Citation
The impact of a physicians' assistant clinic on a rural southern county

Material Information

Title:
The impact of a physicians' assistant clinic on a rural southern county a descriptive evaluation
Creator:
Burke, Robert Edmund, 1947-
Publication Date:
Language:
English
Physical Description:
x, 144 leaves : ; 28 cm

Subjects

Subjects / Keywords:
Academic communities ( jstor )
Counties ( jstor )
Diseases ( jstor )
Health care industry ( jstor )
Health care services ( jstor )
Health care utilization ( jstor )
Hospitals ( jstor )
Patient care ( jstor )
Physicians ( jstor )
Waves ( jstor )
Clinics -- Utilization -- Case studies ( lcsh )
Physicians' assistants -- Public opinion ( lcsh )
Public opinion -- Florida -- Gilchrist County ( lcsh )
Rural health services -- Case studies ( lcsh )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (leaves 137-143).
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Robert Edmund Burke.

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Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
Copyright Robert Edumund Burke. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Resource Identifier:
04168425 ( OCLC )
ocm04168425

Full Text












THE IMPACT OF A PHYSICIAN'S ASSISTANT CLINIC
ON A RURAL SOUTHERN COUNTY: A DESCRIPTIVE EVALUATION





by

ROBERT EDMUND BURKE





















A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY








UNIVERSITY OF FLORIDA 1977


































COPYRIGHT BY

ROBERT EDMUND BURKE, 1977


































For my parents,

EDMUND LEO and MARY VERONICA















TABLE OF CONTENTS


LIST OF TABLES .................. ....... vi

LIST OF FIGURES . . . . . . . . . . . . . . . . . . . . . . . . viii

ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix


Chapter
I. OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . .

Introduction . . . . . . . . . . . . . . . . . .. . . . 1
Research Questions . ................. 2
Background . ... ............... ... 3
Societal and Cultural Conditions . ........ .. 4
The Physician's Assistant . ............. 7
Summary . . . . . . . . . . . . . . . . . . . . . . 8
A History of Rural Health Care Delivery . ....... 9 Overview of Community . . ... .. . .. . . .. .. . 11
Background . . . . . . . . . . . . . . . . . .. .. . 11
History of Health Care Services . ........ . . 12
County Political Situation . ............. 13
Summary .................. ..... 15

II. REVIEW OF LITERATURE . . . . . . . . . . . . . . . . . . . 17

Introduction . . . . . . . . . . . . . . . . . . . ... 17
The Physician's Assistant Literature . . . . . . . . . . 17
The Role of the Physician's Assistant . ....... 19 Licensure . . . . . . . . . . . . . . . . . .. .. . 20
The Recruitment of the Physician's Assistant . .... 20 The Training of the Physician's Assistant . ..... 21 The Evaluation of the Physician's Assistant . .... 22
Health-Services Utilization .............. . 24
Summary ... ............... ..... 25

III. CONCEPTUAL FRAMEWORK . .................. 27

Introduction . . . . . . . . . . . . . . . . . . . ... 27
Approaches to Health Services Utilization Analysis . . . 28 The Andersen-Newman Model . .............. 29
Summary . . . . . . . . . . . . . . . . . . . . . . . . 35

IV. RESEARCH METHODOLOGY . .................. 38

Design . . . . . . . . . . . . . . . . . . . . . . . . . 38
Data Collection . . . . . . . . . . . . . . . . . .. . 39
iv











TABLES OF CONTENTS
(CONTINUED)


Chapter
IV. (Continued)
The Sample . . . . . . . . . . . . . . . . . . . ... 39
Field Test . . . . . . . . . . . . . . . . . .. .. . 41
The Data . ....... ....................... .. 41
Reliability and Validity . . . . . . . . . . . . . . . 45
Statistics . .. . . .. .. ... .. . . ... ... . 47
Summary . . . . . . . . . . . . . . . . . . . . .. . 47

V. FINDINGS. . . . . . . . . . . . . . . . . . . . . ... . . 49

Overview . . . . . . . . . . . . . . . . . . . . . . . 49
Descriptive Survey Results . . . . . . . . . . . . . . 51
Discussion of the Six Specific Questions . . . . . . . 56 Summary . . . . . . . . . . . . . . . . . . . . .. . 84

VI. SUMMARY AND CONCLUSIONS . ................ 91

APPENDIX A . . . . . . . . . . . . . . . . . . . . . . . . .. . 100

APPENDIX B . ... . . . . .. .. ................. 110

BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . .. . 137

BIOGRAPHICAL SKETCH ................... ... 144









LIST OF TABLES
(CONTINUED)


Table Page 14. Change in Amount of Worry about Receiving Emergency Medical Services, Preclinic, Postclinic Opening
Controlled for Clinic Utilization . ........... 68

15. Change in Amount of Worry about Having an Undetected Disease, Preclinic, Postclinic
Opening Controlled for Clinic Utilization . ........ 69

16. Clinic Utilization by Prospective Utilization . ...... 72

17. Perception of Physician's Assistant Clinic as Compared to Usual Care Received by Prospective
Physician's Assistant Clinic Utilization . ........ 74

18. Change in Number of Physician Visits, Preclinic, Postclinic Opening Controlled for Clinic Utilization . . . 75

19. Change in Amount of Hospitalization, Preclinic, Postclinic Opening Controlled for Clinic Utilization . . . 77

20. Change in Utilization of Prescription Drugs, Preclinic, Postclinic Opening Controlled for
Clinic Utilization. . .................. . 78

21. Change in Having a Pap Test, Preclinic, Postcllnic Opening Controlled for Clinic Utilization . ........ 79

22. Discriminant Function for Wave I Prediction Results .... ............. ....... 83

23. Discriminant Functions for Wave II Prediction Results . . . . . . . . . . . . . . . . . . . . . . . . .. 85

24. Comparison of Wave I and Wave II Variable Means for Nonutilizers .................. . .. 86

25. Comparison of Wave I and Wave II Variable Means for Utilizers . . . . . . . . . . . . . . . . . . . . . . . 87

26. Wave I Variable Means by Utilization . ........ . . 88

27. Wave II Variable Means by Utilization . ........ . . 89






vi















LIST OF TABLES


Table Page
1. Timetable for Data Collection for Impact of
Physician's Assistant Clinic Study . ........... 31

2. General Format Change in Predisposing, Enabling,
and Illness-Level Variables as a Function of
Utilization of the Physician's Assistant Clinic . ..... 50

3. Wave I and Wave II Survey Comparisons of Predisposing
Sample Characteristics . .......... ... .... 52

4. Wave I and Wave II Survey Comparisons of Enabling,
Health Behavior Variables . . ... . .. ... .. . .. . 54

5. Wave I and Wave II Survey Comparisons of IllnessLevel Variables . . . . . . . . . . . . . . . . . . . ... 55

6. Clinic Utilization by Occupation of Male
Head-of-Household ................... .. 57

7. Clinic Utilization by Respondent's Age . ......... 59

8. Clinic Utilization by Family Physician Visits . ...... 60

9. Family Physician Visits by Prospective Clinic
Utilization . . . . . . . . . . . . . . . . . . . . . .. . 62

10. Change in Perception of State of Health, Preclinlc, Postclinic Opening Controlled for Clinic Utilization . . . 63

11. Change in Perception of Health Interference with Daily Activities, Preclinic, Postclinlc Opening
Controlled for Clinic Utilization . .. ... ....... 65

12. Change in Perception of Receiving Enough Care, Preclinic, Postclinic Opening Controlled
for Clinic Utilization . .................. 66

13. Change in Amount of General Worry, Preclinic, Postclinic Opening Controled for Clinic
Utilization . . . . . . . . . . . . . . . . . . . . . . . . 67




vii















LIST OF FIGURES


Figure Page
1. Andersen-Newman Model of Determinants of
Health Care Utilization . . . . . . . . . . . . . . . . . . 31

2. Model of Determinants of Health Care
Utilization . . . . . . . . . . . . . . . . . . . . . . . . 32

3. The Andersen-Newman Model: Determinants of
Health Service Utilization . ................ 34

4. The Modified Andersen-Newman Model:
Determinants of Health Service Utilization . ........ 36


































viii
















Abstract of Dissertation Presented to the Graduate Council
of thie University of Florida in Partial Fulfillment of the Requiroemnts
for the Degree.of Doctor of Philosophy

THE IMPACT OF A PHYSICIAN'S ASSISTANT CLINIC
ON A RURAL SOUTHERN COUNTY: A DESCRIPTIVE EVALUATE ION

By

Robert Edmund Burke

August, 1977

Chairman: George Warheit, Ph.D. Major Department: Sociology

The physician's assistant became a primary health-care provider"!n 1968. Since that time the physician's assistant has been the subject of- editorial debate and commentary. Research has just begun

-n lyzing t-ihe physician's assistant as a health provider. The focus of thii3 dissertalion is to descriptively evaluate the community accept'rcce c a clinic operated by physician's assistants in a rural so.tihr'in c';urty, wr.ere no other primary health service was avail able. "he prin-cipal research question was: as measured by clinic utilizaiocn, id i he county :ccept !he physician's assistant clinic? This qus+ion ws addressed by anp:lysis of two surveys. The first survey was c.':ducted ,, rl year before cthe clinic opened, the second one year ffter h. clinic had beguqr, operation.

Bca:,se ther-e w:.s no primary health care available in the county, It was :beieved thai Ihe county was in riee. of "these services and that ':e stabi ishmeint of the clinic would help al !';w 'te an extreme need.


IX










The analysis employed a health-service utilization framework. Variables which affected clinic utilization were examined. The results of those analyses are important to the growing body of research literature and to health planners who have the responsibility for developing and monitoring new primary health-care providers in the expanding health system. The survey data did not support that the county residents were experiencing extreme health-care needs. The data demonstrate that the residents had become accustomed to traveling thirty miles to the medical centers of a nearby city.

The findings suggest the clinic was utilized by county residents for some health care and that there was positive change in certain illness-level variables amoig the utilizers of the clinic.





























X















CHAPTER I
OBJECTIVES

Introduction

This dissertation presents data from a research project designed to investigate the establishment and community acceptance of a physician's assistant clinic in a rural southern community.

It was assumed by health planners at a nearby university that a

county without recognized, established, and professional medical-carepersonnel living and practicing within its boundaries would probably be in a state of extreme need. The physician's assistant clinic was seen by some of these planners as a potentially viable method of alleviating, at least somewhat, the acute shortage of primary-care deliverers in rural areas in Florida and elsewhere.

In order to assess the effectiveness of the physician's assistant clinic in meeting health care needs, a series of health surveys was planned. These surveys were designed to provide Information about the service utilization patterns of residents of the county before and after the physician's assistant clinic became operational. After an initial health survey of the target county was completed, a second one was designed to answer two basic questions: 1) what was the impact of the physician's assistant clinic on the health practices of those In the county; and 2) were the services provided a viable alternative to traditional primary medical care? The method of examining the impact of the new professionals upon the county was the measurement of the utilization of health services rates of a purposive sample of county

1







2

residents. These data allow a comparison between the users of the physician's assistant clinic and the users of traditional health care modes.

The community under investigation, as will be shown in the next section, is typical of many rural counties in the United States. The county is sparsely populated, relatively homogeneous, and dependent upon other neighboring counties for the majority of necessary services. The impact of the physician's assistant clinic on the health practices of this rural county was seen as having far reaching implications in that if this clinic was successful, it would become a model for planners of rural health care delivery at a regional and national level. The research reported in this dissertation is significant for two reasons. First, from a sociological perspective, it describes the acceptance and utilization of a physician's assistant clinic and second, as applied basic research, it can be a guide for future planning of health services in rural communities.

Research Questions

The research focused on one general question: will the residents of a rural community accept and utilize a physician's assistant clinic? This question is comprehensively addressed by these six specific subquestions.

1. Who in the community will utilize the clinic?

2. For what illnesses or injuries will they utilize the clinic?

3. Will they continue to utilize the clinic over time?

4. Will the clinic be compared favorably to other health-care services received?







3


5. Will utilization of the clinic affect the health seeking and utilization behaviors of those in the community?

6. Will the clinic be utilized by all segments of the community?

These questions are addressed by analysis of the two health surveys. The questions were the issues that were important to the developers and sponsors of the clinic.

The establishment of the physician's assistant clinic was not a spontaneous event. The growth of advocacy for health care services nationally and the conditions specific to the target community contributed to the explanation of the development of the physician's assistant clinic. Both of these conditions are discussed in the next section. Background

The availability of medical care has become a concern to many varied segments of society. Those in medical organizations, politicians, sociologists, and the consumer public have their own perspectives regarding the need for medical care. Several events are, perhaps, casually related to this surge of demands for health care. These events include national health insurance programs which have been successful in other western nations, third party payment agencies which have made health care services available to individuals not previously covered, and the federal programs of Medicare and Medicaid which have withstood their shaky beginnings and, in fact, have recently become broader in scope and medical care coverage.

The availability of medical services due to third party payment by both the private and public sectors has had a great impact on the health care delivery systems in the United States. More individuals







4

have coverage for health care services than at any other time in history. As third party payment became more prevalent, the maximum or ceiling charges permitted by third party payers became the floor or minimum charges for providers. This fact, together with increasing inflation, has resulted in a spiral effect in health care costs. Additionally, labor unions have applied pressure to management for more health care coverage. The additional coverage has affected both the corporate profits and the costs of their products to the consumer. This has had a circular inflationary effect on the economy. It also has the effect of increasing the demands by the public for health care services. In addition to increased demands, strict professional control has kept providers in scarce supply.

On analysis, the mass media reflect the value of health and

health-related products in contemporary society. The media commercials suggest that health is an individual's right and that good health is the most important product not only for the individual but also for the society to obtain and maintain. In the last decade, health spas and health food stores sprang up over night to meet the demands for health products and services. "Natural ingredients," "organic" foods and cosmetics, as well as "health" clothes such as the jogging suit have all just recently become household words and items. In light of these formal and informal pressures for more and more services a basic question persists: how can the American medical system meet these increasing demands and at the same time remain in control of their distribution, quality, and the fees charged for them? Societal and Cultural Conditions

As noted above, many societal factors are making increased demands upon the organized medical system for additional health-care deliverers.







5

According to Health United States 1975 (1976), in 1973 there was one physician for every 562 individuals in the United States. Physicians, however, are clustered in metropolitan areas where there was one non-federal physician providing patient care for every 500 residents. The ratio for small nonmetropolitan areas was about one physician for every 2,000 to 2,500. The population-physician ratio was about four or five times greater in the nonmetropolitan areas than in metropolitan ones. Furthermore, while there has been a decline in the number of general practitioners in the past ten years, there have been increases in the number of other medical specialties that are considered to be primary care deliverers. These specialties are internal medicine, pediatrics, and obstetric-gynecological medicine. Health manpower does not seem to suffer from shortage as much as from distribution problems and this maldistribution is undoubtedly related to many present demands.

The attraction of the physicians to rural areas had been unsuccessful. Placing physician's assistants in rural areas where a metropolitan based physician would be able to monitor them by telephone and periodic visits would aid in the physician, rural population location incongruence. Utilizing physician's assistants in this way, a physician would be able to serve a rural population without having to leave the metropolitan area on a permanent basis.

A simplistic method of conceptualizing this situation is to view the consumer and the medical system as two sections of an equilibrium model. In order to exist and be maintained, all crucial demands for services must be met. Thus, today's consumer demands for increased medical services should produce or result in an increase in the medical resources available. On the other hand, a technique which would






6

convince the consumer to decrease his demands for services would allow equilibrium to exist without having to change the medical system. There are four methods whereby the consumer and the medical system may approach equilibrium.

One method of meeting the demand for more primary health care services would be to redistribute existing primary health professionals. Any such proposed redistribution would meet with strong professional resistance on the part of the medical community: it is not a very viable consideration.

Another method of meeting rural health needs would be to produce more physicians pledged to practice in rural areas. There are two problems with this possible solution. First, the number of physicians is largely controlled by the medical profession and a plan to increase the number of physicians would not meet with ready acceptance from this group. Second, federal loan-programs which are forgiven If physicians agree to practice in rural communities have not been successful. Less than five percent of those who received these loans have requested forgiveness. They, perhaps, have been socialized through their educational experience to believe rural areas are not the best location for their practice.

A third method would be for communities to actively recruit foreign

medical school graduates but foreign medical school graduates have not been attracted to rural communities; they require colleagueal relationships to facilitate American licensure. The reasons these three methods of attracting physicians to rural areas have failed are both economic and social. Rural areas typically do not have the availability of laboratories, pharmacies, hospital beds, and other support networks required for physicians to prosper professionally and personally.







7

A fourth method proposed to extend the resources of the medical

system has been efforts to develop a new paraprofessional. The primary function of such a provider is the provision of primary health care services to rural communities. This method has been endorsed by the AMA because this new paraprofessional would permit the medical system to expand under the direct control of the existing medical associations. This new paraprofessional is only licensed to give primary health care services under the direct supervision of a licensed physician. This method has been actively supported for the last ten years by both the established medical system and the government. Furthermore, the acceptance of this new position would necessitate societal adaptation. Potential consumers would have to be made aware of the new position, know the services performed and become convinced of their quality. The physician's assistant can be considered AMA's response to the societal demands for more care. This new provider calls for adaptation from the societal members in terms of their attitudes, expectations, and behaviors.

The Physician's Assistant

As noted, one of the primary ways the medical system responded to the increased demands for more providers was by the creation of a new heatlh care status, the physician's assistant. This new health care provider was sanctioned by the American Medical Association, when In 1970 they drafted "Guidelines for the Development of New Health Occupations" and in 1971 the AMA House of Delegates approved "Essentials of an Approved Education Program for the Assistant to the Primary Care Physician" (Johnson, 1975). The latter document clearly defined the essential types of patient services a physician's assistant may perform:









1) The initial approach to a patient of any age group
in any setting to elicit a detailed and accurate
history, perform an appropriate examination, and record
and present pertinent data in a manner meaningful to the
physician;

2) Performance and/or assistance in performance of routine
laboratory and related studies as appropriate for a
specific practice setting, such as the drawing of blood
samples, performance of urinalyses, and the taking of
electrocardiographic tracings;

3) Performance of such routine therapeutic procedures as
injections, immunizations, and the suturing and care of
wounds;

4) Instruction and counseling of patients regarding physical
and mental health on matters such as diets, disease,
therapy, and normal growth and development;

5) Assisting the physician in the hospital setting by making
patient rounds, recording patient progress notes, accurately and appropriately transcribing and/or executing standing
orders and other specific orders at the direction of the
supervising physician, and compiling and recording detailed
narrative case summaries;

6) Providing assistance in the delivery of service to patients
requiring continuing care (home, nursing home, extended
care facilities, etc.) including the review and monitoring
of treatment and therapy plans;

7) Facilitation of the physician's referral of appropriate
patients by maintenance of an awareness of the community's various health facilities, agencies, and resources.
(Johnson, 1975, p. 23)

Summary

This section presented a discussion of the factors influencing

the increased demand for health services and how the creation of a new

medical provider meets these demands. The physician's assistant was

viewed as the AMA's creation, an ameliorative agent whose function is to

provide primary care. This new paraprofessional is accepted and

controlled by the medical profession and legitimated by state statutes.

