Effectiveness

and Efficiency of Indigenous Health Aides in a

Pediatric Outpatient

Department WILLIS A. WINGERT, MD JUDY GRUBBS, PHN EDWARD F. LENOSKI, MD DAVID B. FRIEDMAN, MD

The effectiveness of indigenous health aides in providing health care supervision and coordination for indigent families was assessed and compared with that of public health nurses.

Introduction Families described as disadvantaged share certain characteristics which combine to produce a self-defeating effect and cause the usual approaches of social and health improvement to have little measurable effect. These Dr. Wingert is Professor of Pediatrics and Community Medicine, University of Southern California School of Medicine, University of Southern California School of Medicine, and Director, Ambulatory Pediatric Services, Los Angeles County, University of Southern California Medical Center, Los Angeles, California 90033. Ms. Grubbs was Project Director, Pediatric Outpatient Department, at the time of this study. She is presently Instructor, University of California, Los Angeles, School of Nursing. Dr. Lenoski is Assistant Professor of Pediatrics, University of Southern California School of Medicine, and Director, Pediatric Emergency Services, Los Angeles County, University of Southern California Medical Center. Dr. Friedman is Professor of Pediatrics, University of Southern California School of Medicine. This project was supported by Grant H-117, Department of Health, Education, and Welfare, Health Services and Mental Health Administration. The paper was presented at the Ambulatory Pediatric Association Annual Meeting, Washington, DC, May, 1972.

families have been characterized by: * Having both social and medical problems of considerable magnitude; * Lack of ability to make decisions important to the individual or family'; * Social isolation and alienation2; * Present or "now" orientation rather than future-

oriented'; * A nonlinguistic mode of communication, using tone-physical volume expression rather than words2; * A relatively low priority for health, in contrast to that for food, shelter, and entertainment. Each of these characteristics has been shown to interfere with the family's compliance with medical advice and with regular well-child health supervision. Each presents a challenge to the health worker, and the combination of several can be devasting to the best intentions. A demographic and ecological survey3 in 1965 of 3058 indigent, minority group families in the Los Angeles

County, University of Southern California Pediatric Outpatient Department demonstrated the effect of the above characteristics. The lack of systematic health supervision INDIGENOUS HEALTH AIDES 849

for children was clearly reflected, in that: * The proportion of children born in public hospitals was 73 per cent. Of these, 66 per cent were delivered in our Medical Center; * Forty-one per cent of the children and 28 per cent of the parents had contacted a private physician for health care in the past. A review of the reasons for contact indicated that the care was largely crisisoriented and episodic rather than continuous supervision (e.g., prenatal care, respiratory infections, gastroenteritis) for both children and adults; * Half of the children had not been completely immunized against one or more specific preventable communicable diseases for which protection is available and should have been provided by that age; * The incidence of visual defects identified (0.6 Per cent) fell far below the expected incidence4'5 of 6 to 8 per cent; * Of 225 children under 5 years of age, 25 per cent had demonstrable iron deficiency anemia (PCS < 30); * Of 1091 children tested for the first time, 215 were reactive to the Tine test for tuberculosis; * Of the children appearing in the emergency room, 25 per cent had a chronic or recurring illness and the family used emergency room type of intermittent crisis-oriented care as the sole approach to medical care; * Less than 1 per cent of the children were seriously ill and 75 per cent had only a mild, self-limited illness or no identifiable illness; * The families were larger than the average middle class family (three children per family compared to 2.3 national average); * Compliance in keeping scheduled appointments was only 52 per cent in general medical clinics and 60 per cent in specialty clinics; * Half of the families were broken, usually without a father figure; * The unemployment rate was 30 per cent; * Over 50 per cent of the families received some form of welfare assistance. It was apparent that these families required assistance to identify and correct the multiple related medical and social problems with which they were unable to cope. It was also apparent that the hospital physician, with his multiple responsibilities, could not handle this task. Traditionally, the public health nurse (PHN) would seem well suited to this function because of the nature of her training. These personnel are in short supply and the financial investment required for adequate numbers to provide intensive services is prohibitive. In addition, professionals do not always communicate effectively with disadvantaged minority group clientele, resulting in patient dissatisfaction and noncompliance.6 7 In an attempt to resolve these problems and provide effective services economically, the indigenous, trained health aide, who shares common ethnic origin, language, and group interest, appeared to offer a solution. These aides 850

