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In all cases we have film ed the best available copy. University Microfilms International 300 N. Z E E B RD., A N N A R B O R . M l 4 8 1 0 6 8216535 Davis, Willie Dell, Jr. AN ANALYSIS OF HEALTH EDUCATION AND COM M UNITY ORGANIZATIONS AS FACTORS IN IMPROVING PREVENTIVE HEALTH BEHAVIOR IN TWO PREDOMINATELY AFRICAN-AMERICAN TOWNSHIPS IN RURAL LAKE COUNTY, MICHIGAN, U TILIZIN G SELECTED TECHNIQUES OF INTERNATIONAL COMMUNICATION PH.D. 1982 Michigan Slate University University Microfilms international 300 N. Zeeb Road, Ann Arbor,MI 48106 PLEASE NOTE: In all cases this material has been filmed in the best possible way from the available copy. Problems encountered with this document have been identified here with a check mark V 1. Glossy photographs or pages 2. Colored illustrations, paper or print______ 3. Photographs with dark background_____ . ^ 4. Illustrations are poor co p y ______ 5. Pages with black marks, not original copy______ 6. Print shows through as there is text on both sides of page______ 7. Indistinct, broken or small print on several pages 8. Print exceeds margin requirements_____ 9. Tightly bound copy with print lost in 10. Computer printout pages with indistinct print_______ 11. Page(s)____________ lacking when material received, and not available from school or ^ spine_____ author. 12. Page(s)____________ seem to be missing in numbering only as text follows. 13. Two pages num bered____________. Text follows. 14. Curling and wrinkled pages______ 15. Other _____________________________________________________________________ University Microfilms International AN ANALYSIS OF HEALTH EDUCATION AND COMMUNITY ORGANIZATIONS AS FACTORS IN IMPROVING PREVENTIVE HEALTH BEHAVIOR IN TWO PREDOMINATELY AFRICAN-AMERICAN TOWNSHIPS IN RURAL LAKE COUNTY, MICHIGAN, UTILIZING SELECTED TECHNIQUES OF INTERNATIONAL COMMUNICATION By Willie D. Davis, Jr. A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY College of Education Department of Secondary Education, Comparative and International Education ABSTRACT AN ANALYSIS OF HEALTH EDUCATION AND COMMUNITY ORGANIZATIONS AS FACTORS IN IMPROVING PREVENTIVE HEALTH BEHAVIOR IN TWO PREDOMINATELY AFRICAN-AMERICAN TOWNSHIPS IN RURAL LAKE COUNTY, MICHIGAN, UTILIZING SELECTED TECHNIQUES OF INTERNATIONAL COMMUNICATION By Willie D. Davis, Jr. Statement of the Problem The projection of funding in the Health Care Field is that it will decrease. Preventive health measures adopted by individuals is necessary to improve the health of a community. Additionally the vertical "system" of Health Care has been ineffective in providing the community with an adequate system of community education. An improved system of community education related to Health can be provided by adding a community-based Health Committee to the vertical "system" of Health Care. Methods The procedure used for this study is a communication - systems model designed by Bordenave called the people-centered approach. This model utilized the process of a Health Education Model called the "Critical Pathway to Achievement" developed by Isely, Sanwogou and Martin for use in the Cameroon. Multidimensional Scaling Analysis by Ramsey was used to evaluate the above approach's implementation in a rural area of the United States. The research design includes an experimental- group from combined Yates and Webber Townships; two predominately black townships and a control-group from the predominately black township of Covert, Michigan. The experimental-group has a Health Committee which Willie D. Davis, Jr. administered the Health Education Process; Health Committee. and elderly. the control-group has no Samples drawn from the population were "black, poor There were forty-five sampled. The statistics employed for hypothesis testing were the Chi-Square for the hypotheses and the t-Test for the subhypotheses at the .05 level of significance respectively. Results Although the experimental-group committee's objective was accomplish­ ed (i.e., persuading a physician to reside within the community) the data analysis reflects a significant change in attitude-behavior on only two variables when comparing the experimental and control-group; the rela­ tionship of Health Programs to the Health Care System and Young People respectively. This change is possibly due to an intervention which is not under the control of this study and variations of which appeared in both the experimental and control-communities; a Hypertension Control Program. Other specific hypotheses showed no significant differences between the experimental and control-group and overall only the significant difference of the two variables above proved conclusive. Dedicated To My People ii ACKNOWLEDGMENTS First I would like to thank my advisor and chairperson who has not only given me guidance and encouragement during all aspects of this dissertation but has helped me in aspects of organization. Also I would like to thank my committee members for their perseverance and guidance during the course of this academic portion of my life. Additionally, I would like to thank my family who has stood by me for the duration of this academic perici and all of my friends who have offered me encouragement. iii TABLE OF CONTENTS List of Tables ...................................................... vi List of Figures ..................................................... vii Chapter I ............................................................ 1 Introduction ................................................... 1 Need for the Study ........................................ 6 Furpose(s) of the Study .................................. 8 Problem Statement and Significance ...................... 9 Definitions ................................................ 10 Limitations of the Study ................................. 12 Delimitations of the Study ............................... 13 Chapter II ........................................................... 15 Review of the Literature ...................................... 15 People-Centered Approach ................................. 15 Community Orginazations .................................. 19 Epidemiological Research Methods ........................ 25 Communication and Education .............................. 27 System Content ............................................ 29 Systems Approach .......................................... 35 Summary .................................................... 38 Chapter III ......................................................... 39 Methods and Procedures ........................................ 39 Multi-Dimensional Scaling ................................ 39 Semantic Differential ..................................... 44 Instrument Development ................................... 46 Reliability and Validity of Semantic Differential ...... 47 Sites ...................................................... 49 Procedures ................................................. 54 Hypotheses and Subhypotheses ............................. 59 iv Chapter IV .......................... 64 Analysis of the Data .......................................... 64 Analysis P r o c e d u r e .......*................................ 64 Statistical Analysis ...................................... 64 Chapter V ............................................................ 102 Summary, Discussion and Recommendations ..................... 102 Summary .................................................... 102 Discussion ................................................. 104 Recommendations ........................................... 110 Bibliography ........................................................ 113 Appendix A - Survey Pre-Test .................................... 119 Appendix B - Survey Post-Test .................................. 127 Appendix C - Survey Preliminary Test ............................ 132 Appendix D - Communication Process ............................... 136 v LIST OF TABLES Process Chart Demographic Data for Experimental and Control Groups Variable List Summary of Statistics (Three Dimensions. Analysis of Dimensionality using the Chi-Square Test for Pre-Tests and Post-Tests for the Experimental and Control Groups. Analysis of Difference Between Pre-Tests and Post-Tests for the Experimental and Control Groups in Three Dimensions using the Chi-Square Test. Analysis of Homogeneity of Variance for the Experimental and Control Groups at the Pre-Test and Post-Test Levels. Analysis of the Equality of Means for the Pre-Test versus the Post-Test for the Experimental Group by Variable. Analysis of the Equality of Means for the Pre-Test versus the Post-Test for the Control Group by Variable. LIST OF FIGURES Bordenave Communication Model 4 Experimental Group Post-Test Dimension 2 vs Dimension 1 (Overlay) 70 Experimental Group Pre-Test Dimension 2 vs Dimension 1 71 Control Group Post-Test Dimension 2 vs Dimension 1 (Overlay) 72 Control Group Pre-Test Dimension 2 vs Dimension 1 74 Experimental Group Post-Test Dimension 3 vs Dimension 1 (Overlay) 76 Experimental Group Pre-Test Dimension 3 vs Dimension 1 77 Control Group Post-Test Dimension 3 vs Dimension 1 (Overlay) 79 Control Group Pre-Test Dimension 3 vs Dimension 1 80 Experimental Group Post-Test Dimension 3 vs Dimension 2 (Overlay) 82 Experimental Group Pre-Test Dimension 3 vs Dimension 2 83 Control Group Post-Test Dimension 3 vs Dimension 1 (Overlay) 85 Control Group Pre-Test Dimension 3 vs Dimension 2 86 vli CHAPTER I INTRODUCTION One of the means of Improving the quality of life of the rural poor in developing nations is the provision of improved health education and/or health information. Among the indicators that measure whether the quality of life has actually improved are longer life spans, less infant mor­ tality, decrease in diseases such as tuberculosis and malaria, provisions for safe water and better nutrition. 1 Because of the desire to Improve health conditions, numerous pro­ grams involving health education have been designed to aid the rural poor. However, many of the programs Involving health have had limited success In causing significant measurable positive change In the indicators that characterize the quality of life. 2 In "Community Organization as an Approach to Health Education in Rural Africa," by Raymond Isely, Lardja L. Sanwogou, and Jean F. Martin, a model of health education was used in an attempt to bring about measurable behavioral change in four villages in the Cameroon. approach combined the "vertical" system of health care, Their (i.e., a system where the Ministry of Health designs health care and designates its employees as providers to the villages, without benefit of village Inhabitants), with a village Health Committee. The Health Committee 1 Willie D. Davis, Jr., "A Plan to Improve the Quality of Life of the Rural Poor" (Unpublished Paper - East Lansing, Michigan, 1978). 2 Raymond B. Isely, Lardja L. Sanwogou, and Jean F. Martin, "Com­ munity Organization as an Approach to Health Education in Rural Africa," International Journal of Health Education 22, Supplement (3) (1979). 1 2 (in a co-operative effort) interphased with the National Ministry of Health to provide a health education program to bring about measurable behavior change. In their article, Isley, Sanwogou, and Martin emphasize several examples of successful programs in health education and they state: "These various examples emphasize organization of the people as the key approach to health education and preventive programs generally. As Newell wrote (1975): 'Health for the people is becoming health with the people and eventually health by the people.' The same approach was Implemented by the University of Pittsburg-Oceac Project when it began in Cameroon in 1972."3 Bordenave aptly calls this the "People Centered Approach."^ The approach of the University of Pittsburg-Oceac Project required the involvement of the people of a village in improving their own health through "individual and collective change in health and health related behavior."3 To accomplish this task village committees were established in the Cameroon to plan health education and to train auxiliary nurses as village health workers. The village committees consist of heads of the village who assess the health needs of the population, identify health problems, plan and implement health programs, and generally promote health. The committees interphase with governmental agencies (The Ministry of Health) through two steps: 1) assigning visiting health workers to health centers; 2) keeping officials informed of project developments 3I bid, p. 5. A Juan E. Diaz Bordenave, Communication and Rural Development (Paris: UNESCO, 1977). 5 Isely, Sanwogou and Martin, o£. cit., p. 3 3 and Involving them in program evaluation using a jury of four Ministry officials who judge the quality of the committee’s work. The Ministry in turn recognized that the people's participation was an essential com­ ponent of any program aimed at improving community health and that this participation is particularly needed to achieve better coverage with regard to preventive care and to encourage current efforts at organizing village health committees in South-Central and Northern Cameroon. Because of the success of this approach the Government of Cameroon and USAID agreed to sign a new contract to extend to other areas of the country the experiences gained in South-Central Cameroon. Behavioral outcomes of this project included the building of (per village) an average of 15.6 latrines, 3.5 protected springs, 4.1 garbage pits, and 3.4 animal enclosures, and overall showed achievement on five fronts: 1) the establishment of a network of village health workers; 2) a resurgence of self-reliance in some villages; 3) a concrete example of health education in action for future trainees; 4) a decision to make the Mefou Department of the Ministry of Health the site of the project, a "community health" laboratory for the University Center for Health Sciences of the University of Yaounde; and 5) the establishment of (with the support of the World Health Organization), a Regional Health Education Training Center for French-speaking Africa at the University Center for Health Sciences. The process used to achieve the above outcome in the Cameroon Project is called the "Critical Pathway to Achievement" (See Process Chart, p.4). FIGURE 1 PROCESS CHART 4 P M C I S b CHARI Cameroon progress—C r itic a l Pathway 10 Achievement bordenave C o p u n ic a tlo n System Sarhaugh's Cross-Cultural C cw unicallon Health Education Aodet-PREUDE C iih tftn g i n f o n u i i w flee tin g v illa g e leader* In p u t-A s s e s s in g the needs o f the can a u n it/ fo u r v a ria b le * to consider fo r e ffe c tiv e communication 1. N orld view 2 * Perceived re la tio n s h ip and In te n t 3. Code (language) 4 . Empathy (accepting norms, ro le s and values) C onsideration o f the q u a lity o f life Phase 1— 1. Social problem* 11. Health problems W ithering I n fo r M tio n both demographic m d on so c ia l in d h e itth problems Input Phase 11—e p ls te m lo lo g ita l and medical data c o lle c tio n O rganizing a Health Coaaaittee ( lo c a l) Input Phase 11—rank h e a lth problems S e ttin g and assessing health problems Input Phase I I —rank h e a lth problems Choosing one problem to work on P ro c e s s -In te rn a l in te ra c tio n and cooperation through in f o r ­ mation and interchange Phase l l —w lth e p iste m io lo g ica l and medical data c o lle c tio n s e le c t top h e a lth problem Inform ing the Camalttee about the problem Process—tran sform ation o r in puts In to outputs Phase 111—assess b e h a vio rla l causes o f h e a lth problems* behavior diagnosis Assessing lo c a l resources Process—c o n s tra in t assess* ■ent ( fa c to r th a t Inpede the s o lv in g o f h e a lth problems) Phase IV—fa c to rs th a t a ffe c t h e a lth behavior (educational diagnosis) * , predisposing fa c to rs ** a ttitu d e s , b e lie f s , va lu e *, perception, f a c ilit a t e s o r hinder* personal m o ti­ va tio n f o r a change b. enabling fa c to rs —b a r r ie r * created by s o c ia l forces o r systems c . r e in fo rc in g fa c to rs — re la te d to feedback the le a rn e r receives from others S e ttin g staged o b je c tiv e s Process—d e tlp i o f the output and outcones to be achieved S e ttin g re s p o n s ib ilitie s — tln e schedules Output—c ontent o f the output mode (what th e message consists o f) Phase V—decis io n a* to which o f the three fa c to rs above or combination w i l l be the focus o f the In te rv e n tio n In p le n e n tttfo n Control o f the environment— execution o f the output message being sent to the c o v m n ity Phase VI—development and im olesentatlon o f the plan (in te rv e n tio n ) Feedback—evaluation o r modi­ fic a tio n s necessary Phase Y l l —fv a lu a tlo it. There are s ix plans o f evaluation th a t ranqe sfiq>1e record to a complex evaluation research p ro je c t. A choice awst be made as to which plan to use. Evaluation o f re s u lts D iffu s io n process—Roger* and Shoemaker Change agent create* needs fo r c lie n t Change agent analyse* problem Change agent creates in te n t f o r c lie n t to change System e ffe c t norms, so cia l sta tu s and h iera rchy which lapede o r f a c il it a t e r a te o f d iffu s io n (c o n s tra in ts ) D iffu s io n process—character­ is t i c * o f Innovations a lso functions o f d iffu s io n s 1. focmledge 3. Decision 2. Persuasion 4. Confirm ation Type o f ( lu p lr personal mas* media o r in te r ­ 6 The evaluation component of the "Critical Pathway to Achievement" in terras of an assessment of the committee's impact on health attitudes, health related behavior and health status of the population is not cur­ rently available. Accomplishments such as latrine building, protecting springs and declarations of intentions for the year to come remains at present the only means of evaluation. However, this present project (author's study) will use the "Critical Pathway to Achievement," and add an evaluation component with experimental and control conditions. This approach essentially takes the "Critical Pathway to Achievement," translates its components into a communication system like that developed by Bordenave in his "People-centered Approach" (See Process Chart p. A) which allows for a quantitative evaluation of a process involving a Health Committee.^ Need for the Study Health Education is a very crucial component of the State Health Plan of Michigan. Governor Milliken stated in his State of the State (1979) Message: The two main points of focus are (1) health promotion, including health education, fitness, nutrition and prevention of diseases and conditions which result in premature death or disability, and (2) improvement in the nature, structure and cost of the health services delivery system.? "Health Education of the Public: A Statement of Public Policy," also a Michigan document, addresses itself through recommendations and Bordenave, oj). cit., 1977. ^Milliken, William G . , "State of the State Message," January, 1979. 7 goals to a policy statement for Health Education throughout the state and also the relevance of Health Education to racial/ethnic groups by stating: Health Education for various racial/ethnic groups is extremely important . . . All aspects of Health Education should be addressed to these groups, taking into account language, cul­ tural and educational differences . . . The goal of the Rural Health Initiative (RHI) is "to emphasize preventive and health education programs."8 Evaluation in Health Education is crucial and the need for carrying out evaluation research in health education is important. At the Tenth International Conference on Health Education in London in September, 1979, Maria Antonia Modolo in her summary of the methodology section singled out a Dr. Beni of whom she speaks: He stressed the importance of scientific research in Health Education Methodology and the lack of a theoretical basis concerning the solutions to health behavioral problems due to an overemphasis on studies of the problems.° Gunarantne emphasized the adoption of postwar models of the "western" health service delivery systems (of which health education is a part as Is the technology of mass media communication) and the underproductiveness of this approach because of its disregard for different cultural, social, political, economic, social and geographical patterns. He states: One of the principal limitations of health care is the poverty of research about individual, cultural, societal and health behavior and the nature, motivations and determinants of health learning and change in response to Health Education.