Hence, they will be in existence for some time to come and are worthy of

being studied.







9

A History of Rural Health Care Delivery

"The notion that rural life had its health handicaps, in spite of fresh air and sunshine, was expressed as early as 1862 by the Commissioner of Agriculture to President Abraham Lincoln" (Roemer, 1976, p.3). Several sporadic attempts to alleviate the rural health problems were initiated late in the nineteenth century. It was not until the enactment of the Sheppard-Towner Act in 1921, however, that a systematic attempt was made to strengthen rural county health departments by making available grant funds to support maternal and child health centers. The depression of 1929 was a setback to this rural health initiative as the Sheppard-Towner Act was terminated. In order to build up preventive health programs, Titles V and VI of the Social Security Act of 1935 had the effect of reinstating the Sheppard-Towner Act. By 1942, some 1,800 counties had public health coverage. The remaining 1,250 counties without coverage were typically rural with small population bases. At the close of World War II, an effort was made to consolidate counties In order to provide public health coverage. In 1945, Dr. Haven Emerson launched the "basic six" program of APHA. The duties of public health departments were to be concerned with six tasks: 1) communicable disease control, 2) environmental sanitation, 3) maternal and child health preventive services, 4) health education, 5) vital statistics, and 6) laboratory services. These services, although needed, do not include direct primary patient care. This component of rural health-care delivery was left to private physicians. Some states had proposed plans to recruit physicians to their own rural areas. New Hampshire in 1923, Virginia in 1942, and Tennessee in 1953 had each enacted legislation to actively recruit and financially support physicians for their rural areas. In 1967, the National Advisory






10

Commission on Health Manpower requested there be not only a growth in numbers of physicians but also an increase of manpower in the delivery system with new categories of health professionals.

Other countries have had a history of medical assistants as primary health-care deliverers. Russia had developed the "feldsher", a type of medical or physician assistant in the 1870s, to function as the primary deliverer of health care in the rural regions. Other countries, e.g. Iran and Mexico, also have similar requirements for newly trained physicians. Following these models, in the late 1960s, federal grant moneys were made available to academic institutions to develop training programs for medical assistants; nurse practitioners, physician's assistants, and midwives were being trained under the auspices of both medicine and the federal government. Furthermore, in 1970, the Emergency Health Personnel Act established the National Health Service Corps. Under this act, physicians, nurses, and dentists were sent to needy communities where they practiced in lieu of fulfilling their active military obligation. These programs were designed to increase the medical manpower in rural areas.

To augment the increase in health manpower, several federal acts

were passed to increase the supply of hospital beds in rural areas. The most famous of these was the National Hospital Survey and Construction Act of 1946. This legislation, better known as the Hill-Burton Act, provided grant funds to states for the construction of hospitals. The maximum aid was earmarked for rural communities. Today, there Is no longer a disparity of bed supply between urban and rural areas. In fact, the trend in the past thirty years is that hospital utilization by rural-living individuals is upward. With transportation improvements,









rural residents seem to be bypassing the rural community hospital for the more sophisticated ones in urban areas.

This history demonstrates that the delivery of primary health

care to rural communities has been an issue in this country for over a hundred years. It has not been, however, until the last decade that a systematic attempt has been made to alleviate the problems of rural primary health care.

Overview of Community

The goal of this section is to describe three important factors

in the county which have a bearing on the acceptance of the physician's assistant clinic. First, the historical background of the community is discussed. Second, the history of medical services available in this community is outlined, and third, the local political situation which gave rise to the initiation of the physician's assistant clinic is presented.

Background

The county which served as the research site is situated In North Central Florida. Its north and west boundary is formed primarily by the Suwannee River as it makes its winding path to the Gulf of Mexico. The adjacent county due east is a standard metropolitan statistical area, which has a state university and is a major agricultural trade crossroads. The research county is primarily agricultural. One of Its largest employers is the forestry division of a national lumber conglomerate. The county is not self-sufficient. It does not have a hospital, college, railroad, or major shopping area. Some of the churches are served by itinerant or missionary ministers who drive in each Sunday. The major churches are Baptist and Church of Christ.







12
The county seat has one restaurant, a high school, court facilities, several hardware and farm implement dealers, a library, and a bank. A bus serves the county.

The central section of the county is swamp land. The major inhabited area forms an "L" shaped figure along the western and southern edge of the county. There is a state highway going eastwest along the southern edge of the county. According to the 1970 census, the county has 3,551 residents, of whom 3,259 are white and 287 are black. The toal male population is 1,797; the total female population is 1,754. History of Health Care Services

The health services in the county have been limited. At one time, there was a general practitioner living in the county seat; he did not remain in practice long as age and ill health caused him to retire. His son took over the practice but left the county for personal reasons. On his departure, the county was without its own physician. Residents in need of medical services-had no alternative but to go elsewhere.

There were naturopaths functioning in and around the county; the

river doctor, for example, was a naturopath who, for a fee of five dollars in cash, treated clients and distributed various herbs and teas for cures. The author learned about the river doctor from a clinic patient. The river doctor saw clients in his mobile home located outside the county seat on the bank of a river, hence the name. According to this informant, the river doctor's cures had been effective and his business brisk. The informant explained the only reason she came to the physician's assistant clinic was that the clinic billed patients at the end of the month. By the time the bill arrived, she would have






13


the ability to pay her fee; the river doctor wanted cash and extended no credit.

Residents of the county in need of hospitalization were sent to the county hospital in a neighboring county. In the mid-sixties, two other hospitals opened in that county, a university teaching hospital and a Veterans Administration Hospital. These were followed by a private hospital in 1972. This county grew to become a major medical center. The residents of the research county have always been dependent on this neighboring county for hospital services. With the health-care delivery in the research county having a history of being scarce, its residents developed a routine of leaving the county to seek medical care. With the road to the neighboring county wide, flat, and accessible, it may not have been considered a burden by county residents to drive to a major medical center, thirty miles to the east. County Political Situtation

The-author also learned that a deceased state legislator had been an influential political resource in and for the county. The representative was considered to be the individual responsible for establishing an adolescent detention center built at the far southwest corner of the county. The residents and professional staff did not socialize with the county residents but the center did provide jobs. The representative and the mayor of the county seat were both responsible for creating the County Health Board.

This board received state funds for creation and maintenance of a medical facility. Some of these funds subsidize the physician's assistant clinic. The County Health Board approached the Department of Community Health and Family Medicine at the medical college of the







14

university and requested a rural health clinic, similar to one operating in another rural county. The response from the medical college was not to create a clinic similar to their existing one but rather to use the opportunity to establish a clinic where the physician's assistant was the principal deliverer of primary care.

Three factors, a new County Health Board eager to begin a primary health-care-delivery system, an aggressive Department of Community Health and Family Medicine, and the existence of an acute shortage of health care services all came together. The result of the confluence of these three factors was the proposal of an innovative health care system, the physician's assistant clinic.

The Department of Community Health and Family Medicine and the Community Health Board came to an agreement whereby the clinic opened with two physician's assistants who were under the direct supervision of a physician. In addition, two other physicians from the medical college also served the clinic. During the negotiation and planning stage, the state representative who was a vital voice in this process, died. His death, however, did not hamper the establishing and opening of the clinic.

This overview has presented a community profile and a history

of health services and has sketched the political factors which influenced the establishment of the physician's assistant clinic. This information gives perspective to the issue of acceptance and utilization of an innovative health care service. The county is not industrial, is not used to rapid changes, is tied closely to the land, and is dependent upon its neighboring communities for services. The fact that no health care services were available in this community is consistent







15

with the community history. The political factors described are the important reasons for the establishment of the physician's assistant clinic.

Summary

The history of health-care delivery shows that only recently has there been an attempt in this country to systematically address the issue of providing primary health care to rural areas. The country had far fewer communities without physicians in 1900 than today. Two reasons were given to explain this fact. First, the choice location to practice medicine is the metropolitan areas. Secondly, rural family practice physicians since World War II have been moving to metropolitan areas. These locations have medical centers, laboratories, pharmacies, and other profession-oriented services which facilitate the practice of medicine.

This research describes the establishment and acceptance of a physician's assistant clinic in a rural community. It addresses several important questions concerning the utilization of a new type of health service for rural communities. The community overview demonstrated that this community is typical of many rural American communities. The results of the research are relevant and important to the study community as well as to other similar rural communities. The next chapter presents a literature review concerning physician's assistants and health services utilization research. The rich literature which focuses primarily on physician utilization lends itself to an analytical framework for the research.







16

Chapter III presents a conceptual and analytical framework.

Chapter IV presents the methodology of the research design, the data collection procedures, and description of key variables. Chapter V presents the conclusions and summary of the research.














CHAPTER II
REVIEW OF LITERATURE

Introduction

The goal of this chapter is to review the literature on physician's assistants in the context of the health-services delivery field. The review is designed to provide a framework for the presentation of the findings.

The Physician's Assistant Literature

The physician's assistant as a health provider came into existence in 1968, hence, the literature is limited from that year to the present. The literature can be placed into five categories:

1) The role of the physician's assistant,

2) The legality of the physician's assistant,

3) The recruitment of the physician's assistant,

4) The setting up of the physician's assistant training

programs, and

5) The evaluation of the physician's assistant.

Ford (1976) attempted to address the sociological implications of the physician's assistant. Her research suggests that sociological inquiry into issues of authority, power, status consistence, quality of care, etc., have not been empirically dealt with. Instead, research that is based in other professions, primarily nursing, have looked at the physician's assistant from outside in order to achieve their own professional goals and legitimacy. Ford, herself, falls into the same 17






18

reasoning process as she directly compares the development of the physician's assistant with the development of the nurse practitioner. This is problematic in that both of these emerging occupational roles have different origins and power bases. The nurse practitioner is primarily a development of entrepreneurial nursing; the physician's assistant as currently developed is directly subservient to a local practicing physician.

The sociological aspects of the physician's assistant have not

been addressed directly in the research literature. Thus, this review limits itself to the five categories of available research concerning the physician's assistant.

The literature has been written chiefly by physicians, nurses, and medical administrators. Literature written by the physician's assistants themselves has, as yet, not emerged.

Sadler, Sadler, and Bliss (1972), who are physicians and attorneys, were the first to prepare a comprehensive treatise dealing with the various components, issues, and questions surrounding the physician's assistant. Their research presented each of the above listed research topics and focused primarily on an analysis of the physician's assistant in terms of recruitment and his role in the medical system. They also addressed themselves to the medical and legal ramifications of the position in the total system. Their research, however, is not based on empirical data but is a descriptive general overview of the areas listed above. Nevertheless, their monograph was the first attempt to view most of the issues concerning the physician's assistant in a systematic manner.






19

The Role of the Physician's Assistant

The greatest body of physician's assistant literature is concerned with defining the role. These articles, interestingly enough, are primarily written by nurses who view the development of the physician's assistant as "the symptom" of the inability, both of medicine and nursing, to define their individual roles, to respect each other's competencies, or to deliver an acceptable level of care (Rothberg, 1973).

Andreoli (1972) raises a different aspect of role behavior. From her observation, the physician's assistant's relationship with a patient usually begins before the patient is hospitalized and ends, not with patient discharge, but rather is continued for posthospitalization checkups. Andreoli states the nurse is educated, whereas the physician's assistant is only trained in certain techniques. Lambertsen (1972, p. 32), also a registered nurse, considers the role of the physician's assistant an immediate extension of the physician and argues: "Territorial disputes (between physician's assistants and nurses) have no place in the decisions that must be made. The objectives for health manpower must focus on the ultimate potential of every person." The nurses are raising the issue of where in the health manpower network the physician's assistants are to be placed. Are the physician's assistants going to take away some of the newly carved professional territory of the nurse? The physicians, on the other hand, see the role of the physician's assistant as an immediate extension of themselves. Estes (1973, p. 197) describes the role of the physician's assistant: "...the assistant must be able to assist in and function in any of the sites in which the M.D. is active--clinic, hospital, or patient's home--and must be available at night as well as days. Because of this requirement for mobility and






20

the fact that nurses were in short supply, it was decided to utilize men rather than women." The definition of the role is one factor. The actual role taking and role behavior of the physician's assistant has yet to be systematically described or verified in the literature. Licensure

The second most commonly reported aspect of the physician's

assistant concerns legitimation. By whom will the physician's assistant be licensed, and, if licensed, to whom and for what is he legally responsible? Can a nurse take professional orders from a physician's assistant? Young (1972) reports that the AMA had placed a moratorium on the approval of new licenses for all new health paraprofessionals. Before these paraprofessionals are given approval for licensure by the AMA, Young suggests two issuesneed to be resolved. The first is to standardize the physician's assistant in regard to training and practice. The second is to establish consensus of role definitions of not only the physician's assistant but the M.D. as well. In other words, if an M.D. must supervise his physician's assistant, of what does this supervision consist? Some states such as Florida grant licenses to physician's assistants. However, this law clearly states physician's assistants are responsible to the physician under whose supervision he works. Furthermore, the physician's assistant is to work only under a physician and a physician is allowed only two physician's assistants in his employ. (Florida Statutes, Chapter 458.135, 1975)

The Recruitment of the Physician's Assistant

Another issue of the literature is that of recruitment. The first

recruitment of physician's assistants (Estes, 1971) was aimed at military corpsmen who already had some medical experience. Now that the Viet Nam






21

conflict has passed and military service has become voluntary, the availability of corpsmen has declined. Horsley and Aschenbrener (1973), as well as Onion and Schulten (1973), agree since the services of a physician's assistant are most needed in the rural areas of this country, an attempt must be made to recruit high-school graduates who have a strong desire to serve in these areas. They suggest those desiring to work in rural areas be given preferential treatment. The literature, again, is ideologically biased and does not take into account the impact that the training as a socialization agency may have on changing the physician's assistant's mind as to where he will practice. The Training of the Physician's Assistant

The taining of a physician's assistant and the establishment of

training programs have been dealt with in the literature, with considerable overlap. Again, however, little or no empirical research Is found. Stone and Bassett (1972) conclude that the greatest benefit of the Medex training program is that the physician's assistant and the M.D. have a one-to-one relationship, thereby allowing the physician's assistant to learn first-hand and by experience. Adamson (1971) suggests physician's assistants be trained along with M.D.'s and R.N.'s primarily to learn where they fit into the health-care system. Adamson, therefore, is suggesting that the training emphasize socialization. Bergen and Clapp (1972) clarify that the training program is terminal; that is, there is limited mobility. They feel the physician's assistant program must not become a manner in which a student can later be admitted to medical schcol to become a doctor. Johnson (1976) concerned his research primarily with the anticipatory socialization process and the training stages of becoming a physician's assistant. He finds that







22

physician's assistants are products of both the medical system and the societal system. More importantly, he states (p. 185),

"The A.M.A. established guidelines for these programs and
for the use of physician assistant in each state. In this
manner, the medical profession has essentially controlled the introduction of the physician assistant. Furthermore, the physician's assistant from training stage to practice
stage, unlike physicians themselves, remains in a dependent relationship to a physician."

The Johnson research and this research are complementary. The former focuses on socialization and training; this research analyzes community impact and acceptance once the physician's assistant is in practice. The Evaluation of the Physician's Assistant

The last section of the literature involves the evaluation of the physician's assistant in the medical environment. Four studies have been found that use data as a basis for evaluation. Coe and Fichtenbaum (1972) evaluate the physician's assistants employed in a small community hospital. The evaluation is based on interviews with other members of the hospital staff. They analyzed the perception of the physician's assistant role through others in the role set and found no consensus on the role definition of the physician's assistant. The physician's assistant were seen by the nurses as a vehicle for their own upward mobility. The number of physician's assistants at this hospital is not mentioned nor is the method of interpretation of their interviews. Strunk (1973) examines patient attitudes toward the physician's assistant. He develops a two-factor index based on a sample of 300. He finds that acceptance of the physician's assistant for minor medical care is greatest among nonmarried middle-class respondents who have had some exposure to college. The acceptance drops, however, for







23

major medical care. Ford (1972) examines the case loads of physicians who have been utilizing a physician's assistant and found there Is an increase in case load of 20 percent. Demaria, Cherry and Truesdell (1971) report on the peer review of physician's assistants In the Marines. The peers were not other physician's assistants but M.D.'s. This program evaluation shows the benefits of their own training program. They find their physician's assistants perform at a better-than-acceptable level. Their research demonstrates that, by utilizing physician peer review, their training program goals have been met.

Evaluation may be of several types. Evaluation can be of the program (Demaria, Cherry and Truesdell, 1971); the process (Coe and Fichetenbaum, 1972; Johnson 1976); the outcome (Ford, 1972; Strunk, 1973) and the impact upon the community. No literature could be found dealing with the Impact of the physician's assistant on the community.

The review of literature demonstrates that the physician's assistant, as a new health provider, has been described with regard to his real and ideal roles in the health care system. The legal, training, recruitment, and program issues are reported primarily from an editorial or ideological perspective. These reports, however, contribute to this research since they clearly demonstrate the need for analysis of not only the physician's assistant as a new phenomenon but also the acceptance of this new health provider by the community at large. As presented in the following chapters, this research is similar to that of Strunk (1973). But, unlike Strunk's, it describes the response of a community to physician's assistants where they are the only primary health care providers available. The evaluation of Strunk focuses on current physician's assistant utilizers in an acute






24

care setting. This research represents a logical progression in the systematic analysis of a new health-care provider.

