PUBLIC HEALTH BRIEFS

criteria. Such information should be employed with caution in studies of occupations and cancer as the above results show. Coding of a single occupation from the responses to a "general" occupation question results in the loss of information which may be useful in identifying occupation risk factors of cancer. The following information on occupations must be available in order to adequately assess an occupation as a risk factor of cancer: 1. The occupations of the respondent over his lifetime; 2. The length of time the respondent was employed in each occupation; 3. The respondent's occupation at the time of the interview. Cancer registries and hospital charts should be target areas for improving the recording of occupation data. Clinicians should be encouraged to record at least the most usual occupation of their patient with additional information recorded for patients who work in areas known to be potentially hazardous to health. After defining the "cases" and appropriate controls, interviewing subjects themselves with a standardized questionnaire should be seriously considered when specific occupational activities are suspected as carcinogenic. It is possible to design questionnaires which elicit detailed occupational information which have internal validity as the interobserver reliability test results have indicated. The household questionnaire data on work activities or working conditions of fishermen as possible risk factors failed to show evidence of positive associations which suggest any independent contribution to malignancy. The questionnaire data also revealed that using the mouth as a "third hand" in the handling of nets protected fishermen, rendering them less than half as likely to acquire the disease from those in the occupation who employed other techniques.1 The weaknesses of routinely collected data in terms of

the accuracy and quality of data3 can be overcome and controlled in the "one-time" questionnaire survey. The questionnaire survey also has the advantage of being carried out independent of the routine data collection systems thus removing many of the problems of delay in collecting and processing the material. In addition, the questionnaire survey data can be coded to answer the particular questions of the study rather than having to opt for generalized coding schemes designed to meet the needs of many potential users so often necessary in routine data collection systems. In this study of the etiology of lip cancer, employing multiple sources of data to assess the importance of commercial fishing as an occupational risk factor, we have defied Finagle's Laws on Information: " 1. The information you have is not what you want. 2. The information you want is not what you need. 3. The information you need is not what you can obtain."4

REFERENCES 1. Spitzer, W. O., Hill, G. B., Chambers, L. W. et al. The occupation of fishing as a risk factor in cancer of the lip. N. Engl. J. Med. 293:419-42, 1975. 2. Doll, R., Payne, P., Waterhouse, J. A. H. (ed.): Cancer Incidence in Five Continents; A Technical Report. Vol. 1. Distributed for the International Union against Cancer by Springer-Verlag, Heidelburg, New York, 1966. 3. Alderson, M. R. Evaluation of health information systems. Br. Med. Bull. 30:203-208, 1974. 4. Murnaghan, J. H. Health services information systems in the United States today. N. Engl. J. Med. 290:603-610, 1974.

ACKNOWLEDGMENTS Supported by grants from the National Cancer Institute of Canada and Health and Welfare Canada (606-2042-20).

Neighborhood Health Centers: An Assessment PETER R. BREYER, PHD The idea of health centers emerged in America during the early twentieth century and represented an attempt to reorganize and improve the administration, delivery, and financing of ambulatory care services to the urban poor. During the mid-sixties, a national health center policy was developed with ambitious goals of serving large numbers of urban Address reprint requests to Peter R. Breyer, PhD, Deputy Director, Urban Health Institute, 7 Glenwood Avenue, East Orange, NJ 07017. This paper, submitted to the Journal August 3, 1976, was revised and accepted for publication October 13, 1976. AJPH February, 1977, Vol. 67, No. 2

poor. This present research examines nine health centers in New Jersey to determine the degree to which original goals of this policy were met and to suggest areas for future improvement.