-^ g Michigan State Health Planning Committee Advisory Council and the Office of Health and Medical Affairs, Health Education of the Public (1976) p. 41, 1. Q Marie Antonio Modolo, "Theme 3: Methodology". Journal of Health Education 23(3) (1979). International ^ V . T. H. Gunaratne, "Health for All by the Year 2000; International Journal of Health Education (23) Supplement (3) (1980). 8 In Health Services Research, Fall, 1978, Arthur Weissman, Senior Vice President of the Kaiser Foundation Health Plan supported this view by this statement: In view of the increasing interest in Health Education and the need for changing lifestyles and modifying behavior for disease prevention and health maintenance, research is needed to provide techniques and strategies for motivating people to improve their own health. And in the same book in an article, Stephen M. Shortell and James P. LoGerfo spoke of health services research while highlighting areas requiring further study: Above all, if health services research is to have an increased impact on public policy, there is a need for the development of social science theories and for their application to research in health problems and especially to program evaluation, the latter being particularly important to effective decision m a k i n g . H In the document mentioned earlier called Health Education of the Public: A Statement of Public Policy, the need for scientific research is again emphasized as one of its goals, that is: to expand research in health behavior and health education, including community based evaluation studies focused on target groups, and, . . . innovative approaches in health education need to be tried and tested in order 1 to determine the best methods o of delivering health education. Purpose(s) of the Study It is the purpose of this study to 1) comparatively evaluate the effectiveness of a community organization (health committee) as a com­ ponent of health education of an existing health care system Regional Arthur Weissman, "Some Issues in Health Services Research"; Stephen M. Shortell and James P. LoGerfo. "Health Services Research and Public Policy"; Health Services Research (13)(3) (1978) pp. 229-234. 12 Michigan, op cit., pp. 8-21, 9 Health Care with an existing Health Care System which does not have an education component administered by a Health Committee, 2) serve as a model innovation for health projects in rural areas of the United States and developing countries, 3) add to the body of the literature of non- formal education and its application to health education in improving the life of the rural poor, and A) be applicable to the body of literature which studies the effect of community organization on health education of the rural poor. The indicators that will be used to mea­ sure the effectiveness of a community organization (health committee) are health-related behavior change and attitudes toward existing Health Care Systems. Problem Statement and Significance There is great concern developing in the health care field toward preventive health care. With the projections of less and less funding for health care, preventive health measures adopted by the individuals is necessary to improve the health of the community. Health Care is a vital need of a community and the vertical "system" of health care has not been effective in providing the community with infomation of its services ucation.^ 13 or an adequate system of community ed­ It is hypothesized that an improved system of health educa­ tion can be provided by adding a horizontal (A relationship where a Health Committee, in conjunction with a Health Care Agency, designs 13 U.S. Department of Health, Education and Welfare, Public Health Service, National Institues of Health, Toward an Educated Health Con­ sumer , by Carter Marshall, Teaching of Preventive Medicien Series, Publication No. (NIH) 77-881 (1977). 14 Isely, Sanwogou and Martin, op c i t . 10 an education intervention) community-based Health Committee to the vertical "system" of health care. To test this hypothesis it is proposed that the outcomes of a Health Committee's interactions with the vertical "system" of Health Care be evaluated to measure its effectiveness against a community which has no Health Committee, only a vertical "system" of health care. Definitions There are several terms which need to be defined for aproper standing of the purposes of this study. under­ They are: Health Education— "A process that informs, motivates, and helps people to adopt and maintain healthful practices and lifestyles and advocates social and environmental changes as needed to facilitate healthful living conditions and behavior." 15 System— A set of facts, principles, rules, etc., classified or arranged in a regular, orderly form so as to show a logical[functional] plan linking the various parts; a set or arrangement of things sorelated or connected as to form a unity or organic w h o l e . ^ Non-Formal Education— "Any organized systematic, educational activity carried on outside the framework of the formal system to provide selected types of learning to particular subgroups in the population, adults ■^Michigan, Health Education of the Public, p. 16. ^ W e b s t e r ' s New World Dictionary of the English Language, second college edition, (1972), p. 1445. 17 System is also defined for the purposes of this study as "any set of interacting parts that maintains its boundaries while exchanging influences with its environment" as shown in Bordenave's Communication and Rural Development, p. 18. This refers to its usage as a communica­ tion system. 11 as well as children. 18 Preventive Medicine— Those activities that are the direct responsi­ bility of the individual in the prevention of disease and in the pro­ tection and the promotion of himself and his family . . . fall for the most part upon the family health advisor. Usually this person is the private physician, who aid and guides all memebers of the family in all matters pertaining to individual health protection. 19 Primary Prevention— "Those activities undertaken to prevent the occurrence of disease or illness."2^ Secondary Prevention— "Those activities undertaken to intervene after disease can be detected, but before it is symptomatic." 21 Tertiary Prevention— "Those activities undertaken to prevent the progression of symptomatic disease or illness." 22 Epidemiology— "The field of science dealing with the relationship of the various factors which determine the frequencies and distributions of an infectious process, a disease or physiological state in a human community." 23 18 Phillip H. Coombs and Manzoor Ahmed, "Attacking Rural Poverty, How Non-formal Education Can H e l p . Baltimore: John's Hopkins University Press, 1974, P. 8. 19 Wilson G. Smillle, Preventive Medicine and Public Health. New York: The MacMillan Company, 1952, p. 16. 20 U.S. Department of Health, Education and Welfare, Public Health Service, Office of the Assistant Secretary for Health, Report of the Departmental Task Force on Prevention, September 1978, p. 16. 21Ibid., p. 16. 22Ibid., p. 16. 23 Dorland's Illustrated Medical Dictionary, 245th edition, (1965) p. 499. 12 Epidemic— "Attacking many people in any region at the same time, widely diffused and rapidly spreading. A disease of high morbidity which is only occasionally in a human community. ... tensive prevalence of any particular disease." A season of the ex- 24 Endemic— "Present in a community at all times, but occurring in only a small number of cases. ... A disease of low morbidity that is constantly present in a human community." 25 Vertical System— A system in which a Health Care System designs the health care delivery system and designates employees as providers to a com­ munity without the benefit of a Community-based Health Committee or commun­ ity inhabitants. Horizontal System— A system in which a Health Care System designs, in conjunction with a Community-based Health Committee, health care delivery to a community. Limitations of the Study Assignment of Subjects to Experimental and Control Groups There is no random assignment of subjects to the experimental and control-groups. The sample is stratified to include the elderly, poor and black which form a large proportion of the population of Yates, Webber and Covert Townships. 2AIbid., p. 400. 2^Ibid., p. 486 13 Random sampling will not suffice for the purposes of this study. In the words of Kerlinger: Indeed it is relatively uncommon, at least for describing character­ istics of populations and the relations between such characteristics. It is, nevertheless, the model on which all scientific sampling is based.^6 The stratification of the sample allows us to match the experimental groups only in terms of age, income level, race, and rural status. Infer­ ences to other segments of the population are not valid. One area in which the groups are not matched is education. This limitation excludes an analysis based on education level as a matching criteria and points to a difference in the two groups. Control of Intervening Variables The experimenter has no control of activities generated by any health agency within either of the communities either control or experimental. Variables introduced beyond the control of the experimenter can limit the conclusions drawn in this study. Delimitations of the Study This study applies only to rural communities which have a health committee or similar group which utilizes health education to aid the vertical Health Care System in the delivery of Health Services and Health Care. It Is further limited to only one aspect of the Health Care System; preventive medicine by the poor, black, and elderly which utilizes Health Education as a method to promote preventive health care. 26 Fred N. Kerlinger, Foundations of Behavioral Research, New York: Holt, Rinehart and Winston, Inc., 1973, p. 129. These 14 limitations are necessary for the purpose of an adequate evaluation of Health Education in a rural community by a single investigator. CHAPTER II REVIEW OF THE LITERATURE This chapter will review the literature of projects, studies and philosophy which underlie the People-centered Approach to Health Educa­ tion, community orgainzations, Health Education and its relationship to Communication, Communication and its relationship to System and Epidemio­ logic Studies using classical research designs. People-Centered Approach Gunaratne as noted above (Chapter I) emphasizes that the adoption of post-war models of the ’'Western" health care service delivery system has been unproductive because of its disregard for the study of cultural, social, economic and other patterns as a prerequisite for designing health education strategies. He states: . . . health administrators sought to teach the backward, super­ stitious, uneducated villagers about the virtues of 'modern health services' by employing a corp of well-trained health ed­ ucators. The results have been unproductive, to say the least in the developed and developing world.^ Isely, Sanwogou and Martin 2 while not as harsh in their assessment of "Western" health programs feel that these types of programs have had limited success in causing a positive .change in the quality of health care. ^Gunaratne, ^p. cit. 2 Isely, Sanwogou and Martin, op. cit. 15 1 6 Developmental theorists, when discussing these types of programs In developing nations, feel that the non-success of these programs is due 3 mainly to their underlying philosophy. Carnoy contends that many de­ velopmental projects are used by the developed nations as mechanisms to promote imperialistic designs under the guise of education. Pinar 4 feels that the educational curriculum of these programs do not reflect the needs of the inhabitants of a country nor recognize the rights of the inhabitants to participate in the shaping of their future. Friere"* contends that “banking" educational systesm (information deposits which the students receive, memorize and repeat) are tools for the domination and domestication of the masses and do nothing to promote the person's growth. Yet Friere contends that this growth must be a dynamic part of any educational system. He contends that the hierarchial (vertical) re­ lationship between the teacher and learner must be eliminated and replaced by a new relationship which projects in roles of teachers and learners, both types of participants. In this way both teacher and learner become communicators of knowledge (horizontal relationship). Two conditions, according to Friere, are necessary for this dual communication of knowledge; 1) faith in the ability of people to learn, change and liberate themselves from conditions of ignorance, poverty and exploitation and 2) direct contact of the learners with their own reality and its problems and the analysis of the constraints imposed on them by 3 Martin Carnoy, Education as Cultural Imperialism: Me Company, 1974. ^William Pinar, Curriculum Theorizing: California: McClutcheon Publications, 1975 The Reconceptulists, Berkley Paulo Friere, Pedagogy of the Oppressed, England: 1972. David Penquin Books, 17 social structure and official ideology. This is called conscientizacao by Friere, which is defined as learning to perceive social, political, and economic contradictions, and to take action against the oppressive elements of reality.^ Minkler and Cox discuss the approach used by Friere and its use in health care. They state: Over the several years, applications of the Friere method to the health field in rural areas of Latin America, Africa and in inner-city communities in the United StateB have demonstrated the effectiveness of this method for improving health conditions while creating in people a critical awareness of the root causes of their problems and a concomitant readiness to take action based on this awareness.^ Minkler and Cox discuss two applications of the "Friere Method." In Honduras women were used successfully to promote health through developing radio schools, housewife clubs and training sessions. The Honduran w o m a n ’s role as Health Worker was secondary to her role as "conscienticizor." The second application occurred in an inner-city community in the "Tenderloin" area of San Francisco, an area populated with 14,00016,000 elderly persons who rent single rooms and live below the poverty level. The elderly, because of the high crime rate, drug addiction, alcoholism, and prostitution were roombound, forgoing food and medical attention rather than venturing outside. success. This project did not meet with Lack of kinship bonds, lack of sense of group or community, and the existence of competing interest groups who attempted to garner the political visibility and the financial resources that go with serving 6I bid., p. 19 y Meredith Minkler and Kathleen Cox, "Creating Critical Consciouness in Health," International Journal of Health Services, (10) (2), 1980. 18 this area were given as reasons for failure. Minkler and Cox state: The health education project was viewed with suspicion by a powerful element in the existing aid structure of the community and the project grant therefore was not renewed after the first year.® Minkler and Cox compare the people-centered approaches of Friere and Mao Tse Tung of China and their relationship. Both Friere and Mao stress full participation of the people through dialoguing and similar means as Q essential to effective liberation and change. Schwartz studied the participation of the Chinese masses in community involvement by analyzing the "mass line strategy" (mass participation and community involvement) which is practiced through the "need to try and serve the masses from their perception of reality by becoming one with them.^ Using this strategy the Chinese Communist Party, militia and health personnel worked and lived among the local residents. This approach used in preventive mass health campaigns produced great success in controlling schistosomiasis, birth control and veneral diseases. Schwartz compares the mass line strategy with Western health education principles and remarks that they are similar in principle, however the translation of these principles into action is considerably different. He states: The mass line contains within it some of the basic principles of health education. If we extrapolate these same health education principles, they lead to practices which have their fullest expression in the PRC (Peoples Republic of China). China therefore, is sine qua non for understanding the practice of fundamental 8Ibid, p. 320. 9I bid, p. 313 ^ D a n Schwartz, "The Mass Line as Consumer Participation and Community Involvement," International Journal of Health Education, 20, Supplement (3) (1977), p. 2. 19 health education principles as they relate to consumer participation and community involvement This view is shared by Rifkin who states: Through the use of health teams and auxiliary workers, through the implementation of mass campaigns, through the integration of Western and Traditional medicine and practitioners and through a continuing emphasis on health work in rural areas, the health system sets guidelines for distributing medical resources in order that the majority of people have access to health protection and medical care. For this reason and for many others, the new Chinese medical and health care system will continue to be of interest both to the medical profession and national policy makers who must find solutions for the existing medical problems among the rural peoples of the world.12 Finally Bordenave on the issue of people-centered movements, contends: On the whole, the behavior of communicators, teachers, change agents, advertising experts, politicians and so on has revealed an orienta­ tion that is essentially vertical, directive, aimed at manipulation and indoctrination . . . However in recent years this concept of development (vertical, etc.) has been challenged as a result of repeated failures and a new notion of development, more centered on the people concerned, has been proposed. At the same time, the "modernization11 orientation of development communications has begun to be criticized and modified.13 Community Organizations Bordenave believes that the people-centered approach can be interna­ lized through community organizations. If a community can organize be­ hind a need such as vocational skill training or solving problems of health care, it takes them past the stage of contact with their own U Ibid, p. 12. 12 Susan B. Rifkin, "Health Care for Rural Areas," Medicine and Public Health in the Peoples Republic of China, John E. Fogarty International Center for Advanced Study in the Health Sciences, U. S. Department of Health, Education and Welfare, Public Health Service, National Institutes of Health, No. (NIH) 72-67 (Wash. D.C.) 1972, p. 147, 13 Bordenave, o p . c i t . , p. 21. 2 0 reality and its problems to an active participation in solving these problems. Awareness is not enough. This active participation can be translated into forming pressure groups, collectives, and/or committees which deal with a topic such as health care and designing a health educa­ tion program to meet health care needs. Community organization and the coordination of available health care resources appear to be a viable way of improving health services if done through a system of health education. The most notable case gives impetus to this study; "Community Organization as an Approach to Health Education in Rural A f r i c a . H e r e a model was set up to establish village committees in the Cameroon to plan health education and the training of auxiliary nurses as village health workers. The project was successful in getting village communities to plan concretely for the future. One village, in particular, for which data was collected showed a remarkable change in behavior with creating four protected springs. the villagers building latrines and The villages in this project show some remarkable similarities to Yates and Webber Townships (area of study) in these areas of comparison: 1) little agricultural development; 2)exodus of much of the active segment of the population; 3) poverty; 4) elitest education (little relevance to development needs of the a r ea); 5) de­ pendent population, i.e., the elderly, young, and poor. Bertrand and Bertrand 15 concluded a study in Columbia, South America on a program in community organization which, in response to acute health 14 Isely, Sanwogou and Martin, op. c i t . ^"\june Bertrand and William Bertrand, "Health Education Among the Economically Deprived of a Columbian City," International Journal of Health Education, 22 (2), 1979. 