participation itself. The core of the "Partnership in Health" concept, though not specifically identified in the legislation is that the various groups involved in health planning have different priorities for health care. Comprehensive health planning agencies are intended as mediating groups (Cartwright and Zander, 1968) in which representatives of these various interests meet and their differences in priorities negotiated and resolved. Since CHP has the greatest potential for affecting the environment of professional health organizations, their representatives will likely have strong motivation to be involved in CHP decisions. On the other hand, the consumer without an effective constituency and upon which CHP appears to have neither short nor long-term affects is prone to dis- illusionment and eventual apathy. The professional constituency gives an additional structural advantage to its representative in that he enters decision-making meetings already in possession of information on issues which had resulted from his participation in the informal communication network of professionals. The consumer, on the other hand, may spend the entire meeting orienting himself to the current issues rather than providing consumer input into the decisions. The third structural advantage offered by the constituency of the professionals is that Agency members are usually aware of the direct impacts their decisions have on such organi- zations, and therefore take Specific efforts to listen to their concerns. Members are equally aware that impact on consumers is diffuse that it is unlikely that consumers present will be directly affected by their decisions and that generally no constituency stands to be directly affected. 106 Therefore with even the best intentions on the part of the professionals and staff, certain inherent disadvantages will exist for consumer members. The implications of the current study are that traditional education alone cannot overcome this inherent structural disadvantage. Instead, a consumer constituency such as the Consumer Support Group is necessary to overcome informational, attitudinal, and structural disadvantages. The motivation to participate implies an ability to gain rewards by affecting relevant outcomes of health planning. This implies that there are health planning outcomes which are relevant to the representative and his constituency and that he has the power to affect them. Additional efforts need to be made to more directly and effectivelylink community organizations with their representatives and with CHP outcomes so that the CSG may either be augmented or replaced by this broader constituency base. The development of an effective constituency implies the deve10pment of a power base for consumer representatives (French and Raven, 1959) the issue of power, so often skirted in discussions of community repre- sentation must be faced if citizen participation is to be dealt with effectively. Negotiation and resolution of priorities presupposes two conditions for productivity-parity between the negotiating parties and admission of conflicting viewpoints. CHP guidelines have defined the source of legitimate consumer power as 51% majority augoverning boards and committees. Beck's (1972) research documented the lack of such parity in actual power. As the information and legitimacy of consumer representatives increases so also will their power, and this should be welcomed as a prerequisite for meaningful negotiation. With the exercise 107 of power will come some conflict. This need not be feared. Instead it should be encouraged so that all available resources can be utilized in reaching the final decisions (Collins and Guetzkow, 1964) and the full advantages of recipient participation in decision-making can be realized (Coch and French, 1948; French et al., 1958; Gilmer, 1961; Likert, 1967; Meier, 1955; Tannenbaum, 1968). The effects of the autonomous small group training program were tested in the format of a social innovative experiment (Fairweather, 1967). The value of a rigorous evaluation was that it prevented the program from being declared successful merely because it existed, and of it being declared unsuccessful if it proved politically unpopular. The disadvantages of conducting research in a community setting such as the Agency also existed. The lack of understanding of research constraints sometimes produced pressures on the researcher from within the training group or from outside of it to alter the experimental design. The researcher had to be versatile in fulfilling the roles of teacher, mother, daughter, arbitrator, hate object, or friend alternatingly. The lack of appreciation for evaluation sometimes made data collection less than satisfactory. The effects of the CSG were predicted on the basis that each participant would have ample Opportunity to practice his newly learned skills in meetings of his committee. In fact, the erratic nature of the field situation was that some committees met only once during the entire six months of the experimental period. Indeed it appeared that in the post-experimental period, members eXpanded membership for themselves so as to provide more meeting opportunities in which to utilize their skills. Measurement reactivity is always a danger in applied settings. 