Health-Services Utilization

Concepts such as primary health care delivery and health services

utilization are necessary and meaningful for analysis and interpretation of the results of the study. Many studies have been undertaken whose purpose is to explain why individuals utilize a health care facility in order to build a predictive model for health care facilities and programs planning.

Bodenheimer (1970), Freeborn and Greenlich (1973), and Rogers (1973) determined that availability of services or access to services were the primary issues of health care utilization. Chen (1973) developed a utilization index that was composed of length of time to get an appointment, length of travel time, and length of waiting room time. These research efforts were primarily monocausal. Donabedian (1973), Mechanic (1972), Shortell (1973), Beck (1973), Andersen et al. (1971), Anderson and Bartkus (1973), and Andersen and Newman (1973) have all forsaken a simplistic unicausal explanation for health services utilization in favor of multifactor explanations. Donabedian's (1973) research documents that socio-organizational variables such as geographic or distance variables explain health service utilization. Mechanic (1972) further confirms the importance of these variables but more importantly states that the individual must also be willing to seek health care and perceive he is in need of these health services. Mechanic further argues these components of health-care seeking behavior are learned and are a function of cultural or subcultural values. Shortell's (1973)









research suggests although there are many factors which influence health service utilization, the individual must also want this service. Beck (1973) argues the primary reasons for nonutilization are the cost of the service and its general availability.

These studies typically use the use-of-service as the primary unit of measurement, that is, individuals who either have utilized and/or are utilizing the service. These rates-under-treatment studies do not take into account individuals who may need the service and are not users. Anderson and Bartkus (1973), for example, have developed a behavioral model for the choice of health care. They key variable is the patients' ability to recognize symptoms as an indicator of need and health seeking behavior. Since the sample was composed of patients at a student health clinic, it may not be representative of the population. Unfortunately, Anderson and Bartkus do not build their model with respect to nonusers who may be in need of health care.

Andersen (1968) and Andersen and Newman (1973) have developed a general model of health care utilization that divides the variables that are influential in determining health care utilization into three major categories: predisposing, enabling, and illness level. This health services utilization model is used in this study as a framework for presentation of survey data and explanation of the acceptance of the physician's assistant clinic by the community. This model Is described in depth in the next chapter.

Summary

This chapter has presented a review of literature of research to date concerning physician's assistants and health care services utilization. It was documented there is a need for research which






26


focuses on the factors which influence the utilization of physician's assistants. In addition, many models or explanations of health services utilization have appeared in the last decade. Some have simplistic unicausal explanations; others have developed multifactor indices and scales for purposes of explanation. The Andersen-Newman model of health service utilization provides a framework for the interpretation of data such as those collected in the research county health surveys. It is the major framework for data interpretation. The next chapter will further define the Andersen-Newman model and explain its applicability to this research.














CHAPTER III
CONCEPTUAL FRAMEWORK

Introduction

"Existing research concerning the physician's assistant can be characterized as fragmented" (Ford, 1975, p. 16). The literature review contained in Chapter II demonstrates the fragmentation. Ford further states these fragments will only become of value to the understanding of the physician's assistant when they are drawn together. Research concerning the physician's assistant is shown to typically involve separate aspects of the physician's assistant such as his training, his legality, his tasks and functions, and his evaluation. The research is also a fragment of a holistic analysis of the physician's assistant. The goal of this research is to describe the process of testing whether a physician's assistant clinic is a viable alternative to traditional primary health care. The acceptance of the physician's assistant is one of the missing research fragments and the one to which this research addresses itself. It is necessary to utilize existing theoretical models to give meaning to the analysis of the sociological problem. The physician's assistant as a self-contained role has not been the topic of any research. The physician's assistant has, in its brief history, been the subject of topical research endeavors.

To strengthen the interpretation of the survey data, which are

the basis of this research, a model of health service utilization was employed. It was assumed that the factors which have been shown to 27







28

influence the utilization of transitional health services would also be the factors which would influence the utilization of a new health service. A description of the variables is contained in this chapter.

Approaches to Health Services Utilization Analysis

The evaluation of the utilizaton of a new medical care service has many stages and approaches. Andersen (1973) has classified these approaches into the following:

1) Sociocultural Approach. This approach incorporates the

perspective that health service organization and utilization are related to complex societal and cultural norms

and values.

2) Sociodemographic Approach. This approach emphasizes population based characteristics for explaining variations

in utilization.

3) Social-Psychological Approach. This approach seeks to

explain processes by which individuals realize that they are ill and decide on a source of medical care.

4) Organization Approach. This approach tends to examine

differences in utilization as a result of the structure

of the delivery system.

5) Social Systems Approach. This approach attempts to

examine utilization as a function of interactions of

interrelated components with one another and the population at large.

Each approach tends to examine a set of variables and their relationship to utilization of health care services. It is not the intention of this research to describe these approaches in detail, listing the






29


advantages and disadvantges of each. A discussion, however, of the social systems approach and its applicability to this study is presented. It is necessary that the approach used in examining health service utilization be clearly related to the study objective. Though each approach may be considered distinct, the variables incorporated in a specific model may not be unique to that model alone, as is the case of the social systems model. Instead, variables should be selected for analysis because they are consistent with the approach and that in turn will satisfy the research objectives.

The evaluation of health care is a new and complex area of Investigation. Historically, the evaluation of health care has been limited to professional peer review. Hollingshead (1973, p. 540) states,. "Evaluation of health care by a process more objective than peer review is indicated but, while the voice of the consumer is being raised about cost and quality of health care, sociologists have given little attention to the murmurings of the populace." Through the utilization of both survey research and observation methodologies, this dissertation measures the impact of the new, emerging health-care provider, the physician's assistant, on a rural community by measuring and Interpreting the murmurings of the populace. Although sociological methods are in a constant state of growth and development, this dissertation is the first analysis and discussion of the impact of the physician's assistant based on these methods. It uses the social systems model of health service utilization as its theoretical foundation.

The Andersen-Newman Model

Andersen and Newman (1973) have developed atheoretical framework concerning societal and individual determinants of medical care






30

utilization in the United States. Figure 1 schematically presents their framework.

The Andersen-Newman model is based upon the analysis of the

main components of the framework and their relationships to each other. The major premises of the model are: 1) societal determinants affect individual determinants directly and also through the service system, and 2) individual determinants influence the health services consumed by the individual. The second premise of the model, individual determinants of health service utilization, has the same variables for analysis as those collected in this survey. As such, this model groups the survey data into theoretically interpretable categories that Influence health service utilization.

Individual characteristics of the population affect the health care they receive. The model suggests that health service use is dependent on: 1) the predisposition of the individual to use services (predisposing), 2) his ability to secure services (enabling), and 3) his illness level.

Because of the limited scope of the survey data, the societal

determinant component of the model cannot be validated and analyzed. Thus, this research focuses on the health service system, the individual determinants, and the health service utilization components of the model. Figure 2, "Model of Health Care Utilization", depicts the segment of the Andersen-Newman model used in the analysis.

The predisposing variables illustrate that individual characteristics prior to the onset of illness are related to use. For example, people in different age groups have various types and amounts of illness and, therefore, different patterns of utilization. The enabling







31

SOCIETAL DETERMINANTS HEALTH SERVICE SYSTEM


Technology Resources
Norms Organizations







INDIVIDUAL DETERMINANTS


Predisposing Enabling Illness Level






HEALTH' SERVICES UTILIZATION Type
Purpose Unit of Analysis





FIGURE I Andersen-Newman Model of Determinants of Health-Care Utilization








32
HEALTH SERVICE SYSTEM


Change in Organization






INDIVIDUAL DETERMINANTS Predisposing Enabling Illness Level






HEALTH SERVICE UTILIZATION


Physician's Assistant Clinic Purpose Acceptance





FIGURE 2 Model of Determinants of Health-Care Utilization







33

variables relate to the means available to use services. Health insurance coverage is a primary enabling variable since it permits an individual to act on a value or need concerning use. Illness-level variables represent the most direct case of utilization. Given that predisposing and enabling variables are favorable, there must be the perception by the individual of illness or the possibility of its occurrenceto motivate use. The nature and extent of the care, once illness is perceived, is partly determined by the service providers.

Andersen and Newman have developed some tentative generalizations based upon review of the literature and their own experience concerning the relative importance of each set of variables in predicting utilization. Illness level is seen to be the major determinant in predicting utilization, followed by demographic, family resource, and social structure variables. Figure 3 presents these variables schematically.

The Andersen-Newman model has been tested on survey data from the National Opinion Research Center. Their research findings suggest, from a theoretical perspective, this model has taken into consideration the primary determinants of health services utilization to the degree that the need for explanatory variables is minimal (Andersen and Newman, 1973, p. 108).

The Andersen-Newman model, however, does not directly take into account the reality of no medical services directly available in the community. They do consider the ratio of health personnel to the population as a community variable, but, if the ratio is zero as it was in the research county before the opening of the physician's assistant clinic, then perhaps the effect of no available health-care services is understated.






34

PREDISPOSING > ENABLING * ILLNESS-LEVEL
I I I
Demographic Family Perceived


Age Income Disability Sex Health insurance Symptoms Marital status Type of regular Diagnoses** Past illness source General state Access to regular
source


Social Structure Evaluated
Community

Education Symptoms Race Ratios of health Diagnoses Occupation personnel and Family size facilities to Ethnicity* population Religion* Price of health Residential services
mobility Region of country* Urban-rural
character*


Beliefs


Values concerning
health and illness**
Attitudes toward
health services
Knowledge about
disease



* Not available directly from survey, but due to the relative homogeneity
of the community they can be assumed as constants.

** Not available from survey.



FIGURE 3

The Andersen-Newman Model:

Determinants of Health Service Utilization






35


The model used in this research added the existence-nonexistence of medical care services as a distinct variable in the enabling category. The result modified theAnderserrNewman model, but this modification did not dramatically change the model. The model was further validated by contrasting changes in these variables by actual family utilization of the new health-care service. Figure 4 presents the modified Andersen-Newman model.

Summary

The goal of this chapter was to develop a conceptual model for

the analysis of the physician's assistant clinic. The purpose of this study is the description of the evaluation, acceptance, and utilization of the physician's assistant clinic by the community. The socloanthropologic overview presented in the previous chapter suggested that even though the community appears geographically isolated, it has a history of dependence on its neighboring communities for social, economic, education, religious, and health needs.

The outcome of this research should describe the determinants, predisposing, enabling, or illness-level variables, which have been affected by the use of the physician's assistant clinic. The outcome should also describe which factors demonstrate the ability of the community to adapt its existing pattern of health service utilization in a manner which suggests the acceptance of the physician's assistant clinic as a viable mode of health-care delivery. Furthermore, the outcome should describe the level of acceptance of the clinic by demonstrating what factors made some individuals utilizers of the physician's assistant clinic while others remained nonutilizers or selective utilizers.






36

PREDISPOSING 0 ENABLING b ILLNESS-LEVEL
I I
Demographic Family Perceived


Age Health insurance Disability arital status Type of regular Symptoms source General state Access to regular
source


Social Structure Evaluated Community

Occupation None Family size Ratios of health Ethnicity* personnel and Religion* facilities to Residential mobility* population Price of health
services
Region of country*
Urban-rural
character*

Beliefs


Values concerning New medical service
health & illness available Attitudes toward
health services



* not available directly from survey, but due to the relative homogeneity
of the community they can be assumed as constants.



FIGURE 4

The Modified Andersen-Newman Model:

Determinants of Health Service Utilization







37

Given these questions which guided this research, the available survey data, and the descriptive nature of this study, this chapter has outlined a model of health service utilization which has optimal conceptual features for later data analysis. The next chapter discusses in detail the research design, the research questions, the methodology, and the variables and statistics used in the analysis.















CHAPTER IV
RESEARCH METHODOLOGY

Design

As noted previously, the purpose of this research is to address two issues: 1) is the physician's assistant a viable alternative to the traditional health-care provider; and 2) is the physician's assistant accepted as legitimate by the consumers being served? The level of acceptance is measured by the utilization of the clinic by the community. In order to accomplish these research objectives, a two-stage survey obtained data along three dimensions: health perception, health attitudes, and health care service utilization. The data collection instruments used in the first stage were developed by health planners at a state university medical center; the second were developed by the author in collaboration with sociologists and health planners. Data from these sources include measures of self-perception of health, attitudes about health and health care, and, finally, health care utilization patterns.

The data have certain limitations. Neither of the survey instruments contained previously tested scales or indices of health care utilization and further, the data did not contain any health care outcome measures usually found in health services studies. The first data obtained were to be used as descriptions of behavior and attitudinal factors that affected the utilization of the physician's assistant clinic. The original health planners did not view this research

38







39

in a theoretical sense; their perspective was immediate and practical. After the first health survey was completed, a broader, more theoretical orientation emerged; it focused on the concerns and questions dealing with more generic issues, e.g., the legitimacy and acceptance of the new health care provider and his clinic. It was at this point that the author become involved.

Data Collection

The data were collected from two waves of survey interviews and from a six-month observation period at the offices which housed the newly opened physician's assistant clinic. The first Interviews were administered two months before the clinic opened; the second were administered after fourteen months of operation. The observation was undertaken about one year after the clinic had commenced services.

-Table 1 shows the data-collection timetable.

TABLE 1

Timetable for Data Collection for Impact
of Physician's Assistant Clinic Study



Spring Summer Fall Winter Spring Summer 1971 1971 1971 1972 1972 1972 Wave I Survey

Clinic Operating

Wave II Survey

The Sample

The health planners decided that the research questions could be answered most effectively by the adult female in each household who was typically responsible for the health care of her family. Usually, in a nuclear family, this person is the mother. A purposive sample of one-third






40


of the households in the county was chosen. The sample size was based on the following logic. Since the population of the county was 3,551 and the average American family has approximately four members, it was estimated there were about 900 households in the county. Thus, a sample of one-third of the households, or 300 families, was the sampling objective for the first survey. Since over 85 per cent of the adults in the county were registered to vote, the sample of households was drawn randomly from voter registration lists.

Immediately after the sample was collected, it was compared to the census characteristics of the county. It was determined that blacks were underrepresented by 3 percent. A quota sample of 3 percent was added to proportionately represent the blacks. A total of 227 family households was reached. Once located the adult female most responsible for the household was interviewed and asked to report on her own health perceptions and behaviors as well as those of her spouse, children, and other adults living in the same household. Data were not available which described the reasons that the sampling objective of 300 was not reached.

During the second survey wave, attempts were made to reinterview each of these 227 family households; 85 percent (193) were located and reinterviewed. Thirty-four first-year respondents were not able to be interviewed, five had died during the year, twenty-one had moved and the remaining eight were never home or refused an interview.

In order to determine if the administration of the first-wave

interview had sensitized and biased the participants with regard to the physician's assistant clinic and influenced the utilization of the same, a comparison group of family households was added during the second wave. This group was selected using the same sampling technique.







41

Eighty-six households were interviewed. One family interview was incomplete and deleted. Comparisons were made between this group and the reinterviewed group. No differences were found with respect to clinic utilization and the sociodemographic variables. This finding meant that the first survey did not bias county residents with respect to clinic utilization. Further comparative analysis between these two groups was not undertaken. These 85 additional Wave II Interviews were added to the sample when description of events thatoccurred within the past year are presented. Whenever changes in predisposing, enabling, and illness-level variables are presented only the responses of those females who participated in both interviews are used.

Field Test

After the second interview schedule was prepared, a field test was

conducted, 6 interviews were completed. After the field test was analyzed, the schedule was critically reviewed. As a result, some minor revisions were made. No items were deleted or added.

The Data

The general question was: will the residents of a rural community accept and utilize the physician's assistant clinic? Responses to Items collected during the interviews provide the independent, dependent, and control variables. Complete interview schedules are contained In Appendices A and B. There are six specific questions used to comprehensively address this general question. The first specific question was: who in the community will utilize the clinic? Items used to address this question were:

1) Age of respondent, classified into six intervals ten

years apart beginning at age 15;







42

2) Marital status, categorized as single, married, widowed,

and separated/divorced;

3) Occupation of the male head-of-the-household (an indicator

of socio-economic status). The U. S. Census categories were collapsed to reflect a rural community. The first

category contains all professional and white collar workers;

the second, craftsmen and foreman; the third, operatives;

the fourth, laborers; and the fifth, farmers;

4) Family composition, categorized as nuclear complete,

living with relatives, and living alone;

5) Distance of the household to the clinic, measured in

miles, but collapsed into three categories: within the

county seat, within ten miles of the county seat, and

other;

6) Welfare recipient during the year, categorized as yes

or no;

7) Health insurance status, insured or not; and,

8) Length of residence in the county.

Although data were collected about respondent's education, race,

and residential mobility, they were not used in the analyses due to their lack of discriminatory ability. The county was assumed to be a prior homogeneous with respect to ethnicity and religion. Data concerning ethnicity and religion were not collected. These characteristics of the research county were descriptively clarified in Chapter I.

The second specific question was: for what illnesses or injuries will the county residents utilize the clinic? The Items that address







43
this question are the above items plus questions concerning the health-seeking behaviors for other service modes, namely physicians, hospitals, and other health services.

The third question was: will the community residents continue

to utilize the clinic over time? The items that address this question are clinic utilization and health behavior change variables. Clinic utilization was defined as use of the clinic during the year by the respondent or a member of the respondent's nuclear family. New variables were created to show change from Wave I to Wave II. These change variables compare the responses between the two survey waves. For example, if the perception of the level of worrying was lower during the second wave than it was during the first, that was considered a positive change. If the worry was higher in the second wave than in the first, that was considered a negative change. If no change was detected between the two surveys, that variable was scored as stable. This type of variable creation permitted testing of the significance of change by means of a sign test. Since the data were ordinal level, a variable that quantified the magnitude of the change would be erroneous. A change variable was created for each item that measured health behavior or health attitude:

1) Perception of state of health;

2) Perception of health interference with daily activities;

3) Perception of receiving enough medical care;

4) General worry;

5) Worry about receiving emergency medical services;

6) Worry about having an undetected disease.







44

The fourth question was: will the clinic be compared favorably to other health-care services received? Four questions comparing the physician's assistant clinic to other health-care agencies were asked. The comparison questions were in regard to:

1) Cost;

2) Perceived quality of care;

3) Ease in making appointments; and,

4) Ease in talking to clinic staff;

and are shown in the Wave II precoded interview schedule In Appendix B. The possible responses to these questions were "the clinic was better or easier than the other health-care service," "it was about the same as the other health care service," and "it was worse or harder than the other health care service."