2 1 care needs designed a program which included a series of health topics including preventive medicine and nutrition. This program obtained significant results among those who participated; in greater-knowledge of health concepts, awareness of health hazards, and to some extent, changes in health-related behaviors. Fehrsen, 16 in an African community, undertook a study which assessed community health needs by village inhabitants. A medium of communication, song, was successfully used to spread health education messages. M e r t e n s ^ reports a plan in community development in Canada which trained Eskimos and Indians through a Community Health Worker Programme. This program was successful in getting people to adopt and practice re­ commended health measures and working out solutions to their own problems. The program explains Medical Service Programs to the Indian and the Eskimo, and helps to maintain good liaison links between all agencies and the people. Ogionwo 18 found the community involvement approach to Health Educa­ tion to be superior to the individual approach especially in terms of efficiency in factors which influenced acceptance or rejection of re­ commended health measures (i.e., demographics such as age, marital status and sex, attitudes toward illness, attitudes to life in general, sets of values, degree of social Interaction, etc.). "^G. S. Fehrsen, "The Use of Traditional Means of Communication in an African Community,11 International Journal of Health Education, 22 (3), 1979. ^ E t h e l G. Mertens, "Health Education and Community Development," International Journal of Health Education, 12 94), 1969. TO W. Ogionwo, "Socio-psychological Factors in Health Behavior," International Journal of Health Education, 16 (2), 1973. 2 2 Cox 19 conducted a study in which the elderly are used as community health workers to educate their peers. She concluded that the elderly are receptive to educational programs presented by their peers and many are interested in undertaking the training themselves. German 20 supports Health Education for the elderly and her findings have important implications; that the elderly are educable, that the elderly will comply with instructions and that future Health Education programs should be aimed at the elderly because of its high population among the people in this country. Moore 21 supports this study in a dissertation titled ’’The Impact of a Health Education Program on Poor Black Elderly Persons," a study involving an experimental and contro1-group. She exposed the experi- mental-group to ten two-hour sessions of health education designed to improve their knowledge of health education. no health education sessions. The contro1-group received A t-Test used to compare the mean scores of the experimental and control groups was significant at the .05 level. 19 Carole Cox, "Using the Elderly as Community Health Workers," International Journal of Health Education, 22 (1), 1979. 20 Pearl S. German, "The Elderly: A Target Group Highly Accessible to Health Education," International Journal of Health Education, 21 (4), 1978. 21 Emily Louise McClinton Moore, "The Impact of a Health Educational Program on Poor Black Older Persons," (Ph.D. Dissertation University of South Carolina, 1980). 23 A Community Health Education Program to control heart disease in the Province of North Karelia, Finland which has the highest documented heart disease rate in the world is discussed in Lehman, et al., 23 and Puska et al. 24 22 Tuomilehto Because of their concern for their own health the North Karelians petitioned the government for relief. The result was a comprehensive community program to control cardiovascular disease through primary and secondary prevention. A control-group and an experimental-group were used and the student t-Test was used to test for significance. The results showed a significant drop in heart attacks by 14 percent and the incidence of stroke among North Karelians aged 30 to 64 dropped 40 percent. Most significantly, 90 percent of the sample group par­ ticipated in a program whose objective was: . . . to carry out a systematic program and reallocate the existing service resources to control this modern epidemic; to integrate the activities of the existing health and social services in the community and to have the full participation of the community; and to have a continuous follow-up of progress and feed back to the c o m m u n i t y . 25 Under the auspices of Dr. Victor Sidel and his colleagues in the Department of Social Medicine of Montefiore Hospital and Medical Center 22 Phyllis Lehman, ’Health Education1 Healthy Peo p l e : The Surgeon General’s Report on Health Promotion and Disease Prevention, U.S. Depart­ ment of Health, Education and Welfare, Public Health Service, Office of the Assistant Secretary for Health and Surgeon General, DHEW (PHS), No. 79-5510A (Wash. D.D.), 1979. 23 Jaakko Tuomilehto et al., "Community Programme for Control of Hypertension in North Karelia, Finland," The Lancet, Oct. 25, 1980. 24 Pekka Puska et al., "Changes in Coronary Risk Factors During Comprehensive Five-Year Community Programme to Control Cardiovascular Diseases" (North Karelia Project,), British Medical Journal (2), 1979. 25lbid. p. 1174. 24 a program called the Community Health Participation Program, trained Interested residents in a Bronx New York Community as Health Coordinators who serve as unpaid health promoters. In a two-year period they Initiated projects in their apartment buildings which included: . . . counseling individual tenants and families on matters of physical and mental health, referring neighbors to social agencies and community help when needed. . . giving first aid in emergencies. . . and organizing self-help groups and health work shops in a variety of areas ranging from stopping smoking to parenting.26 Its affiliation with the hospital has allowed the program to draw upon the hospital's resources for specific assistance when needed. In Lowndes County, the poorest of 67 counties in Alabama, and the third poorest In the United States, a group of local citizens formed a community corporation, The Lowndes County Health Services Association, In 1973. Through their efforts and others a clinic was opened. After June, 1977, a Health Education project was begun which emphasized Patient Education and community based education under a contract with the Tuskegee Area Health Education Center, a non-profit community-based organization. Its patient education component however was more suc­ cessful than its community-based educational efforts. The patient educa­ tion protocol was reproduced In quantity by the Bureau-funded primary care health centers, both urban and rural. Requests are received from other states and countries for master copies of the patient education protocol. 26 2' H. Carson Biggs, ed., "Community Self-Help Program Uses Chinese Model," Self-Help Reporter 2 (1), 1978, p. 1-2. 27 Bureau of Health Education, Focal Points, U.S. Department of Health, Education and Welfare, Public Health Service, Center for Disease Control, (Atlanta, Georgia, May, 1980). 25 Community Health Education Studies Using Epidemological Research Methods There are some studies which have been done in communities without the objective of involving the community in implementing and carrying out strategies of Health Education. These studies use research methods that involve the use of research designs which test the significance of certain types of health educational interventions (i.e., preventive and curative measures to control disease). Solon et al., 28 evaluated in the Phillippines, the relative effectiveness of three intervention strategies to control Vitamin A deficiency in Cebu which causes blindness, a condition called Xeroph­ thalmia. One of 662 children aged 1 to 6 were blinded by factors associated with Xerophtalmia. The three strategies used were 1) Public Health and Horticulture including Health Education and a village co­ operative pharmacy, 2) supplying Vitamin A in capsule form and 3) putting Vitamin A into a food substance used in soups, stews and other dishes served to young people. A multivariate analysis using multiple re­ gression was used to test for significant results at the 05 level. The third intervention strategy, putting Vitamin A into the food substance proved to be the most effective though the authors recommend a combination of all three strategies for future prevention strategies. One weakness however, the authors explain, is the absence of a control-group. However, the main objective of the research is to deter­ mine the relative effectiveness of the three intervention strategies. 28 Florentino Solon et al., "An Evaluation of Strategies to Control Vitamin A Deficiency in the Philippines," American Journal of Clinical Nutrition 32 (July, 1979). 26 Hudson and Parker 29 in a study to isolate the effects of introducing a new technology using satellite-radio for health education to influence health care delivery in rural Alaska compared nine (9) satellite-radio villages (experimental-group) with four (4) high-frequency radio villages (control-group). Using a t-Test to test for significance, a significant difference was recorded in radio contacts between health aides and doctors and in the number of medical cases treated. Farquhar et al., in a field experiment in three northern California towns called the Stanford Heart Disease Prevention Program conducted extensive mass media campaigns over a two-year period. munities was used as a control-group. One of the com­ The purpose of this experiment was to reduce the risk of cardiovascular disease through community health education. In the control-community the risk of cardiovascular disease increased and in the the treatment communities there was a substantial, sustained significant decrease in risk. The measure used to test for significance at the .05 level was the multiple logistic function. Lehman 31 supports this study. Vertinsky et al., 32 used the Chi Square test of significance at the .01 and .05 level of significance to measure the rate of compliance with a screening program for a genetic disease of Tay-Sachs which effects Jews. 29 Heather E. Hudson and Edwin B. Parker, "Medical Communication in Alaska by Satellite," New England Journal of Medicine, 25 (Dec. 20, 1973). 30 John W. Farquhar et al., "Community Education for Cardivascular Health," The Lancet 1, (June 4, 1977). 31 Phyllis Lehman, o p . cit. 32 Patricia A. Vertinsky et al., "A Study of Compliance Factors in Voluntary Health Behavior, International Journal of Health Education, 19 (1), 1976. 27 Their findings in relationship to the preventive aspect of voluntary health behavior showed significant results in determining that social responsibility to the community is a strong indicator of compliance and that health education triggers positive health behavior. Four studies cited above in the previous section which involve the community in Health Education and Epidemiological Research Designs with statistical significance tests are the studies of Cox Tuomilehto et al. 35 and Puska et al. 33 , Moore 34 , 36 Communication and Education Some of the literature related to Health Education is concerned with communication theory and models. Marshall states: To health educators the challenges are two-fold. Successful com­ munication of the belief that the maintenance of good health is an appropriate and achievable individual goal and responsibil­ ity. . . . Mass communication may not have a direct effect but it does exert a significant influence through various mediating factors. For example, the health education message urging people to have their blood pressure taken is mediated by individual perceptions of personal susceptability, the severity of the disease , . .37 Marshall, in addition, contends that Health Education and communi­ cation are related by designing a chart in which he shows that the Communication Task of socializing new members in modern society is done through inter-personal channels involving parents, older children and 33 C o x , op. cit. ■^Moore, o£. c i t . 35 Tuomilehto et al., oj^. cit. 36Puska et a l . , o p . cit. 37 Marshall, Toward an Educated Health Consumer, U.S. Department of Health, Education and Welfare, p. 3 - 1 7 t 1 977 . 28 professional teachers, and In a mass channel pattern by school systems, publishing and educational m e d i a . Wood and Wylie define Communication and Education as being identi­ cal. They state: Communication is education. Education is communication. The process is theoretically identical. Formal educational situa­ tions can be interpreted basically as institutionalized com­ munication proceedings designed for specific individual and societal purposes— to pass on man's heritage of knowledge and culture, to discover new knowledge, to acquire skills for earning a living, to develop appreciation for certain values and so forth. Webster defines Education as developed . . . " information." . . knowlege, ability, etc., thus and Communication as " . . . a giving or receiving of On a closer analysis of the key words, Knowledge and Information we find they are imbedded in each others definitions. In­ formation according to Webster is " . . . transmission of knowledge, knowledge acquired in any manner, facts, data, learning . . . " Know­ ledge is defined as " . . . acquaintance with facts, range of information, awareness or understanding, what is known, learning, enlightment." 39 Thus if Education is Knowledge and Information and Communication is Information and Knowledge, Education and Communication are identical. Friere discusses the relationship between communication and educa­ tion. His "problem posing" brand of education "intentionally rejects 38 Donald N. Wood and Donald G. Wylie, Educational Telecommunications, California: Wadsworth Publishing Company, 1977, p. 11-12. 39 Webster's New World Dictionary of the English Language. 29 communiques and embodies communication"^ and speaks of solidarity in these terms: . , . Solidarity requires true communication and the concept by which such an educator is guided, fears and pre­ scribes communication. Yet only through communication can human life hold meaning. The teacher's thinking is authen­ ticated only by the authenticity of the student's think­ ing. . . . Authentic thinking, thinking that is concerned about reality, does not take place in ivory tower isolation, but only in communication.^ Bordenave also addresses the link between education and communica­ tion. He quotes Beegle and Loomis' definition of communication in these words: Communication was defined as the process by which information, decisions, and directives pass through a social system and the ways in which knowledge, opinions and attitudes are formed or modified. and states in his own words: Present day innovative educational technology is above all a discipline of synthesis and a trend toward synthesis is what seems very much required in development communication studies both to extend our knowledge of possibilities and potentials, and to humanize the range of earlier theories . ^ An examination of the process chart (Figure 1, p. 4) gives a visual representation of the relationship between health education and communication models. The Cameroon-Critical Pathway to Achievement, model on the process chart, and PRECEDE ^Friere, 45 44 the basic are Health Education Models. o p . cit., p. 66. 41Ibid, p. 63. ^Bordenave, o£. cit., p. 15 43Ibid, p. 21. 44 Isely, Sanwogou and Martin, o£. cit. 45 Lawrence W. Green et al., Health Education Planning: A Diagnostic Approach, Palo Alto, California: Mayfield Publishing Company, 1980. 30 The Bordenave Communication System , Sarbaugh*s Cross-Cultural Communi­ c a t i o n ^ and the Diffusion Process^® are examples of Communication Models. (See Figure 1, p. 4) From the chart it can be deduced that the Bordenave Communication System has the analogous components of both Health Education Systems. The Sarbaugh Cross-Cultural Communication strategy and the Diffusion Process (See Figure 1, p. 4) are important concepts which can be incorpor- into the Health Education/Communication model and supports Bordenave's idea of a "Synthesis" discussed above. Ogionwo 49 , Vertinski et al. 50 , and Rogers and Shoemaker 51 afore­ mentioned studied the effects of mass media vs inter-personal channels of communication in relation to Health Education. Miller and Cantor 52 compared the effectiveness of different types of mass media on blacks and whites and found radio to be an effective channel for Health Education Broadcasts for blacks. System Content "A system" according to Miller is, " A set of interlocking units with Bordenave, o£. cit. 47 L. E. Sarbaugh, Intercultural Communications; A Plan for Study and Practice, Rochelle, New Jersey, Hayden Publishers, 1976. 48 Everett M. Rogers with F. Floyd Shoemaker, Communication o f Innovations, New York: Collier-MacMillan, LTD, 1971. 49 Ogionwo, o p . c i t . ^ V e r t i n s k y et al., o p . cit. "^Rogers and Shoemaker, ojj. c i t . 52m . Clinton Miller, III and Alan B. Cantor, "A Comparison of Mass Media Effectiveness in Health Education," International Journal of Health Education, 23 (1), 1980. 31 relationships among them. 53 Bordenave adds to this definition by defining system as "Any set of interacting parts that maintains its boundaries while exchanging influences with its environment." 5A Bates 55 supports the boundary concept. Systems are further broken into types. Ryan identifies four types: 1. Natural systems: Natural systems include solar systems, mechanical and thermodynamical universes of nature and the human organisms 2. Man-made systems: Man-made systems refer to organizations or structures of related components devised by man, rather than found in the natural state 3. Closed system: A system is closed if there is no import or export of energies in any of its forms, such as informa­ tion, heat, physical materials, and no change of components 4. Open system: An open system is one in which there is an exchange of materials, energies of information between the system and its environment-^ Miller describes three types of systems: Conceptual system: This system in essence defines the variable and the relationships in functional systems; the Concrete system and the Abstracted system Abstract system: The units of abstracted systems are relationships constructed or selected by an observer in the light of his interests, theoretical viewpoint or philosophical bias. Some relationships may be empirically determinable by some operation carried out by the observer, but others are not being only his concepts^/ 53 James Greer Miller, Living Systems, New York, McGraw Hill, Inc., 1978, p. 16. 54 Bordenave, c>£. cit. , p. 16. 55 Erica Bates, "A Systems and Marketing View", International Journal of Health Education, 15 (3), 1972. "^Antoinette T. Ryan, System-Techniques for Programs, Introduction to the Systems Approach, Englewood, Cliffs, New Jersey, 1973, p. 48. 57 Miller, £j>. cit., p. 19. 32 The concrete systems include the open and closed systems, man-made systems and the natural system which is "a special subset of all possible concrete systems." They are composed of moneran, protistans, fungi, plants, animal, groups, organizations, societies and supranational systems. all have the following characteristics: They They are open systems, with significant inputs, throughputs, and outputs of various sorts of matterenergy and information." Bates 59 58 discusses a definition of a "system and its application to health education. She views health education as a consumer-oriented marketing strategy. Using marketing-oriented research on community atti­ tudes to mental health, a health education program was devised using the "open" system concept. Redd 60 in using the man-made open system defines the purpose of this type of system, When created, the specific system's purpose and content must be identified, and that purpose will dictate the various uses of system components. The specific types of components determine a man-made system content. The nature of component interaction, two-way communication among components will determine system processes and subsequent output. Diffusion research is concerned with behavioral change. Rogers and Shoemaker in Communication of Innovations define diffusion as "The pro­ cess by which innovations spread to the members of a social system," and 38Ibid, p. 18. 59 Bates, o £ . c i t . 88Lawrence N. Redd, "A Descriptive Study of the Use of Tele­ conferencing via a Two-way Cable Television in Racially Unbalanced Schools," (Ph.D. dissertation, Michigan State University, 1976). 33 says of diffusion research, "But in diffusion research we usually focus on bringing about overt behavior change, that is adoption or rejection of new ideas, rather than just change in knowledge or attitudes." 