108 In-depth interviews with each volunteers and surveys of all other members indicated that they perceived this effect to be minimal. It was equated for training and comparison groups and if any major effects did result from measurement, it was fatigue with the extensiveness of it rather than differential sensitivity to measurement topics. It should be remembered that research of this kind takes enormous commitment from those partici- pating in it. Even the best planned field research can tax the limits of the most dedicated participants. Overall cooperation with the integrity of the research was quite excellent given the emotional nature of the project and the setting in which it occurred. One of the major limitations of measurement in field experiments is that it usually stOps at some point adcording to a priori plan. In this case some confounding of training and comparison groups occurred after the removal of eXperimental constraints therefore, the long range effects of the program could not be as clearly defined. Additionally, because strict measurement of the training group's actions were terminated at the end of the experimental period description of their progress was second- hand. In the current research, commitments to the people involved did not allow for maintenance of the eXperimental constraints beyond a six month period. In the future, when possible, experimental constraints should be maintained longer and more longitudinal measurement taken. Wood (1973) recommended that this is especially necessary in the light of recent evidence (Levine and Weitz, 1971) that group power structures interact with task difficulty and time of criterion measurement in their effects on group performance. Next, several comments should be directed towards two critical incidents which occurred during the program, the controversy precipitated by one member during Phase I with the 109 subsequent resignation of the CSG member at the end of Phase I, and the resignation of the Agency Executive Director at the beginning of the post-experimental period. At the time of the initial controversy within the CSG, doubt existed with regard to the group's continued viability. However, after the resignations occurred the members who remained formed a highly cohesive group which had the eXperience of weathering conflict and the confidence of being able to handle it. Since this was one of the objectives of the training program it was probably best that these resignations occurred. One potential rival explanation of the results of the experimental could be that the self-selection of participants during the program was the primary causal factor. This should not be denied as a partial cause but as a primary cause. The program was never intended for those who were not interested nor would any implementation be so. Intensive efforts were undertaken to eXplain the specific nature of the program to potential members. Some did not apparently understand the explanation adequately or their needs accurately. Some others understood their need to be informed only and dropped out after that phase. This would indicate that the best that be done for some consumers, and perhaps appropriately so is to provide a simple information orientation. This is recommended as a simultaneous addition to small group training to be utilized by those who desire only that. Several comments should also be devoted to the nature of advocacy research itself. While promoting change in the relative influence of consumers, it was necessary for the researchers to be constantly aware of the fine distinction between building a group on its own merits and building it at the expense of others. It was also necessary to be aware 110 that the same researchers who were actively advocating this group would subsequently be evaluating its success. In the current research, program coordination and evaluation efforts were fiarly clearly separated so that possible contamination of the evaluators judgement was minimized. Even though extensive efforts were made to communicate this structure, it was not as clearly perceived by Agency staff and members. Future advocacy research would do well to use a partnership of program coordi- nation and evaluation such as that employed in this research and to do even more to have the relationship understood. It was also necessary to be aware that unlike laboratory research strong personal feelings develop between researcher and participants and that the standard experi- mental format is independent of these. Future advocacy research must be aware of this potential problem and also include provisions for its successful resolution. Finally, it should be specifically noted that field research of this kind is quite difficult both because of the tre- mendous political pressures and power struggles which can develop when real change occur and the simultaneous necessity of retaining the inte- grity of the research design and the equilibrium of the researchers theme selves. Finally, the current experiment yields recommendation for future research in the area of training for consumer participation and consumer participation itself. Description of the post-experimental period, especially the critical incident of the Director's resignation demonstrated also that trans- forming participation into relevant action involved the use of power. 