Nonutilizers of the clinic typically would not respond to the

comparison questions and those who did generally indicated they were relying on hearsay information. Thus, their responses were not analyzed.

The fifth question was: will utilization of the clinic affect the health-seeking and utilization behaviors of those in the community? The items that address this question are changes in health-related behaviors and attitudes as measured by changes in enabling and illness-level variables. These include changes in physician visits, clinic visits, and medicine intake. The items show health-related behavior were:

1) Health interference with daily activities;

2) Previous medical-care utilization;

3) Present health-care utilization; and,

4) Stated prospective utilization of the physician's assistant

clinic.






45

The items that show health attitudes were:

1) Self-report of perception of state of health;

2) Worry as measured by response to the question, "How often

are you worried or nervous?";

3) Worry about emergency health care determined by response

to the question, "How often do you worry about being able

to receive health-care services for an emergency?";

4) Worry about personal health determined by response to the

question, "How often do you worry about having an Illness

or disease that has not been detected?";

5) Self-report of perception of receiving enough medical care; 6) The respondent's and the community's liking of the clinic.

The sixth question: will the clinic be utilized by all segments of

the community?; was addressed by the development of discriminant functions or utilizers and nonutilizers. These functions contain the variables which had demonstrated significance.

Reliability and Validity

Reliability and validity must be addressed in all surveys. A

brief review of reliability in this research will be discussed. Reliability refers to the consistency of the measures over time. Three types of reliability were applicable to the survey data: observer reliability, internal reliability, and, for longitudinal and multistage studies, testretest reliability. Experiment observer reliability was demonstrated by means of a controlled simulation. In this experiment, both interviewers recorded answers to survey questionnaires while observing a simulated interview. The answers of the interviewers were compared. The average agreement was calculated by dividing the number of correct







46

responses by the total number of questions and dividing by two, the number of interviews. The average agreement was 92 percent. Since there were only two interviewers in Wave II, a further statistical procedure was unnecessary. No observer reliability experiment was performed for Wave I.

Other tests of reliability that are frequently used in survey research are tests to measure the Internal consistency and tests to measure estimate of test-retest reliability. Reliability tests for internal consistency and test-retest reliability were not performed on the crucial health related variables. Tests for these types of reliability were performed for the predisposing, sociodemographic variables. Because there was no logical inconsistencies overtime for these variables, reliability was assumed.

Validity refers to the ability of an item to measure what it

is intended to measure. Content validity was addressed in this research by having the survey instruments reviewed by other researchers and then field tested. The results determined if questions were ambiguous and potentially low in content validity. It was also believed that the health interview used in this research would not be perceived by the respondents as personally damaging or threatening to the degree that they would give inaccurate responses. The interview was assumed to have face validity.

There are other issues concerning the validity of the data. The

history of health surveys, however, shows that If the limits are recognized a priori, health surveys, such as the one utilized In this research, are meaningful indicators of health-service utilization. There







47

was no way to test the validity of the responses. Theoretically, It would be possible to calculate the validity of some of the survey items by comparing health utilization responses, with medical records or health insurance claims. These comparisons, however, were not available for this research.

Statistics

The descriptive analysis was performed by utilizing contingency table statistics. The most prevalently used were Chi-square, sign test, and Gamma. As an attempt to reinforce the descriptive findings of the impact of the clinic on the county and for future program planning, clinic utilization was also analyzed by means of discriminant function analysis. The discussion of this analysis Is presented in the following chapter.

Summary

This chapter has outlined the design and methodology used in this research. The design was a two-stage health survey of adult females presumed to be most knowledgeable of their family's health needs and behaviors. A purposive sample of 193 respondents representing approximately one third of the households in the county was selected. The sample was asked questions concerning their own health perceptions and utilization behaviors. They were also asked to be informants for the health perceptions and utilization behaviors of other members of their families. The items and statistics used in the analyses were described and a discussion of the issues of reliability and validity was presented.

Chapters 1, II and III have described the conceptual issues of the research and have grouped these issues with relevant research literature and the research questions. These factors have led to a discussion of






48

an analytical framework with which the issues of the research can be addressed. This chapter has presented the methodological tools used within the framework. The following chapter presents the culmination of these four chapters by presenting the research findings.














CHAPTER V
FINDINGS

Overview

Chapter I presented a number of questions that had guided this

research. These questions are not formal but are used for the purpose of interpreting the findings. The findings are reported as responses to these questions. The major research question was: will the residents of the county utilize and accept the physician's assistant clinic? To address this question, six specific questions are needed.

1) Who in the community will utilize the cllninc?

2) For what illnesses or injuries will they utilize the

clinic?

3) Will they continue to utilize the clinic over time?

4) Will the clinic be compared favorably to other healthcare services received?

5) Will utilization of the clinic affect the health seeking

and utilization behaviors of those in the community?

6) Will the clinic be utilized by all segments of the

community?

Before these questions are addressed in detail, a review of the

technique for measuring changes-over-time and a discussion of the survey results are presented.

It was noted in the previous section that only some of the Illnesslevel items changed between the survey waves. It would be simplistic to

49







50

state that the changes in illness-level variables were due solely to the opening of the physician's assistant clinic. Even in a rural, stable community like the research county, other factors not measured In this research could have caused the changes to occur. Variables that captured these changes were needed. As described in Chapter IV, by summarizing and creating new variables from the survey data, the needed change variables were developed.

These variables were then crosstabulated by whether or not an individual within the family had utilized the physician's assistant clinic. Thus, the two comparison groups are utilizers and nonutilizers of the clinic. The data were then compared to determine if, according to the specific illness-level variable, the utilizers and nonutilizers of the clinic were independent. Sign tests were calculated for the changes in both groups. Since each group, the utilizers and nonutilizers, had equal opportunity for change, the sign change would determine which group changed more significantly. Table 2 presents the general format for the presentation of these data.


TABLE 2


General Format
Change in Predisposing, Enabling, and IllnessLevel Variables as a Function of Utilization of the Physician's Assistant Clinic



Family Utilized Family Not Utilized Clinic Clinic Change in Positive change Positive change Variables No change No change Negative change Negative change






51

In the preceding chapter, the sample design was discussed; a brief review is needed. When change variables are presented, the maximum N is 193. These are respondents who participated In both surveys. When data are presented that do not involve change, the maximum N is 278, the 193 who responded to both surveys plus the additional group of 85. Table N's may fall below these totals because of missing responses.

Descriptive Survey Results

The results of each survey are compared and discussed within the Andersen-Newman Framework.

Predisposing variables. Table 3 depicts the predisposing characteristics of the sample for both survey waves. It can be quickly ascertained that the respondents who are missing from the Wave II survey do not affect the sample characteristics. With respect to the predisposing variables, changes were nonexistent from Wave I to Wave II. This table shows that the sample were primarily white, married, high school graduates who were living in nuclear, complete families within the county for more than twenty years. The respondents have reported themselves to be rural, stable and family oriented. More importantly the sample remained the same with respect to these variables over the year's time.

Approximately, 9 percent reported they or their immediate families had received some type of welfare during the past year, 90 percent reported they own at least one car and 60 percent reported ownership of two or more cars and/or trucks. Data on Income were collected but determined that farmers, some small business owners, and other selfemployed individuals were reporting only net Income, the amount remaining after business costs and depreciations were deducted. Others reported







52

TABLE 3

Wave I and Wave II Survey Comparisons of
Predisposing Sample Characteristics (Percentages)



Wave I Wave II
Survey Survey

Age
< 35 16 16 35 to 64 62 62 S65 22 22

Race
White 92 94 Black 8 6

Marital Status
Married 79 77 Single 4 2 Widowed 14 18 Separated or Divorced 3 3

Living Arrangement
Nuclear Complete 70 70 Nuclear Incomplete 23 21 Alone 7 9

Length of Time Residing
in Gilchrist County
More than 20 Years 67 70 5 to 20 Years 21 19 Less than 5 Years 12 11

Education
Less than High School Graduate 63 62 High School Graduate 33 37 College Graduate 4 I




N 227 193







53

gross incomes. No clear, reliable method of making the amounts comparable could be ascertained. Income, as a key variable, was deleted from further analysis.

Enabling variables. Table 4 presents a listing of these variables. These health behaviors have remained constant between the two survey waves. There are, however, two interesting findings. The first Is that both before and after the clinic opened, 80 percent of the sample had seen a physician. This clearly suggests that the county residents were already high users of health-care services, and that the opening of a new healthcare service did not radically alter this high health-care service rate. The second interesting finding was that the use of patent medicines increased between the survey waves. When this finding was controlled for clinic utilization, no significant difference was found. One explanation is that the Wave II interviewers probably explained more precisely what was meant by patent medicines than did the Interviewers in the Wave I survey.

Illness-level variables. Table 5 presents the illness-level variables. The respondents were asked several questions concerning their attitudes and perceptions of their state of health as well as their worry about receiving care. No significant differences were observed between the two survey waves. There are two interesting findings. In Wave II, the perception of receiving enough medical care increased by 13 percent. Secondly, worry about receiving health-care services In an emergency declined in the "often" and "all the time" categories 17 percent, from 28 percent in Wave I to 11 percent in Wave II. These findings suggest that there has been some impact of the physician's assistant clinic. The impact is presented more completely in the next section.







54
TABLE 4

Wave I and Wave II Survey Comparisons of
Enabling, Health Behavior Variables (Percentages)



Wave I Wave II

Saw A Physician
Yes 80 80 No 20 20

Mean Number of
Physician Visits 4 4.5

Hospitalized
Yes 10.5 9.5 No 89.5 90.5

Took Prescription Drug During Year
Yes 43 50 No 57 50

Used Patent Medicine During Year
Yes 19 47 No 81 53

Used a "Nerve Pill" During Year
Yes 16 25 No 84 75

Women had Pap Test
Yes 44 40 No 56 60

Pregnant
Yes 5 5 No 95 95




N 227 193







55

TABLE 5

Wave I and Wave 11 Survey Comparisons of Illness-Level Variables
(Percentages)


Wave I Wave II

Perceived State of Health
Good & excellent 63 71 Fair 21 18 Poor and very poor 16 II

Perceived Health Interference with Daily Activity
Never 50 56 Seldom 12 16 Sometimes 17 6 Often II 13 All the time 10 9

Perceived Receiving Enough
Medical Care
Yes 71 84 No 29 16

Worry
General
Never 10 10 Seldom 21 19 Sometimes 30 42 Often 39 30

Receiving Health Care
Services in an Emergency
Never 47 58 Occasionally 25 31 Often 25 7 All the Time 3 4

Have Undetected Disease
Never 67 66 Occasionally 23 29 Often and All the Time 10 5




N 227 193







56

Tables 3 and 4 presented a comparison by survey wave of predisposing and enabling variables. These figures show the predisposing variables and the enabling variables show no dramatic change. Table 5 presented some changes that occurred after the physician's assistant clinic opened for illness-level variables. Fewer persons perceived themselves to be in poor health and fewer reported that their health interfered with their daily activities. A smaller percentage of the respondents were as worried about receiving medical care in an emergency than during the previous year. Hospitalization and visits to physicians appeared to be the same. Medicine intake, patent medicine, prescription drugs, and nerve pills had all increased during the year.

The next section more closely examines these changes by analyzing the differences in the illness-level variables as a function of family utilization of the clinic. This analysis provides answers to the research questions.

Discussion of the Six Specific Questions

The first specific question is: who in the community utilizes

the clinic? Two predisposing variables, age of respondent and occupation of male head-of-household, are discussed. Tables 6 shows clinic utilization by occupation of male head-of-household, a predisposing variable. There is a significant difference between the utilizers and nonutilizers. The ability to predict utilization by occupation, however, is minimal, Lambda = .10. Additional analysis showed that of those who reported they liked the clinic a great deal, 46 percent were white-collar workers, 23 percent were farmers, 16 percent were craftsmen, 7 percent were operatives, and 8 percent were laborers. Even though the professional and white-collar workers indicate a greater liking for the






57

TABLE 6

Clinic Utilization by Occupation of Male Head-Of-Household



Clinic Utilization Row
Occupation No Yes Total



Professional and White Collar 8 (12) 36 (40) 44 Craftsmen
Foremen 18 (20) 17 (19) 35 Clerical
Operations 13 (20) 9 (10) 22 Sales
Laborers 8 (12) 7 (8) 15 Crafts
Farmers 20 (29) 20 (23) 40 Total 67 89 156


Chi-square = 15.85 Significant p <.01 d.f. = 4






58

physician's assistant clinic, their utilization is not significantly different from other occupational groups. Additional analysis revealed there was no utilization difference between those who liked the clinic a great deal and those who liked the clinic somewhat.

Table 7 presents clinic utilization by age. Age was not a significant factor in clinic utilization. In fact, the percentages of utilizers and nonutilizers in each age group are almost equal.

As further explication of this utilization question, the idea that heavy utilizers and needers of health-care services would be more prone to use the clinic was analyzed. No attempt was made to develop a profile of needs assessment for the research county. Health needs for this analysis are defined as health-seeking behavior. Since 80 percent of the sample had sought health care before the clinic had opened, it was assumed these individuals viewed themselves as having a need for health services. It was established from the survey that the majority of respondents perceived they were or had been receiving enough medical care. Because the health-care needs of the research county were already perceived as met, the clinic would then have to replace existing providers or create a new demand for services. In order for the residents of the county to substitute clinic services for existing services, the clinic would have to become an accepted, viable, and preferred provider of health-care services.

Table 8 presents clinic utilization by family physician visits. The significant Chi-square is interpreted to mean that the utilizers and nonutilizers are independent groups but, more importantly, the Gamma of .39 implies there is a moderate association between more







59
TABLE 7

Clinic Utilization by Respondent's Age



Clinic Utilization
Row
Age of No Yes Total



15-24 4 (3) 4 (3) 8 25-34 18 (13) 18 (13) 36 35-44 29 (21) 32 (23) 61 45-54 32 (23) 29 (20) 61 55-64 26 (19) 25 (18) 51 Over 65 29 (21) 32 (23) 61


Total 138 140 278 Chi-square = 1.054 Not significant d.f. = 5







60
TABLE 8

Clinic Utilization by
Family Physician Visits



Clinic Utilization
Row
Family Physician Visits No Yes Total



None 49 (42) 20 (18) 69 1-5 44 (38) 50 (46) 94 6-10 II (9) 18 (16) 29 More than 10 13 (II) 22 (20) 35 Total 117 110 227 Chi-square = 16.375 Significant p = .001 d.f. = 3







61

physician visits and clinic utilization. This suggests the more individuals use health-care services, the more likely they will utilize the physician's assistant clinic.

Table 9 adds a caution to this interpretation. This table presents family physician visits by prospective clinic utilization. The significant Chi-square suggests that prospective utilization plans are independent of family physician visits. The Gamma of -.25 further suggests that the greater the number of physician visits the lower the prospective clinic utilization, and, further the data indicate that the more visits to a physician a family has, the more likely it is they do not plan to use the clinic. Other survey data verified this Implication in that only eight of the respondents reported that a physician ever referred them to the physician's assistant clinic. It may be that the physicians who treat the residents of the research county do not want to lose patients or perhaps these physicians have not accepted the physician's assistant clinic as a viable alternative for healthcare delivery.

The second specific question is: for what reasons do the individuals utilize the clinic? The respondents who had utilized the clinic answered that physicals, checkups, and colds were the reasons they had gone to the clinic. These responses are not specific enough to address the research question. It was decided this question could be addressed by examining the changes in certain health factors of the utilizers and nonutilizers. Table 10 shows there was not significant difference for the utilizers and nonutilizers of the clinic with respect to change in perceived state of health. The sign test, however, suggests the change among the utilizers had a significantly greater








62
TABLE 9

Family Physician Visits by Prospective Clinic Utilization



Family Physician Visits Prospective More Row Utilization None 1-5 6-10 than 10 Total



All Services 15 (46) 22 (25) 5 (18) 3 (9) 45 Some Services II (33) 39 (44) 15 (53) 19 (56) 84 Emergency
Only or Not
at All 7 (21) 28 (31) 8 (29) 12 (35) 55


Total 33 89 28 34 184


Chi-square = 13.428 Significant p< .05 d.f. = 6 Gamma = -.25







63

TABLE 10

Change in Perception of State of Health, Preclinic, Postclinic Opening Controlled for Clinic Utilization



Clinic Utilization
Perceived State Row of Health No Yes Total



Better State
of Health 26 (31) 41 (37) 67

Same State
of Health 39 (47) 48 (44) 87

Worse State
of Health 18 (22) 21 (19) 39


Total 83 110 193


Chi-square = .74 Not significant d.f. = 2

Sign test
nonutilizers Z = 1.21 accept null hypothesis p = .05 utilizers Z = 2.25 reject null hypothesis p = .05 overall Z = 2.719 reject null hypothesis p = .05







64

probability to be positive. Table 11 demonstrates that the perception of health interfering with daily activities was different between utilzers and nonutilizers. The sign test reports the change for nonutilizers had a significantly greater probability towards more interference. Table 12 shows that perception of receiving enough medical care did not differ between utilizers and nonutilizers by family clinic-participation. The sign tests indicate the probability for change among both groups was toward a perception of receiving more care during the second year than during the first year. The difference is substantially significant.

Table 13 shows there was no difference in general worry by clinic utilization. The sign test indicates the probability for change among both clinic utilizers and nonutilizers was toward less worry. Table 14 shows that there was a significant difference in worry about receiving emergency medical-care services. The sign test further clarifies the utilizers had a significantly greater probability to be less worried about receiving emergency medical-care services. Although there was some change in worry among the nonutilizers, the probability of the change being either positive or negative appeared equal and random. Table 15, more clearly shows that utilization of the clinic may have affected specific worry. This table presents the change in worry about having an undetected disease. The sign test indicates the changes between groups is inverse. The nonutilizers had a significantly greater probability toward more worry than the utilizers.








