The Effect of Outreach Workers' Educational Efforts On Disadvantaged Preschool Children's Use of Preventive Services THEODORE J. COLOMBO, MPH, DONALD K. FREEBORN, PHD, JOHN P. MULLOOLY, PHD, AND VICKY R. BURNHAM, BS Abstract: A special program of outreach services was implemented to assist a poverty population to appropriately use health services in the Kaiser-Permanente Medical Care Program. A study was conducted to determine the effect of outreach workers' intervention on the use of preventive services by this population. Initially, families were divided into two groups, one with and one without outreach workers. Outreach workers (neighborhood health coordinators) were trained in prevention and health education. They were then assigned to specific subgroups of the poverty population to teach the importance of preventive services and to motivate persons to use these services.
This paper focuses on the effect of outreach workers' services on the use of selected preventive care services (immunizations and tine test) by preschool children from poverty families. Preschool children in families with coordinator services had higher use rates for preventive care. The sub-group for which outreach workers were specially trained to focus on preventive procedures for the pre-school group had markedly higher use rates for preventive care. The findings suggest that special intervention programs, using indigenous and nonprofessional outreach workers, can increase preventive service utilization by poverty groups. (Am. J. Public Health 69:465-468, 1979.)
314(e) Comprehensive Health Services Projects, required outreach services. It was assumed that poverty populations needed such services to overcome barriers to care and to obtain appropriate care. The project's outreach workers known as neighborhood health coordinators provided the outreach services. Generally, the outreach workers were women, 30 to 60 years of age, who were indigenous to the poverty community. They all met the income criteria specified by the OEO. None were especially trained as health professionals. The original functions of the neighborhood health coordinator were: 1) to recruit poor families for the project; 2) to teach family members the value of good health and health practices; 3) to motivate persons to utilize health services appropriate to their needs; 4) to assist the project members in participating effectively in the Kaiser-Permanente medical care system; and 5) to direct families to community resources for other, nonmedical problems common to a poverty population. When the project was first funded, "War on Poverty" efforts were in full swing and outreach services were part of many health and social programs as a matter of policy. However, the question of whether the outreach efforts made a difference in the way poor people use health services had not been answered. A number of studies have now reported successful use of outreach services, but most of these have major design problems such as the lack of a control group. Generally, these studies indicate that families receiving outreach tended to make greater use of preventive as well as other types of services. 1-4
The Kaiser-Permanente Neighborhood Health Center Project in Portland, Oregon was funded in 1967 as one of the first programs sponsored by the office of Economic Opportunity (OEO) to operate within an organized medical care setting. The major objectives of the project were to integrate a medically indigent population into this organized system, to assist that group in obtaining access to services, and to help them use the services appropriately. A special program of outreach services was included to attain these objectives and to help the poor deal effectively with this complex medical care system. The outreach program of the Kaiser-Permanente Neighborhood Health Center Project was available only to the federally-financed poverty population and included transportation, the services of nonprofessional community health workers, and supporting professional and administrative personnel and services. The outreach program was an addition to the usual personal health services provided in KaiserPermanente to all its Health Plan members. OEO Neighborhood Health Center guidelines, and later the guidelines of From the Health Services Research Center, Kaiser Foundation Hospitals, Portland, OR. Address reprint requests to Donald K. Freeborn, PhD, Associate Director for Research, Health Services Research Center, Kaiser Foundation Hospitals, 4610 S.E. Belmont Street, Portland, OR 97215. This paper, submitted to the Journal August 22, 1978, and accepted for publication August 28, 1978, is a revision of an earlier submission.
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The objective of this study was to determine if intervention by outreach workers trained in health education techniques could affect the use of preventive services by preschool children in poor families.