111 This delighted some and dismayed others. Criticisms originally came that consumers were "apathetic." As consumer participation became more of a significant reality these became complaints that consumers were "stepping out of their place." If in fact, as pre-experimental survey results in- dicated, power is perceived entirely as a zero-sum quantity and as post- experimental description indicated that power is related to affected rele- vant outcomes, than future research needs to more closely examine utilization of power as a variable in affecting participation of marginal members. Fairweather (1964) reported that rewards received in group partici- pation are an important part of morale in a group and of motivation to participate in it. The current research was not able to control rewards received in Agency participation. Description of the post-experimental period, however, indicated that if sufficient impact on relevant decisions was not forthcoming the motivation to continue in the CSG and the Agency might not long continue. While it might be quite difficult to experi- mentally manipulate rewards in a field setting such as this correlational analysis might clarify the relation between various rewards obtained and participation exhibited. Unfortunately resources in the current study did not allow for a strict experimental comparison between a traditional workshop training method and the autonomous small group training method described here. Future research should conduct a replication of the small group method and compare it with the traditional educational approach. 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National Commission on Community Health Services. Health is a community affair. Cambridge, Mass.: Harvard Press, 1967. Regional Comprehensive Health Planning Council, Inc. Training Institute for the RCHPC, Inc. Unpublished manuscript. RCHPC, Inc., Phila- delphia, 1972. Padgett, E. The political effects of consumer participation: A political 7' scientist's view. Health Education Monographs, 1972, 22, 67-78. Palmer, 3., Sisson, R., Kyle, C. and Hibb, A. Community participation in the planning process. Health Education Monographs, 1972, 22, 5-22. Ready, W. The consumer's role in the politics of health planning. Health Education Monographs, 1972, 83, 51-58. Sakoda, J. M., Cohen, B. H., Beall, G. Test of significance for a series of statistical tests. Psychological Bulletin, 1954, 21, (2). Spence, R. B. Lecture and class discussion in teaching educational psychology. Journal of Educational Psychology, 1928, 12, 454-462. Strauss, M. An interview with consumer representatives. Health Education Monographs, 1972, 22, 41-48. 116 Tannenbaum, A. Control in orggnizations. New York: McGraw—Hill, 1968. Wood, M. T. Power relationships and group decision making in organi- zations. Psychologgcal Bulletin, 1973,.19, (5), 280-293. APPENDICES L2 APPENDIX A OPERATIONAL MEASURES CSG DEVELOPMENT 117 «finesse coauuooa n c.34m v3.3. mSZH mom ac uwwmwn any: £03. 600 «.5 Pump owaH dado aw mono .mom .xnm “haw—30 MB 3.39 3 oouuuflgo a.“ . on . a. o. ggg gang unusual H 28h ROLES - TASK DISTRIBUTION The following statements describe tasks that members of the committee could be performing. Please place a mark in each box for each person who is now actually performing the task described. You may check as many people as you think are performing the task. 10. Task Environmental Frequently suggests issues or problems for discussion and planning. Suggests new ways of solving the problems raised in discussion. Reports technical information for activities of the committee. Brings information obtained from non-members in the committee meetings. Emphasizes "getting work done". Interpersonal Frequently spends time before and after meetings chatting with other members. Encourages members to talk together and share ideas in the committee meetings. Acts as mediator in conflicts of opinion within the group. Gives recognition or thanks for contributions members make during committee meetings. Helps the members of the committee to get along and understand each other. 118 PROBLEM SOLVING ABILITY How many issues of major concern to consumers have been suggested for consideration in the Consumer Support Group? ALL MOST SOME VERY FEW NONE How often have issues of major concern to consumers been discussed at length by the Consumer Support Group? ALL MOST SOME VERY FEW NONE How often has the Consumer Support Group meetings reached a decision on issues which have been brought up for discussion? ALWAYS OFTEN SOMETIMES SELDOM NEVER In arriving at a decision, how often has the Consumer Support Group outlined a detailed plan for carrying out the decision? ALWAYS OFTEN SOMETIMES SELDOM NEVER How often does the Consumer Support Group carry out its decision or plan by getting the necessary information, money, agreements, etc.? ALWAYS OFTEN SOMETIMES SELDOM NEVER 119 3. COHESIVENESS You and the other people in the Consumer Support Group meetings belong to a group that works together. STRONGLY AGREE MODERATELY AGREE NEUTRAL MODERATELY DISAGREE STRONGLY DISAGREE How well do the members of the Consumer Support Group meetings get along together? VERY WELL FAIRLY WELL SO-SO NOT TOO WELL DON'T GET ALONG AT ALL How much do the members of the Consumer Support Group meetings help each other to do a better job? A GREAT DEAL