65
TABLE II

Change in Perception of Health Interference
with Daily Activities, Preclinic, Postclinic
Opening Controlled for Clinic Utilization



Clinic Utilization

Perception of Row Health Interference No Yes Total



Less Interference 15 (18) 29 (26) 50 Same Interference 28 (34) 52 (48) 92 More Interference 40 (48) 29 (26) 85


Total 117 110 227


Chi-square = 9.85 Significance p (.01 d.f. = 2 Sign test
nonutilizers Z = 3.37 reject null hypothesis p = .05
utilizers Z = 0
overall Z = 8.99 reject null hypothesis p = .05






66


TABLE 12

Change in Perception of Receiving
Enough Care, Preclinic, Postclinic Opening
Controlled for Clinic Utilization



Clinic Utilization

Perception of Row Receiving Enough No Yes Total



More Care than
First Year 13 (16) 24 (22) 37 Same Care as
First Year 64 (78) 80 (73) 144 Less Care than
First Year 5 (6) 5 (5) 10


Total 82 109 191


Chi-square = 1.23 Not significant d.f. = 2 Sign test
nonutilizers Z = 1.88 reject null hypothesis p = .05 utilizers Z = 3.5 reject null hypothesis p = .05 overall Z = 3.9 reject null hypothesis p = .05






67



TABLE 13

Change in Amount of General Worry, Preclinic, Postclinic
Opening Controlled for Clinic Utilization



Clinic Utilization

General Row Worry No Yes Total



Less Worry 65 (78) 50 (69) 115 More Worry 18 (22) 22 (31) 40


Total 83 72 155 Chi-square = 1.59 Not significant d.f. = I Sign test
nonutilizer Z = 4.94 reject null hypothesis p = .05 utilizer Z = 3.30 reject null hypothesis p = .05 overall Z = 6.83 reject null hypothesis p = .05






68


TABLE 14

Change in Amount of Worry about Receiving Emergency
Medical Services, Preclinic, Postclinic Opening
Controlled for Clinic Utilization



Clinic Utilization

Worry about Receiving Row Emergency Medical Services No Yes Total



Less Worry 18 (22) 50 (50) 68 Same Worry 43 (54) 46 (45) 89 More Worry 19 (24) 5 (5) 24


Total 80 101 181 Chi-square = 21.175 Significant p< 0.001 d.f. = 2 Sign test
nonutilizer Z = -.16 accept null hypothesis p = .05 utilizer Z = 6.06 reject null hypothesis p = .05 overall Z = 4.59 reject null hypothesis p = .05






69


TABLE 15

Change in Amount of Worry about Having an Undetected Disease, Preclinic, Postcllinic Opening Controlled for Clinic Utilization



Clinic Utilization

Worry about Having Row an Undetected Disease No Yes Total



Less Worry II (14) 26 (25) 37 Same Worry 47 (60) 63 (61) 110 More Worry 21 (26) 14 (14) 35


Total 79 103 182 Chi-square = 6.761 Significance p (.05 d.f. = 2 Sign test
nonutilizer Z = -1.77 reject null hypothesis p = .05 utilizer Z = 1.89 reject null hypothesis p = .05 overall Z = .23 accept null hypothesis p = .05







70


Using bivariate contingency-table analysis and an extension of

the binomial test showed that with regard to perceived state of health, health interference with daily activities, perception of receiving emergency medical care, and worry about having an undetected disease that there was an overall significantly positive change for the utilizers of the clinic. The utilization of the clinic demonstrates an inverse relationship with perception of worry about receiving emergency medical services. After a family utilized the clinic, there was a reduction of specific health-related worry.

The major reported reasons for clinic utilization were generic. The utilization, however, resulted in significant, positive changes in health perception and worry. Thus, it was shown that, in addition to direct health care, the utilizers of the clinic had more positive change in health-related perceptions.

The third specific question is: will the county residents continue to utilize the clinic over time? It addresses the continuance of prospective utilization of the clinic. The question in the Wave II survey which addressed prospective utilization is: "Would you go to the medical center in the county seat for all your health-care needs, some of your health-care needs, only in the case of an emergency, or not at all?" The respondents reported as follows: I would go to the clinic for all health-care needs (22 percent), some (46 percent), emergency only (22 percent), and not at all (10 percent). These figures raise additional questions. Is there a difference in prospective utilization if one has already utilized the clinic? Do differences in perceived quality of care result in a difference in prospective utilization? Both utilizers and nonutilizers stated that their






71

prospective utilization of the physician's assistant clinic would be for some of their medical care but not for all of it. These data suggest that the clinic will be utilized for some of the health-care needs of the community.

Table 16 presents utilization with respect to intended future

utilization. The clinic utilizers are a significantly different group than the nonutilizers in regard to prospective utilization. The Chisquare is significant at p 4 .05. The ability to relate actual utllization from prospective utilization is moderately low with Gamma = .24. These data indicate a tendency. Once the clinic is actually utilized, the user is somewhat more likely to return to the clinic for some of his(her) health-care needs. Furthermore, those who used the clinic were quite satisfied with the care rendered. Of those utilizers who liked the clinic a great deal, 90 percent could not list anything they disliked. Consistently, those who utilized the clinic perceived both the cost and quality of care to be the same or better than their usual place of health-care services. Of those who intended to use the clinic for some or all of their health-care-service needs, 65 percent perceived the cost of services at the physician's assistant clinic to be less than the cost of services at their usual place of health-care services.

These findings suggest that some dissonance of acceptance or nonacceptance by the community of a nonlicensed primary health provider was resolved after a member of the family had utilized the clinic. The reason for the initial utilization could not be obtained from the survey data. After the utilization of the physician's assistant clinic the user probably felt more favorable about the clinic in that the user was more likely to continue to use the clinic for some of his health-care needs than the nonutilizers.








72
TABLE 16

Clinic Utilization by Prospective Clinic Utilization



Clinic Utilization

Prospective Row Utilization No Yes Total



All Services 9 (12) 36 (33) 45 Some Services 23 (31) 61 (56) 84 Emergency Only
or Not at All 42 (57) 13 (II) 55


Total 74 110 184 Chi-square = 43.295 Significant pt .05 d.f. = 2 Gamma = .24







73

A logical additional inquiry was made to determine if the perception of quality of care of clinic utilizers was an important factor in their decision for prospective utilization. It may be inferred from Table 17 that there was a difference of perceived quality of care at the clinic by planned future use of the clinic. Those who intended to utilize the clinic for some or all of their health-care-service needs appeared to perceive the clinic to be providing the same if not better quality of care than was otherwise available. Those who did not plan to use the clinic appeared to perceive the quality of care to be the same or worse than the quality of other care. Because so few responded that the care at the clinic was not as good as other providers and so few responded that they do not intend to use the clinic at all, it would be misleading to perform any statistical test on these data.

The idea that the health-care needs of the county were being met by the physician's assistant clinic can not be statistically supported with these data. There is an indication that those who have utilized the clinic will continue to. These data also lead to the speculation that the residents were perhaps rigidly entrenched in their previous patterns of health-care-services utilization and they did not perceive the need of the physician's assistant clinic for the major portion of their health-care-service needs. Table 18 presents the change in physician visits by clinic utilization. No differences were shown. It was thought that if there were more physician visits, then there would be lower clinic utilization. It was also thought that If clinic utilizers had an increase in physician visits, then the physician's assistant had identified patients to be referred to physicians for additional specialized treatments, thereby causing these patients' utilization rates of







74
TABLE 17

Perception of a Physician's Assistant
Clinic as Compared to Usual Care Received by
Prospective Physician's Assistant Clinic Utilization



Perception of Care at Clinic Compared to Usual Care Received Prospective Row Utilization Better Same Not Good Total


All Care 8 30 0 38 Some Care 8 54 3 65 Emergency
Care Only I 5 3 9 Not at All 0 I I 2


Total 17 90 7 114






75


TABLE 18

Change In Number of Physician Visits, Preclinic, Postclinic Opening Controlled for Clinic Utilization



Clinic Utilization

Physician Row Visits No Yes Total



More MD Visits 15 (29) 16 (25) 38 Same MD Visits 20 (40) 27 (42) 47 Less MD VIsits 16 (31) 22 (33) 31


Total 51 65 116


Chi-square = 2.78 Not significant d.f. = 2 Sign test
nonutilizer Z = -.17 accept null hypothesis p = .05 utilizer Z = -.97 accept null hypothesis p = .05 overall Z = .84 accept null hypothesis p = .05







76

physicians to increase. These arguments cannot be verified In the survey data. The point here is that the residents were already users of health services. The survey reported that 80 percent of the informants had utilized some type of health-care service before the clinic had opened. For a county with no health-care services, this is a high percentage. The clinic, then, should not be viewed as the only provider of primary care, it should be viewed as a more convenient alternative.

Table 19 presents change in hospitalization by clinic utilization. The utilizers and nonutilizers are shown to be independent groups. The nonutilizers, however, had a significantly greater probability for less hospitalization in Wave II than in Wave I. The change in hospitalization for utilizers was random. The idea then, that the physician's assistant clinic was functioning as a referral source, is speculative at best.

Table 20 presents change in utilization of prescription drugs. There was no difference between the utilizers and nonutilizers of the physician's assistant clinic nor was there any significant probability of the direction of change overall among the groups. As an indicator of preventive medical-care practice, data concerning Pap tests were collected in the surveys. Table 21 shows that there was no significant difference between the physician's assistant clinic utilizers in regard to consistently, yearly, having a Pap test. There was no significant probability of the direction of the change overall.

These findings regarding health-care utilization indicate there has been a minimal change which could be attributable to the utilization of the physician's assistant clinic. The reason the clinic had no dramatic affect on the health-seeking behaviors of the respondents during this







77

TABLE 19

Change in Amount of Hospitalization, Preclinic, Postclinic Opening Controlled for Clinic Utilization



Clinic Utilization

Row
Hospitalization No Yes Total



Less Hospitalization 39 (33) II (10) 50 Same Hospitalization 69 (59) 86 (78) 155 More Hospitalization 9 (8) 13 (12) 22


Total 117 110 227 Chi-square = 18.073 Significant p< 0.001 d.f. = 2 Sign test
nonutilizer Z = 3.04 reject null hypothesis p = .05 utilizer Z = -.04 accept null hypothesis p = .05 overall Z = 2.62 reject null hypothesis p = .05






78


TABLE 20

Change in Utilization of Prescription Drugs, Preclinic, Postclinic Opening Controlled for Clinic Utilization



Clinic Utilization

Utilization of Row Prescription Drugs No Yes Total



Taking More
Prescription Drugs 6 (7) 8 (7) 14 Taking Same
Prescription Drugs 66 (80) 90 (82) 156 Taking Less
Prescription Drugs II (13) 12 (II) 23


Total 83 110 193


Chi-square = .25 Not significant d.f. = 2 Sign test
nonutilizer Z = 1.21 accept null hypothesis p = .05 utilizer Z = -.89 reject null hypothesis p = .05 overall Z =-1.48 accept null hypothesis p = .05






79


TABLE 21

Change in Having Pap Test, Preclinic, Postclinic Opening Controlled for Clinic Utilization



Clinic Utilization

Having Row Pap Test No Yes Total



Had Pap Test
Second Year,
Not First 12 (15) 9 (8) 21 No Change 60 (72) 85 (77) 145 Had Pap Test
First Year,
Not Second II (13) 16 (15) 27


Total 83 110 193


Chi-square = 1.93 Not significant d.f. = 2 Sign test
nonutilizer Z = .21 accept null hypothesis p = .05 utilizer Z =-1.40 accept null hypothesis p = .05 overall Z = .86 accept null hypothesis p = .05







80

research time-frame may be due to the already high health service utilization.

The sixth question is: will the clinic be utilized by all segments of the county? The method for addressing this question is to use the findings thus far reported to make explicit and test a model of clinic utilization with each wave of survey data. The rationale for this analysis was to attempt a multifactor description of acceptance by the county of the physician's assistant clinic. It was also desired to determine if the collected descriptive data could be interpreted meaningfully by a multivariate statistical technique. Because there are two survey waves, answers to questions regarding who Is more likely to use a new health-care service before and after it was available could be determined and the results then compared. If there are significant differences In the characteristics of these two groups, the results would be of Interest to health-care planners and policy makers.

To this point, the analysis has used bivariate contingency table statistics. Several variables, however, have been shown to affect utilization of the physician's assistant clinic. They were perceived state of health, perceived health interference with daily activity, worry about receiving health care in an emergency, utilization of prescription drugs, family utilization of physician services, perception of receiving enough medical care, occupation of the male head-ofhousehold, and prospective utilization of the physician's assistant clinic. The interaction between these variables has not been explored. A multivariate analysis was undertaken to determine if these variables together would influence physician's assistant clinic utilization.







81

The multivariate technique chosen was discriminant analysis. The purpose of this analysis was to determine if certain items or factors could predict and classify who would utilize the clinic. Several utilization models were discussed in Chapter II. These models focus on current utilizers of medical services and their illness symptoms. Andersen and Newman state, "The Model should also serve as a guide in the selection of relevant variables to include in the analysis" (1973, p. 106).

The objective of discriminant analysis is to develop one or more functions from a given set of variables which will discriminate between members of the various groups. Discriminant analysis derives the function by maximizing the between group differences and minimizing the within group variances. The two groups used in this analysis are those who reported themselves or their families as utilizers of the clinic and those who did not report any utilization.

Discriminant analysis provides two kinds of results. First, after a group of variables are found to discriminate between utilizers and nonutilizers, the analysis selects those variables of a group with the greatest power to discriminate between these utilization categories. Second, the variables selected by the analysis are checked with the observed survey data to determine the percentage of the data that the model predicts.

From the data collected before the clinic opened, the discriminant analysis determined that the greater differences between utilizers and nonutilizers was a function containing the items, occupation of male head-of-household, health interference with daily activities, worry about receiving emergency medical care, and distance of home from the









physician's assistant clinic. This implies that the higher the occupational status, the greater the worry about receiving emergency medical care, and the closer one lives to the clinic, then the more likely one was to use the clinic. These findings are representative of the predisposing, enabling, and Illness-level components of the framework. Table 22 presents the prediction results for Wave I data. The model predicted that, out of the forty-four actual nonutilizers, thirty-seven would not utilize the clinic within the first year. It also predicted that, out of the sixty utilizers, forty would utilize the clinic within the first year. This means the nonutilizers have been accurately identified by these variables 84.1 percent of the time and utilizers 66.7 percent. The weighted average correctly classified was 74 percent.

The discriminant function derived from Wave II data was different. The reason the set of variables has changed is that the differences between variable means for utilizers and nonutilizers in Wave II are closer to zero than in Wave I. In general, this means that both utilizers and nonutilizers experienced change during the year. Furthermore, the selected set of variables in the Wave I function no longer clearly discriminates differences. Utilizers and nonutilizers in Wave II can no longer be classified as different in terms of perception of health, health interference with daily activities, and worry about receiving emergency medical care. Occupation of male head-of-household remained a classifying item in Wave II, but the difference added less discriminating power to the function than it did in Wave I.







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TABLE 22

Discriminant Functions for Wave I Prediction Results





No. of Predicted Group Membership Actual Group Cases Nonutilizer Utilizer Nonutilizers 44 37 7 Utilizers 60 20 40 Percent of "Grouped" Cases Correctly Classified: 74.04 percent







84

The discriminant function that determined the greatest difference between utilizers and nonutilizers in Wave II was a function composed of prospective utilization, distance from home to clinic, and perception of receiving enough care. The utilizers used the clinic If they intended to use the clinic for some or all of their health-care needs, lived close to the clinic, and perceived that they were receiving enough medical care. Table 23 presents the prediction results. These variables were able to accurately predict nonutilization 81 percent of the time and utilization 65.6 percent of the time. The segments of the framework represented were distance from the clinic, an enabling component, and perception of enough care, an illness-level component. The predisposing component was no longer included.

Tables 24 and 25 depict the comparison of the means of the selected variables for Wave I and Wave II. Tables 26 and 27 depict the comparison of selected variables by utilizer and nonutilizers. These four tables delineate the items and their importance in the discriminante functions.

The data have shown the clinic has not gained its share of potential utilizers in the county. The results of the discriminant analysis isolated predictive determinants of potential utilizers. The policy makers of the clinic must decide if this is the segment of the county that they want to serve.

Summary

This chapter presented the results and the interpretations of

the survey findings. Six specific questions were addressed. The composition of each survey was presented. The lack of change or impact of the survey items was demonstrated, as each of the six specific questions was addressed. The conclusion drawn from these analyses addressed the








85
TABLE 23

Discriminant Functions for Wave II Prediction Results



No. of Predicted Group Membership Actual Group Cases Nonutilizer Utilizer


Nonutilizers 42 34 8 Utilizers 64 22 42 Percent of "Grouped" Cases Correctly Classified: 71.70 percent






86


TABLE 24

Comparison of Wave I and Wave II
Variable Means for Nonutilizers




Variables Wave I Wave II Occupation 3.0682 2.9286 Marital Status 1.0682 1.0000 Perceived State of Health 1.3182 1.3571 Perception of Health 1.8182 1.7857
Interference

Worry About Emergency 1.5909 1.6667
Health Care Services

Use of Prescription Drugs 1.6364 1.6190 Perception of Enough Care 1.2045 1.1667 Sector 2.4773 2.4524 Family Physician Visits 0.8636 1.6667







87

TABLE 25

Comparison of Wave I and Wave II
Variable Means for Utilizers




Variables Wave I Wave II


Occupation 2.3167 2.3906 Marital Status 1.0333 1.0156 Perceived State of Health 1.3500 1.3125 Perception of Health 1.6167 1.7188
Interference

Worry About Emergency 2.1333 1.5000
Health Care Services

Use of Prescription Drugs 1.6000 1.5469 Perception of Enough Care 1.2500 1.0469 Sector 1.8667 1.8750 Family Physician Visits 0.9833 1.5625







88
Table 26

Wave I Variable Means by Utilization




Variables Nonutilizers Utilizers Occupation 3.0682 2.3167 Marital Status 1.0682 1.0333 Perceived State of Health 1.3182 1.3500 Perception of Health 1.8182 1.6167
Interference

Worry About Emergency 1.5909 2.1333
Health Care Services

Use of Prescription Drugs 1.6364 1.6000 Perception of Enough Care 1.2045 1.2500 Sector 2.4773 1.8667 Family Physician Visits 0.8636 0.9833








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TABLE 27

Wave II Variable Means by Utilization




Variables Nonutilizers Utilizers Occupation 2.9286 2.3906 Marital Status 1.0000 1.0156 Perceived State of Health 1.3571 1.3125 Perception of Health 1.7857 1.7188
Interference

Worry About Emergency 1.6667 1.5000
Health Care Services

Use of Prescription Drugs 1.6190 1.5469 Perception of Enough Care 1.1667 1.0469 Sector 2.4524 1.8750 Family Physician Visits 1.6667 1.5625 Prospective Utilization 2.6429 1.8281







90

the major research question which asked, did the county accept, as measured by clinic utilization, the physician's assistant clinic as a viable source of primary health-care delivery. In addition to bivariate analysis, a multivariate analysis was undertaken. The latter analysis is limited by the data. The items used in the discriminant analysis are primarily ordinal. It would be erroneous to discuss the magnitude of the items in each function. A discussion of the direction of each variable, however, is valid. The analysis does list the ranking of the response categories. For example, the Wave I discriminant function demonstrated that occupation of the male head-of-household was a key variable in the pattern of utilization. The higher the occupation score then, the greater the prediction of clinic utilization. This means that white-collar workers are more prone to use the clinic. Because of the limitations of the data, it does not mean that whitecollar workers have an exact mathematical probability of using the clinic that is greater than the other occupational groups.