AJPH AUGUST, 1975, Vol. 65, No. 8

are said to be ideally suited to "bridge the gap" in communication and motivation between professionals and the poor and to extend health manpower by performing under supervision at a professional level. The present study was designed: (1) to determine whether 1 year's comprehensive health supervision could be shown to improve the health and social welfare of indigent families; and (2) to compare the effectiveness of professional PHNs with that of supervised nonprofessional indigenous health aides in providing such health care supervision.

Methods Recruitment Seven health aides were recruited from the community served by the hospital. Three were Mexican-Americans and four were black. All were women from 18 to 59 years of age. Trainees were selected solely on the basis of a personal interview by the project director and supervising PHN. If the candidate appeared to have average intelligence, could read and write legibly (regardless of poor reading ability), and was interested in the position as described, she was considered for appointment. Disqualifying criteria were a record of felony, drug abuse, alcoholism, or a middle class or "professional" attitude. For the latter reason, we avoided recruiting any person who had prior training as a nurse, vocational nurse, or hospital attendant.

Training Program o The formal training program was limited to 2 months of lectures, conferences, and demonstrations with continuous on-the-job instruction and weekly conferences thereafter during the next 10 months. Didactic lessons were kept to a minimum, and the teaching was done on the job by the PHN project supervisor with occasional involvement of the project directors. To preserve the aides' colloquial language, use of medical terms was avoided as much as possible. The training program included methods of problem identification and approaches for resolution of the identified problems for all members of a family. This multiphasic screening included: * History of episodic illness (principles of interview

technique) * Determination of immunization status (comparison

with Academy of Pediatrics' recommendations) * Screening for tuberculin reactors (Tine method) * Testing visual acuity and extraocular muscle balance

(Titmus optical tester) * Auditory screening (AMBCO pure tone audiometer, range 200-5000 cps and 0-80 db) * Inspection for gross dental caries, malocclusion, and poor oral hygiene * Identification of common dermatological problems * Assessment of perceptual-motor and intellectual

development (by Winterhaven and Goodenough Draw-A-Person tests)

* Delineation of physical development (height and weight) * History of psychological or behavior problems * Estimation of gross speech defects * Determination of hemoglobin (A-O hemoglobinometer) * Estimation of diet by history (comparison with American Academy of Pediatrics' recommendations) * Determination of school problems: level attained, grades, conduct, absences, relationship to teachers and peers * Assessment of need for and methods of family planning * History of gynecological problems and utilization of an annual Papanicolaou test for the mother * Evaluation of social and cultural environment, including housing and living conditions, appropriate clothing, finances, employment, transportation, need for further education or training, and utilization of recreational facilities.

Methods of Recording Data At the end of the 2-month training program, the aides were expected to perform a complete survey of a family within 1 month, utilizing appropriate, simple forms for recording and covering all aspects as noted above. The aides were evaluated periodically by written and oral examination to identify those needing extra instruction.

Procedures

Families of chronically ill children attending pediatric specialty clinics were evaluated by the PHN supervisor to determine their suitability for participation in the study. Criteria included presence of a chronically ill child for continuity; at least two children in the family; multiple medical and/or social problems; inability to cope with the problems; and willingness to accept the service offered. The supervisor then assigned families randomly among two experienced PHNs, the three Mexican-Americans, and three black aides by use of a nine-digit table of random numbers. A standard list of medical and social resources was compiled for problems expected to be encountered in every parameter surveyed. These resources were utilized by PHNs and aides alike. The PHN supervisor verified the availability and cooperation of each referral resource by personal contact with the director of the resource. When the study personnel (coordinators) identified a problem, they took one of several actions: (1) they personally corrected the problem, i.e., dietary advice and oral iron for iron deficiency anemia; immunization; transportation; (2) they made an automatic referral to a standard resource: Health Department for tuberculosis; eye clinic for vision less than 20/30; Alcoholics Anonymous, etc.; (3) the aides consulted with the PHN supervisor, and the PHNs with the project director, concerning appropriate referral; weekly staff meetings at which family problems