61 Change in a social system is social change according to Rogers and Shoemaker, "Change occurs when a new idea's use or rejection has an effect. Social change is therefore an effect of communication. The process of social change consists of three sequential steps: invention, diffusion, and consequences. Invention is the process by which these new ideas are created or developed. Diffusion is the process by which these new ideas are com­ municated to the members of a social system. Consequences are the changes that occur within a social system as a result of the adoption or rejection of the innovation." 62 Rogers and Shoemaker take the traditional S-M-C-R- model of communi­ cation— a source (S) sends a message (M) via certain channels receiver or receivers (R). (C) to a He modifies this by adding an (E) effects; consequences over time which are knowledge, attitude change, persuasion, and behavioral change. 63 Bordenave in reviewing the communication model which essentially uses the same concepts as the model developed by Rogers and Shoemaker 64 Among the many criticisms thrown at the diffusion model were that it does not take account of the constraints imposed by social structures in the developing countries, it pays insufficient attention to the quality of the practices to 61 Rogers and Shoemaker, ££. cit., p. 12-13. 62Ibid, p. 7. 63Ibid. 64, Ibid. states: 34 be diffused and to the competency of adoption agents, and it relies on a dripping-down view of development communication, which fails to provide for feedback and communication from farmers to the source of i n n o v a t i o n . 65 Wilbur, while using the SMCR, speaks of constraints. barriers to communication. He calls them He mentions cross-cultural barriers, over­ lapping but different backgrounds, interests and loyalties. He quotes Knutson: Barriers or potential barriers to effective communication are always present for at least some members of the intended audience. Success in communication depends upon the ability of the communicator to discover these barriers early in order that remedial actions may be taken. Early actions to correct weaknesses may contribute significantly to success.66 By introducing the notion of "system", Bordenave 67 transforms the communication model into its present form which takes into account the terms, source, message, etc., and transforms them into input, output, etc. This model is designed for rural areas in developing countries. Thus, it the concepts of man-made open systems of Ryan 68 , Miller 69 , and R e d d ^ are combined with models of communication by Rogers and Shoemaker 71 and Bordenave 72 , we have a system designed for rural areas in "developing" nations and with one further modification a Health Education/ Communication System model for a rural area in a developed nation. 65Bordenave, jog. cit. , p. 24. ^ M u r i e l Bliss Wilbur, Educational Tools for Health Personnel. New York: MacMillan, 1963, p. 27. 67 Bordenave, og. c i t . 68t , Ryan, eg. cit. ^ M i l l e r , op. c i t . 70 Redd, op. cit. 71 Rogers and Shoemaker, o p . c i t . 72 Bordenave, o p . cit. 35 Systems Approach Redd defines System Approach as "A methodology which empowers man to design, develop, and evaluate complex organized entities." 73 Braden and Herban discuss the system approach in the study of man in these words: The systems theory approach provides a methodology that utilizies a common language which can enhance inter­ disciplinary communication. . . . The system approach to the study of man can be appreciated as an effort to restore meaning (in terms of intuitively grasped, under­ standing of wholes) while adhereing to the principles of discipline generalization and rigorous deduction. It is an attempt to make the study of man both scientific and meaningful. Baric has developed a technique which looks at a system as a whole and the effect of extraneous variables which act upon it. He calls this Operational Research which "is the application of scientific methods, techniques and tools to the problems involving the operations of a system so as to provide those in control of the sytem with optimum solutions to the problems." 75 The procedure of Operational Research has three components, 1) de­ fines the system; 2) sets up a system model and 3) chooses and applies appropriate techniques of analysis and interpretation of findings (through math and probability theory), 73 Redd, ^p. cit., p. 77. 74 Carrie Jo Braden and Nancy L. Herban, Community Health: A System Approach, New York: Appleton, Century, Crofts, 1976, p. XII, 3. ^ L e o Baric, "An Introduction to Operations Research in Health Education," International Journal of Health Education. 11 (2), 1968, p. 50. 36 Health Education Procedure/Communication A communication system has as Its component parts: Input, process, output, control of the environment, constraints and feedback. 76 To be an effective system, It must adhere to these component parts which can each 77 be evaluated (See Figure 1). When this author suggests that a develop­ mental project can be broken into separate interacting parts and each part comparatively called a component part of a system, he Is linking development to communication. By then modifying this system by actually taking a development project in health education and comparing its parts or procedures to the component parts of the system, he can effectively make the connection between that project and its operation as a communi­ cation system. analysis, Because systems will be used as a method of experimental the project can be so analyzed. Several rural development plans have been analyzed using this model. Radio Sutatenza, Columbia, succeeded in promoting greater agricultural productivity using the system design through working directly with study groups and adult education utilizing available governmental agencies and the radio. And in Tanzania, a program called Mtu ni Afya (Man is Health) utilized the concept of preventive health education to achieve enornous success in creating behavior change, I.e., building latrines, providing safe water, and establishing preventive measures to control malaria and tuberclulosis. This was accomplished by using group leaders In village ^Bordenave, £p. c l t . 77 Redd, cit. 37 FIGURE 1 BORDENAVE COMMUNICATION MODEL D. E, Control What Is done to change the environment Constraints /S N/ Internal Interaction and Cooperation A. Input * A Now we have different needs or must choose a new model for development B. Process C. Through Infor­ mation and Inter­ change F. Output Feedback Environmental Reactions and its needs Model adapted from Communication and Rural Development. Juan E. Diaz Bordenave 38 communities, radio, and printed materials. involved. Two million people were In addition, a 20 percent gain in knowledge of health matters was observed using a multiple choice testing design. 78 This combined health education procedure/communication program has been actualized in rural areas of some of the "developing" nations. The above Health Education Communication System will be used as a model for health education in rural areas of a "developed" nation (See Figure 1). Summary This study relates to several areas and this literature review attempts to tie these areas together using theory and practical situations. The concepts of Health Education, Community Organization and Peoplecentered Approach have been joined through a review of studies. Other studies have tied together the notions of Communication, Education and System. A third area has sought to tie together Health Education, Com­ munity Organization and classical Experimental Condition. With this background this study was conducted in order to test Health Education under experimental conditions administered through a Communication System with the goal; the participation of the people it is trying to reach. The study used experimental conditions including an experimental and a control-group. 78 Bordenave, o p . c i t . CHAPTER III METHODS AND PROCEDURES This chapter will explain the analytic procedure of multi-dimensional scaling which will be used to assess attitude-behavior changes in the townships of Yates and Webber (experimental) and Covert Also the "semantic differential" scaling will be discussed. (control-group). and its application to multi-dimensional Additionally the process of the system approach, sample determination, Research Design, Hypotheses and Sub­ hypotheses will be examined. Multi-Dimensional Scaling (MDS) Multi-dimensional Scaling (MDS) is an analytic tool which can be used to assess both attitude and behavior change. MDS operates on the premise that there is a direct relationship between the psychological concept of dissimilarity (among objects) and the mathematical concept of distance. Semantically this notion of dissimilarity can be represented in terms of magnitude. Magnitude in mathematical terms can be described as a measure of distance (Euclidean distance).^" Battistlch states that: Basically, multidimensional scaling Is a means of representing the relationships within a set of objects through a geometric or James 0. Ramsey, Multiscale; For Programs for Multi-dimensional Scaling by the Method of Maximum Likelihood, Chicago International Educational Services, 1978. 39 40 spatial model. Any scale (such as an attitude scale, for example) may be thought of as a dimension which orders objects according to some criterion. The location of the object on the dimension represents its "strength” in terms of the underlying criterion, which the distance between any pair of objects ordered along the dimension represents their "similarity" in terms of the criterion.2 Subjects, however, generally use more than one criterion to judge objects or concepts (i.e., more than one judgment scale). Thus multiple dimensions will be needed to represent the dissimilarity relations and 3 each object will have a location on each dimension. Using a special application of the "semantic differential" (discussed later in this section) objects are paired with each other on a question­ naire and each subject is asked to rate the degree of dissimilarity between concepts on a numerical scale (i.e., 0- 1 0 , 0-1 0 0 , etc.); the greater the degree of perceived dissimilarity, the greater the scaled numerical value. A dissimilarity matrix is created from this process consisting of m(m-l) elements, m is the number of objects or concepts. For the purpose of this study we examine the half matrix m(m-l)/2. Multi-dimensional scaling analysis has several properties and advantages useful for research in attitude and behavior change. Among its properties are included the ability to analyze individual differences (individually perceived) between subjects, the strength each dimension contributes to the distance approximates each subject's data and defines which object of an object-concept pair is most precisely located within 7 Victor A. Battistich, "Multidimensional Scaling," Center for Evaluation and Assessment, College of Social Science, Department of Psychology, Michigan State University, East Lansing, Michigan, p. 1. 3Ibid. 41 the conceptual framework of the subject. The advantages are, in relation­ ship to traditional data analysis, one, non-evaluative dissimilarity data which lessens the ambiguity associated with wording a questionnaire. Ramsey states, "Dissimilarity judgements do not appear to predispose these evalua­ tive reactions on the part of the subject to anything like the same degree [reference to traditional data analysis]." A second advantage is that the dissimilarity data is semantically neutral. Ramsey again asserts "Judge­ ments of this sort do not predispose the subject to use any particular property. Thus the properties they use are a natural consequence of the judgemental context." A third advantage is that MDS programs all have the capability for assessing the internal consistency of responses to ascertain whether a subject is responding in a haphazard or confused fashion and a fourth advantage is that the data to parameter ratio is typically better for dissimilarity data. Ramsey's final statement on this subject is: By this is meant that one is usually collecting more independent observations for each scale value estimated when dissimilarity data are employed than when one asks direct questions concerning these scale values. This is due to the fact that the number of pairs of stimuli increases as the square of the number of stimuli (object-concepts), and so, as a consequence, do the number of observations per parameter to be estimated. This statistical advantage is precisely what makes hypothesis testing so much more a possibility for MDS programs than ins the case for other types of data.4 Barnett, Serota and Taylor discuss the relationship between attitude change and multi-dimensional scaling analysis. They begin by describing the Woelfel-Saltiel theory of attitude change. They state: At its simplest level, the theory suggests that an attitude is the joint effect of a set of messages, x, x 2 . . . xn. 4 Ramsey, o p . cit., p. 13-14. 42 The consequent attitude Is the linear sum of the messages divided by a number(n) of messages. This is represented as a = ij gi . . . Attitude change, then is treated as a single quanti" tative function of the number of messages an individual has received about a given attitude object.^ Messages can come from several different sources when influencing an attitude just as a subject's responses on a semantic scale can be ing fluenced by more than one judgment scale. Barnett, Serota and Taylor digress on this subject: . . . all information from all media can be seen as contributing to the magnitude, balance and mass of an attitude and the observation of attitude can be treated as a longitudinal activity rather than a discrete event, and change can be treated, mathe­ matically, as motion in multi-dimensional space.^ Thus the Woelfel-Saltiel attitude theory lends itself nicely to analysis by a multi-dimension scaling process. Barnett, Serota and Taylor tested the Woelfel-Saltiel theory in a longitudinal study on changing political attitudes and predicting the behavior of voters. Analysis. Data was analyzed using Multi-dimensional Scaling Baseline data was collected from a stratified random sample of registered voters, and from this data the position of each candidate was assessed relative to the voters and campaign issues. From this analysis it was suggested that the candidate design his campaign to present himself as close as possible to the voters and the issues that they considered important. Two later surveys to assess the campaign George A. Barnett, Kim B. Serota, James A. Taylor, "Campaign Communication and Attitude Change: A Multi-dimensional Analysis," Human Communication Research. New Brunswick, N.J. ; Rutgers University, 1976, p. 227-228. ^Battistich, op. cit. , ^Barnett, Serota, Taylor, op. c i t ., p. 228. A3 design were conducted using separate samples and at different times. The election of the candidate over the incumbent Indicated the success of this approach. Three of the four hypotheses initiated by the Woelfel-Saltiel theory were supported. By working prediction with prior transition The authors state: with various analytic techniques (such as the voter equation) and seeking improvements from experience studies, it has been possible to begin to make the „ from attitude measurement to behavioral prediction. 9 Barnett uses the Galileo method of Multi-dimensional Scaling Analysis to measure organization culture. Seigel and by Barnett and Carson. He cites two studies by Seigel found that students attending professional schools of accounting saw themselves closer to Big and Firms (object-concepts) and Sole Practitioners (object-concept) than student majors in departments of accounting. These findings came from matched samples of eight schools of each type and represent the first year of a longitudinal study of the organizational culture of the accounting pro­ fession. These results may help decide future recruitment policies of several large firms as well as the educational policies of the profession. Barnett and Carson used the Galileo method to study the organiza­ tional culture in the profession of technical writing/communication. This study showed that on the two-dimension continuums of sciencehumanlties and print-electronic media, subjects located themselves much closer to humanities than science and far from the electronic media. These findings suggest that members of this profession move themselves toward science and electronic media. g Barnett, Serota and Taylor, op. cit., p. 241. 9 George A. Barnett, The Measurement of Organizational Culture, New York Rensselor Polytechnic Institute, (Unpublished paper, date unknown). 44 Semantic Differential "The semantic differential (SD) is a method of observing and measuring the psychological meanings of concepts." 10 This measurement tool was invented by O s g o o d ^ to measure the connotative meanings of concepts as points in what he has labeled as semantic space. Battistich 12 earlier discussed the notion of multi-dimension scaling and that object concepts could be located at points on dimensions in multi-dimensional space. An example would be a graphic two-dimensional model using the notion of a linear relationship and a co-ordinate representation. An object-concept would have a value on each axis (dimension) forming an ordered pair [i.e., (x, y)]. Any number of axes (dimensions) can be used to describe an object's location in multi-dimensional space. A three dimensional representation of an object's location would have the co-ordinates of (x,y,z). Osgood's 13 semantic space is determined by three basic dimensions, evaluation, potency and activity. They account for 69 percent, 15 per­ cent and 13 percent respectively of the variance in semantic-differential analysis. 14 Osgood states: There is no question about identification of the first ^ K erlinger, o£. cit., p. 566. ^ C h a r l e s E. Osgood, George J. Sucl, Percy H. Tannenbaum, The Measurement of Mea n i n g . Urbana, Illinois: University of Illinois Press, 1957. 12 13 Battistich, op. cit., Osgood, Suci, Tannenbaum, op. cit. ■^Frank R. Hartman, "A Behavioristic Approach to Communication: A Selective Review of Learning Theory and a Derivation of Postulates," Audio Visual Communication Review, (H)(5), 1963. 45 dimension of the semantic space— an evaluative factor Is first in magnitude and order of appearance in both analyses. . . . The potency determinant in semantic judgments displays the poorest corresponsdence between factor and dimension, but even here the evidence is fairly satisfactory. . . . It is also clearly interpretable as an activity determinant on a qualitative basis.1^ In communication studies the semantic-differential is very useful as an instrument of evaluation. Hartman contends: Of the existing instruments for measuring the various aspects of meaning, only the semantic-differential appears useful to the practical communicator. Osgood, on the measurements of communication effects asserts: Communication effects are changes in the meaning of concepts central to the message, changes in the location of these con­ cepts in the (potentially) n-dimensional space provided by a semantic-differential. Such changes may be measured in toto by applying the D-measure between pre and post-message scores on all factors, or they may be assayed on the unidimensional (or even single scale) basis. In either case, a greater wealth of information derives from such a multi-dimensional instrument.17 The D-measure mentioned above is a measure of distance. Kerlinger states: If two concepts are close together in semantic space, they are alike in meaning for the individual or group making the judgment. Conversely if they are separated in semantic space, they differ in meaning. What is needed is a measurement of the distance between any two concepts. Osgood and his colleagues therefore use the so-called D-statistic, a very simple measure which is defined: Dij * = J ~2 dij2 [Note the similarity between this formula and the earlier formula of Barnett on the linear sum of an attitude] where D is the linear distance between the coordinates of i and j on the same factor (Evaluation, Potency, Activity) .18 ^Osgood, ^ Ha r t m a n , Suci and Tannenbaum, op. cit., p. 44-45. 0£. cit., p. 185. ^Kerlinger, o p . cit., p. 574. 