The findings and interpretations are assembled and discussed in the next chapter, Summary and Conclusions.




Full Text

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THE IMPACT OF A PHYSICIAN'S ASSISTANT CLINIC ON A RURAL SOUTHERN COUNTY: A DESCRIPTIVE EVALUATION ROBERT EDMUND BURKE A DISSERTATION PRESENTED TQ THE GRADUATE COUNC THE UNIVERSITY OP FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR DEGREE OF DOCTOR 3F PHlLOSOPhY UNIVERSITY OF FLORIDA 1977

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COPYRIGHT 3Y ROBERT EDMUND BURKE, 1977

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For my parenrs, •DMUNO LEO and MARY VERONICA

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TABLE OF CONTENTS LIST OF TABLES yi LIST OF FIGURES v!iI ABSTRACT I x Chapter I. OBJECTIVES 1 Introduction 1 Research Questions 2 Background 3 Societal and Cultural Conditions 4 The Physician's Assistant 7 Summary 3 A History of Rural Health Care Delivery 9 Overview of Community 1] Background ] \ History of Health Care Services 12 County Political Situation 13 Summary 1 5 II. REVIEW OF LITERATURE 17 introduction 17 The Physician's Assistant Literature 17 The Role of the Physician's Assistant 19 Licensure 20 The Recruitment of the Physician's Assistant 20 The Training of the Physician's Assistant 21 The Evaluation of the Physician's Assistant 22 Health-Services Utilization 24 Summary 25 III. CONCEPTUAL FRAMEWORK 27 introduction 27 Approaches to Health Services Utilization Analysis ... 23 The Andersen-Newman Mode I 29 Summary 35 IV. RESEARCH METHODOLOGY 38 Design 38 Data Co! lection 39

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TABLES OF CONTENTS (CONTINUED) Chapter IV. (Continued) The Sample 39 Field Test 41 The Data 41 Reliability and Validity 45 Statistics 47 Summary 47 V. FINDINGS 49 Overview 49 Descriptive Survey Results 51 Discussion of the Six Specific Questions 55 Summary 34 VI. SUMMARY AND CONCLUSIONS 91 APPENDIX A 100 APPENDIX 3 110 BIBLIOGRAPHY 157 BIOGRAPHICAL SKETCH 144

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LIST OF TABLES (CONTINUED) Table Page 14. Change in Amount of Worry about Receiving Emergency Medical Services, Preclinic, Postclinic Opening Control led for CI inic Uti I i ration 63 15. Change in Amount of Worry about Having an Undetected Disease, Preclinic, Postclinic Opening Control led for CI inic Uti I izaticn 69 16. Clinic Utilization by Prospective Utilization 72 1". Perception of Physician's Assistant Clinic as Compared to Usual Care Received by Prospective Physician's Assistant Clinic Utilization 74 18. Change in Number of Physician Visits, Preclinic, Postcl inic Openi ng Control led for Clinic Uti I i zation ... 75 19. Change in Amount of Hospitalization, Preclinic, Postcl inic Opening Control led for CI inic Uti I i zation ... 77 20. Change in Utilization of Prescription Drugs, Preclinic, Postcl inic Opening Controlled for Clinic Utilization 73 21. Change in Having a Pap Test, Preclinic, Postclinic Opening Control led for CI i nic Uti I i zation 79 22. Discriminant Function for Wave I Prediction Results S3 25. Discriminant Functions for Wave II Prediction Results 35 Comparison of Wave I and Wave II Variable Means for Nonuti I izers 36 25. Comparison cf Wave I and Wave II Variable Means for Utilizers 87 26. Wave I Variable Means by Utilization 88 27. Wave II Variable Means by Utilization 89 .;

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LIST OF TABLES "able Page 1. Timetable for Data Collection for Impact of Physician's Assistant Clinic Study 31 2. General Format Change in Predisposing, Enabling, and Illness-Level Variables as a Function of Utilization of the Physician's Assistant Clinic 50 3. Wave I and Wave II Survey Comparisons of Predisposing Sample Characteristics 52 4. Wave I and Wave II Survey Comparisons of Enabling, Health Behavior Variables 54 5. Wave I and Wave li Survey Comparisons of IllnessLevel Variables 55 6. Clinic Utilization by Occupation of Male Head-of-Househol d 57 7. Clinic Utilization by Respondent's Age 59 3. Clinic Utilization by Family Physician Visits 60 9. Family Physician Visits by Prospective Clinic Uti I ization 62 10. Change in Perception of State of Health, Preclinic, Postcl i n ic Open i ng Control I ed for CI inic Uti I ization ... 53 11. Change in Perception of Health Interference with Daily Activities, Preclinic, Postcl inic Opening Controlled for Clinic Utilization 65 12. Change in Perception of Receiving Enough Care, Precl inic, Fostcl inic Open i ng Control I ed for Clinic Uti I ization 66 13. Change in Amount of General Worrv, Preclinic, Postcl inic Opening Controled for Clinic Utilization . . 67

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LIST OF FIGURES Figure Page 1. Andersen-Newman Model of Determinants of Health Care Utilization 31 2. Model of Determinants of Health Care Uti I ization 32 3. The Andersen-Newman Model: Determinants of Health Service Utilization 34 4. The Modified Andersen-Newman Model: Determinants of Health Service Utilization 36

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Abstract of Dissertation Presented to the Graduate Council ha University of Florida in Partial Fulfillment of the Requirement' for the Degree of Doctor of Philosophy THE IMPACT OF A PHYSICIAN'S ASSISTANT CLINIC ON A RURAL SOUTHERN COUNTY: A DESCRIPTIVE EVALUATION Ey Robert Edmund Burke August, 1977 rman: George Warfieit, Ph.D. r Department: Sociology The physician's assistant became a primary health-care provider ?cS. Since that lime the physician's assistant has been the subof oei'i'orial debate and commentary . Research has just begun /zing the physic ian ! s assistant as a health provider. The focus 1 i .' dissertation is to descriptively evaluate the community accepter c clinic ooerated by physician's assistants in a rural •h. 'a county, wr.ere no other primary health service was available. yp.'Cipai rese'Trch question was: as measured by clinic utiliza, did 1 he coun+y accept I he physician's assistant clinic? This \-.jf vuiS addressed by analysis of two surveys. The first survey ;oi-:di;cted ene year before the clinic opened, the second one year I'd,; clinic bed bonur operation. '3 :;.'.'::'. sc= there was no primary health care available in the county, .•believed thai fhe cownty was in naeu of these services and that :-:, I abi iahment of the clinic would help a I ' e v ' ; ate an extreme need.

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The analysis employed a health-service utilization framework. Variable.' which affected clinic utilization were examined. The results of Niese analyses are important to the growing body of research literature and to health planners who have the responsibility for developing and monitoring new primary health-care providers in the expanding health system. The survey data did not support that the county residents were experiencing extreme health-care needs. T he data demonstrate thai" the residents had become accustomed to traveling thirty miles to the medical centers of a nearby city. The findings suggest the clinic was utilized by county residents for some health care and that there was positive change in certain i I Iness-level variables among the utilizers of the clinic.

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CHAPTER I OBJECTIVES I introduction This dissertation presents data from a research project designed to investigate the establishment and community acceptance of a physician's assistant clinic in a rural southern community. It was assumed by health planners at a nearby university that a counf-y without recognized, established, and professional med ica l-careperscnnel living and practicing within its boundaries would probably be in a state of extreme need. The physician's assistant clinic was seen by some of these planners as a potentially viable method of alleviating, at least somewhat, the acute shortage of primary-care deliverers in rural areas in Florida and elsewhere. in order to assess the effectiveness of the physician's assistant clinic in meeting health care needs, a series of health surveys was planned. These surveys were designed to provide information about the service utilization patterns of residents of the county before and after the physician's assistant clinic became operational. After an iniriai health survey of the target county was completed, a second one was designed to answer two basic questions: 1) what was the impact of The physician's assistant clinic on the health practices of those in the county; and 2) were the services provided a viable alternative to traditional primary medical care? The method of examining the impact of the new professionals upon the county was the measurement cf the utilization of health services rates of a purposive sample of county 1

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2 residents. These data allow a comparison between the users of the physician's assistant clinic and the users of traditional health care modes. The community under investigation, as will be shown in the next section, is typical of many rurai counties in the United States. The county is sparsely populated, relatively homogeneous, and dependent upon other neighboring counties for the majority of necessary services. The impact of the physician's assistant clinic on the health practices of this rural county was seen as having far reaching implications in That if this clinic was successful, it would become a model for planners of rural health care delivery at a regional and national level. The research reported in this dissertation is significant for two reasons. First, from a sociological perspective, it describes the acceptance and utilization of a physician's assistant clinic and second, as anolied basic research, it can be a guide for future planning of health services in rural communities. Research Questions The research focused on one genera I question: will the resiaents of a rural community accept and utilize a physician's assistant clinic? This Question is comprehensively addressed by these six soecific subquest ions. 1. Who in the community will utilize the clinic? 2. For what illnesses or injuries will they utilize the clinic? 5. Will they conTinue to utilize the clinic over time? 4. Will the clinic be compared favorably to other health-care services received?

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5. Will utilization of the clinic affect the health seeking and utilization behaviors of those in the community? 6. Will the clinic be utilized by all segments of the commun ity? These questions are addressed by analysis of the two health surveys. The questions were the issues that were important to the developers and sponsors of the clinic. The establishment of the physician's assistant clinic was not a spontaneous event. The growth of advocacy for health care services nafionaliy and the conditions specific to the target community contributed to the explanation of the development of the physician's assistant clinic. Both of these conditions are discussed in the next section. Backg round The availability of medical care has become a concern to many varied segments of society. Those in medical organizations, politicians, sociologists, and the consumer public have their own perspectives regarding the need for medical care. Several events are, perhaps, casually related to this surge of demands for health care. These events include national health insurance programs which have been successful in other western nations, third party payment agencies which have made health cire services available to individuals not previously covered, and the federal programs of Medicare and Medicaid which have withstood Their shaky beginnings and, in fact, have recently become broader in scope and medical care coverage. The availability of medical services due to third party payment by both the private and public sec+ors has had a great impact on the hoiiith care delivery systems in the United States. More individuals

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4 have coverage for health care services than at any other time in history. As third party payment became more prevalent, the maximum or ceiling charges permitted by third party payers became the floor or minimum charges for providers. This fact, together with increasing inflation, has resulted in a spiral effect in health care costs. Additionally, labor unions have appied pressure to management for more health care coverage. The additional coverage has affected both the corporate profits and the costs of their products to the consumer. This has had a circular inflationary effect on the economy. It also has the effect of increasing the demands by the public for health care services. In addition to increased demands, strict professional control has kept providers in scarce supply. On analysis, the mass media reflect the value of health and health-related products in contemporary society. The media commercials suggest that health is an individual's right and that coed health is the most important product not only for the individual but also for the society to obtain and maintain. In the last decade, health spas and health food stores sprang up over night to meet the demands for health products and services. "Natural ingredients," "organic" foods and cosmetics, as well as "health" clothes such as the jogging suit have all just recently become household words and items. In light of these formal and informal pressures for more and more services a basic question persists: how can the American medical system meet these increasing demands and at the same time remain in control of their distribution quality, and the fees charged for them? Societa l and Cultural C o ndit ions As noted above, many societal factors are making increased demands upon the organized medical system for additional health -care deliverers.

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According to Health United States 1975 (1976), in 1973 there was one physician for every 562 individuals in the United States. Physicians, however, are clustered in metropolitan areas where there was one non-federal physician providing patient care for every 500 residents. The raTio for small nonmetropo I i tan areas was about one physician for every 2,000 to 2,500. The population-physician ratio was about four or five times greater in the nonmetropo! i tan areas than in metropolitan ones. Furthermore, while there has been a decline in the number of general practitioners in the past ten years, there have been increases in the number of other medical specialties that are considered "fo be primary care deliverers. These specialties are internal medicine, pediatrics, and obstetric-gynecological medicine. Health manpower does not seem tc suffer from shortage as much as from distribution problems and this maldistribution is undoubtedly related to many present demands. The attraction of the physicians to rural areas had been unsuccessful. Placing physician's assistants in rural areas where a metropolitan based physician would be able to monitor them by telephone and periodic visits would aid in The physician, rural population location incongruence. Utilizing physician's assistants in this way, a physician would be able to serve a rural population without having to leave the metropolitan area on a permanent basis. A simplistic method of conceptualizing this situation is to view the consumer and the medical system as two sections of an equilibrium model. In order to exist and be maintained, all crucial demands for services must be met. Thus, today's consumer demands for increased medical services should produce or result in an increase in The medical resources available. On the other hand, a technique which would

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convince the consumer to decrease his demands for services would allow equilibrium to exist without having to change the medical system. There are four methods whereby the consumer and the medical system may approach equilibrium. One method of meeting the demand for more primary health care services would be to redistribute existing primary health professionals. Any such proposed redistribution would meet with strong professional resistance on the part of the medical community: it is not a very viable consideration. Another method of meeting rural health needs would be to produce more physicians pledged to practice in rural areas. There are two problems with this possible solution. First, the number of physicians is largely controlled by the medical profession and a plan to increase the number of physicians would not meet with ready acceptance from this ^r^p. Second, federal loan programs which are forgiven if physicians agree to practice in rural communities have not been successful. Less than five percent of those who received these loans have requested forgiveness. They, perhaps, have been socialized through their educational experience to believe rural areas are not the best location for their practice. A third method would be for communities to actively recruit foreign medical school graduates but foreign medical school graduates have not been attracted to rural communities; they require colleagueal relationships to facilitate American licensure. The reasons these three methods of attracting physicians to rural areas have failed are both economic and socio!. Rural areas typically do not have the availability of laboratories, pharmacies, hospital beds, and other support networks required for physicians to prosper professionally and personally.

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7 A fourth method proposed to extend the resources of the medical system has been efforts to develop a new paraprofess iona I . The primary function of such a provider is the provision of primary health care services To rural communities. This method has been endorsed by the AMA because this new paraprofess iona I would permit the medical system to expand under the direct control of the axisting medical associations. This new paraprofessiona I is only licensed to give primary health care services under The direct supervision of a licensed physician. This method has been actively supported for the last ten years by both the established medical system and the government. Furtnermore, the acceptance of this new position would necessitate societal adaptation. Potential consumers would have to be maGe aware of The new position, know the services performed and become convinced of their quality. The physician's assistant can be considered AMA ' s response to the societal demands for more care. This new provider calls for adaptation from the sccietal members in terms of their attitudes, expectations, and behaviors. The Physician's Assis+ant As noted, one of the primary ways the medical system responded to the increased demands for more providers was by the creation of a new heat I h care status, The physician's assistant. This new health care provider was sanctioned by the American Medical Association, when in 1970 they drafted "Guiae lines for the Development of New Health Occupations" and in 1971 the AMA House of Delegates approved "Essentials of an Approved Education Program for the Assistant to the Primary Care Physician" (Johnson, 1975). The latter document clearly defined the essential types of patient services a physician's assistant may perform:

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i) The initial approach to a patient of any age group in any setting to elicit a detailed and accurate history, perform an appropriate examination, and record and present pertinent data in a manner meaningful to the physician; 2) Performance and/or assistance in performance of routine laboratory and related studies as appropriate for a specific practice setting, such as the drawing of blood samples, performance of urinalyses, and the taking of electrocardiographic tracings; 3) Performance of such routine therapeutic procedures as injections, immunizations, and the suturing and care of wounds; 4) Instruction and counseling of patients regarding physical and mental health on matters such as diets, disease, therapy, and normal growth and development; 5) Assisting the physician in the hospital setting by making patient rounds, recording patient progress notes, accurately and appropriately transcribing and/or executing standing orders and other specific orders at the direction^of the supervising physician, and compiling and recording detailed narrative case summaries; 6) Providing assistance in the delivery of service to patients requiring continuing care (home, nursing home, extended care facilities, etc.) including the review and monitoring of treatment and therapy plans; 7) Facilitation of the physician's referral of appropriate patients by maintenance of an awareness of the community's various health facilities, agencies, and resources. (Johnson, 1975, p. 23) This section presented a discussion of the factors influencing the increased demand for health services and how the creation of a new medical provider meets these demands. The physician's assistant was viewed as the AMA's creation, an ameliorative agent whose function is to provide primary care. This new paraprofessiona I is accepted and centre! led by the medical profession and legitimated by state statutes, rience, they will be in existence for some time fo come and are worthy of being studied.