were reviewed were helpful in determining disposition of problems. Coordinators visited each home to assess environmental factors. The PHN or aide also acted as family advocate on all family contacts with the Pediatric Outpatient Department. Thus, the family was assured of seeing a familiar face on every visit. Project personnel were available for telephone advice during the daytime and occasionally, by personal choice, at night and on weekends. The coordinators contacted each of their families at least once each month either by a visit to the home or by telephone. The coordinators followed up on all scheduled appointments, both their own referrals and those of physicians and outside agencies; reappointments were made as indicated. If one reappointment was missed, the appointment was considered broken.

Analysis of Data

After 12 months of comprehensive supervision by a PHN or aide, the PHN supervisor and a data analyst reassessed the family's health and social progress. For purposes of statistical comparison of effectiveness, the PHN and the health aide were considered independent variables. The dependent variables applicable to each family member which were identified and quantitated included: * Ability to perform technical tasks: the amount of data obtained * Ability to interpret data: the number and type of problems identified * Ability to solve problems: the number of identified medical and social problems corrected or alleviated * Ability to motivate compliance: the number and types of appointments kept and broken * Impact of 12 months of supervision on the family: social conditions, changes in income, employment, environment, education, and patterns of obtaining emergency care. The data analyst supervised the accurate compilation and transfer of data to cards for computer processing.

Results Evaluation of Performance At the end of the study, the project director and the PHN supervisor evaluated the aides' performance. Of the seven aides, five performed entirely satisfactorily. One aide performed at a lower level because of inconsistent work habits and need for repeated counseling and another's performance was considered substandard, since she was unable to keep records properly and had difficulty in responding to her clients' problems. It should be noted that all of the aides themselves had personal or family problems. These problems contributed to the poor performance of the two least successful aides. The 2-month formal training program proved to be adequate for learning specific tasks. At the completion of INDIGENOUS HEALTH AIDES 851

the formal course, all of the aides were able to perform the required tasks with minimal supervision. Deficiencies included recording data, punctual appearance for appointments and in meeting deadlines in collection of data, and organizing their work day efficiently. Frequent counseling sessions were required to maintain performance.

Sample The sample consisted of 108 families randomly assigned among two white PHNs, three Mexican-American aides, and the three black aides. To verify whether the distribution was truly random, the demographic characteristics of the three samples were compared by chi-square analysis by two methods. In the first analysis, the independent variable was the demographic characteristics of the sample while the dependent variable was the professional classification of the coordinator (PHN and aide). By this method, the distribution of the families was similar except for the availability of a telephone in the black aides' sample. In the second analysis, the independent variable was the category of coordinator and the dependent variable, the demographic characteristics. By this method, the sample was found to be truly randomly distributed. The two nurses were assigned 30 families, the three Mexican-American aides 37, and the three black aides 41. The irregularity of distribution was caused by the oldest aide, who reached the maximum caseload that she could handle (10 families) before distribution of the sample was complete. The PHNs' sample consisted of 123 children and 49 adults, the Mexican-American aides' 165 children and 72 adults, and the black aides' 169 children and 74 adults. Of the 108 families, the following demographic characteristics were noted: 24 per cent were caucasian, 42 per cent were black, and 34 per cent were MexicanAmerican; 71 per cent did not own a car; 52 per cent had annual incomes below the accepted poverty level for family size; 51 per cent were welfare recipients; 31 per cent had no telephone; and 11 per cent did not speak English. The data were compared according to the ethnicity of the coordinators-white, black, or Mexican-American-in order to determine whether any ethnic group had difficulty

crossing cultural barriers in dealing with clients of another race. However, the results did not suggest differences in performance between the three ethnic groups. Subjectively, the minority group aides did not report any problems in communicating with ethnic and cultural families different from their own cultural background and made home visits freely into any ethnically dominated geographic area during the daytime. Task Analysis