Methodology For the purpose of this study, health centers were defined to include the following characteristics: 179

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1. Provision of diagnostic and treatment services as a principle activity; 2. Support provided entirely or partially by federal, state or local grant funds, exclusive of Medicare or Medicaid; and 3. Identification of the centers as independent units in terms of administration and physical location. Nine centers were identified in New Jersey which met this criteria.* Employing a self-administered questionnaire followed up by on-site interviews, data regarding the structure and operations of the nine centers were collected during 1974 for the period 1973. The nine health centers were assessed in terms of their performance toward three major objectives of the dominant OEO-related health center policy, namely:' 2 1. Provide comprehensive ambulatory care health serv-

ices; 2. Initiate innovations in ambulatory care delivery through use of new professional and para-professional manpower and new patterns of staff interaction; 3. Deliver ambulatory health services in an efficient manner with maximum utilization of third-party fi-

nancing. Each of these objectives was defined operationally through key attributes or characteristics of the health center model drawn from policy statements of OEO, HEW, and the literature in the field.3-10 Reliability of data for attributes involving structural characteristics of centers as provision of specific services and staffing levels was self evident. With process attributes as continuity of physician care and average per visit costs, criteria were established to determine the presence or absence of attributes and final determinations made through on-site interviews with center directors, medical directors, and other appropriate center personnel.

problem-oriented records, failure to utilize health care teams more fully, lack of staff for preventive health care activities, and the absence of new professional and paraprofessional persons to augment the capabilities of physicians and to expand the scope of ambulatory care services. The centers as a group illustrated deficiencies with regard to efficiency and fiscal viability. In general, they appeared unable to deliver services in an efficient manner with little hope of establishing financial viability in the most basic sense. Of particular concern were the very low rates of physician utilization and the low level of third-party collections as a percentage of total expenditures. Further investigation of centers six and seven, both of which performed poorly with regard to efficiency/fiscal viability, was conducted to help identify reasons for such performance. The major finding common to both centers was poor and inefficient administration which was in part encouraged by grant funding. The grant funding mechanism provided few incentives for maximization of resources while penalties were never imposed for inefficiencies. Both centers had physicians who worked only a fraction of the time for which they were paid, and both failed to take full advantage of third-party reimbursements. With the gradual reduction of grant support which has occurred since the survey period, both centers have been forced to eliminate obvious inefficiencies and adopt more aggressive policies regarding third-party collections. Performance between centers for all three objectives varied considerably from a total of eight attributes to 17, with the relationship between objectives illustrated in Table 2. Many of the centers which ranked higher in regard to comprehensiveness or innovation tended to rank lower in relation to efficiency/fiscal viability and vice versa. The implication is that centers which offer comprehensive and innovative services are less likely to be efficient or fiscally viable.

Findings The aggregate performance of the nine centers in relation to the three objectives is presented on Table 1. The centers performed poorly in regard to all objectives with no center achieving all of the attributes for any one objective. More specifically, the centers as a group failed to offer comprehensive services either by virtue of services offered on-site or in regard to arrangements for specialty and inpatient care. The centers offered only the most basic of primary care services without providing continuity of physician services for center patients when hospitalized. The centers as a group did not succeed in delivering services in a particularly innovative manner as originally envisioned. Particular weaknesses included the absence of *Excluded from this group are public health clinics operated by health departments, expanded hospital outpatient departments without a separate identifiable form, children and youth programs, health maintenance organizations, and proprietary organizations which had obtained small amounts of grant support and function under the title "health center." 180

Discussion Given the nature of public policy-making and the atmosphere in which the health center policy was developed, the performance of the nine centers is not unexpected. The three objectives utilized in this assessment and the manner in which they were defined as per stated health center policy may have been over-ambitious and impossible to attain given the resources available. If we view the performance of the nine centers within this context, we find that they did succeed in providing basic primary care services which were "innovative" in the sense of being an alternative to the traditional models of practice in the hospital emergency room and outpatient department. In addition, services provided were plainly more accessible by virtue of location, hours of operation, and the absence of financial barriers. When assessing the nine health centers in New Jersey within this broader perspective, it could be concluded that their performance was mixed but that they accomplished much of interest and value, given their constraints. AJPH February 1977, Vol. 67, No. 2