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A History of Rural Health Care Delivery "The notion that rural life had irs health handicaps, in spite of fresh air and sunshine, was expressed as early as 1 S62 by the Commissioner of Agriculture to President Abraham Lincoln" (Roemer, 1976, p. 3). Several sporadic attempts to alleviate the rural health problems were initiated late in the nineteenth century. It was not until the enactment of the Sheppard-Towner Act in 1921, however, that a systematic attempt was made to strengthen rural county health departments by making available grant funds to support maternal and child health centers. The depression of 1929 was a setback to this rural health initiative as the Sheppard-Towner Act was terminated. In order to build up preventive health programs, Titles V and VI of the Social Security Act of 1935 had the effect of reinstating the Sheppard-Towner Act. By 1942, some 1,800 counties had public health coverage. The remaining 1,250 counties without coverage were typically rural with small population bases. At the close of World War II, an effort was made to consolidate counties in order to provide public health coverage. In 1945, Dr. Haven Emerson launched the "basic six" program of APHA. The duties of public health departments were to be concerned with six tasks: 1) communicable disease control, 2) environmental sanitation, 3) maternal and child health preventive services, 4) health education, 5) vital statistics, and 6) laboratory services. These services, although needed, do not include direct primary patient care. This component of rural health-care delivery was left to private physicians. Some states had proposed plans to recruit physicians to their own rural areas. Mew Hampshire in 1923, Virginia in 1942, and Tennessee in 1953 nad each enacted legislation to actively recruit and financially support physicians for their rural areas. in 1967, the National Advisory

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10 Commission on Health Manpower requested there be not only a growth in numbers of physicians but also an increase of manpower in the delivery system with new categories of health professionals. Other countries have had a history of medical assistants as primary health-care deliverers. Russia had developed the "feldsher", a type of medical or physician assistant in the 1370s, to function as the primary deliverer of health care in the rural regions. Other countries, e.g. Iran and Mexico, also have similar requirements for newly trained physicians. Following these models, in the late 1950s, federal grant moneys were made available to academic institutions to develop training programs for medical assistants; nurse practitioners, physician's assistants, and midwives were being trained under the auspices of bcTh medicine and the federal government. Furthermore, in 1970, the Emergency Health D ersonnel Act established the National Health Service Corps. Under this act, physicians, nurses, and dentists were sent to needy communities where they practiced in lieu of fulfilling their active military obligation. These programs were designed to increase the medical manpower in rural areas. To augment the increase in health manpower, several federal acts were passed to increase the supply of hospital beds in rural areas. The most famous of these was the National Hospital Survey and Construction Act of 1946. This legislation, better known as the Hill-Burton Act, provided grant funds to states for the construction of hospitals. The maximum aid was earmarked for rural communities. Today, there is no longer a disparity of bed supply between urban and rural areas. in fact, the trend in the past thirty years is that hospital utilization by rural-living individuals is upward. With transportation improvements,

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rural residents seem to be bypassing the rural community hospital for the more sophisticated ones in urban areas. This history demonstrates that the delivery of primary health care to rural communities has been an issue in this country for over a hundred years. It has not been, however, until the last decade that a systematic attempt has been made to alleviate the problems of rural primary health care. Overview of Community The goal of this section is to describe three important factors in the county which have a bearing on the acceptance of the physician's assistant clinic. First, the historical background of the community is discussed. Second, the history of medical services available in this community is outlined, and third, the local political situation which gave rise to the initiation of the physician's assistant clinic is presented. Background The county which served as the research site is situated in North Central Florida. its north and west boundary is formed primarily by the Suwannee River as it makes its winding path to the Gulf of Mexico. The adjacent county due east is a standard metropolitan statistical area, which has a state university and is a major agricultural trade crossroads. The research county is primarily agricultural. One of its largest employers is the forestry division of a national lumber conglomerate. The county is not self-sufficient. It does not have a hospital, college, railroad, or major shopping area. Some of the churches are served by itinerant or missionary ministers who drive in each Sunday. The major churches are Baptist and Church of Christ.

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12 The county seat has one restaurant, a high school, court facilities, several hardware and farm implement dealers, a library, and a bank. A bus serves the county. The centra! section of the county is swamp land. The major inhabited area forms an »L» shaped figure along the western and southern edge of the county. There is a state highway going eastwest along the southern edge of the county. According to the 1970 census, the county has 3,551 residents, of whom 3,259 are white and 237 are black. The toal male population is 1,797; the total female population is 1,754. History of Health Care Services The health services in the county have been limited. At one time, There was a general practitioner living in the county seat; he did not remain in practice long as age and ill health caused him to retire. His son took over the practice but left the county for personal reasons. On his departure, the county was without its own physic; Residents in need of medical services "had no alternative but to go :i an. e I sew he re. There were naturopaths functioning in and around the county; the river doctor, for example, was a naturopath who, for a fee of five dollars in cash, treated clients and distributed various herbs and teas for cures. The author learned about the river doctor from a clinic patient. The river doctor saw clients in his mobile home located outside the county seat on the bank of a river, hence the name. According to this informant, the river doctor's cures had been effective and his business brisk. The informant explained the only reason she came to the physician's assistant clinic was that the clinic billed patients at the end of the month. By the time the bill arrived, she would have

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13 the ability to pay her fee; the river doctor wanted cash and extended no credit. Residents of the county in need of hospitalization were sent to the county hospital in a neighboring county. In the rnid-sixties, two other hospitals opened in that county, a university teaching hospital and a Veterans Administration Hospital. These were followed by a private hospital in 1972. This county grew to become a major medical center. The residents of the research county have always been dependent on this neighboring county for hospital services. With the health-care delivery in the research county having a history of being scarce, its residents developed a routine of leaving the county to seek medical care. With the road to the neighboring county wide, flat, and accessible, it may not have been considered a burden by county residents to drive to a major medical center, thirty miles to the east. Co unty Political Situfation The" author also learned that a deceased state legislator had been an influential political resource in and for the county. The representative was considered to be the individual responsible for establishing an adolescent detention center built at the far southwest corner of the county.. The residents and professional staff did not socialize with the county residents but the center did provide jobs. The representative and the mayor of the county seat were both responsible for creating the County Health Board. This board received state funds for creation and maintenance of a medical facility. Some of these funds subsidize the physician's assistant clinic. The County Health Board approached the Department of Community Health and Family Medicine at the medical college of the

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14 university and requested a rural health clinic, similar to one operating in another rural county. The response from the medical college was not to create a clinic similar ho their existing one but rather to use the opportunity to establish a clinic where the physician's assistant was the principal deliverer of primary care. Three factors, a new County Health Board eager to begin a primary health-care-delivery system, an aggressive Department of Community Health and Family Medicine, and the existence of an acute shortage of health care services ail came together. The result of the confluence of these three factors was the proposal of an innovative health care system, the physician's assistant clinic. The Department of Community Health and Family Medicine and the Community health Board came to an agreement whereby the clinic opened with two physician's assistants who were under the direct supervision of a physician. In addition, two other physicians from the medical college also served the clinic. During the negotiation and planning stage, the state representative who was a vital voice in this process, died. His death, however, did not hamper the establishing and opening of the c I i nic . This overview has presented a community profile and a history of health services and has sketched the political factors which influenced the establishment of the physician's assistant clinic. This information gives perspective to the issue of acceptance and utilization of an innovative health care service. The county is not industrial, is not used to rapid changes, is tied closely to the land, and is dependent upon its neighboring communities for services. The fact that no health care services were available in this community is consistent

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15 with the community history. The political factors described are the important reasons for the establishment of the physician's assistant c I i nic. Summary The history of health-care delivery shows that only recently has there been an attempt in this country to systematically address the issue of providing primary health care to rural areas. The country had far fewer communities without physicians in 1900 than today. Two reasons were given to explain this fact. Firsr, the choice location to practice medicine is the metropolitan areas. Secondly, rural family practice physicians since World War II have been moving to metropolitan areas. These locations have medical centers, laboratories, pharmacies, and other profession-oriented services which facilitate the practice of medicine. This research describes the establishment and acceptance of a physician's assistant clinic in a rural community. It addresses several important questions concerning the utilization of a new type of health service for rural communities. The community overview demonstrated that this community is typical of many rural American communities. The results of the research are relevant and important to the study community as well as to other similar rural communities. The next chapter presents a literature review concerning physician's assistants anci health services utilization research. The rich literature which focuses primarily on physician utilization lends itself to an analytical framework for the research.

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16 Chapter Ml presents a conceptual and analytical framework. Chapter IV presents the methodology of the research design, the data collection procedures, and description of key variables. Chapter V presents the conclusions and summary of the research.

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CHAPTER I I REVIEW OF LITERATURE Introduction The goal of this chapter is to review the literature on physician' assistants in the context of the health-services delivery field. The review is designed to provide a framework for the presentation of the f i nd ings. The Physic ian's Assistant Literature The physician's assistant as a health provider came into existence in 1963, hence, the literature is limited from that year to the present. The literature can be placed into five categories: D The role of the physician's assistant, 2) The legality of the physician's assistant, 3) The recruitment of the physician's assistant, 4) The setting up of the physician's assistant training programs, and 5) The evaluation of the physician's assistant. Ford (1976) attempted to address the sociological implications of the Physician's assistant. Her research suggests that sociological inquiry into issues of authority, power, status consistence, quality of care, etc., have not been empirically dealt with. Instead, research that is based in other professions, primarily nursing, have looked at the physician's assistant from outside in order to achieve their own professional goals and legitimacy. Ford, herself, falls into the same 17

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18 reasoning process as she directly compares the development of the physician's assistant with the development of the nurse practitioner. This is problematic in That both o^ tnese emerging occupational roles have different origins and power bases. The nurse practitioner is primarily a development of entrepreneurial nursing; the physician's assistant as currently developed is directly subservient to a local practicing physician. The sociological aspects of the physician's assistant have not been addressed directly in the research literature. Thus, this review limits itself to + he five categories of available research concerning the physician's assistant. T he literature has been written chiefly by physicians, nurses, and medical administrators. Literature written by the physician's assistants themselves has, as yet, not emerged. Sadler, Sadler, and 3liss (1972), who are physicians and attorneys, were the first to prepare a comprehensive treatise dealing with the various components, issues, and questions surrounding the physician's assistant. Their research presented each of the above listed research topics and focused primarily on an analysis of the physician's assistant in terms of recruitment and his role in the medical system. They also addressed themselves to the medical and legal ramifications of the position in the total system. Their research, however, is not based on empirical data but is a descriptive general overview of the areas listed above. Nevertheless, their monograph was the first attempt to view most of the issues concerning the physician's assistant in a systematic manner.

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The RoI g of the Physic ian' s Assistant The greatest body of physician's assistant literature is concerned with defining the role. These articles, interestingly enough, are primarily written by nurses who view the development of the physician's assistant as "the symptom" of the inability, both of medicine and nursing, to define their individual roles, to respect each other's competencies, or to deliver an acceptable level of care (Rothberg, 1973). Andreoli (1972) raises a different aspect of role behavior. From her observation, the physician's assistant's relationship with a pafient usually begins before the patient is hospitalized and ends, not with patient discharge, but rather is continued for posthosp i ta I ization checkups. Andreoli states the nurse is educated, whereas the physician's assistant is only trained in certain techniques. Lanhertsen (1972, p. 32), also a registered nurse, considers the role of the physician's assistant an immediate extension of the physician and argues: "Territorial disputes (between physician's assistants and nurses) have no place in the decisions that must be made. The objectives for health manpower must focus on the ultimate potential of every person." The nurses are raising the issue of where in the health manpower network the physician's assistants are to be placed. Are the physician's assistants going to take away some of the newiy carved professional territory of the nurse? The physicians, en the other hand, see the role of the physician's assistant as an immediate extension of themselves. Estes (1973, p. 197) describes the role of the physician's assistant: "...the assistant must be able to assist in and function in any of the sites in which the M.D. is active— cl inic, hospital, or patient's home — and must be available at night as well as days. Because of this requirement for mobility and

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tho fact thai" nurses were in short supply, it was decided to utilize men rather than women." The definition of the role is one factor. The actual role taking end role behavior of the physician's assistant has yet to be systematically described or verified in the literature. Licensure The second most commonly reported aspect of the physician's assistant concerns legitimation. By whom will the physician's assistant be licensed, and, if licensed, to whom and for what is he legally responsible? Can a nurse take professional orders from a physician's assistant? Young (1972) reports that the AMA had placed a moratorium on the approval of new licenses for all new health paraprofessiena I s. Before these paraprofessionals are given approval for licensure by the AMA, Young suggests two issues need to be resolved. The first is to standardize the physician's assistant in regard to training and practice. The second is to establish consensus of role definitions of not only the physician's assistant but the M.D. as well. In other words, if an M.D. must supervise his physician's assistant, of what does this supervision consist? Some states such as Florida grant licenses to physician's assistants. However, this law clearly states physician's assistants are responsible to the physician under whose supervision he works. Furthermore, the physician's assistant is to work only under a physician and a physician is allowed only two physician's assistants in his employ. (Florida Statutes, Chapter 458.135, 1975) The Recruitment of the Physician's Assistant Another issue of the literature is that of recruitment. The first recruitment of physician's assistants (Estes, 1971) was aimed at military corpsmen who already had some medical experience. Now that the Viet Nam

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21 conflict has passed and military service has become voluntary, the availability of corpsmen has declined. Horsley and Aschenbrener (1973), as well as Onion and Schulten (1973), agree since the services of a physician's assistant are most needed in the rural areas of this country, an attempt must be made to recruit high-school graduates who have a strong desire to serve in these areas. They suggest those desiring to work in rural areas be given preferential treatment. The literature, again, is ideologically biased and does not take into account the impact that the training as a socia I i zarion agency may have on changing the phvsician's assistant's mind as to where he will practice. The Training of the Physician's Assistant The taining of a physician's assistant and the establishment of training programs have been dealt with in the literature, with considerable overlap. Again, however, little or no empirical research is found. Stone and Bassett (1972) conclude that the greatest benefit of the Viedex training program is that the physician's assistant and the M.D. have a one-ro-one relationship, thereby allowing the physician's assistant to learn first-hand and by experience. Adamson (1971) suggests physician's assistants be trained along with M.D.'s and R.N.'s primarily to learn where "hey fit into the health-care system. Adamson, therefore, is suggesting that the training emphasize socialization. Bergen and Clapp (1972) clarify that the training program is terminal; that is, there is limited mobility. They feel the physician's assistant program must not become a manner in which a student can later be admitted to medical school to become a doctor. Johnson (1976) concerned his research primarily with the anticipatory socialization process and the training stages of becoming a physician's assistant. He finds that

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22 physician's assistants 5.re products of both the medical system and the societal system. More importantly, ne states (p. 185), "The A.M. A. established guidelines for these programs and for the use of physician assistant in each state. In this manner, the medical profession has essentially controlled the introduction of the physician assistant. Furthermore, the physician's assistant from training stage to practice stage, unlike physicians themselves, remains in a dependent relationsnip to a physician." The Johnson research and this research are complementary. The former focuses on socialization and training; this research analyzes community impact and acceptance once the physician's assistant is in practice. The Evaluation of the Physician's Assistant The last section of the literature involves the evaluation of the physician's assistant in the medical environment. Four studies have been found that use data as a basis for evaluation. Coe and Fichtenbaum (1972) evaluate the physician's assistants employed in a small community hospital. The evaluation is based on interviews with other members of the hospital staff. They analyzed the perception of the physician's assistant role through others in the role set and found no consensus on the role definition of the physician's assistant. The physician's assistant were seen by the nurses as a vehicle for their own upward mobility. The number of physician's assistants at this hospital is not mentioned nor is the method of interpretation of their interviews. Strunk (1973) examines patient attitudes toward the physician's assistant. He develops a two-factor inaex based on a sample of 300. he finds that acceptance of the physician's assistant for minor medical care is greatest among nonmarried middle-class respondents who have had some exposure to college. The acceptance drops, however, for

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23 major medical care. Ford (1972) examines the case leads of physicians who have been utilizing a physician's assistant and found there is an increase in case load of 20 percent. Demaria, Cherry and Truesdell (1971) report on the peer review of physician's assistants in the Marines. The peers were not other physician's assistants but M.O.'s. This program evaluation shows the benefiTS of their own training program. They find their physician's assistants perform at a better-than-acceptab le level. Their research demonstrates that, by utilizing physician peer review, their training program goals have been met. Evaluation may be of several types. Evaluation can be of the program (Demaria, Cherry and Truesdell, 1971); the process (Coe and Fichetenbaum, 1972; Johnson 1976); the outcome (Ford, 1972; Strunk, 1973) and the impact upon the community. No literature could be found dealing with the impact of the physician's assistant on the community. The review of literature demonstrates that the physician's assistant, as a new health provider, has been described with regard to h i s real and ideal roles in the health care system. The legal, training, recruitment, and program issues are reported primarily from an editorial or ideological perspective. These reports, however, contribute to this research since they clearly demonstrate the need for analysis of not only the physician's assistant as a new phenomenon but also the acceptance of this new health provider by the community at large. As presented in the following chapters, this research is similar to that of Strunk (1973). But, unlike Strunk's, it describes the response of a community to physician's assistants where they are the only primary health care providers available. The evaluation of Strunk focuses en current physician's assistant utilizers in an acute

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2' care setting. This research represents a logical progression in the systematic analysis of a new health-care provider. Health-Servi ce s Utiii zation Concepts such as primary health care delivery and health services utilization are necessary and meaningful for analysis and interpretation of the results of the study. Many studies have been undertaken whose purpose is to explain why individuals utilize a health care facility in order to build a predictive model for health care facilities and programs planning. Bodenheirner (1970), Freeborn and Greenlich (1973), and Rogers (1973) determined that availability of services or access to services were Tne primary issues of health care utilization. Chen (1973) developed a utilization index that was composed of length of time to get an appointment, length of travel time, and length of waiting room time. These research efforts were primarily monocausal. Donabedian (1973), Mechanic (197.?), Shortell (1973), Beck (1973), Andersen et al. (1971), Anderson and Bartkus (1973), and Andersen and Newman (1973) have all forsaken a simplistic unfcausal explanation for health services utilization in favor of mult if actor explanations. Donabedian' s (1975) research documents that soc io-organ i zationa I variables such as geographic or distance variables explain health service utilization. Mechanic (1972) further confirms the importance of these variables but more importantly states that the individual must also be willing to seek health care and perceive he is in need of these health services. Mechanic further argues these components of health-care seeking behavior are learned and are a fund ion of cultural or subcultural values. Shortell's (1973)

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2 j research suggests although there are many factors which influence heaiti service utilization, The individual must also want this service. Beck (1973) argues the primary reasons for nonuti I ization are the cost of tht service and its general availability. These studies typically use the use-of-service as the primary unit of measurement, that is, individuals who either have utilized and/or are utilizing the service. These rates-under-treatment studies do not take into account individuals who may need the service and are not users. Anderson and Bartkus (1973), for example, have developed a behavioral model for the choice of health care. They key variable is the patients' ability to recognize symptoms as an indicator of need and health seeking behavior. Since the sample was composed of patients at a student health clinic, it may not be representative of the population. Unfortunately, Anderson and Bartkus do not build their model with respect to nonusers who may be in need of health care. Andersen (1968) and Andersen and Newman (1973) have developed a general model of health care utilization that divides the variables that are influential in determining health care utilization into three major categories: predisposing, enabling, and illness level. This health services utilization model is used in this study as a framework for presentation of survey data and explanalion of the acceptance of the physician's assistant clinic by the community. This model is described in depth in the next chapter. S ummary This chapter has presented a review of literature of research to date concerning physician's assistants and health care services utilization. It was documented there is a need for research which

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26 focuses on the factors which influence the utilization of physician's assistants. In addition, many models or explanations of health services utilization have appeared in the last decade. Seme have simplistic unicausal explanations; others have developed multifactor indices and scales for purposes of explanation. The Andersen-Newman model of health service utilization provides a framework for the interpretation of data such as those collected in the research county health surveys. It is the major framework for data interpretation. The next chapter will further define the Andersen-Newman model and explain its aDp I icab i I i ty to this research.