QUITE A BIT SOME LITTLE NONE Suppose that as a result of strong opposition to the CSG, from people outside of the CSG it was in real danger of folding up, how much effort would you be willing to spend in order to prevent this? A GREAT DEAL QUITE A BIT SOME LITTLE NONE Suppose that as a result of general member disinterest, the CSG was in real danger of folding up, how much effort would you be willing to spend in order to prevent this? A GREAT DEAL QUITE A BIT SOME LITTLE NONE 120 1. INFORMATION-PERCEIVED In the Consumer Support Group, I have found out what is going on in the community as it relates to health delivery. I feel very strongly this way. I feel pretty much this way. I feel this way more or less. I feel this way hardly at all. I do not feel this way. In the Consumer Support Group I am finding out what needs, problems, and opinions of other consumers are. Same as above. In the Consumer Support Group, I am learning how to understand the Agency as an organization and the issues and proposals which are being considered in the Agency. Same as above. 121 LEGITIMACY-PERCEIVED CONSUMER SUPPORT GROUP 1. I am finding out that other people share the same feelings I have about being a consumer representative in the Agency. I feel very strongly this way. I feel pretty much this way. I feel this way more or less. I feel this way hardly at all. I do not feel this way. The members of the Consumer Support Group make me feel that my contribution to the Agency is important. Same as above. The members of theConsumer Support Group make me feel that my contribution to the group is important. Same as above. People in the Consumer Support Group give me support for the ideas I have about the health needs of consumers. Same as above. People in the Consumer Support Group give me support and encouragement for my participation in the Agency. Same as above. 122 LEGITIMACY-PERCEIVED (continued) THE AGENCY 1. At the present time, I feel comfortable as a consumer representative in Agency meetings. I feel very strongly this way. I feel pretty much this way. I feel this way more or less. I feel this way hardly at all. I do not feel this way. I feel that I get along well with the members of my Agency committee at the present time. Same as above. I feel that I am fairly influential in my committee meetings at the present time. Same as above. In Agency committee meetings, I now have the feeling that people genuinely appreciate my contributions as a consumer. Same as above. In Agency meetings I feel that I know what I can and should be doing as a consumer representative. Same as above. In Agency meetings, I feel that I have a group of people backing me up in what I say and do. Same as above. In Agency meetings I feel as if I am more effective as a consumer representative than I was before. Same as above. 123 APPENDIX B OPERATIONAL MEASURES EFFECTS OF THE AUTONOMOUS SMALL GROUP TRAINING l. OPERATIONAL MEASURES EFFECTS OF THE AUTONOMOUS SMALL GROUP TRAINING Information Information I - General Please tell me what major department in the Federal government finances the agency's annual budget? Please tell me what a Health Maintenance Organization (HMO) is? Please tell me the difference between an "a" agency and a "b" agency in Comprehensive Health Planning? Post Alterations - Add Please tell me what a Design Grant is? Please tell me what Out-Patient means? Please tell me the difference between skilled nursing and basic nursing? Please tell me what the term Nominal Group means as used in the Agency? Please tell me what O.E.O. is? Please tell me the difference between Medicare and Medicaid? Post Alterations - Delete Please tell me what a Health Maintenance Organization (HMO) is? Information II - Staff Would you give me the names of as many of the staff members as you know? Information III - Committee Names Would you name as many of the Planning Committees as you know? 124 Information IV - Committee Chairmen Would you name the chairmen of these committees? Information V - work Program Would you name as many items of next year' a work program as you can remember? Constituency Effect Constituengy_Identification Quite often people do not formally represent any organization but they still reflect the opinions and needs of a greater number of people than just themselves. Do you think that any of the people you know on this list reflects the needs and opinions for any larger group of people? Effect upon representative Were you selected specifically to represent any group at agency meetings? If so, which group were you selected to represent? Quite often people do not formally represent any organization but still reflects the opinions and needs of a greater number of people than just themselves. Do you think you reflect the needs and opin- ions of any larger group of peOple? If so, which groups of people are these? How likely is it that the people you mentioned would find out what you do at the agency? (Very likely, Probably, Maybe, Unlikely, Very Unlikely) Do you feel that the peOple you mentioned expect you to do anything in particular at the agency? How much do these people influence what you do? How important is it that you have these people to back you up? Are you more likely to speak up at meetings with these people backing you up? Do you feel that your contribution will carry more weight with these