PUBLIC HEALTH BRIEFS TABLE 1-Comprehensiveness, Innovation and Efficiency/Fiscal Viability of Health Centers According to Attributes of 9 Centers Attribute

1

Comprehensiveness 1. Center physician treatment of patients when hospitalized 2. Provision of x-ray services 3. Provision of pharmacy services 4. Provision of health education services 5. Provision of nutrition services 6. Provision of Ob/Gyn services 7. Provision of laboratory services 8. Provision of dental services 9. Provision of social services 10. Provision of pediatric services 11. Existence of form agreement with back-up hospital 12. Provision of general medical services SubTotal Innovation 1. Presence of at least one new health professional 2. Use of problem-oriented records 3. Center reimbursement for required specialty services 4. Utilization of health care teams 5. One staff person or more for preventive health activities 6. Services provided after 5:00 p.m. and on weekends 7. Presence of at least one new health non-professional 8. Assignment of one primary care physician 9. Use of family registration system 10. Conduct comprehensive physical exam on initial visit 11. Use of appointment system Sub Total

2

Center 3 4 5 6 7

8 9

X X X X X X X X X X X X X XX X X X X X X X X X X X X X X X X X X X X 2 5 7 5 106

X X

X X X X X X X X X X X 6 10 2

X X X X X

X X X X X X X X X X X X X X X X X 4 5 6

X XXX X X X X X X 7

X X X X X X X X X X 5 7

X

X X 4

X X X X X X 8

X

X X

X X 5

Total

1 2 2 3 3 4 4 5 6 7 7 9

1 2 3 3 5 6 6 7 9

9

EfficiencylFiscal Viability 1. Charge schedule reflecting actual costs 2. More than 2.7 patients seen per physician hour 3. More than 20% of expenditures supported by third party and direct collections 4. Average medical encounter cost of $50.00 or less 5. Administrative personnel costs 15% or less of total

2 3 5 5

Sub Total

XX X XX X X X X X 2 2 1 5 0 1 1 1 3

Totals

8 12 14 17 15 14 1119 10

expenditures

TABLE 2-Ranked Performance of Centers According to Number of Attributes Achieved Per Objective Comprehensiveness

(5) (8) (3) (6) (7)

5

(2) (4)

5 2 9

(1)

(9)

Efficiency/Fiscal Viability

Innovation

# Attributes Center Achieved

10 10 7 6 6

X X

1 X

6. Existence of arrangements for billing of Medicare

# Attributes Achieved

X

8 7 7 6 5 5 5 4 4

AJPH February, 1977, Vol. 67, No. 2

# Attributes Center Achieved

(8) (4) (6) (3) (5) (2)

(9) (1)

(7)

5

3 2 2 1 1 1 1 0

Center

(4) (9) (1) (2) (3) (6) (7)

(8) (5)

X X

ACKNOWLEDGMENTS This investigation was based on empirical data produced by a 1974 study conducted by the Urban Health Institute entitled "Health Centers in New Jersey: A Study of Alternatives in Ambulatory Care." The author wishes to acknowledge the assistance of the Director of the Institute, Donald Malafronte, principal author of the Institute study, the New Jersey Department of Health, and the New Jersey Regional Medical Program for their financial help in supporting the study.