18 Kerlinger, o£. cit., p. 574 46 Instrument Development The format for thlB survey is a designed application of the semanticdifferential and uses multi-dimensional analysis to measure the distance between concepts of health-related items. Osgood, Suci and Tannenbaum distinguish this application of the semantic-differential from other applications by stating: Instead of limiting one's attention to separate pairs of con­ cepts (or subjects) as above, all (m(m-l))/2 [m = number of concepts] pairs can be studied simultaneously. Using formula (1), the distance between each concept and every other concept can be calculated and entered into a mXm matrix. This matrix represents the semantic structure of the set of m concepts, giving the distances or similarity relations among all objects. The set of distances representing the semantic structure are "plotable" in a space having the same or fewer dimensions as ^ the number of dimensions represented in the measuring instrument. The concepts developed for this measuring instrument were generated from questions asked of the citizens of Webber and Yates Townships. These questions were 1) What do you think of health care?, 2) Who is in need of health care?, and 3) What Health and Community Organizations are available? These questions were open-ended to elicit broad and varied responses. In addition, Regional Health Care, The District Health Department, The Chamber of Commerce of Yates Township and an Interagency Brown Bag Meeting of various organizations in Lake County were visited and asked these three questions. From these contacts the ten most commonly used concepts in relationship to three proposed dimensions of, 1) health education, 2) community organization (Independent Variables) and 3) behavior-attitude change (Dependent Variable) were 19 Osgood, Suci and Tannenbaum, op. c i t .. pp. 93-94. 47 generated and paired. The concepts to be scaled were 1) Community Or­ ganizations, 2) Regional Health Care, 3) Young People, 4) Health Ed­ ucation, 5) District Health Department, 6) Disease Prevention, 7) Old People, 8) Yourself, 9) Seeking Medical Help, 10) Health Programs. The order of concepts above catne as a result of random selection with replacement. The concepts were then paired in this fashion: Concept 1 with Concept 2, Concept 1 with Concept 3 . . . 4 . . . until each concept had been paired with each other (See Appendix 1). There are various survey forms which use this pairing format. Three types of analysis are indicated using the semantic-differential as a measuring instrument for both Individuals and groups, 1) differences in factor or dimension scores across time for individuals and groups 2) the significance of different D scores across time for individuals and groups and 3) differences between and within conceptual structures between individuals and groups. 20 Reliability and Validity of Semantic Differential Standard reliability procedures for linear regression were applied to the semantic-differential which represents the data obtained through dissimilarity judgments. The relationship between dissimilarity and distance is essentially linear. 21 The Multi-dimensional scaling analysis (MULTISCALE) produces regression co-efficients and standard errors for both individuals and groups. 20Ibid. 21 22 Ramsey, op. c i t . ^ Ibid. 22 The method used to determine 48 the reliability co-efficient for linear regression 23 is similar to Kerlinger's treatment for determining the reliability co-efficients for analysis of variance. 24 Barnett, Serota and Taylor 25 suggest that we aggregate the data to determine the reliability co-efficients. The reliability co=efficients using aggregates from the pre- and post-tests for the experimental-group (Yates and Webber Townships, Lake County) were .93 and .97 respectively. The reliability co-efficients for the pre - and post-tests for the control-group (Covert Township, Van Buren County) are .85 and .94 respectively. The semantic-differential has been found to be sufficiently reliable and valid for many research purposes. validity. 26 In this study it has content The concepts were generated from responses garnered from the experimental population from a questionnaire given randomly. The Pearson product moment correlation co-efficient was used to measure construct validity. Kerlinger 27 and Napior 28 suggest that using correlation be­ tween concept pairs (scales) can be used to test validity correlations. Co-efficients for the ten concepts ranged as follows: Group pre - and post-tests; Group pre - and post-tests; Experimental .63-.80 and .73-.88 respectively. .65-.91 and .66-.93 respectively. Control These were significant at the .001 level. 23 William L. Hays, Statistics for the Social Sciences, (New York: Holt, Rinehart and Winston, Inc., 1973) 24 Kerlinger, ££. c i t . 25 Barnett, Serota and Taylor, op. cit. 2< W 27 28 ~ I bid. David Napiro, "Nonmetric Multidimensional Techniques for Summated Ratings" Multi-Dimensional Scaling, New York: Seminar Press, 1972, pp. 158-178. 49 Sites Experimental Group Rural Lake County: Yates and Webber Townships Lake County is the poorest county in Michigan. developed and sparsely populated. 29 It is under­ It has little or no major manufact­ uring, agricultural industries or businesses. In addition 22.9 percent of the inhabitants have an income below the officially defined poverty level, 29.4 percent of the Inhabitants have an income below the officially defined poverty level of 125 percent and 889 families of approximately 1,400 receive some aid from ADC (Aid to 30 Dependent Children). Lake County also faces a growing number of elder­ ly persons as a percentile of its population. The age group 20 to 44 years of age is only 20.6 percent of the population as compared to 31.4 percent for the state. 31 This is primarily due to the out migra­ tion of the younger population in search of employment, educational facilities and interesting worthwhile acitivites. In the crucial matter of health and health care, these problems exist: There is a higher death rate for Lake County when compared to the rest of the state for almost all kinds of disease except for in­ fluenza, penumonia, alcoholism, cirrhosis of the liver, arterioscelerosis and stroke. Diabetes and heart disease rank especially high 29 David I. Verway, ed., Michigan Statistical Abstract, East Lansing, Michigan: Michigan State University, 1978. ^ M ichi g a n , 1970 Census. 31 Shyamalendu Sarkar, Some Economic Aspects of Lake County Health Industry: Characteristics, Revenues and Expenditures, Facility and Problems, (East Lansing, Michigan, Agricultural Experiment Station, Michigan State University, 1975). 50 for the county. Lake County has no hospitals and there are only four doctors in Lake County. This ratio of 1 to 1,775 people can be compared to a statewide ratio of 1 to 984 (The Michigan Health Council's recommendation for doctor to person ratio is 1 to 600). The situation is similar for registered nurses in Lake County— there are only five. 33 (1 to 1,400 people) There is only one health care facility in Lake County, Regional Health Care which is located in the Village of Baldwin. 8 a.m. to 5 p.m. Monday through Friday. person must leave the county. It is open from For hospital or nursing care a For major surgery operations, they must go to Grand Rapids which is 80 miles away. Regional Health Care (RHC) in its proposal for funding from the Rural Health Initiative (a federal program), defined as one of its pro­ blem areas for 1979-80: Because of its rural location and limited exposure through the mass media, Regional Health Care lacks the capability of adequately informing the community of its services and does not have an effective method of providing community education.34 In Yates Township (part of Lake County), according to the 1970 census, 72 percent of the heads of the household earned less than $6,000 dollars per year, 53.3 percent earned less than $5,000 per year, and 45.3 per­ cent earned less than $3,000 per year. 30.7 percent of the families are below the official poverty level in yearly income. Additionally, 32 J I bid. 33 Michigan Department of Public Health, Office of Statistics Research and Evaluation and Vital Statistics, 1978. ^Michigan, "Regional Health Care, Inc., Rural Health Initiative Continuation Grant Application," prepared by Regional Health Care (Baldwin, Michigan, 1979-80). 51 61.1 percent of persons 14 years and older receive public assistance, social security or railroad retirement. 35 In comparison Webber Township presents comparable statistics. Eighty percent of the heads of household earned less than $6,000 dollars per year, 75.9 percent earned less than $5,000 per year, 52.6 percent earned less than $3,000 per year and 39.2 percent of persons 14 years and older receive public assistance, social security or railroad retirement. 36 Control Group - Van Buren County: Covert Township Van Buren County's median income consistently ranks lower than that of the state. Of the families in Van Buren County, 35.6 percent earned less than $7,000 per year in 1970 and also in that year the county ranked 34th out of 83 counties in Michigan in the percentage of families re­ ceiving welfare assistance. is last in per capita income. In an eight county Health Service Area, it 37 Because of out migration of the young population, Van Buren County faces a growing population of elderly people; 35.7 percent of its population is over 60 and 30.6 percent of those over 65 have an income below the poverty level. 38 In the area of Health and Health Care, heart disease, cancer and cerebrovascular disease all rank higher than their counterparts across 35 Michigan, 1970 Census. 36Ibid. 37 Jane Miller, "Community Assessment, Bangor, Michigan," (Masters Thesis Wayne State University, 1979.) 38Ibid. 52 the state as a cause of death. In the Bangor area where many of the people from Covert Township go for medical help, one doctor said "the rate of hypertension has reached epidemic proportions." as a high disease category in terms of numbers. Diabetes ranks 39 Health care facilities exist at Bangor, Hartford, and South Haven. The Health Center at Bangor is small and designed for migrants, though permanent residents use it. The hospital in South Haven has the reputa­ tion of being of poor quality and offering poor health care services. The County Health Department handles immunizations and has small clinics. None of these facilities has an adequate health education system accord­ ing to administrators at these facilities. There is one doctor for every 2,025 people and one active register­ ed nurse per 510 people, much lower than the state's recommendations (1 to 600 for doctors to persons). Covert Township (control group), according to the 1970 census: 49.5 percent of the heads of households earned less than $6,000 per year, 42.1 percent of the heads of households earned less than $5,000 per year, and 29.4 percent of the heads of households earned less than $3,000 per year. In addition, 35.8 percent of persons 14 years and older receive public assistance, social security, or railroad retirement. 40 Covert is a large rural township, yet has no health facilities; only one small manufacturing firm, and few retail businesses. 40 Michigan 1970 Census. 53 From this preliminary research, this author suggests that Covert Township will serve as a suitable control group to compare with Yates and Webber Townships. Sample The samples chosen for this study are an example of purposive sampling 41 and has certain limitations (see earlier reference to limitations of the study). However, randomness was introduced to determine which site would serve as an experimental or control-group (coin flip). Final samples consist of 23 heads of households in the control-group and 22 heads of households in the experimental-group. This is reduced from a sample size of 38 subjects in the control-group and 37 subjects in the experimental-group. The final samples are those subjects who were administered the post-test. The reduced sample is due to these factors: 1) Several in each sample were removed because of lack of understanding the test; 2) Moved from the area; 3) Husbands refused to allow wives to take the post-test; 4) Not interested; 5) Sick and unable to respond. The final sample consisted of the following characteristics: Experimental Group Sixty percent earned less than $5,000 per year, 78 percent earned less than $7,000 per year. 47.6 per­ cent were over 60 years old and 76.2 percent were over 45 years old. 58.8 percent were females and 95.2 percent were black and 63.6 percent had less than a high school education. 41 Kerlinger, o p . cit., p. 129. 54 Control Group 60.8 percent earned less than $5,000 per year and 65.2 percent earned less than $7,000 per year. 47.8 percent were over 60 years old and 87 percent were over 45 years old. 65.2 percent were female and 100 percent were black and 30.4 percent had less than a high school education. (See Table 2) Procedure The following procedure is analogous to the "Critical Pathway to Achievement" and its communication system counterpart;" "The Bordenave System Design" (See Page 4). as division headings with the are It uses the terms of the Bordenave System exception of the term constraints which assessed at each level or division. The analogous portions of the Critical Pathway to Achievement are entered under each division term. The outline below will demonstrate the procedure. (See Appendix 4 for Detailed Intervention by the Health Committee) Procedure 1. Input-Assessing the Needs of the Community a. Gather information, both demographic and on social and health problems. b. Meet township leaders. c. Organize Health Committee. d. Arrange a meeting at which the survey results will be reported. 42 1. Ask for priority problems. 2. Analyze potential obstacles (constraints). 3. During this meeting and subsequent meeting, problems will be prioritized. /0 After attempting to form a Health Committee in Yates Township, the investigator discovered the existence of the Lake County Health and Services Association, a non-profit community corporation in existence since 1964. 55 TABLE 2 DEMOGRAPHIC DATA FOR EXPERIMENTAL AND CONTROL GROUPS EXPERIMENTAL GROUPS (n=22) CONTROL GROUPS (ii=23) Earned less than $5,000/year 60% 60.8% Earned less than $7,000/ year 78% 65.2% Age over 60 years 47.6% 47.8% Age over 45 76.2% 87.0% Females 58.8% 65.2% Males 41.2% 34.8% Less than High School Education 63.6% 30.4% Race (Black) 95.2% 100% 56 2. Process— Internal Interaction and Cooperation Through Information and Interchange a. 3. b. The committee choose one problem to work on. Inform the committee of feasible ways of working on the problem. c. Assess local resources— the committee makes the decision of what local resources to use. d. Planning the work and setting— the committee plans the output; the methodology of handling the health process. The committee assesses methods of communication which best fit their particular community. Output— Setting Responsibilities and Time Schedules a. b. 4. 5. Inform the committee about preventive measures applying to each problem, the relative cost of various approaches; their feasibility and effectiveness (constraints are considered). The responsibility of carrying out health education shall be assigned to those who will implement it. Manual and Intellectual activities are assigned. Time schedules shall be set to establish deadlines for completion of health education programs accord­ ing to needs priority. The responsibility for the design of the message and the method of sending out the message is finalized (output). The Execution of Health Education Messages; Control of The Environment a. Health education and actual environmental behavior, health prevention measures, use of health facilities. b. Constraints are encountered, evaluated, and a plan to deal with them is designed. Evaluation— Feedback; Effects of Constraints, Degree of Success of the Program of Health Education a. A post-test will be given to assess the degree of health prevention behavior and the use of health care facilities. 57 Experimental Design A two group before and after (pre-test, post-test) experimental Design will be used and is shown in the chart on the next page. design has certain weaknesses. not assigned randomly. This The most notable is that subjects are The assumption of homogeneity of variance between the experimental and the control group will be tested at the .01 level of significance. 58 Experimental Design Pre-Test Experimental Group Yates and Webber Township* Lake County Post-Test Intervention by Committee Who Implement Health Education n=23 n=22 « m 83 84 FIGURE 12 CONTROL GROUP POST-TEST DIMENSION 3 VS DIMENSION 2 LEGEND 1. Community Organization 6. Disease Prevention 2. Regional Health Care 7. Old People 3. Young People 8. Yourself 4. Health Education 9. Seeking Medical Help 5. D i s t r i c t Health Department 0. Health Programs FIGURE 13 CONTROL GROUP PRE-TEST DIMENSION 3 VS DIMENSION 2 LEGEND 1 . Community Organization 6. Disease Prevention 2. Regional Health Care 7. Old People 3. Young People 8. Yourself 4. Health Education 9. Seeking Medical Help 5. D i s t r i c t Health Department 0. Health Programs I'M ” •* -«.J -21.* 85 as.r 86 87 TABLE 4 SUMMARY STATISTICS (Three Dimensions) Experimental Group Pre-Test Post-Test Log Likelihood Control Group Pre-Test Post-Test 70.938 39.1.926 112.962 172,108 52 67 177 58 Final STD Error Estimate .564 .408 .679 .504 Unbiased STD Error Estimate .585 .422 .704 .524 67 67 69 69 918 921 926 858 Total Iterations Number of Parameters Number of DF for Errors TABLE 5 Analysis of Dimensionality Using The Chi-Square Test for Pre-Tests and Post-Tests for The Experimental and Control Groups Pre-Tests Experimental Group (n=22)________ Control Group (n=23) Two Dimensions Unbiased STD Error Log Likelihood Number of Parameters Three Dimensions Three Dimensions Two Dimensions .592 .585 .717 .704 55.572 70.938 -134.487 -112.962 60 67 62 69 7 Degrees of Freedom 30. 732 Chi-Square 43.050 Post-Tests Experimental Groun (^22) Two Dimensions Unbiased STD Error Log Likelihood Number of Parameters Three Dimensions Three Dimensions Two Dimensions .427 .428 .543 .524 376.645 391.926 144.875 172.108 60 67 62 69 Degrees of Freedom Chi-Square Control Group (n-23) 7 30.562 54.466 89 Hypothesis 2: There will be a significant difference between pre-test and post test scores. The Chi-Squate test for significance will be used at the .05 level. The pre-test and post-test was designed to measure the changes in attitude-behavior in three dimensions; Health Education, Community Organization and Behavior. It was postulated that a significant change would occur between these two tests due to an education intervention (i.e., Health Education implemented by a Health Committee). If the hypothesis is confirmed not only should there be a significant difference between the pre-test and post-test of the experimental-group but that it will be significant when compared to the control-group. Chi-Square values of 76.684 and 65.341 with 23 degrees of freedom at the .001 level showed significant results for the experimental and control groups respectively (See Table 6 ). An F-test for homogeneity of variance was administered to the data for the experimental and control groups at the pre-test level. The F- statistic of 1.028 is not significant at the .05 level and the groups' variances are not significantly different. The F-statistic of 1.61 is not significant at the .05 level for the experimental and control groups. Degrees of fredom were 21 and 22 for the experimental and control groups respectively (See Table 7). Thus the hypothesis is not confirmed. significantly is noteworthy. That both groups changed A further examination of the data indicates an intervening variable may have entered which may explain some of the results. 90 TABLE 6 Analysis of Significance of Differences Between Pre and Post Test for the Experimental and Control Groups in Three Dimensions Using the Chi-Square Experimental Group Addition of Pre-Test, Post-Test Statistics Combined Pre-Test, Post-Test Statistics Number of Subjects 44 Unbiased STD Error •513 Log Likelihood Number of Parameters 44 386.180 462.864 111 134 23 Degrees of Freedom 76.684* Chi-Square Control Group Conmined Pre-Test, Post-Test Statistics Number of Subjects 46 Unbiased STD Error .627 Log Likelihood Number of Parameters Addition of Pre-Test, Post-Test Statistics 46 -6.195 59.146 115 138 Degrees of Freedom Chi-Square *Significant at .05 level of significance 23 65.341* 91 TABLE 7 ANALYSIS OF HOMOGENEITY OF VARIANCE FOR THE EXPERIMENTAL AND CONTROL GROUPS AT THE PRE-TEST AND POST-TEST LEVELS PRE-TEST EXPERIMENTAL GROUP Number of Subjects Mean T. x ? 