ABILITY TO SURVEY

Of 2205 individual items of data required for a complete health and social survey of all family individuals, the nurses obtained data in 1470 (67 per cent); the aides obtained data in 4371 of 6570 items (66 per cent) (Table 1). Thus, there was no significant difference in the proportion of total data obtained by professionals and by

paraprofessionals. ABILITY TO IDENTIFY PROBLEMS Table 1 demonstrates that professionals identified a

significantly higher percentage of problems than the aides. The nurses found a higher incidence of adult problems in immunization, hearing, gynecology, weight, and visual acuity than the aides. In the pediatric age group the nurses were able to identify a higher proportion of problems than the aides in immunizations, tuberculosis, vision, hearing, dermatology, behavior, and perceptual-motor and intellectual functioning.

ABILITY TO CORRECT IDENTIFIED PROBLEMS

Table 1 indicates that the PHNs corrected or alleviated 57 per cent of all identified pediatric problems while the aides corrected 50 per cent. The difference was not significant statistically. However, the nurses were significantly more effective in solving adult problems. While the nurses corrected almost two-thirds of the problems identified, the aides corrected less than half. Except for mental health problems, the PHNs corrected every category of

TABLE 1-Comparative Effectiveness of Nurses and Aides Variable % of data obtained % of adult problems

Aides

PHNs (172 Subjects)

(480 Subjects)

Significance

67 41

66 30

Not significant p = 0.01

33

22

p = 0.01

35

24

p =

63

37

p < 0.01

57

50

Not significant

identif ied % of pediatric problems identif ied % of total problems identif ied % of adult problems

corrected % of pediatric problems corrected

852 AJPH AUGUST, 1975, Vol. 65, No. 8

0.01

adult problems more effectively than the aides, significantly so in the important area of family planning: 86 per cent corrected by the PHNs and 55 per cent by the aides.

school attendance nor grades improved despite the coordinators' efforts. Finally, the compliance of the family in keeping appointments for the chronically ill child at his respective clinic did not improve during the year of family supervision. Prior to this study, of 223 scheduled appointments at their respective specialty clinics, the PHNs' sample kept 79 per cent; the aides' sample kept 83 per cent of 561 appointments. During the 12 months' intervention, however, of 252 scheduled appointments, the PHNs' sample kept 78 per cent and the aides' sample kept 81 per cent of 665 appointments.

MOTIVATING COMPLIANCE IN KEEPING SCHEDULED APPOINTMENTS Table 2 indicates that the coordinators were equally effective in motivating parents to keep appointments made by the coordinators for the children in the sample. However, the PHNs were significantly more successful than aides in motivating adults to keep appointments for themselves. This correlates with the diminished success of the aides in correcting adult problems. While the difference is statistically significant, the aides, in fact, motivated at least 80 per cent of the adults to keep appointments, a favorable response in view of the expected usual compliance rate in this population. In addition to referrals for correction of problems identified by survey, the coordinators also made appointments for their clients to social agencies, hospital clinics, and health departments and supervised scheduled chronic disease clinic appointments. The data indicate that the coordinators motivated the families to keep 80 per cent of all appointments with no significant difference between professionals and aides. With regard to type of referral, the aides proved more effective than nurses in persuading patients to keep scheduled specialty clinic appointments and in visiting health agencies outside the hospital.

Discussion The typical pediatric outpatient department of a large urban hospital has 10 to 50 different specialized clinics. If a child has sickle cell anemia, heart disease, chronic osteomyelitis, and myopia, he must attend at least four different clinics, each clinic limiting its attention to one specific condition or ailment, and none considering the whole child, his home environment, his education, or other significant medical problems such as deafness, dental caries, or lack of immunizations. Since this method of delivery of care involves long periods in waiting rooms and the care often may be impersonal, it is easy to understand why people do not avail themselves of this modality of medical service unless forced to do so by the severity of the child's illness. The problem is that of fragmentation: the clinic is disease-centered, not child- or family-centered. The patient often becomes "lost" between specialty clinics. The transportation and babysitting problems provide the dilemma of bringing three of four siblings to the clinic with the sick child or spending part of the family's income for babysitters. An alternative is to keep a young child, often 6 or 7 years of age, out of school to babysit younger siblings. Suchman' has observed that indigent families are characterized by medical and social disorganization ("ethnocentricity") and often are incapable of making major decisions. Yet it is this population that is forced to travel farther and make more decisions in shopping for medical services than the average middle class family. The objective of this project was to study the effect of superimposing a family health coordinator on the existing