Medical Care Setting Outreach and medical care services were provided to approximately 7,000 persons in 1,500 low income families, enrolled as Health Plan members in the Kaiser-Permanente Medical Care Program, Oregon Region. Those enrolled in the organization's Neighborhood Health Center Project from 1967 through 1975 represented around 4 per cent of the total Kaiser-Permanente membership. The Neighborhood Health Center population was younger than the general Health Plan membership; it had larger families and was more likely to have single parent families.5 The Kaiser-Permanente Medical Care Program serves a cross section of the population in metropolitan Portland, Oregon. Health Plan membership now numbers approximately 215,000 persons or about 15 per cent of the Standard Metropolitan Statistical Area (SMSA) population. Kaiser-Permanente is a prepaid, group practice form of health care organization and a federally qualified Health Maintenance Organization (HMO). Medical and dental services are provided by full-time practitioners in an integrated, hospital-based delivery system. Ambulatory facilities are located in population centers throughout the community including the areas where most of the poor reside.
Description ofStudy and Study Design Two separate and distinct outreach evaluation studies were made during the course of the Kaiser-Permanente Neighborhood Health Center Project. The first study began in September 1969 and addressed the general question of the effect of outreach workers' services on patterns of medical care utilization. All families enrolled from October 1, 1967, to August 31, 1969, were assigned neighborhood health coordinators. On September 1, 1969, all families currently enrolled were randomly divided into three groups: 25 per cent of all project families had neighborhood health coordinator services discontinued; another 25 per cent were allowed these services only if they requested them; the remaining 50 per cent retained full coordinator assistance. Families enrolling after September 1, 1969 were randomly assigned into one of these groups. Family members receiving full coordinator assistance and those able to request them were grouped together into a "with-coordinator" category. Persons in families not assigned coordinators or persons in families where coordinator assistance was discontinued were included in the "'without-coordinator" category. Each of these two categories were further divided into two groups based on date of enrollment in the program: families enrolled before September 1, 1969, and families enrolled on or after September 1, 1969. The "'without-coordinator" category in the latter enrollment 466
group was the only coordinator group that included persons who had never received coordinator services.* The results from the first study indicated that there were major differences in the amount of services used as measured by the rate of medical care contacts per 100 memberyears, suggesting improved access for groups with coordinators. But the way in which services were used was similar for persons with and without coordinators.6 The second study, to be described in this report, was conducted from September 1, 1972 to August 31, 1973, and focused on the use of preventive services. Several steps were taken to implement this second study. First, after consultation with physicians and public health professionals, the following priority areas were defined: * Primary preventive or early detection procedures and examinations for the preschool group; * Early detection physical examinations for school age children and family planning information for older teenagers; and * Early detection physical examinations for adults and Pap smears for women of child-bearing years. Fifteen of the staff of 20 coordinators were organized to address these educational priorities. They were assigned randomly into one of three preventive service teams. The five coordinators in Team One were assigned to address the preventive service priorities of the preschool age group; Team Two was to focus on persons of school age in its familis; and Team Three gave priority to adults.** Although each coordinator retained her original caseload of families, the target population for each team consisted of those individuals in the coordinator caseloads who fell into the age groups assigned for preventive service priorities. The role of coordinators was to provide information and to educate selected persons regarding the chosen preventive services. They were expected to encourage and motivate people to obtain the services within the Kaiser-Permanente program. A six-month education and training program was designed to prepare coordinators for those functions; they were enrolled in courses at a local community college that taught communication skills, health care and health education concepts, and related subjects. An inservice training program augmented the academic work. This program was conducted by project staff and used physicians and other providers as teachers. The inservice program specifically addressed the importance of and rationale for the preventive
services. *The "on request" and "full coordinator assistance" groups were not analyzed separately because the project administration staff believed that coordinators had visited the homes of some families assigned an "on request" status. Every effort was made to preserve the integrity of the research design, but some participants and some coordinators resisted the discontinuation of outreach services. It is difficult to estimate accurately the effect of this factor on study results, although it appears to have been minor. It would affect only the "before" September 1969 enrollment group since those families added after this data never had any contact with coordinators. **There was a fourth team of five coordinators which addressed a different objective: to reduce the rate of broken appointments in the poverty population to the level of the Health Plan membership. Because this focus was not a preventive one, it is excluded. AJPH May, 1979, Vol. 69, No. 5
OUTREACH WORKERS AND PREVENTIVE SERVICES
This paper presents data only for preschool children (04 years of age) who were in coordinator caseloads of all three preventive teams. It analyzes use of preventive services by the children during the year when the study objectives were implemented and for a base year preceding the study period.*** The analysis is restricted to those individuals in families enrolled on or after September 1, 1969. We have concentrated on the data for preschool children because this group represents a sizable proportion (33 per cent) of the total Neighborhood Health Center Center population analyzed in the study year, and preventive care, especially immunizations, can prevent disease and affect long-term health outcomes. The evidence is less clear cut for Pap smears and physical examinations. Furthermore poor children have been found to underuse preventive services when compared with more affluent children and thus are a high-risk group.8 Because the findings were similar for each preventive category, and because focusing on this large and important group allowed us to examine the major study objective, we report the findings only for the 0-4 age category.