REFERENCES

1. Bamberger, L. From the community's point of view. Bull. N.Y. Acad. Medicine, 42:1140-1150, 1966. 2. Office of Health Affairs, Office of Economic Opportunity, History of the OEO Health Service Program, Staff Paper, Washington, DC, 1971. 181

PUBLIC HEALTH BRIEFS 3. Bryant, T. E. Goals and potential of the neighborhood health centers. Medical Care 8: 93, 1970. 4. Mechanic, D. Public Expectations and Health Care. New York: Wiley-Interscience, 1971. 22-23. 5. Geiger, J. H. The neighborhood health center. Arch. Envir. Health, 14:912-916, 1967. 6. Schorr, L. B. and English, J. Background, context and significant issues in neighborhood health center programs. Medical Care, 6:289-296, 1968. 7. Schumaker, C. J. Major. Changes in health center sponsorship:

I. Impact on patterns of obtaining medical care. Am. J. Public Health, 61:1536-1544, 1971. 8. Cowen, D. L. and Sharbaro, J. A. Family centered health care-A viable reality? The Denver experience. Medical Care, 10:1964-1973, 1972. 9. Snoke, D. S. and Weinerman, E. R. Comprehensive care programs in university medical centers. Journal of Medical Education, 40:625-657, 1965. 10. Sparer, G., Dines, G. and Smith, D. Consumer participation in OEO-assisted neighborhood health centers. Am. J. Public Health, 60:1092, 1970.

Housing and Nutrition of Psychiatric Aftercare Patients KENNETH TARDIFF, MD, MPH Living arrangements have been a key issue in the increasing trend toward discharge of patients from large mental hospitals. Do patients fare better living with their families, in independent apartments, or with other patients in semi-supervised homes in the community? There has been some interest in the patient's adjustment in the family1-3 but most of the controversy has been concerned with group facilities in the community where formerly hospitalized patients live together in a semi-supervised setting. Some suggest these group facilities provide an effective, inexpensive alternative to mental hospitalization4 while others believe that they provide only custodial care and are nothing more than new back wards of mental hospitals transplanted into the community.5-8 It should be noted that previous studies have focused only on the interpersonal functioning of the patient and others living with him and not on such essentials as the physical characteristics of the patient's shelter and his daily diet. It is in the tradition of public health to consider housing and nutrition as essential for health. Mental health is no exception.

Methods Subjects were selected from the active caseload of the community mental health service in Vancouver, B.C. All active patients were sorted into four groups according to living arrangements: a) living alone in apartments; b) in group homes with an average of eight other patients; c) with their families and the patient not responsible for food preparation; Address reprint requests to Dr. Kenneth Tardiff, Assistant Professor of Psychiatry, State University of New York at Stony Brook, School of Medicine, Stony Brook, NY 11794. At the time of the study, he was a special consultant for the Greater Vancouver Mental Health Service, British Columbia, Canada. This paper, submitted to the Journal August 27, 1976, was revised and accepted for publication October 6, 1976. 182

and d) with their families and the patient responsible for food preparation. From the 159 potential subjects selected by a random number table, there were 121 patients available for interviews with no important differences between participants and non-participants except that non-participants tended to have used fewer services and to have been more likely employed. Research assistants interviewed patients and their therapists, and rated living arrangements of the patients. All data were recorded on pre-coded forms.*

Findings Significant demographic and clinical differences between patients in the four types of living arrangements are noted in Table 1. Physical health and number of psychiatric admissions in the past two years were most interesting in that patients living alone fared worst in both. As seen in Figure 1, patients living alone also had the poorest housing as rated by research assistants (Scales 4, 5, 7) and the least degree of satisfaction with their housing (Scale 1). Ratings of housing and satisfaction for patients in group homes were better than those for the patients living alone and comparable in some cases to patients living with families, who had the best in housing. On the other hand, group homes provided the least amount of autonomy and private living space (Scale 3). Despite poorer facilities for preparation of food, patients living alone were roughly equal to patients living with families and responsible for food preparation in regard to frequency of cooking, availability of food, and infrequency of dining outside the home, although patients living alone spent twice as much per person for food. Patients in group homes did not cook and ate at communal meals pro*Details of methodology and instruments available from the author on request. AJPH February 1977, Vol. 67, No. 2

Neighborhood health centers: an assessment.

PUBLIC HEALTH BRIEFS criteria. Such information should be employed with caution in studies of occupations and cancer as the above results show. Codin...
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