Impact of Coordinated Care on the Family The following dependent social variables were compared from initial and final family surveys: welfare, acquisition of Medicare card and food stamps; health insurance; adequate clothing; ownership of residence; and financial situation. With one exception, there was no measurable improvement in any of these parameters at the end of 1 year. A significantly greater proportion of the aides' families became welfare recipients (or were made aware of their welfare rights) (Table 3). In regard to the index chronically ill child (Table 4), there was no significant decrease in the number of hospitalizations and no change in the pattern of utilization of the emergency room for crisis care. Neither the child's

TABLE 2-Compliance in Keeping Scheduled Appointments Variable

95

pediatric corrective

(Appt. N = 97)

adult corrective resources % appointments kept by

family to other resources* *

Not

89

% appointments kept to resources % appointments kept to

Significance

Aides

PHNs

(Appt. N

=

82

94

82)

(Appt. N = 130)

79

81

(Appt. N = 639)

(Appt. N = 1749)

(Appt. N

=

significant

305) p =

0.03

Not significant

Appointments to social agencies, health departments, hospital clinics. INDIGENOUS HEALTH AIDES 853

TABLE 3-Impact of 12 Months' Coordination on the Family's Social Conditions PHNs (%)

On welfare Have Medicare card Food stamps Health insurance Adequate clothing Own home Finance-income less than $400/month

Aides (%)

Initial

Final

Initial

Final

63 60 53 4 70 7 25

62 54 45 8 85 4 19

45 47 40 4 84 24 54

61 60 51 5 87 30 57

health care delivery system. A single identifiable individual based in the pediatric outpatient department became the advocate or health supervisor or health coordinator of the family of a chronically ill child. Lesser,8 speaking from experiences in Maternal and Infant Care Projects, states that women of low income and limited education are interested in their own health and in giving good care to their children, and respond readily to programs that demonstrate interest, responsiveness, and courtesy to patients and individuals. Fink et al.9 have demonstrated that parents' compliance and comprehension are improved significantly when a public health nurse "management specialist" is added to the traditional outpatient medical services. We anticipated that the parents would respond to the program, keep appointments, and raise their general level of health. Since the environment and social circumstances influence the state of health or the disease process, we added social services to our care system but these were surveyed and delivered by the same advocate who coordinated the medical care. Realizing that disadvantaged families make decisions poorly, we emphasized the principle of what Cornelyl 0 terms "patient pursuit"; i.e., seeking the patient for follow-up of all problems, making all appointments and reappointments if necessary, providing transportation, accompanying the patient to clinics and social agencies. The coordinator therefore took major responsibility for the families' problems. Our preliminary survey verified the fact that almost all of the sample families were overwhelmed with social and medical problems, the social usually having a higher priority. The addition of a chronically ill child to this melange reduced the parents to a state of helplessness or hopelessness. We hoped that by solving some of the overpowering problems, some of the families eventually might be able to cope better with the problems superimposed by the chronic illness. The educational background of the PHN, combining health, social service, and patient counseling, would appear to be ideal for the job description of a health coordinator. However, existing health services are financially strained by rising costs and increasing demands. Nursing salaries are high. Furthermore, Korsch et al.6'7 have demonstrated the 854