Data Sources and Methods Research medical technicians routinely recorded information on every medical care contact for all individuals in the Neighborhood Health Center population. Data for each contact included time, place, type of service and type of provider, information on episodes, and the content of each visit. These data were computerized and the file continuously updated. The measure of preventive health care behavior used is the number of primary procedures received by children 0-4 years of age during outpatient visits with pediatricians or visits to special injection clinics provided by Kaiser-Permanente. Primary procedures are broadly defined as the administration of those substances designed either to prevent disease or detect disease early in children: diptheria, pertussis, tetanus (DPT); poliomyelitis; rubella, mumps, measles vaccines; and tine test.i The tables included in this study show the procedure rates for children 0-4 years of age in each coordinator prevention team. Utilization rates were computed using the number of primary procedures received as the numerator and person-years of project eligibility as the denominator. The reason for using person-years as the denominator is that Health Plan members have varying lengths of eligibility. Using person-years allows one to take this factor into account and provides a standard base of comparison for utilization rates. This computation required the summation of the total ***Since families were randomly assigned to a "with-coordina-
tor" group or to a "without-coordinator" group, it has been assumed that the specific age distributions within the 0-4 age group are
similar. lThese procedures generally occur in this health care system in the first four years of life. Children 5 years of age and older, new to the system, who did not obtain these before joining the program also received these primary procedures. AJPH May, 1979, Vol. 69, No.5
months of Health Plan eligibility for each person during each 12-month observation period. The sum was divided by 12 months to obtain the total number of person-years of eligibility during the base year and the study period.tt
Findings The major study objective was to determine whether outreach intervention could affect the use of preventive services by preschool chilren. As can be seen from Table 1, children in the preschool coordinator team had a 55 per cent higher rate than did children without coordinators; 227 per one hundred person-years vs. 146 per one hundred personyears, (p = .01). Children in the caseloads of the other intervention teams also tended to have higher rates. This was especially noticeable for the team assigned to adult preventive care. The rate for the preschool children in this group was 40 per cent higher than the rate for children whose families had no coordinator intervention; 204 per one hundred personyears vs. 146 per one hundred person-years, (p = .04). We also examined preventive use in the base year preceding the special coordinator intervention program. Coordinators were then working under a set of objectives related to helping people use the medical care system effectively. In the base year, the "with-coordinator" and "without-coordinator" groups showed small and nonstatistically signifiTABLE 1-Average Number of Primary Procedures Per 100 Person-Years by Coordinator Group for Preschool Children in the Neighborhood Health Center Population Study Year, On or After September 1969
Number Person-Years Rate SE SE
Wihout Coordinator Group
School Preschool Age Adults Total
204 569 100 288 204 198 23 16
169 116 146 16
216 95 227 27
149 93 160 19
ttIn order to compute the exact variance of a utilization rate based on person-years of eligibility, it is necessary to aggregate contact records into a summary record for each study individual. If rn study individuals have i months of eligibility and if the variance of the number of utilization events among these individuals is S2, then the variance of the rate is given by (n S Y>i nil2)These exact variances were computed for total direct contacts for the coordinator and noncoordinator groups used in the present study. Since the required summarized individual records were not available for primary procedures, an approximation procedure was employed. The empirical relationship between the coefficient of variation for direct contacts and person-years of eligibility was used to approximate the standard errors of the procedure rates. 467
COLOMBO, ET AL.