people backing you up? 125 3. Influence - Power a. Influence Tannenbaum—Personal Unlimited How much influence do you think you have on planning decisions in the agency? (A great deal, Quite a bit, Some, Little, None) Would you like it to be different? (Yes, No) How much influence would you like to have? b. Influence (Tannenbaum—Group Unlimited) In general, how much influence does the staff have on planning decisions in the agency? (A great deal, Quite a bit, Some, Little, None) Would you like it to be different? (Yes, No) In your opinion, how much influence should the staff have? In general, how much influence do health providers have on planning decisions in the agency? Would you like it to be different? In your opinion, how much influence should health providers have? In general, how much influence do consumers have on planning decisions in the agency? Would you like it to be different? In your opinion, how much influence should consumers have? c. Influence (Zero-Sum) In summary, then how much is a typical decision influenced by the staff, how much by the providers, and how much by the consumers? In other words, given 1001 of the influence in the agency, what percent (to the nearest 102) is exerted by each of these three groups respectively? Would you like it to be different? (Yes, No) What percent of influence would you prefer for each group? 126 4. 5. Roles-Task Distribution - Same as CSG Measure (Appendix A) Attraction-Acceptance (Individual) The following statements are ways in which a person could describe other people on a committee. For each person that you know on this list of committee members, please indicate, using the following choices, how much you agree that each statement describes that person: (Strongly agree, Moderately agree, Neutral, Moderately disagree, Strongly disagree) A. He makes anvaluable contribution to the tasks of the committee. B. When you are undecided on an issue, he can usually persuade you to accept his viewpoint. C. You enjoy working with him on the committee. D. In general, he is the same kind of person you are. E. In general, be is interested in the same things you are. P. You benefit from his association with the committee. Attraction-Acceptance (Group) The following statements are ways in which a person could describe his committee. Please indicate how much you agree with each state- ment. A. You enjoy attending meetings of the committee. B. The committee makes a valuable contribution to planning in the field of health services. C. In general, you try to do what the committee expects a member to do. D. The committee is dealing with the same things you are interested in. E. You usually go along with the committee's decision on issues. Post Alteration The following questions ask you how you feel about the other people on your committee. For each person that you know on this list of committee members, please check the category which best describes your response to the questions. (repeated each page) A. How would you describe his contribution to the tasks of the committee? (Not valuable at all, Not too valuable, So-So, Moderately valuable, Very valuable) B. When you are undecided on an issue, how like is it that he can per- suade you to accept his viewpoint? (Very unlikely, Unlikely, Maybe, Probably, Very likely) 127 C. How much do you enjoy working with him on the committee? (Not at all, Not too much, Somewhat, Quite a bit, Very much) D. In general, how much is he the same kind of person you are? (Very different, Quite a bit different, Somewhat the same, Quite a bit the same, Almost the same) E. In your work on this committee, is he interested in the same things you are? (Same as D above) F. How much do you benefit from his association with the committee? (Not at all, Not too much, Somewhat, Quite a bit, Very Much) Legitimacy - Personal How important do you feel your participation is in Comprehensive Health Planning? (Very important, Fairly important, Somewhat important, Not too importnat, Not important at all) Miscellaneous - General a) Suppose that as a result of strong opposition to the agency from.within the community, the agency was in real danger of folding up. How much effort would you be willing to spend in order to prevent this? (A great deal, Quite a bit, Some, Little, None) b) Suppose that as a result of_ggneral member disinterest, the agency was in real danger of folding up. How much effort would you be willing to spend in order to prevent this? (Same as above) c) How well do you think the agency is doing in the field of Comprehensive Health Planning? (Very well, Fairly well, All right, Poorly, Very Poorly) d) How long do you think it will take before such planning will have significant effects on the quality of health services? (More than 10 years, 6-10 years, 3-5 years, 1-2 years, Less than 1 year) e) How much time and effort would you be willing to spend to increase consumer participation in the agency? (A great deal, Quite a bit, Some, Little, None) f) Approximately how many peOple outside of the agency do you talk to about Comprehensive Health Planning? (A great many, Quite a few, Some, A few, None) 128 Post Alterations - Delete Consumer participation is a necessary part of Comprehensive Health planning? (Strongly agree, Moderately agree, Neutral, Moderately disagree, Strongly disagree) Considering health