AJPH AUGUST, 1975, Vol. 65, No. 8

extensive problems of lack of communication between the health professional and the parent. The gulf is widened by the social, economic, educational, and often ethnic and linguistic factors between professionals and the disadvantaged population. The indigenous nonprofessional health coordinator, recruited from a low economic, minority ethnic neighborhood, would seem ideally suited to communicate meaningfully with the indigent outpatient department population. The indigenous worker speaks the idiomatic language of the poor and, being poor and in a minority group herself, may elicit a greater degree of trust than the white professional. The indigenous coordinator has first-hand knowledge of the problems and, if not educated to identify with the professionals, an empathy for her client. Rieff and Reissman' 1 describe these unique characteristics as a capability to act as a bridge between the middle classoriented professional and the client from the lower socioeconomic class, these special skills being rooted in their background, based on what they are, not on what they are taught. Finally, indigenous workers, because of their lack of professional education and certification, are available at far less financial cost than PHNs. The literature now is voluminous on the training and utilization of indigenous health workers. For the most part, these health aides are employed to carry out relatively simple tasks, or groups of tasks. These may include screening procedures or providing health information to or interviewing minority poor populations, sometimes on a door-to-door basis. Professionals sometimes delegate monotonous clerical or other tasks to the nonprofessional: tasks that the professional dislikes. But these tasks also will seem dull to some of the indigenous recruits whose intelligence is normal or above and who have been hampered in the past only by lack of education and motivation. One of our objectives was to determine whether indigenous workers could be trained to do a complex system of screening tasks; could make meaningful, responsible decisions ragarding health problems; could counsel clients in diverse health fields; and could perform in each of these parameters with a degree of reliability approaching that of the professional. While a structured list of resources and professional consultations were available, the aides attempted to work as independently as possible, utilized the approach to the patients which they themselves felt to be most effective, and assumed as much responsibility as they felt they could take. Thus, the indigenous worker's ability to serve patients effectively was challenged at a professional level. Our data indicated that the aides were able to collect and record data and perform a battery of technical multiphasic screening procedures as capably as highly educated professionals. In this complex survey, neither registered nurse nor aide was able to obtain more than two-thirds of the required data and neither was more successful in obtaining data on children than adults. Many adult males and other adolescents never could be found at home for testing. However, the coordinators reported

TABLE 4-Impact of Coordination on Chronically IlIl Children

(30 Chronically IlIl Children)

Aides (78 Chronically IlIl Children)

26 26

53 66*

PHNs

No. of hospitalizations in prior 12 months in survey 12 months No. of unscheduled emergency room visits prior to survey during survey *

143 177

62 66

Significant increase in aides' sample

(p = 0.02).

almost no refusals once they had established a concerned relationship with the initially suspicious families. Having gathered the data, however, the aides could not identify problems as effectively as nurses, either by comparing their results with known standards or, in some cases, by using independent judgment. Our data indicate that the well trained professionals identified a significantly higher proportion of problems than the aides in both adult and pediatric samples in almost every parameter surveyed. Several factors influenced this variable: the accuracy of their testing, their ability to reason accurately, the extent of their experience, and their interpretation of what constitutes deviant behavior in children and adults. The aides' interpretation of what constitutes a pediatric behavior problem probably differed widely from that of highly trained and experienced nurses. We noted this many times in their reports at the weekly conference. Several of the more objective tests were better suited to quantitation, e.g., Tine testing and visual screening. Consequently, either the aides performed these simple tests erroneously more frequently, or the samples truly differed in spite of randomization. We conclude that aides can recognize major problems in all areas surveyed almost but not quite as effectively as an experienced PHN. A critical area in which the aides failed is recognition of visual and auditory defects in children, both of which are detrimental to learning. A longer formal training period and periodic review of technique may be required to improve the ability of the paraprofessional to identify these problems. The aides and professionals did not differ significantly in their pediatric problem-solving ability, but the nurses proved superior to the aides in helping adults. The emphasis in the training program was pediatric and the past experience of the PHNs in dealing with adult problems probably influenced the results. Major factors that interfered with problem-solving were a lack of dental resources for restoration of teeth and the high incidence of malnutrition in the form of obesity, which all coordinators

failed, not unexpectedly, to correct effectively. Korsch et al.,6'7 in extensive studies of the professional-patient relationship, have noted that the greater the satisfaction with services received, the higher the rate of compliance with prescribed instructions. Compliance is