cant differences in procedure rates for preschool children (p = .32, Table 2). The differences between coordinator categories during the study year were much greater than during the base year (55 per cent vs. 14 per cent). The procedure rates for both groups were generally higher in the base year than in the study year. This was expected since essentially the same cohort was assessed in each year. Those persons who received primary procedures in the base year would be at risk for a smaller number in the study year, thus reducing the number of persons requiring them in the latter period. The main focus here is the degree of difference in rates between coordinator categories for each year.
Discussion Coordinator intervention had a pronounced impact on the use of preventive services by preschool children. The rates of use for preventive procedures were generally higher for persons who had coordinators. Moreover, the magnitude of difference in use between the coordinator groups and noncoordinator group was greater in the study year than in the base year. The development of specific preventive objectives and implementation of special educational programs, using indigenous and nonprofessional outreach workers, seem to be an effective intervention approach. Another finding is that a coordinator educational intervention program with the specific objective of improving use of preventive services of a particular age group seems to TABLE 2-Average Number of Primary Procedures Per 100 Person-Years by Coordinator Status for Preschool Children in the Neighborhood Health Center Population, Base Year, On or After September 1969 Age: 0-4
Number Person-Years Rate SE
353 368 368 27
325 101 322 37
have a generalizing effect on other family members. That is, the rates for preschool children in different coordinator intervention groups, each with a diverse preventive focus, were higher than those in the without-coordinator group. This finding supports research done in settings other than health where focusing on parents has been found to be an effective means for changing children's attitudes and behaviors.9 The main implications of this study go beyond the specific problems of medically indigent groups. Many individuals need help in using services appropriately and have difficulty in coping with complex medical care systems. Health promotion and health maintenance are unrealized goals in many organized health care settings. The results of this study suggest that one effective intervention technique for encouraging appropriate preventive care is the use of nonprofessional, especially trained outreach workers.
REFERENCES 1. Domke HR and Coffey G: The neighborhood-based public health worker: Additional manpower for community health services. Am J Public Health 56:603-608, 1966. 2. Luckham J and Swift D: Community health aides in the ghetto: The Contra Costa project. Medical Care 7:332, 1969. 3. Cauffman, JG, et al: Community health aides: How effective are they? Am J Public Health 60:1904, 1970. 4. Moore FI and Stewart JC: Important variables influencing successful use of aides. Health Services Report 87:555-561, 1972. 5. Greenlick MR, Freeborn DK, Colombo TJ et al: Comparing the use of medical care services by a medically indigent and a general membership population in a comprehensive prepaid group practice program. Medical Care 10:187-200, 1972. 6. Freeborn DK, Mullooly JP, Colombo T, and Burnham V: The effect of outreach workers' services on the medical care utilization of a disadvantaged population. J Community Health 3:306320, 1978. 8. Bice, TW, et al: Economic class and use of physician services. Medical Care 11:287-2%, 1973. 7. Guzick DS: Efficacy of screening for cervical cancer: A review. Am J Public Health 68:125-134, 1978. 9. Brookover WB, Paterson A and Thomas S: Self-concept of ability and school achievement. East Lansing: Michigan State Uni-
ACKNOWLEDGMENTS This work was supported in part by Grant 002-P-20-2, DHEW and is based on a presentation at the Annual Meeting of the American Public Health Association, Miami Beach, Florida, October 1976. The authors particularly wish to express gratitude to Phyllis Turner, technical editor.
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