22 22 4.99 4.34 1227.8 I Variance 30.086 21 F-Statlstic 22 1.028* POST-TEST EXPERIMENTAL GROUP Number of Subjects Mean E x ? I CONTROL GROUP 22 23 4.95 4.06 1128.3 Variance Degrees of 897.1 30.939 Degrees of Freedom CONTROL GROUP 764.17 26.74 16.73 21 22 Freedom F-Statistic *Not significant at the .05 level 1.6* 92 Intervening Variable During the period between the pre- and post-test administration both control and experimental communities experienced a program which provided hypertension screening and control. The experimental-group*s program was financed through Regional Health Care and the control-group's program was administered from an out-county source through the Covert Community Center. This program also Included diabetes control. The development prompted an observation that examined whether 1) Health Programs would move toward Regional Health Care In the experimental-group and 2) Health Programs would move toward the Community Health Center in the control-group. The former was significant in the experimental-group (discussed later as Subhypothesis 2H). for the control-group. However it is not significant (See Tables 8 and 9, Variable 17) In addition to the effect created between Regional Health Care and Health Programs it appears from the data that a relationship exits between Young People and Health Programs. The hypertension program specifically sought to detect hypertension in youth and the middle-aged in the experimental-community. The comparison of t-Tests for the variable matching Young People and Health Programs showed a significant result for the Experimental Group. Control Group. However, this does not hold true for the (See Tables 8 and 9, Variable 24) Overall this hypothesis falls to be supported. The overall difference appears to be attributed to a variable other than the designed variable which represented Inducing a physician to stay in the community. However, the hypertension program administered by Regional Health Care had the full support of the Health Committee which agreed to spread the educational message by interpersonal channels. 93 TABLE 8 Analysis of the Quality of Means for the Pre-Test Vs Post-Test for the Experimental Group by Variable Variable Pre-Test Mean Post-Test Mean t Value Degrees of Freedom 1-tali/ Probability V 1 5.500 5.818 - .38 42 .353 V 2 6.136 5.591 .65 42 .259 V 3 4.773 5.591 - .98 42 .166 V 4 5.227 5.818 - .66 42 .257 V 5 5.7273 4.955 .88 42 .192 V 6 4.046 4.773 - .81 42 .212 V 7 4.546 5.1364 - .60 42 .277 V 8 3.8636 4.6364 -1.03 42 .155 V 9 5.409 4.500 1.15 42 .130 V 10 5.864 5.636 .27 42 .393 V 11 5.955 5.773 .24 42 .404 V 12 5.591 6.136 - .66 42 .255 V 13 5.773 5.091 .95 42 .174 V 14 4.409 3.955 .58 42 .282 V 15 6.227 5.3182 .90 42 .186 V 16 5.091 4.636 .50 42 .312 V 17 6.682 5.136 1.86 42 .035* V 18 5.818 5.455 .49 42 .314 V 19 5.909 6.00 - .12 42 .451 V 20 7.046 5.909 1.56 42 .063 V 21 6.591 6.455 .17 42 .433 V 22 3.546 4.182 - .88 42 .192 V 23 6.0455 5.3182 .81 42 .212 V 24 6.9091 5.6364 1.78 42 .042* V 25 4.909 5.318 - .60 42 .277 V 26 4.864 5.182 - .44 42 .333 V 27 4.318 3.818 .71 42 .240 V 28 3.955 4.3182 - .45 42 .329 *Signifleant at the .05 level 94 TABLE 8 Continued Variable Pre-Test Mean Post-Test Mean t Value Degrees of Freedom I- Tail / Probability V 29 4.0901 4.182 - .13 42 .449 V 30 4.773 4.727 .07 42 .474 V 31 5.046 5.182 - .20 42 .421 V 32 4.455 4.273 .27 42 .395 V 33 5.000 5.596 - .65 42 .259 V 34 5.364 5.091 .35 42 .362 V 35 5.136 5.091 .06 42 .477 V 36 5.273 5.000 .37 42 .357 V 37 3.455 4.091 -1.03 42 .155 V 38 3.682 3.864 - .36 42 .361 V 39 4.773 4,818 - .07 42 .474 V 40 2.909 3.5000 - .87 42 .194 V 41 3.636 4.046 - .60 42 .275 V 42 4.455 4.864 - .55 42 .293 V 43 3.409 3.227 .24 42 .405 V 44 4.091 4.636 - .69 42 .248 V 45 4.137 4.682 - .78 42 .221 95 TABLE 9 Analysis of the Equality of Means for the Pre-Test Vs Post-Test for the Control Group by Variable Variable Pre-Test Mean Post-Test Mean t Value 1-Tail/ Probability Degrees of Freedom V 1 4.652 4.652 .13 44 .449 V 2 6.0870 4.783 1.45 44 .077 V 3 4.957 4.696 .34 44 .369 V 4 4.348 4.217 .16 44 .436 V 5 5.391 5.130 .26 44 .396 V 6 2.826 3.348 - .66 44 .258 V 7 2.957 3.391 - .57 44 .285 V 8 4.044 3.696 .40 44 .347 V 9 4.044 4.478 - .56 44 .289 V 10 5.261 4.739 .53 44 .299 V 11 4.130 4.696 - .54 44 .297 V 12 3.217 3.379 - .58 44 .284 V 13 4.261 3.609 .67 44 .254 V 14 4.044 4.000 .04 44 .483 V 15 7.1304 5.522 1.40 44 .085 V 16 4.783 4.261 .50 44 .309 V 17 4.957 3.957 .98 44 .168 V 18 4.957 4.826 .16 44 .438 V 19 5.218 5.391 - .22 44 .412 V 20 5.130 4.435 .75 44 .230 V 21 6.391 5.609 .95 44 .173 V 22 2.565 3.174 - .94 44 .176 V 23 4.522 4.391 .17 44 .434 V 24 5.391 4.609 o CTi * 44 .187 V 25 4.957 4.391 .63 44 .266 V 26 4.652 3.566 1.25 44 .109 V 27 4.391 4.130 .35 44 .365 V 28 3.435 3.435 0 44 [ .500 96 TABLE 9 Continued Variable Pre-Test Mean Post-Test Mean t Value Degrees of Freedom 1-Tail/ Probability V 29 3.739 3.435 .37 44 .358 V 30 4.217 3.261 1.13 44 .132 V 31 4.391 3.783 .70 44 .243 V 32 3.522 3.739 - .29 44 .388 V 33 5.826 4.087 1.64 44 .054 V 34 4.044 4.217 - .19 44 .425 V 35 3.913 4.217 - .37 44 .359 V 36 4.913 4.522 .45 44 .329 V 37 3.000 3.391 - .47 44 .320 V 38 3.609 3.348 .35 44 .366 V 39 5.044 4.130 .98 44 .166 V 40 2.661 2.566 - .54 44 .296 V 41 3.435 3.130 .41 44 .344 V 42 4.435 3.739 .87 44 .194 V 43 2.783 2.565 .28 44 .390 V 44 4.174 4.174 0 44 .500 V 45 3.435 3.913 44 .272 - .62 97 Subhypotheses A series of subhypotheses were developed relative to hypothesis 2. They were statistically analyzed at the .05 level of significance by use of the t-Test comparing means (Tables 8-9). They will also be analyzed using multi-dimensional scaling from observation of the two-dimensional plots. Subhypothesis 2A: There is a significant decrease in the magnitude between Concept 9 (Seeking Medical Help) and Concept 2 (Regional Health Care). From inspection of the two-dimensional plots for the experimental- group the two concepts appear to move closer to each other on the hori­ zontal axis, further apart on the vertical axis and further apart in twodimensional space. The t-statistics for the experimental and control- group respectively are .50 and .50 which indicates a decrease in the magnitude of the means but the decrease was not statistically signifi­ cant (See Tables 8 and 9, Variable 16), Therefore the hypothesis is not confirmed for either experimental or control group. Subhypothesis 2B: There is a decrease in the magnitude between Concept 6 (Disease Prevention) and Concept 8 (Yourself (Variable37)). 3 Earlier Smlllie linked Prevention to the private physician and the 4 Departmental Task Force on Prevention defined the different types of prevention; primary, secondary and tertially in the context of a physician practicing preventive medicine. The Lake County Health and Services Association defined as its number one priority to bring a private 3 Smlllie, o£. cit. Departmental Task Force, o£. cit. 98 physician into the community. Thus if a physician enters a community it is hypothesized that the magnitude between Yourself and Disease Preven­ tion would decrease. An examination of Figures 1 and 2 do not show a decrease in the semantic space between Concept 6 and 8 . shows a movement apart from each other. In contrast it The t-statistics for the experi­ mental-group and control-group respectively are -1.03 and -.47 which shows no significant relationship at the .05 level. This hypothesis is not supported by the data. Subhypothesis 2C: There is a decrease in the magnitude (distance in semantic space) between Concept 6 (Disease Prevention) and Concept 2 5 (Regional Health Care (Variable 13)). According to Sraillie's definition if the perceived source of preventive Health Care is located within Regional Health Care the semantic distance between the two concepts should decrease. An examination of Figure 2 and Figure 3 shows no appreciable decrease in semantic space, however in a three dimensional representa­ tion which shows an added plot which represents Dimension 3 vs Dimension 1, Figure 6 and 7 show a comparably short distance between Concepts 6 and 2. Please note that Concept 2 and 6 provide a dimensional axis in and of itself. The movement toward similarity when tested through the t-Test shows a decrease in means but is not significant at the .05 level. An examination of the two-dimensiona representations of the control-group (Figures 4, 8 and 5. ) shows no appreciable decrease between Concepts 2 and 6 . The t-statistics for the experimental and control groups respectively are .95 and .67 which Bhows no significant difference 5 Smillle, o p . cit. 99 at the .05 level. Therefore this hypothesis is not supported. Subhypothesis 2D; There is a decrease in the magnitude (distance in semantic space) between Concept 8 (Yourself) and Concept 2 (Regional Health Care (Variable 15)). Health Education messages under the Woelfel- Saltiel Theory^ generated from Regional Health Care is hypothesized to improve the attitude toward Regional Health Care and thus decrease the magnitude in semantic space between the two concepts. An examination of the three-dimensional plots shows no appreciable change in semantic space. The t-statistics for the experimental-group and control-group respectively are .90 and 1.40. Though there is a considerable change in means (See Tables 8 and 9), there is no significant difference at the .05 level. Thus this hypothesis is not supported. Subhypothesis 2E: 4 There is a decrease in magnitude (Health Education) and Concept 2 (Regional Health Care between (Concept (Variable 11)). It follows that if Regional Health Care institutes a media approach and/or an interpersonal approach to create positive behavior change, a signifi­ cant difference in magnitude in semantic space would manifest itself. Neither graphic representation nor t-statistics of .24 and -.54 for the experimental and control groups respectively at the .05 level of signifi­ cance support this hypothesis Subhypothesis 2F: 4 There is a decrease in magnitude between Concept (Health Education) and Concept 1 (Community Organization (Variable 3)). ^Barnett, Serota and Taylor, ojk cit. 100 Interpersonal communication is the form used to change behavior by the Lake County Health and Services Association; a community organization. An examination of Figures 2 and 3 which involve the experimental-group shows no appreciable decreases in magnitude between the two concepts. The t-statistics for the experimental-group and control-group respectively are -.98 and .34 which confirms this conclusion at the .05 level of significance. Thus the hypothesis is not supported. Subhypothesis 2G: There is a significant decrease in magnitude between Concept 2 (Regional Health Care) and Concept 7 (Old People (Variable 14)). There is a close relationship between the Concept Old People and Yourself (the shortest distance measure of all concept pairs). The same relationship between Concept 8 and Concept 2 should hold true for Concept 2 and Concept 7. would be significant. It has been postulated that the decrease A review of Figures 2 and 3 shows a semantic decrease in space for the experimental-group. The t-statistics for the experimental and control groups are .58 and .04 respectively and not significant at the .05 level. Subhypothesis 2H: The hypothesis is not supported. There is a decrease in magnigude (distance in 7 semantic space) between Concept 2 (Regional Health Care) and Concept 0 (Health Programs (Variable 17)). Messages geared toward an increase in positive attitude toward Regional Health Care and the knowledge of physicians at the Center should lessen the semantic space between Health Programs and Regional Health Care. These two concepts seem to ^Concept 10 is labeled as Concept 0 on the graphs (Figures 2-13). 101 be placed on the same dimension. On closer examination Concept 0 appears close to the origin in all three dimensions. It appears not to move as close to Concept 2 as to moving away from Category 6 . However the t-statistic for the experimental-group of 1.86 is significant at the .05 level. The Figures for the control-group show some movement toward each other but the t-statlstic of .98 is not significant at the .05 level. Thus the hypothesis is supported for the experimental-group and is not supported for the control-group. Subhypothesis 21: There is a decrease in magnitude between Concept 1 (Community Organizations) and Concept 2 (Regional Health Care (Vari­ able 1)). Regional Health Care and the Lake County Health and Services Association collaborated on the Health Education Project and the design of the education intervention. Because of this relationship it had been postulated that the attitude between these two organizations would increase on the positive side and that they would move closer together in semantic space. The two-dimensional plots do not indicate such a movement and the t-statistics for the experimental and control groups of -.38 and .13 show no significant difference at the .05 level. hypothesis is not supported. This CHAPTER V SUMMARY, DISCUSSION AND RECOMMENDATIONS Summary of the Study This chapter will briefly review the purpose of the study, explain the main parts of the literature review and the type of analysis and summarize the results of the data hypotheses, and subhypotheses. The final portions of this chapter will discuss the implications and recom­ mendations for further research. Purpose The main purpose of this study is to comparatively evaluate the effectiveness of a community organization (health committee called the Lake County Health & Services Association) as a component of health education of an existing health care system. Additional purposes are to serve as a model Innovation for health projects in rural areas, form part of the literature of non-formal education and communication organizations as they relate to health education of the rural poor in developed nations. Literature Review The literature review Includes an explanation of the people-centered approach, literature relating to this approach, literature reviews on community organizations, community development, community health educa­ tion and communication and education. A theoretical review linking the notion of system with communication is also included. The literature re­ view has shown that a Health Education Intervention can be tested experi­ mentally. In addition, the review provided a rationale which tested a rural communication effort. 102 103 Methods and Procedures Multi-dimensional Scaling, the method of analysis and the form of the testing instrument is explained in this section. Additional explanations of related procedures and theory are given concerning the semantic differential and attitude-behavior change. Hypotheses and subhypotheses are presented with the explanation of their generation as are the samples for the experimental and control-groups and a research design which includes pre- and post-tests. Data Analysis Multi-dimensional Scaling Analysis allows for comparisons between groups. It tests the dimensionality of group responses on attitude- behavior scales. A visual representation of the magnitude or distance between object-pairs is presented in graph-form and statistics are generated to do hypothesis and subhypothesis testing. The emphasis during analysis is the degree of change between preand post-test scores for the experimental-group and this degree of change is contrasted with the degree of change between pre- and post­ test scores of the control-group. For hypothesis testing the Chi-Square is used and for subhypothesis testing the t-Test for equality of means is used. Research Findings The results indicate that there is only a small, if any, change in the experimental population due to the Health Education intervention strategy implemented by the Health Committee (The Lake County Health and Services Association). Hypothesis 1 is supported, Subhypothesis 2H which predicted a decrease in magnitude between Regional Health Care and Health Programs is supported. 104 However Hypothesis 2 was not generally supported. Subhypotheses 2A (Seeking Medical Help and Regional Health Care), 2B (Disease Prevention and Yourself) and 2C (Disease Prevention and Regional Health Care) which involve the Behavior Aspect of the attitude-behavior continuum were not supported. Subhypotheses 2D (Yourself and Regional Health Care), 2G (Regional Health Care and Old People), and 21 (Community Organizations and Regional Health Care) which involve the attitude end of the attitude-be­ havior continuum were not supported. Subhypotheses 2E (Health Education and Regional Health Care) and 2F (Health Education and Community Organiza­ tion) which involve Health Education were not supported. Discussion Hypothesis 1 tests whether three dimensions is an appropriate number of dimensions in which to test the responses of the subjects. It was found across both experimental and control-groups that three dimen­ sions provided the best number to approximate the data. This was con­ firmed by use of the Chi-Square variable at the .05 level of significance. The design of the questionnaire sought to define the three dimen­ sions as Health Education, Behavior and Community Organization. However, three other dimensions emerged, two easily defined and one which is un­ interpretable on the basis of data collected. Dimension 1 is an age con­ tinuum going from Old People to Young People; Dimension 2 is a continuum which goes from Institutional Care to Self Care. Hypothesis 2 tests whether the Health Education Intervention has any Impact on attitude-behavior of the subjects. It was found that across both the experimental and control-groups that some changes had occurred. Because there was a significant change in the control-group 105 just as there was a significant change in the experimental-group it can be concluded that the change is not due to the Independent Variable, Health Education. However, the result of the Health Education Interven­ tion was positive; one of the doctors decided to remain in the community. This was evidenced by the doctor verbally and the purchasing of a house within the county although not in Yates or Webber Township. The Chi-Sqaure Test indicated a significant difference between the pre-test scores and post-test scores on both the experimental and con­ trol-groups. To test which variables accounted for the difference, sub­ hypotheses were developed. strategy. One important difference emerged from this The t-Test applied to the means of the forty-five individual variables showed no significant t-scores for any of the variables in the control-group at the .05 level, while two of the forty-five variables were significant at the ,05 level for the experimental-group. 