related to the parents' sense of urgency of the situation, which implies that the parents have some perception of their child's illness.' 2 This, of course, may be an under- or overestimation, depending on how well the parents communicated with the professional. Compliance is also related to the nature of the regimen prescribed, to the patient's comprehension of the medical advice, which in turn may be related to low education, and to the doctor-patient relationship. We used compliance rate as a measure of parent satisfaction and of parent communication with the coordinator who interpreted and supplemented the physician's advice and generally had a more intimate relationship with the family than the physician himself. Our population, without supervision, has a compliance rate of 53 per cent for scheduled appointments in the general medical clinics and 60 per cent in pediatric specialty clinics such as cardiac and neurology. The coordinators improved compliance to a rate of 80 to 90 per cent. Review of literature7 1 3-1 5 indicates repeatedly a figure of 20 per cent noncompliance or nonreachable by any method yet devised. Considering this unreachable 20 per cent, the coordinators appeared to improve the compliance rate to the maximum attainable. Many of the kept appointments resulted in improved vision, hearing, emotional support, and dental repair that otherwise probably would not have occurred. These corrections will be important in the child's future educational or social growth. While the aides were equally successful in improving the compliance rate for children, they were significantly less effective in persuading adults to keep appointments. The superiority was statistical rather than practical since at least 80 per cent of the aides' adult sample complied. The difference does not appear to imply a less warm relationship but rather a need to extend the training period of the aide to include more extended instruction regarding adult problems. What was the impact of 12 months' efforts to improve the medical habits and social circumstances of the disadvantaged families? The aides, coming from similar economic backgrounds, remained intensely interested in problems of clothing, furniture, welfare rights, and transportation. However, the PHNs also devoted much effort in the social field and proportionately made more social agency appointments for their clients than the black aides. In general, however, the survey and the efforts of the coordinators, PHNs and aides alike, appeared to have no measurable favorable effect on the environment or habits of the disadvantaged families. The families did not get off the welfare roles-in fact, unemployment increased, but this was probably due to a general recession in the area during that time. The coordinators may have been helpful in obtaining welfare funds for their unemployed families. The families did not acquire more possessions characteristic of the middle class-health insurance or home ownership, for example-nor did they improve their lot as indigent families and get more food stamps, Medicare cards, better clothing, or higher income. The lack of impact on the chronically ill children was especially striking. The number of unscheduled episodic INDIGENOUS HEALTH AIDES 855

emergency room visits did not decrease noticeably and the care of the chronic illness remained fragmented between emergency room and specialty clinic. In the nurses' sample, the number of hospitalizations did not change, while the number dropped in the Mexican-American aides' group and increased markedly in the black aides' sample. While many variables related to the disease itself can affect the incidence of hospital visits, we had hoped that the coordinators would be able to educate the parents in home care of episodic illness or at least counsel them by telephone and avert a trip to the emergency room. Apparently, we have so strongly indoctrinated our patients to seek help for illness immediately, whether it be a well known recurrence or a new symptom, that the parent continued to use the emergency room inappropriately and arbitrarily. Not only were the coordinators unsuccessful in breaking the emergency room habit and promoting continuous care in the specialty clinics, but they also were unsuccessful in improving the child's attendance record at school or his grade point average, which may have been related to school absence. In fact, the Mexican-American aides' sample had a higher rate of absenteeism and a greater proportion of the black aides' children failed in school after a year's care than before. Finally, the attendance rate at the specialty disease clinic did not improve. The chronically ill children continued to fail about 20 per cent of their scheduled appointments and the coordinators could not improve upon this either by counseling or providing transportation. Experienced PHNs appeared to be no more successful than the aides in dealing with this problem. The rationale for employing indigenous aides usually is stated to be improved communication between highly educated white middle class professionals and low socioeconomic minority group, poorly educated populations-or "bridging the gap." A second concept is that the paraprofessional performs routine functions which will save professional time, thus extending health manpower. Finally, an aide may act as a community representative, offering a cultural and economic viewpoint to the professionals with the purpose of improving administrative policies to the benefit of the disadvantaged-or "meeting the needs of the community." With regard to the latter two functions, the aides performed superbly. Our data indicate that they survey, recognize problems, and solve identified problems statistically or practically as effectively as PHNs. They are equally effective in motivating parents to keep scheduled appointments for their children. Their informational contribution concerning cultural customs, folklore, eating habits, and minority outlook were invaluable in policy-making for care of children in the Outpatient Department. However, there is no evidence that any changes in the health or welfare of the study population occurred because of improved communication at a colloquial level or because of common cultural interests. The aides were no more successful than the white middle class nurses in improving the health or welfare of their sample. 856 AJPH AUGUST, 1975, Vol. 65, No. 8