delivery in general, how important a part is Comprehensive Health Planning? (Very important, Fairly Important, Somewhat Important, Not too important, Not important at all) The following statements are grouped into paris. Wbuld you check one statement from each pair which best describes your feelings? A. Better coordination of existing services should be given first priority in meeting today's health problems. B. Planning new programs should be given first priority in meeting today's health problems. A. Consumers and providers in the agency should formally speak for some group of people. B. Consumers and providers in the agency should express only their own personal Opinion. A. This community needs Comprehensive Health Planning. B. The people already providing health services can take care of health planning themselves. Formal Participation Attendance: Official agency minutes Verbal Participation: Meeting Interaction Form-same as CSG measure (Appendix A) Informal Participation - Communication Network A. Could you name the peOple you know at the agency other than those on the committee(s) you belong to? B. Using the categories below, approximately how many times a month do you speak with each person you mentioned? (More than 8 times, 5-8 times, 3-4 times, 1-2 times, less than 1 time) C. What prOportion of your discussions with each one are health-related? 129 10. Post Alteration The following pages contain a list of Agency members according to the committees they serve. Please check the first.column after the person's name if you know the person. Then check one of the remaining columns indicating how often you speak with that person outside of regular Agency committee meetings. (A few times a year or less, Once every couple of months, Once a month, 192 times a month, More than twice a month) Items Analyzed for Pro-Experimental Only a) Demographic What is your occupation? What is your age? Of these educational categories, which one best describes your educational background? (Grammar School, High School, Bachelor's Degree, Para-professional Degree, Master's Degree, Ph.D. Degree, Professional Degree) How much formal educational training have you had in any health related field? (A great deal, Quite a bit, Some, Little, None) Have you participated in the Urban League's Consumer Health Training Program? (Yes, No) Are you, or have you ever been married? (Yes, No) How many children do you have? Of these categories of annual family income, please indicate which category your family falls into? (Under $7,000; $7-12,000; $12—20,000; $20-$30,000; Over $30,000) How many years have you lived in the tri-county area? How many time have you or a member of your immediate family visited a physician in the last year? (More than 10 times, 6-10 times, 3-5 times, 1-2 times, None) How many times have you or a member of your immediate family been hospitalized in the last 5 years? (More than 10 times, 6-10 times, 3-5 times, 1-2 times, None) b) Influence (Arnstein—Levels of Participation) The following statements describe various types of participation consumers could have in Comprehensive Health Planning. A. They are informed of decisions. B. They are consulted before decisions are made. C. They vote on decisions, but outcomes can be modified by those controlling necessary resources. D. They share in making final decisions of resource allocation. E. They have delegated power to make decisions. F. They have control over the decisions. 130 c) Tasks (Group) They help in planning medical facilities. They sulfill legal requirements for operation. They search out ways to serve the needy. They coordinate medical services. They give information about resources available. They give a balance of opinion. They represent community problems and opinions. They deal with other organizations in the community. They gather and report information. They evaluate the feasibility of programs. They help people to be aware of health needs. They inform the community about health prOblems and services. They provide the time and effort necessary for compiling reports and distributing notices. They provide expert opinion. They see to it that planning proceeds smoothly. d) Miscellaneous How long have you been attending meetings at the agency? Do you plan to continue as a member of the agency next year? (Yes, No) Consumer Participation is a necessary part of Comprehensive Health Planning. (Strongly agree, Moderately agree, Neutral, Moderately disagree, Strongly disagree) Considering health delivery in general, how important a part is Comprehensive Health Planning? (Very important, Moderately important, Somewhat important, Not too important, Not important at all) 131 APPENDIX C Non-Significant Results of Participation In The Small Group Training Program a) b) c) d) a) f) Non-significant results of participation.in the small group training program Loyalty to Agency vs. outside oppo- sition Loyalty to Agency vs. member dis- interest Evaluation Agency success Time before CHP has effect Effort to increase consumer partici- pation People talk to about CHP Comparison Group E s 3.78 1.30 3.78 1.30 2.78 0.97 3.50 1.07 3.67 1.32 2.89 1.54 132 >0 3.60 3.10 2.40 2.90 3.20 3.10 Traini Group 08 1.35 1.37 0.97 0.74 1.48 0.88 df l7 l7 17 16 17 17 0.28 1.05 0.81 1.33 0.67 0.35 . x 3 . ML..- .p‘fiewufis .33.. n at HICH IES «1111mm 31