8) (See Table However, only one of these two significant results were predicted via hypothesis, a decrease in the distance (Semantic Space) between Health Programs and Regional Health Care. A confounding variable; the introduc­ tion of the Hypertension Program should not have an effect on the total variable scores for the experimental and control-groups because it was introduced in both communities. However, the program at Regional Health Care was extended to various points in the community whereas the pro­ gram in the control-group was always in the same spot. A second Interesting observation was the relationship which exists in the variable which measures the distance between Young People and Health Programs. A significant difference appeared in the experimental-group whereas none appeared within the control-group. It would appear that several differences exist between the two hypertension programs; 1) The outreach portion of the Lake County Program, 2) The targeted area and 3) The aid 106 of the Lake County Health and Services Association. This may be a negligible effect but for future studies this may prove interesting. Overall it must be concluded that there is only a small difference attributed to the Health Education Intervention. Confounding variables make it difficult to assess what caused the change in attitude-behavior among the respondents. Subhypothesis 2A tests whether subjects associate Disease Prevention with themselves and whether this change is a result of Health Education. However, the subhypothesis is not supported. It is suspected that the general population does not associate having a physician available with Disease Prevention as is the case with the Lake County Health and Services Association. Another explanation is that the messages emanating from the Health Committee or Regional Health Care had no impact on them. Another possible explanation is that not enough time elapsed between the Open House to welcome the physicians and the Post-Test to allow for a significant change in attitude-behavior in relationship to Regional Health Care. This rationale applies to Subhypothesis 2C (Disease Pre­ vention and Regional Health Care) though there is a slight decrease in means from pre-test to post-test. Subhypotheses 2A (Seeking Medical Help and Regional Health Care), 2B (Disease Prevention and Yourself) and 2C (Disease Prevention and Regional Health Care) Involve the behavior end of the attitude continuum. The data suggests that there was not a significant behavior change. Time may be a factor inasmuch as not enough time has elapsed to test the effect of the intervening variable. Secondly, the educational message may not have been comprehensive enough and third the educational message may have had no impact. Time appears to be the factor which needs to be 107 expanded and accounted for In any experiment of this type. Subhypotheses 2D (Yourself and Regional Health Care), 2G (Regional Health Care and Old People) and 21 (Community Organization and Regional Health Care) show no significant results. These subhypotheses relate generally to the attitude end of the attitude-behavior continuum. In essence they support the Woelfiel-Saltiel Theory which relates to the mass of an attitude and its resistence to change. Time and number of messages are suggested as having fallen short in their ability to change attitude-behavior. Change in mean scores of Subhypothesis 2D may be attributed to the Hawthorne effects or knowledge that an experiment is being done. Indeed the test may have served as an educational or informational source. In the control-group some of the subjects related that they knew nothing of the Bangor Health Center. Though the changes are considerable in means there is no significance at the .05 level. Thus it must be concluded there is no significant effect attributed to the intervention in the experimental-group or control-group. over, the t-Test shows no significant results. More­ Overall results for these three subhypotheses can be attributed essentially to the factor of not enough time in which to overcome the mass accumulated by previous attitudes toward Regional Health Care. Subhypotheses 2E and 2F test whether Health Education moves statistically closer to Regional Health Care and Community Organization. However neither of these subhypotheses are supported. From responses by both the control-group and the experimental-group the term education appeared to be associated with the concept of school and young people through Health Education, especially in the non-formal vein, was understood by the Health Committee and the Lake County Health and 108 Services Association. The indications are not the same for the samples from the experimental and control populations. Subhypothesis 2H (Regional Health Care and Health Programs) is the only subhypothesis supported by using the t-Test for equality of means. One other variable; the concept pairs, young people and health programs, shows a significant result when the means of pre- and post-tests were compared on the experimental sample. Subhypothesis 2H results appear to be due to the hypertension program mentioned earlier in discussion on Hypothesis 2. The hypertension program may have involved the notion of "intent" described as part of the diffusion process (See Figure 1, page 4). It is a change agent initiated strategy, not community initiated as the Health Education Strategy. An intent to create change was not tested however it may be the factor which contributed to the significant results. A possible explanation for the relationship between young people and health programs is that the hypertension program was intended to reach younger persons age 2A to 44. The screening sites were in places where younger people congregate; pool halls, functions and programs, grocery stores, banks, etc. Thus these two findings contribute to the overall significance of the experimental group. Observations The test instruments' design and the rationale behind the MultiDimension process was to measure attitude-behavior change. The decision­ making process of the Health Education Model allows the Health Committee to define a health problem and construct objectives to facilitate the problem. Unfortunately the Committee chose an objective which is not conducive to the measurement of attitude-behavior change in the community. This researcher was uncomfortable in measuring the impact 109 of the Health Committee's Educational Intervention on the community through the test instrument. which included the measurement The Committee's objective The instrument did not have a question of the Committee's objective. (i.e., persuading in the community was accomplished). a physician to remain There was an attitude-behavior change in both the experimental and control group at an .05 level of significance as attested by the Chi-Square Test (See Table 4, p. 64). However, there was no significant differences between the experimental and control group except on the two variables. The impact of the doctor's decision to remain in the community may be assessed as the community's reaction to his continued residency. The factor of time is an appropriate discussion to undertake at this point. Alluded to earlier in this section only a shor time elapsed between the Open House which welcomed the physicians to the community and the administration of the Post-Test. It is postulated that not enough time passed for adequate diffusion of Information on the success of the Open House and the decision of the physician to stay within the community. There is a scarcity of sources with which to diffuse information in the experimental community. The only form of media is a weekly newspaper and the nearest radio and television station is over thirty miles away. In contrast the control-group has access to two dally newspapers from South Haven and Benton Harbor, two cities within seven and twenty miles respectively, of the control group. Benton Harbor has a television station and both Benton Harbor and South Haven have radio stations. The channels of information may account for the different educational levels of the two communities. The control-group has almost twice as many high school graduates (96.9% to 36.4%, see Table 2, p. 54). This 110 factor may prove to be a conclusive factor. Conclusion The Health Education Strategy appears to have little effect upon the experimental community. The two variables; Variables 17 (Regional Health Care and Health Programs) and 24 (Health Programs and Young People) were the only onew with significant t-statistics. were significant only in the experimental group. However these variables This factor may be due in part to ’’intent," interaction with the Health Committee or other factors, however neither warrants a definite conclusion. Overall both experimental and control-groups experienced significant changes. There were no significant differences between the pre-tests of the experimental and control-groups in terms of variance nor a signifi­ cant difference between post-tests of the experimental and control-groups in terms of homogeneity of variance. This supports the conclusion that the Health Education Strategy had no effect upon the experimental group. The study of the visual plots of the concepts were inconclusive in trying to analyze differences between pre- and post-tests of the experimental-group and control groups respectively. confirm these conclusions. Chi-Square tests The Chi-Square test also confirms the number of dimensions necessary to analyze the data. The content of the dimensions are somewhat different than expected yet plausible and help to explain the perceptions of the respondents to the survey. Recommenda t ions It is recommended that for greater results in terms of more significant findings, a study of this type be spread over a longer time Ill frame (I.e., a longitudinal study which may be evaluated at several points in time), using a greater variety of types of educational messages and a greater emphasis on Health Education and Health Prevention and Promotion for the Young and Middle-aged Population. Time plays an integral role in the adoption of or change in attitude-behavlor. decision period. Rogers and Shoemaker call this the innovationThey have labeled the recipients of an innovation as early adopters, late adopters and laggards according to the amount of time it takes to adopt a particular innovation. This fact should be taken into consideration for future studies of this type. It is also recommended that a greater variety of types of educa­ tional messages be used in a Health Education project of this type. During the administration of the pre-test, both the experimental and control-group subjects tended to relate Health Education to school situations and to the young. This suggests that a Health Education pro­ ject utilizes both formal and non-formal channels of communication. This approach may take into consideration the Woelfiel-Satiel Theory about attitude-mass and provide a study which lessens the pre­ sent attitude-mass and cause a change in attltude-behavior. An area which also revolves around education is the difference in educational achievement between the experimental and control-group. It was earlier stated that 63.6 percent of the experlmental-group had less than a high school education and only 30.A percent of the control-group had less than a high school education. This factor appears to be the only one which markedly separates the two groups from an examination of the demographic data. The unbiased standard errors and the log likelihoods are considerably different across experimental and control-groups and preand post-tests. However, the change in unbiased standard error from 112 pre-test to post-test is .163 for the experimental-group and .180 for the difference "between pre-test and post-test for the control-group, a difference of .017! It would be interesting to analyze how much difference between experimental and control-group is attributed to educational level of the respondents. It is recommended that a study of this nature be reproduced in a Caribbean nation which manifests the demographics of either the Cameroon or the characteristics of a rural area in the United States. The experiment can be expanded to include two areas of a country which may be similar or resemble two settings with dissimilarity differences such as those that exist between the Cameroon and Webber-Yates Township, i.e., emphasis on Chronic versus Communicable diseases. the Rural versus Urban dissimilarity. Another area might be Comparison studies such as these would add other examples of the applicability of this method to the literature. The last recommendation is that a study of this type put greater emphasis on Health Education and Health Prevention for the young. The make-up of Dimension I provides the basis for the relationship of young people to health-related Items. 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H., "Health for All by the Year 2000 (supplement)," International Journal of Health Education 23 (3) (Geneva, Switzerland: International Union for Health Education, 1980). Hartman, Frank R . , "A Behavioristic Approach to Communication: A Selective Review of Learning Theory and a Derivation of Postulates," Audio-Visual Communication Review 11, Sept., Oct., 1963, pp. 155-190. Hays, William L., Statistics for the Social Sciences. Rinehart and Winston, Inc., 1973). (New York: Holt Hudson, Healther E . , Edwin B. Parker, "Medical Communication in Alaska by Satellite," New England Journal of Medicine 25 (Dec. 20, 1973), pp. 1351-1356. 115 Isely, Raymond B., Lardja L. Sanwogou and Jean F. Martin, "Community Organizations as an Approach to Health Education in Rural Africa (supplement)," International Journal of Health Education 22 (3) (Geneva, Switzerland: International Union for Health Education, 1979). Kerlinger, Fred H., Foundations of Behavior Research. Rinehart and Winston, Inc., 1973). (New York: Holt Kruskal, Joseph and Myron Wish, Multi-Dimensional Scaling, Edited by Eric M. Uslander. (Beverly Hills, California: Sage Publications, 1978). Lehman, Phyllis, "Health Education," Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention, (Washington D.C., U.S. Department of Health, Education and Welfare, Public Health Service, Office of the Assistant Secretary for Health and Surgeon General, DHEW (PHS), No. 79-5510A, 1979), pp. 423-438. Mertens, Ethel G . , "Health Education and Community Development, Inter­ national Journal of Health Education 12 (4) (Geneva, Switzerland: International Union for Health Education, 1969), pp. 178-183. Michigan, Health Education of the Public: A Statement of Public Pol i c y , September, 1976, prepared by the State Health Planning Advisory Council and the Office of Health and Medical Affairs. Michigan, Rural Health Initiative Program, prepared by the Michigan Department of Public Health; Bureau of Personal Health Services, Division of Health Care Systems. Michigan, Manpower Tables: Statistics and Research Office and the Office of Vital Statistics, Lansing, Michigan: Michigan Department of Public Health (1979). Michigan, Michigan Statistical Abstract, edited by David Verway, (East Lansing, Michigan: Michigan State University, 1978). Michigan, Regional Health Care, Inc., Rural Health Initiative Continuation Grant Application prepared by Regional Health Care, Baldwin, Michigan, 1979-80. Miller, James Greer, Living Systems. (New York: McGraw Hill, Inc., 1978). Miller, M. Clinton, III, Alan B. Cantor, "A Comparison of Mass Media Effectiveness in Health Education," International Journal of Health Education 23 (1) (1980), pp. 49-54. Miller, Jane, "Community Assessment, Bangor, Michigan," Master’s Thesis Wayne State University, 1979. Milliken, William G., "State of the State Message," January, 1979. 116 Minkler, Meredith and Kathleen Cox, "Creating Critical Conscious in Health," International Journal of Health Services 10 (2) (Farmingdale, New York: Baywood Publishing Company, 1980), pp. 311-322. Moore, Emily Louise McClintion, "Impact of a Health Educational Program on Poor Black Elder Persons," Ed.D. Dissertation, University of South Carolina, 1980. Napior, David, "Nonmetric Multidimensional Techniques for Summated Ratings," Multi-dimensional Scaling. (New York: Seminar Press, 1972), pp. 158-178. Ogionwo, W . , "Socio-psychological Factors in Health Behavior," (Supplement) International Journal of Health Education 16 (2) (Geneva, Switzerland: International Union for Health Education, 1973). Osgood, Charles E., George J. Suci, Percy H. Tannenbaum, The Measurement of Meaning. (Urbana, Illinois, University of Illinois Press, 1957). Pinar, William, Curriculum Theorizing: The Reconceptulists, (Berkeley, California, McClutcheon Publications, 1975). Puska, Pekka, Jaakko Tuomilehto, Jukka Salonen, L'nsa Neittaanmaki, Juhani, Maki, Jartno Virtamo, Aulikki Nissnen, Kaj Koskela, Tuula Takalo, "Changes in Coronary Risk Factors During Compre­ hensive Five-Year Community Programme to Control Cardiovascular Diseases (North Karelia Project)," British Medical Journal, November 10, 1979, pp. 1173-1178. Ramsey, James 0., Multiscale for Programs for Multi-Dimensional Scaling by Method of Maximum Likelihood. (Chicago: International Educational Services, 1978). Redd, Lawrence N., "A Descriptive Study of the Use of Teleconferencing via a Two-way Cable Television in Racially Unbalanced Schools," Ph.D., dissertation, Michigan State University, 1976 Rifkin, Susan B., "Health Care for Rural Areas," Medicine and Public Health in the Peoples Republic of China, (Washington D.C. John E. Fogarty International Center for Advanced Study in the Health Sciences, U.S. Department of Health, Education and Welfare, Public Health Service, National Institutes of Health, No. (NIH) 72-62, 1972), pp. 137-149. Rogers, Everett M . , F. Floyd Shoemaker, Communication of Innovations. (New York: The Free Press, 1971). Ryan, Antoinette T., "Systero-Techniques for Programs," Introduction to the Systems Approach, (Englewood Cliffs, New Jersey: 1973. *' ''Saxbaugh, L. E., Intercultural Communications: A Plan for Study and Practice," Hayden Publishers, 1976. 117 Sarkar, Shyamalendu, "Some Economic Aspects of the Lake County Health Industry: Characteristics, Revenues and Expenditures, Facility and Problems," East Lansing, Michigan, Agricultural Experiment Station, 1975. Schwartz, Dan, "The Mass Line as Consumer Participation and Community Involvement (Supplement)," International Journal of Health Education 20 (3) (Geneva, Switzerland: International Union for Health Education, 1977). Shortell, Stephen M. , and James P. LoGerfo, "Health Services Research and Public Policy: Definitions, Accomplishments and Potentials," Health Services Research 13 (3) (Chicago Hospital Research and Educational Trust, Fall 1978), pp. 230-237. Smillie, Wilson G . , Preventive Medicine and Public Health. The MacMillan Company, 1952), (New York: Smith, Winfred Joseph, " A Guttman Facet Analysis of Racial Attitudes in Kenya, Nigeria, South Africa, and the United States" (Ph.D. dissertation, Michigan State University, 1975). Solon, Florentino, TomasL. Fernandez, Michale C. Latham, Barry M. Popkin, "An Evaluation of Strategies to Control Vitamin A Deficiency in the Philippines," American Journal of Clinical Nutrition 32, (July 1979), pp. 1445-1453. Tuomilehto, Jaakko, Jukka Salonen, Aulikki Nissinen, Thomas E. Yottke, Pekka Puska, "Community Programme for Control of Hypertension in North Karelia, Finland," The Lancet I I , (Boston, Mass.: Little Brown and Company, October 25, 1980), pp. 900-904. U.S. Department of Health, Education and Welfare, Public Health Service, Center for Disease Control, Bureau of Health Education, Focal Po i n t s , Atlanta, Georgia, May 1980. U. S. Department of Health, Education and Welfare, Public Health Service, National Institute of Health, Toward an Educated Health Consumer by Carter C. Marshall Teaching of Preventive Medicine Series, Publication No. (NIH) 77-881, Bethesda, Maryland: National Institutes of Health, 1977. Vertinsky, Patricia A., Chung-fang Yang, Patrick J.M. MacLeod, David F. Hardwick, "A Study of Compliance Factors in Voluntary Health Behavior," International Journal of Health Education 19 (1) (1976), pp. 16-28. Webster's New World Dictionary of the English Language, Second College Edition. (New York: David B. Guralnik, 1972.) 118 Webster's Mew Collegiate Dictionary. 1976). (Springfield, Mass.: F. C. Merriam, Weissman, Arthur, "Some Issues in Health Services Research," Health Services Research 13 (3) Chicago: Hospital Research and Educational Trust, 1978), pp. 226-230. Wilbur, Muriel Bliss, Educational Tools for Health Personnel. MacMillan, 1963). (New York: Wood Donald N., Donald G. Wylie, Educational Telecommunications. (California: Wadsworth Pub1ishing Company,' 1977). Young, Marjorie A. C., "Review of Research and Studies Related to Health Education Communication Methods and Materials," Health Education Monographs 25, New York: Society of Public Health Educatiors, Inc., 1967, Section 3. APPENDICES 119 APPENDIX A SURVEY PRE-TEST {■'rj SURVEY PRE-TEST HEALTH E13UCATI0H-C0KIUN1TY ORGANIZATION Tow,,-,;,________ , Co,',: □ □ □ □ □ □ □ flat Write »1* lltlS rtl'tjO; 7(oT- ob) ,j] j □ ItateintZOi h(i. 00' iio. Ooy E; ■ : : : : : : TO 20 30 40 £0 GO To Hcaltl two 0406 1-3 fid Education and Seeking Medical Help ° . : _j 10~ 20 : 30 40 : 50 : 60 : : : 70 SO 30 , , , 0403 7- 9 _ , , , 0409 10-12 y Completely : Different 100___________ „ - . , Completely Same : : __: : : : : : : : : Different 0 in 20 30 dp 5Q 6Q 70 BO 90 100 _________ Distr.ct Health Department and Disease Prevention District Health Department and Old People 0 : 10 : 20 : : 30 40 50 : : : _ : 60 ?0 80 90 H : 0506 16-18 , 0507 19-21 Completely : Different 100___________ District Health Department and Yourself Same 0 , _ 0410 13-15 . * Completely Same : . : : : : : : : : i Different 0 10 20 30 40 50 60 70 80 90 100___________ r : 0407 4-6 _ Completely : • Different 90 1 0 0 ___________ llealr.L Education and Health Programs Same . . __ .* •* ■' Different : : : : : : : (T TO 20 30 40 50 60 70 80 90 100 ________ Health Education and Old People Same I 0405 73-75 ! (b E g T n ' c T r d , . , Completely : : : : : : : : : : : Different To 20 30 To 50 60 70 60 90 100__________ _O_5O_0 22-24 _ 0509 25-27 District Health Department and Seeking ,Same 0 : . : : : : : : : i Different TO 20 30 40 50 60 "70 80 90 100__________ Distil :t Health Department and HealLh P roS rcn^ Q m p ,je te iy Same 0 : ( 0510 28-30 : __: : : : : : : Different iO 20 30 40 50 60 70 GO 90 100__________ Dleasd Prevention and Old People Same : : : : : : : : : : ‘ O TO 20 30 40 50 60 70 80 90 100 „ , , Completely : Different 0607 31-33 123 Disease Prevent ion ard Yourself Same : 0 : : : TO 20 30 40 : Completely ; : : : Different 50 60 To' 60 £0__100________ : : Diseas-* Prevention and Seeking Medical Help Completely Same 0 : M . TO 20 : : : 30 20 : : : : SO 60__70 TO 00 : : 0 : : 20 To : 30 : TO : 50 : So : ; Completely : Different 90" Cfmpletely : 0 : :_ : TO' 20 Old P o p l c : : 30" ^0 50 : 60 70 : : 60 : 90 and Seeking Medical Help Cvmpletely Same __: : : : _ : __ : : : : : : D fferent 0 10 20 30 4C7 50 00 7iT 60 90 100___________ Yourse t and" Health pTo^ra..is Ct npletely Same : : : :___ : : : : : : : Different 0 10 20 30 40 £0 GO 70 SO SOjOO__________ UeelTlt'g Medical Help and Health Programs Completely Same : : : : :_ : : : : : : Different 0 To 20 30 40 50" 60 70 60 90 100 Telc„ hone and fl Television Completely Same 0 fferent CT To 20 To" 40 50 60 70 B 0 90 100 cT* T o * 20* 30 40* 50 60 70* 80* 90* Too (T* To* 30* To 0708 43-45 : D’ 'fferent louist-lf and Seeking Medical Help Same 0610 40-42 TOO______ _ _ _ Ctmpletely : : : : D' fferent Same : : : : _: __: __ : 0 10 20 30 40 50 60 70 E0 90 100___________ “Old Pe-jple and Health Frog raws Completely Same: : : ______ : : : : : : : : Cifferent 10 20 30 43 50 CO 70 30 SO 100 ______ Same 0609 37-39 100______________ Old People and Yourself 5ame ■ ‘ Different : 80 70 ( 100___________ Disease Prevention and Health Programs Same (Do Dot Write In This Area) 0603 id-36 50 60* 70* M * 90* Too 0709 46-48 0710 49-51 0809 52-54 0310 55-57 0910 5S-60 61-63 ( Completely Different Completely Different - 124 What are the most important problems in your community. 