In this study, the health coordinators, PHNs and indigenous workers alike, appeared to be ineffective in improving the immediate socioeconomic condition of their families. Although we were not able to measure any changes in this area, anecdotal material from the coordinators supports the idea that changes in intrafamily dynamics did in fact occur. These changes might, over a longer period of time, affect socioeconomic status. Perhaps better usage of existing social agencies and social service personnel would increase the coordinators' effectiveness in this area. However, the all-pervasive poverty and deep-seated problems of many of the families followed in this study makes change difficult if not impossible without important behavioral and interpersonal changes within the families. Expectations of behavioral changes in the long standing-life style in disadvantaged families within the short span of 12 months may be unrealistic. Even middle class individuals with high levels of education, extensive exposure to health information, and a well structured life-style have difficulty changing as exemplified by failure to lose excessive weight, to cut back on cigarette smoking, or to submit to voluntary periodic breast examination for cancer detection. In our training program we need to strengthen at least three areas: * Enhancing the understanding of factors affecting human behavior and the use of such knowledge in working with patients toward constructive change; * Teaching the basic principles of crisis intervention in the field of mental health; * Improving the understanding of the purposes, policies, and procedures of social agencies and mental health facilities. Many nurses, especially recent graduates, have some training in this area and demonstrate their skill and sophistication. However, they still require support from mental health professionals and social service agencies more than provided in this program. From our study, it appears that the ability to speak the colloquial language appeared to be no advantage in improving the compliance rate of or communication with disadvantaged families. Professional insights, sophistication, and skills, if delivered with empathy, remain important assets for effective functioning in the psychosocial area.

References 1. Suchman, E. A. Social Factors in Medical Deprivation. Am. J. Public Health 55:1725-1733, 1965. 2. Morris, N. M., Hatch, M. H., and Chipman, S. S. Alienation as a Deterrent to Well-Child Supervision.

Am. J. Public Health 56:1874-1882, 1966. 3. Wingert, W. A., Larson, W., and Friedman, D. B. The Ecology of a Large Urban Pediatric Outpatient Department. Am. J. Public Health 58:859-876, 1967. 4. DHEW Publication no. (HSM) 72-1031. U.S. Department of Health, Education, and Welfare, Public Health Service, National Center for Health Statistics, Rockville, MD, 1972. 5. North, A. F. Pediatric Care in Project Head Start. The Disadvantaged Child. Vol. II. Head Start and Early

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GROUND WATER QUALITY SYMPOSIUM PROCEEDINGS AVAILABLE Proceedings of the 2nd National Ground Water Quality Symposium, held September 25-27, 1974, Denver, Colorado, are now available. Cost of the proceedings is $10 per copy, prepaid. The symposium was cosponsored by the Environmental Protection Agency and the National Water Well Association. To obtain a copy of the proceedings, send check or money order to: National Water Well Association Suite 130 500 West Wilson Bridge Road Columbus, Ohio 43085 The Third National Ground Water Quality Symposium will be held at Caesar's Palace in Las Vegas, Nevada, September 15-17, 1976. Information concerning this forthcoming meeting and submission of papers can be obtained by writing to NWWA. Dates of the Annual Convention and Expositions of NWWA are: New Orleans, Louisiana 1975 October 5-8 1976 September 12-15 Las Vegas, Nevada

INDIGENOUS HEALTH AIDES 857