9-15 (Do Not Write In This Area) I w ill read you a lis t of information sources and I'd like you to te ll me which one of these gives you most of your nnoith education infor­ mation. Workshops/Presentations . T.V. w TO Meetings Newspaper (2) U) (4) 177 Radio 157 Magazines 17-21 Informal Conversations Other: _____________ Bro< Imres (3) 3. From which inft, of these same sources do you get the best information on Health educition? T.V. (1) (2 ) (3) ~ W ls 7 Newspaper Rad .o Magazines Brc:hures Workshops/Presentations 157 177 187 197 Meetings Informal Conversations Other: ____________ 23-27 125 These „ rt. tj,, lost o p t i o n s that I vf.ll esk you. incoi•- i£- r^-ase tell tve if it U l l s I need v i Uniu tkate to know whr> your ranges. 0-55 p000________ I $5,001-57.00°____________ 2 $ 7 , 0 0 0-59.000 3 $ 9 ,001- $ 12,000___________ A $12 0 01-$15.0C0__________ 5 $ 1 5 ,001-520 003__________ __7 Ov/ay $20. 000_______ * 6 — •«■* H h a t age range do you fall in. v 31 Under 18_________ 1 18-25_______ 2 2 6 - 3 ° ____________3‘ 31-35__________ - _ A 36-Aj^__ __ „5 4 6 - 6 0_____________ 6 O v e r 50__________ 7 M o answer________ 8 Sex(Identify by voice) Female 1 Halo 2 Wliat is your 33 /ace or nationality Block 1 White 2 Hispanic 3 Asian A Other 5 35 126 What Is your level of education? Below elfthth (trade 1 EiRhth 2 Ninth 3 Tenth U Eleventh 5 Qraduated(H.S.) 6 Some Collette 7 Diploma 8 Qraduate School 9 No Answer 0 We nay do sobo further work tilth health coro needs. Do ycut W r k you would ha avallnbr e for a short sesnlon at your own conveilence if wo decide to go further? Could I have your DBaa, address rnd tolophono number? Name Addreco Telephone Number THANK YOU VERY MUCH FOR YOUR CO-OPERATION, 127 APPENDIX B SURVEY POST-TEST SURVEY P.ltiT-TFST IH'AT.'I H I*U UC A T 1OH -C< IHH1TN1T Y OUr.ANI7.AI IOH Code: □ Townships □ CD O □ Not Write Jfi This Area) (01-00) o , C 3 ’'. Date: [“ 1 0 0 1 Ho. Day Ex.'Con Group Time Interview Began: i 1[ " If iI__11 I Time Interview Ended: _________________ Minutes: [ 11 11 Interviewer (In itia ls ): | II I I [__ | Comments: INTRODUCTION HLLLO: My Nome Is __ ______ ______ and I am here to ask you some questions about TRlease Print) Health Eduratiin and the community. We are conduct'n£ a study In this county and I vould like lo talk to the head \ of the h o u s e h o l d . Wc would like Lo find out what people in Lake County think ohout this community and Meal Lit Education. So, I would lik : to ask you some questions that w ill help us get a clear * understanding of your ideas about Health Education and your community. 128 I w ill read you some pairs of Health Education a,.(! community words Please similar or different the following pai rs arc usin’g the 0 to 100 scale. * Hememher, the difference between a telephone mid a telovlolon ia 5 0 . How di fferent -that is how far apart are: (Do Dot Write In This Area) C o m m c i t y Organization and Regional Health Con lor Same : : 0 : ___: : : : : tell me how Completely : Different : lo 20 30 40 50 GO 70 SO 90 100______________ Conuiunity Organisation and Young Peo| 0102 1-3 0103 4-6 Completely Sane: : : : : : : : : : : Different 0 TO 20 30 40 50 60 70 80_90 100 ______ Community ocganization and Health Education 0104 7-9 . Completely aame __: : _ : : : : : : : : : Different 0 TO 20 TO 40 50 60 70 60 90 TOO ______ Community Organization and District Health Pcpartmcn Ctmpletely Same : : : : : : : : : : : D" fferent 0 TO 20 30 40 50 60 70 00 90 '100___________ OIOS 10-12 Community Organization and Disease Prevention 0106 13 0107 1 6 -1 8 OIOS 19-21 Same __: : ___ : 0 10 20 33 40 SO 60 70 SO L’oniii.uni ty Organiza. ion and Old IV-nple Same __: : : : : : 0 10 20 3f 40 50 60 __: __: : 70 GO 90 100 Campletely : D fferent Core:iu‘i11 y Organ! zat tun atuT Vu7irscll Same 0 Ct mpletely : D fferent 90__ 100__________ 10 20 30 40 50 60 To SO coninunxty Organ i l o l u n ana Sucking Mad leal Hi* Ip Some __ : _ 0 : ___ : : : : GO 70 60 90__ 100__________ Lommu.'i ty Organization and Health Programs : 0 TO : : 0~ : : eO 90 100 ini llcaith Center and Young People : : 0 : __ : 0 : : : : : 0203 Completely : D*fferent : : : 28-30 ( 40 : 10 20 30 25-27 40 50 60._ 70 ___:___ : __ : 10 20 30 Regional llealth Same : 20 30 : 0110 Completely : O'fferent : : : : : GO 60 70 60 90 ~1Q0__________ Kt-gional Health Center "and Health Education TO 22-24 40 50 20 30 Keg i o Same : 0109 Completely : Different : __ : __ : 10 20 30 Same Same 15 Completely : : Ti fferent 90 100__________ 40 50 60 center and : : : : : 70 BQ 90__100__________ the District Health Department : 40 50 60 0204 31-33 Completely : Different : : : : 70 60 90 Completely : Different 100__________ 0205 34-36 129 (Do Not Write In This Area) Regional Health Center and Please Preventior Completely Same * * • * * ' 0- ' To* 2 0 * 30* 40 * ■ 50"* 60 * * * Diffprpnt' 6 0 * 90 * 100 70 Regional Health Center and Old People Completely Different Same r i o ' I o 1 o T O 5o 1 ' 7 o e o m Regional Health Center and Yourself 100 r Toff ’Completely Different Same i 0 H l l l 5 0 6 0 7 10206 3 j -39 0 ® l Regional Health Center and Seeking Med icfll H£j[fipletely 0207 40-42 020843-45 0209 46-48 Same (T 20 To 30 40 60 60 To EO 90 100 Regional Health Center and Health Programs Cjmpletely Ci fferent Same r * W ’ 20 30 4 0 ’ 50* 60 70 SO 90 TOO You n 6 People and Health Education Completely Different Same 0“ * T o ’ 20 30 40 Young People and Same : 0 50* GO 70 80 90 100 the District Health Department Completely : Different : : 10 20 30 40 50 60 T ff 80 90 Same Same i D l I l 5 O 6 0 Young People and Old People ( r T a T o W f 100 M 304a 5 0 G o 7o 8090 Toff Completely Different Completely 0 .fferent Young People and Yourself Same O' W * 20 30 W 50 60 TO Completely Different 80 Same 20 * 30* 3 ff 50 60 70 B0 90 100* Young People and Health Programs Same O- T 0'* 2 0 3 0 ^ 0 ' 5 o B 0 ' 7 0 8 0 0305 55-57 0306 58-60 0307 61-63 0308 64-66 f 90* TOO* Young People and Seeking Medical Help O- * To* 0304 52-54 TOO Young People and Disease Prevention r 0210 49-51 90' Too* Completely Different Completely Di fferent 0309 67-69 0310 70-72 - 130 (Do Hot Write In This Area) Health Education and Same : : TO 0" : 20 30 :___ : 40 the District Health : 60 50 : 70 : £0 : 9Q Health Education and Disease Prevention Same : : : : __ : __ : T ? 20 30 40 50 IT Health Education Same : : 0 : 30 : 70 : 80 and Old People : 20 To : 60 : 40 50' 60 : 70 : £0 : 90 : : __ : __ : _ : ___ : ___: 40 SO 60 70 130 90 : 0 10 ~2J 30 i ^ i Completely : Different 100_____________ ■- " , Completely : : Different 90~ 100______________ Health Education and yourself Same : Different 100_____________ _ , , Completely : Different 100_____________ Ileal Lh Education Same : _ : : 10 20" 30 Q and Seekinv Medical Help , , . , r Completely : : : : : Different JO 50 60 70 bO 90 100_____________ Health Education and Health I'racranis Same : : 0_ 10 : 20 30 40 50 : 60 : 70 : DO 90 Completely : Different ICO_____________ District Some Same 04 0G 1-3 0407 <-6 0408 7- 9 0409 10-12 04 10 1 1- 14 Health Department and Disease Prevent Inn completely : ___ : __ : __ : i __ : __ : : Different 0 10 20 20 40 "50 60 76 SO 90 100_____________ 050ft 1ft-18 District Health Department and Old People „ , , ^ Completely : : : __ : __ :__: ___ : __ : : Different 0 __ 1JJ__ 20 30 40 50 60 70 SO 90 100_____________ 0507 District Health Department and Yourself Same : 0~ : T(J : ___: 20 30 : __ : __ :____: 40 60 60 70 80 : 90" „ , . Completely : Different 100_____________ District Health Department and Seeking Med fe Same : Q~ : TO ’ > : 20 30 40 : 50 : 60 : 70 • HO : 90 : Different 100_____________ : : 0 __10 20 : 30 : 40 : : 50 60 : : : 70 80 DO : Q~ : To :___ : 20 30 : 40 : SD : 60 : 70 : : 80 90 0509 25-27 / 0510 28-30 : Different 100_____________ Dieasd Prevention and Old People Same 19-21 0508 22-24 G 1y Distrirt Health Department and Health Prqgrarja^^ie £e (y Same 0405 73-75 . . (BEGIN"CARD 'TWO Completely : Different 100_____________ 0607 31-33 1 131 (Do Hot Write In This Area) Disease Prevention and Y o u r s e 11 Same r ’ TO 20 39 W 50 60 70 80 90 0609 T7-39 Completely Di fferent 0~' TO 20 30 TO Disease 5Ci’ SO' 70 80 90 Too Prevention and Health Programs 0610 60-62 Completely Different Same F 10 23 30 1 50 SO TO 80 1f 90 Too Old People and Yourse Same 0~ TO 20 3D 60 SO 60 0703 63-65 70 80 90 tic 1P Too Completely Di fferent Old I’euple and Seeking Medical Some ........ M 100 Prevention and Scekinv Med leal He Ip Discasi Sane j 0 f>03 34-36 Completely Different cT.To zo 30 W 50 I 70 So’ 90 Too Completely Di fferent QTd Pi-'jple and Health Programs 0709 66-48 0710 69-51 Completely Same F lo 20 30' 60 50 60 70 80 90 Too Yourself and Seeking Medical Help Same F To 20 Yoursell Same 0309 52-54 Completely Di fferent 30 40 59 60 20 80 90 Too and Health Prog rums Cimpletoly D’ fferent F To ¥ I To 50"’ 60 70 80 90 Too Seeklig Medical Help and Health Programs Same 0310 55-57 0910 5B-60 Completely Di fferent r ' To’ 20 30 1 50 60 20 80 90 100 61 -63 Telephone and a Television Same Same Same F' 1 20 30 40* 50 60* 70 80 90 Too Completely Different C< mpletely Different TT To' 20* 30 0“ ' To’ 20 30 40 40 50 60 - 50* 60 70 60 To' 80 90 90 Too Too’ Completely Different ( 132 A P PENDIX C SURVEY PRELIMINARY TEST "ATTO*!-C0*-C'1UT?ITY O R G A N I Z ATION SURVF.Y PRELIMINARY TJ Over $20.000___________ _ J Ho answer__________ „______ ® W hat age ronge do you fall in. yi Under 18________ 1 18-25____________ 2 26-30____________ 3 31-35._____ ______ 4 36-45____________5 4 6 - 6 0 ___________ 6 Over 60__________ 2 Ho a n s w e r — 0 Sexfldcntify by voice) 22 Female_________ Male What __________ 2 is your race or nationality Black________ 1 White______ _ 2 Hispanic_______ _3 Asian________ 4 Other________ _5 135 What io your level of education? j Eichtb 2 Wlnth 3 Tenth k Eleventh 5 GraduatodCH.S.) 6 Soao Collero 7 Dlnlor.a 8 Graduate School 9 Ho Answer 0 n Wo any do coao further work tilth health earn noedu, Do yor thlnls you rsuld to avalist.1e for a short seonion at your own convo tlonco If wo Could 1 havo your oaoe, address and tolophono miobor? Kamo Address Telephone Kuator_ T1IAKK TOD VEMf 1IUCH TOR TOUR CO-OPSRATIOH. decide to £0 further? 136 APPENDIX 0 Input During this phase a survey was administered randomly to citizens in Yates and Webber Townships to assess social and health problems (See Appendix 2). This survey identified problems of health, sources of communication about health and demographic information about age, sex, income, etc. The subjects were also asked to identify leaders of activities within Yates and Webber Townships. In addition the Chamber of Commerce, Regional Health Care, The District Health Department and an Interagency Group were visited. From these visits letters of support for this pro­ ject were solicited from the Yates Chamber of Commerce and the Western Michigan Health Systems Agency. From this procedure the investigator sought to compose a committee to address the health care problems of the Yates-Webber Township Community. However it was discovered that a health committee was already in exist­ ence and had been since 1964; the Lake County Health & Services Association, which was comprised of local citizens. Brief History of the Lake County Health & Services Association This committee was organized on April 23, 1964 and incorporated in October of that year. In 17 years they have had five presidents, five secretaries and one treasurer. Their goal was to improve the living and health conditions in Lake County and surrounding counties. Two of their most notable accomplishments were the aiding in the construction of the early Health Unit built by 0E0 in the 1960's and the present Regional Health Care Center. They steer-headed the drive to build the present nursing home, through calling for millage elections and con­ tacting private groups for this purpose. They fought a lengthy court battle to retain the land for the nursing home. Their meeting room is now located within the nursing home. The investigator attended one of these meetings in August of 1980. The purpose of his research was expalined and the Committee agreed to allow him to present his proposals at the next regular meeting which met in October. At this meeting the investigator gave the results of his ■ survey; asked the Committee to priortize the health problems and to look at particular obstacles (constraints). A discussion ensued and the Committee agreed to make a decision at the next meeting. Process During the next four meetings, one was canceled due to the weather; the Health Committee decided that the number one priority was to recruit a doctor for the community. All available material was gathered to aid in this area including two documents from the U.S. Department of Health, 137 1 2 Education and Welfare ’ . From various conversations with the Health Care Agencies it was discovered that Regional Health Care was expecting two doctors to come to the community under the National Student Health Corp Program.3 The Director of Regional Health Care was then invited to attend the next meeting of the Health & Services Association. The next several meetings involved the devising of strategies to persuade at least one of the doctors from the Health Corp to remain in the community rather than strategies to recruit a physician. The documents mentioned earlier, prior experiences of the Health Committee, advice from the Director of Regional Health Care and Health Education strategies were reviewed. In addition an assessment was made of local resources especially media and interpersonal communication. From this information the Health Committee decided that the community would be informed that two doctors would be coming and Regional Health Care through an educational campaign using the county newspaper, posters, flyers and interpersonal communication through the churches (See Figures 1-4). These activities would culminate in an open house to welcome the doctors shortly after they arrived. The date for the Open House was July 12, 1981. Output Regional Health Care handled the media portion of the Health Education process. They wrote the article for the newspaper, designed flyers and spread messages through their center activities and outreach programs. The Committee contacted churches, made announcements and spread the educational message verbally. The Committee also organized the program for the Open House to be held at Regional Health Care. Control of the Environment The culmination of the Health Education/Communication process was the Open House. One degree of success of the project would be the number of people who attended. Over 100 people attended. Another indicator of success would be whether a doctor would remain in the community after his two-year period was over. Shortly after the Open House one of the doctors purchased a house within the community. This is not an indicator that the doctor will remain but is an indication in the right direction. U.S. Department of Health, Education and Welfare, Public Health Service, Health Services Administration, Bureau of Community Health Services, "Establishing a Health Care Practice in Your Community," no date. 2 U.S. Department of Health, Education and Welfare, Public Health Service, Health Services Administration, Bureau of Community Health Services, "Finding a Doctor for Your Community," Publication No. (HSA) 77-6005 (1977). 3 The National Student Health Corps (NHSC) is authorized by Congress to upgrade or help establish health care practices in areas designated to have a shortage of health manpower. Physicians who have borrowed monies from the Federal Government to finance their education generally pay back their loans by working for two years In the Health Corps. 138 Evaluation Post-Test results were only slightly positive. A total explanation is contained in Analysis of the Data Section of the main body of the paper. 139 FIGURE DJ LAKE C Q U N T V & Service Association____________ H ealth & Service Association ________? - ! — — BOX B A L D W IN , M IC H IG A N . 49304 To the people of Lake County and the surrounding counties please mark your calendars for August 12, 1981, when the Health and Service Association will sponsor an Open House at Regional Health Care in appreciation for the two new Doctors that will be taking care of the patients at the Health Center. As you know we are in dire need of doctors in Lake County and we are so grateful for those that are coming. The Open House starts at 1 o'clock until 5 p.m. We trust we will have a packed house that day. The Health and Service Association hold their meetings on the 2nd Thursday in each month at the Oak Village Nursing Home, in the Extrom Room at 8 p.m. Everyone is welcome to attend our meetings. This organization is responsible for Oak Village Nursing Home in Baldwin. We are working to do many things in Lake County. Please come and join us we need your support and help. Thank you kindly. Mr. Vern Ivez, President Rev. Ellis Davis, Vice President Mrs. Willie, Instructor Ms. Olivia Withers, Acting Secretary. 140 FIGURE D2 H L h Kc A , Serving Lake County u=? a :rT j J J U T H U R S D A Y J L 'L V 2 , 10H1 since 1873 l. $.20 V O L U M E 108 NO. 9 T W E N T Y FACES REGIONAL HEALTH CARE HYPERTENSION CONTROL PROGRAM FREE Blood Pressure Screening, Referral, Follow-Up Clinic Available this week at (liese siles: July * • Lakc-Oseeola State Bank t a.m . to So,m. , July J . Ed's I.G.A. 9 a.m . la Sp.m. , - Ju ly t- Dept, of Social Service! Ja.m . to lln o o n July 9- L ulher M eal* Site 10 a.m . t o l p.m. Fur Further Information Call; ;j:.-lliJI • Open House at R H C ! The public is invited to a ttend ct an open hrtuso at Tlepirjriol i Ik v ilib L 'jr e tljIr U in o il .Suntl.ty, July fru m 2 .uup m. io j w p m in The open hou5e w ill he held (■» u r L o m e tw o new p h y sic ian * tn th e com n m m i) . Tht> public m ay a k n tuur Ltit- r^ r.lily H eir^h - menLs w il Ih e i er Vcdr FIGURE D3 THE LAKE COUNTY STAR I6-THURSDAY, JULY 9,1981" Kegional Health Care has hired two new physicians: Dr. Keith Newall and Dr, Wally Storm. The public is invited to an open house on Sunday, from 2:00 p.m. to 5:00 p.m. to meet the community's newest members and tour the RHC facility. . 142 FIGURE D4 om us in welcoming Joi, I. Dc Kerffi Newell and Dr Uallu Sform n nu sicii lo ourcommuniTU as oar neuu pnustcians. ic uJe inviie 3 4 .. - you to com e ■fc to our f feqicjEQi lieelili Core in a' j\n r\ Baldwin on July 12 from 2 un+,J) 143 FIGURE D5 Discussed at the Interagency Council Meeting July 12th an open house will be held at Regional Health Care from 2:00 a.m. to 5:00 P.m. The purpose of the open house is to welcome our two new physicians: Dr. Keith Newell and Dr. Wally Storm. We are hoping for a good turn out as a show of support for the physicians. As a medically underserved community the recognition of the importance of attracting and keeping these physicians in our area can not be under­ played. Besides our lack of health providers for the community we deal with an increased need. Just to give you an example of why our need is greater consider these points of examples. Our high percentage of elderly citizens increases the rate of chronic diseases. Chronic disease processes need to be closely monitored. The low socio­ economic status in general leads to certain health problesm, such as anemia in children, increasing the demand for health care. The two new physicians are National Health Service Corp physicians. This is a real financial advantage to the community. The physicians will be relatively inexpensive to Regional Care helping allow the sliding fee scale for services to be in the budget. Past data has pointed to the community being to poor to support private physicians and the the comprehensive health service needed. I think we should all take a responsibility for both our health and health care as we cannot separate one from the other. One method of taking responsibility for our health care would be to support these new physicians by our acceptance. I am in hopes that you will take this information and flyers back to your agencies to pass on to community leaders. Discussion followed.