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CHAPTER ! ! I CONCEPTUAL FRAMEWORK I ntroduction "Existing research concerning the physician's assistant can be characterized as fragmented" (Ford, 1975, p. 16). The literature review contained in Chapter II demonstrates the fragmentation. Ford further sxates these fragments will only become of value to the understanding of the physician's assistant when they are drawn together. Research concerning the physician's assistant is shown to typically involve separate aspects of the physician's assistant such as his training, his legality, his tasks and functions, and his evaluation. The research is also a fragment of a holistic analysis of the physician's assistant. The goal of this research is to describe the process of testing whether a physician's assistant clinic is a viable alternative to traditional primary health care. The acceptance of the physician's assistant is one of the missing research fragments and the one to which this research addresses itself. It is necessary to utilize existing theoretical models to give meaning to the analysis of the sociological problem. The physician's assistant as a self-contained role has not been the topic of any research. The physician's assistant has, in its brief history, been the subject of topical research endeavors. To strengthen the interpretation of the survey data, which are the basis cf this research, a model cf health service utilization was employed. It was assumed that the factors which have been shown to 27

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28 influence the utilization of transitional health services would also be the factors which would influence the utilization of a new health service. A description of the variables is contained in This chapter. Approaches to Health Services Utilization Analysis The evaluation of the utilizaton of a new medical care service has many stages and approaches. Andersen (1973) has classified these approaches into the following: 1) Sociocu I tura I Approach. This approach incorporates the perspective that health service organization and utilization are related to complex societal and cultural norms and va I ues. 2) Sociodemograph i c Approach. This approach emphasizes population based character i sri cs for explaining variations in uti I i zat ion. 3) Soci a I -Psychologi ca I Approach. This approach seeks to explain processes by which individuals realize that they are ill and decide on a source of medical care. 4) Organization Approach. This approach tends to examine differences in utilization as a result of the structure of the delivery system. 5) Social Systems Approach. This approach attempts to examine utilization as a function of interactions of interrelated components with one another and the population at large. Each approach tends to examine a set of variables and their relationship to utilization of health care services. It is not the intention of this research to describe these approaches in detail, listing the

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29 advantages and disadvantges of each. A discussion, however, of the social systems approach and its app I icab i I ; hy to this study is presented. It is necessary that the approach used in examining health service utilization be clearly related to the study objective. Though each approach may be considered distinct, the variables incorporated in a specific model may not be unique to that model alone, as is the case of the social systems model. Instead, variables should be selected for analysis because ihey are consistent with Hie approach and that in turn will satisfy the research objectives. The evaluation of health care is a new and complex area of investigation. Historically, the evaluation of health care has been limited to professional peer review. Hoi I i ngshead (1973, p. 540) states,, Evaluation of health care by a process more objective than peer review is indicated but, while the voice of the consumeris being raised about cost and quality of health care, sociologisfs have given little attention +o the murmurings of the populace." Through the utilization of both survey research end observation methodologies, this dissertation measures the impact of the new, emerging health-care provider, the physician's assistant, on a rural community by measuring and interpreting the murmurings of the populace. Although sociological methods ere in a constant state of growth and development, this dissertation is the first analysis and discussion of the impact of the physician's assistant based on these methods. It uses the social systems model of health service utilization as its theoretical foundation. The Andersen-Ne w man Mode I Andersen and Newman (1973) have developed a theoretical framework concerning societal and individual determinants of medical care

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30 utilization in the United States. Figure 1 schematically presents their framework. The Andersen-Newman model is based upon the analysis of the main components of the framework and their relationships to each other. The major premises of the model are: 1) societal determinants affect individual determinants directly and also through the service system, and 2) individual determinants influence the health services consumed by the individual. The second premise of the model, individual determinants of health service utilization, has the same variables for analysis as those collected in this survey. As such, this model groups the survey data into theoretically i nterpretab I e categories that influence health service utilization. Individual characteristics of the population affect the health care they receive. The model suggests that health service use is dependent on: 1) the predisposition of the individual to use services (predisDosing), 2) his ability to secure services (enabling), and 3) his i I I ness I eve I . Because of the limited scope of the survey data, the societal determinant component of the mode I cannot be validated and analyzed. Thus, this research focuses on the health service system, the individual determinants, and the health service utilization components of the model. Figure 2, "Model of Health Care Utilization", depicts the segment of the Andersen-Newman model used in the analysis. The predisposing variables illustrate that individual characteristics prior to the onset of illness are related to use. For example, people in different age groups have various types and amounts of illness and, therefore, different patterns of utilization. The enabling

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SOCIETAL DETERMINANTS 31 HEALTH SERVICE SYSTEM Techno logy Norms Resources Orcan i zations INDIVIDUAL DETERMINANTS Pred i sposi nc Enab I i ng I I I ness Leve ! HEALTH SERVICES UT I L I ZAT I ON lype Purpose Un i t of Ana I ys i FIGURE I Andersen-Newman Model of Determinants of Health-Care Uri zation

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32 HEALTH SERVICE SYSTEM Chanqe in Organization MDt V I DUAL DETERMINANTS Pred i spos i nq Enab I i ng I I I ness Leve I HEALTH SERVICE UTILIZATION Physician's Assistant Clinic Furoose Acceptance FIGURE 2 Mode' of Determinants of Healtn-Care Utilization

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33 variables relate to the means available to use services. Health insurance coverage is a primary enabling variable since it permits an individual to act on a value or need concerning use. Illness-level variables represent the most direct case of utilization. Given that predisposing and enabling variables are favorable, there must be the perception by the individual of illness or the possibility of its occurrence to motivate use. The nature and extent of the care, once illness is perceived, is partly determined by the service providers. Andersen and Newman have developed some tentative generalizations cased upon review of the literature and their own experience concerning the relative importance of each sex of variables in predicting utilization. IMness level is seen to be the major determinant in predicting utilization, followed by demographic, family resource, and social structure variables. Figure 3 presents these variables schematically, the Andersen-Newman model has oeen tested on survey data from the National Opinion Research Center. Their research findings suggest, from a theoretical perspective, this model has taken into consideration the primary determinants of health services utilization to the degree tha+ the need for explanatory variables is minimal (Andersen and Newman, 1973, p. 108). The Andersen-Newman model, howe/er, does not directly take into account fhe reality of no medical services directly available in the community. They do consider the ratio of health personnel to the population as a community variable, bur, if the ratio is zero as it vvas in the research county before the opening of the physician's assistant clinic, then perhaps the effect of no available health-care services is understated.

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34 PREDISPOSING Democraph ic Aqe Sex Marital statu; Past i I I ness social Structure Education Race Occupation rami ly s i z-: Ethnicity* Re I ig ion* Resi dent i a I mob i I i ty # ENABLING I Fami I y I ncome Health insurance Type of regu I ar source Access to regular source Commun i tv Ratios of he

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35 The model used in this research added the existence-nonexi stence of medical care services as a distinct variable in the enabling category. The result modified the Andersen-Newman model, but this modification did not dramatically change the model. The model was further validated by contrasting changes in these variables by actual family utilization of the new health-care service. Figure 4 presents the modified Andersen-Newman model. Summary The goal of this chapter was to develop a conceptual model for the analysis of the physician's assistant clinic. The purpose of this study is the description of the evaluation, acceptance, and utilization of the physician's assistant clinic by the community. The socioanthropologic overview presented in the previous chapter suggested that even though the community appears geographically isolated, it has a history oidependence on its neighboring communities for social, economic, education, religious, and health needs. The outcome of this research should describe the determinants, predisposing, enabling, or i I I nesslevel variables, which have been affected by the use of the physician's assistant clinic. The outcome should also describe which factors demonstrate the ability of the community to adapt its existing pattern of health service utilization in a manner which suggests the acceptance of the physician's assistant clinic as a viable mode of health-care delivery. Furthermore, the outcome should describe the level of acceptance of the clinic by demonstrating what factors made some individuals utilizers of the physician's assistant clinic while others remained nonutilizers or se lecti ve uti I i zers.

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36 PREDISPOSING Demographic Occupation Fami I y si ze Ethn i ci ty* Re I i q ion* Residential mob! Bel i el /a I ues concern i ng hea I th & ill ness attitudes toward health services * ENABL I NG Fan i I y Health insura

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37 Given these questions which guidea this research, the available survey data, and the descriptive nature of this study, this chapter has outlined a model of health service utilization which has optimal conceptual features for later data analysis. The next chapter discusses in detail the research design, the research quesTions, the methodology, and the variables and statistics used in the analysis.

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CHAPTER IV RESEARCH METHODOLOGY As noted previously, the purpose of this research is to address two issues: 1) is the physician's assistant a viable alternative to the traditional health-care provider; and 2) is the physician's assistant accepted as legitimate by the consumers being served? The level of acceptance is measured by the utilization of the clinic by the community. In order to accomplish these research objectives, a two-stage survey obtained data along three dimensions: health perception, health attitudes, and health care service utilization. The data collection instruments used in the first stage were developed by health planners at a state university medical center; the second were developed by the author in collaboration wiTh sociologists and nealth planners. Data from these sources include measures of self-perception of health, attitudes about health and health care, and, finally, health care utilization patterns. The data have certain limitations. Neither of the survey instruments contained previously tested scales or indices of health care utilization and further, the data did not contain any health care outcome measures usually found in health services studies. The first data obtained were to be used as descriptions of behavior and attitudinal factors that affected the utilization of the physician's assistant clinic. The original health planners did not view this research 38

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39 in a theoretical sense; their perspective was immediate and practical. After the first health survey was completed, a broader, more theoretical orientation emerged; it focused on the concerns and questions dealing with more generic issues, e.g., the legitimacy and acceptance of the new health care provider and his clinic. It was at this point that the author become involved. Data Col lection The data were collected from two waves of survey interviews and from a six-month observation period at the offices which housed the newly opened physician's assistant clinic. The first interviews were administered two months before the clinic opened; the second were administered after fourteen months of operation. The observation undertaken about one year after the clinic had commenced services. able i shows the data-collection timetable. TABLE 1 Timetable for Data Collection for Impact of Physician's Assistant Clinic Study wa Spring Summer Fall Winter Sprina Summer 1971 1971 1971 1972 W12 1972 Wave I Survey CI inic Operati ng Wave I I Survey The Sample Tha health planners decided that the research questions could be answered most effectively by the adult female in each household who was typical I y responsible for the health care of her family. Usually, in a nuclear family, this person is the mother. A purposive sample of one-third

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40 of the households in the county was chosen. The sample size was based on the following logic. Since the population of the county was 3,551 and the average American family has approximately four members, it was estimated there were about 900 households in the county. Thus, a sample of one-third of the households, or 300 families, was the sampling objective for the first survey. Since over 35 per cent of the adults in the county were registered to vote, the sample of households was drawn randomly from voter registration lists. Immediately after the sample was collected, it was compared to the census characteri STi cs of the county. It was determined that blacks were underrepresented by 3 percent. A quota sample of 3 percent was added to proportionately represent the blacks. A total of 227 family households was reached. Once located the adult female most responsible for the household was interviewed and asked to report en her cwn health perceptions and behaviors as well as those of her spouse, children, and other adults living in the same household. Data were not available which described the reasons that the sampling objective of 300 was not reached. During the second survey wave, attempts were made to reinterview each of these 227 family households; 35 percent (193) were located and re interviewed. Thirty-four first-year respondents were not able to be interviewed, five had died during the year, twenty-one had moved and the remaining eight were never home or refused an interview. In order to determine if the administration of the first-wave interview had sensitized and biased the participants with regard to the physician's assistant clinic and influenced The utilization of the same, a cemparison group of family households was added during the second wave. This grouo was selected using the same sampling technique.

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41 Eighty-six households were interviewed. One family interview was incomplete and deleted. Comparisons were made between this group and the re interviewed group. No differences were found with respect to clinic utilization and the sociodemographic variables. This finding meant that the first survey did not bias county residents with respect to clinic utilization. Further comparative analysis between these two groups was not undertaken. These 85 additional Wave II interviews were added to the sample when description of events that occurred with i n the past year are presented. Whenever changes in predisposing, enabling, and i I I nesslevel variables are presented only the responses of those females who participated in both interviews are used. Field Test After the second interview schedule was prepared, a field test was conducted, 6 interviews were completed. After the field test was analyzed, the schedule was critically reviewed. As a result, some minor revisions were made. No items were deleted or added. Th e Da ta The general question was: will the residents of a rural community accept and utilize the physician's assistant clinic? Responses to items collected during the interviews provide the independent, dependent, and control variables. Complete interview schedules are contained in Appendices A and B. There are six specific questions used to comprehensively address this general question. The first specific question was: who in the community will utilize the clinic? I terns used to address this question were: 1) Age of respondent, classified into six intervals ten years apart beginning at age 15;

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42 2) Marital status, categorized as single, married, widowed, and separated/divorced; 3) Occupation of the male head-of-the-househol d (an indicator of socio-economic status). The U. S. Census categories were collapsed to reflect a rural community. The first category contains all professional and white collar workers; the second, craftsmen and foreman; the third, operatives; the fourth, laborers; and the fifth, farmers; 4) Family composition, categorized as nuclear complete, living with relatives, and living alone; 5) Distance of the household to the clinic, measured in miles, but collapsed into three categories: within the county seat, within ten miles of the county seat, and other; 6) Welfare recipient during the year, categorized as yes or no; 7) Health insurance status, insured or not; and, 8) Length of residence in the county. Although data were collected about respondent's education, race, and residential mobility, they were not used in the analyses due to their lack of discriminatory ability. The county was assumed to be a priori homogeneous with respect to ethnicity and religion. Data concerning ethnicity and religion were not collected. These characteristics of the research county were descriptively clarified in Chapter I. The second specific question was: for what illnesses or injuries will the county residents utilize the clinic? The items that address

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43 this question are the above items plus questions concerning the health-seeking behaviors for other service modes, namely physicians, hospitals, and other health services. The third question was: will the community residents continue to utilize the clinic over time? The items that address this question are clinic utilization and health behavior chance variables. Clinic utilization was defined as use of the clinic during the year by the respondent or a member of the respondent's nuclear family. New variables were created to show change from Wave I to Wave I I . These change variables compare the responses between the two survey waves. For example, if the perception of the level of worrying was lower during the second wave than it was during the first, that was considered a positive change. If the worry was higher in the second wave than in the first, that was considered a negative change. If no change was detected between the two surveys, that variable was scored as stable. This type of variable creation permitted testing of the significance of change by means of a sign test. Since the data were ordinal level, a variable that quantified the magnitude of the change would be erroneous. A change variable was created for each item that measured health behavior or health attitude: 1) Perception of state of health; 2) Perception of health interference with daily activities; 3) Perception of receiving enough medical care; 4) General worry; 5) Worry about receiving emergency medical services; 5) Worry about havina an undetected disease.

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44 The fourth question was: will the clinic be compared favorably to other health-care services received? Four questions comparing the physician's assistant clinic to other health-care agencies were asked. 1 he comparison questions were in regard to: 1 ) Cost; 2) Perceived quality of care; 3) Ease in making appointments; and, 4) Ease in talking to clinic staff; and are shown in the Wave II precoded interview schedule in Appendix B. The possible responses to these questions were "the clinic was better or easier than the other health-care service," "it was about the same as the other health care service," and "it was worse or harder than the other health care service." Nonirri I izers of the clinic typically would not respond to the comparison questions and those who did generally indicated they were relying on hearsay information. Thus, their responses were not analyzed. The fifth question was: will utilization of +he clinic affecl the health-seeking and utilization behaviors of those in the community? The items that address this question are changes in health-related behaviors and attitudes as measured by changes in enabling and i I I nesslevel variables. These include changes in physician visits, clinic visits, and medicine intake. The items show health-related behavior were: 1) Health interference with daily activities; 2) Previous medical-care utilization; 3) Present health-care utilization; and, 4) Stated prospective utilization of the physician's assistant c I i nic.

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45 The items that show health attitudes were: i) Self-reoort of perception of state of health; 2) Worry as measured by response to the question, "How often are you worried or nervous?"; 3) Worry about emergency health care de + ermined by response to the question, "How often do you worry about being able to receive health-care services for an emergency?"; 4) Worry about personal health determined by response to the quesricn, "How often do you worry about having an illness or disease that has not been detected?"; 5) Sel f -report of perception of receiving encugh medical care; 6) The respondent's and the community's liking of the clinic. The sixth question: will the clinic be utilized by all segments of the community?; was addressed by the development of discriminant functions or utilizers and nonuti I i zers. These functions contain the variables which had demonstrated significance. Reliability and Validity Reliability and validity must be addressed in all surveys. A brief review of reliability in this research will be discussed. Reliability refers to the consistency of The measures over rime. Three types of reliability were applicable to the survey data: observer reliability, internal reliability, and, for longitudinal and multistage studies, testretest reliability. Experiment observer reliability was demonstrated by means of a controlled simulation. In this experiment, both interviewers recorded answers to survey questionnaires wnile observing a simulated interview. The answers of the interviewers were compared. The average agreement was calculated by dividing the number of correct

PAGE 56

46 responses by the total number of questions and dividing by two, the number of interviews. The average agreement was 92 percent. Since there were only two interviewers in Wave II, a further statistical procedure was unnecessary. No observer reliability experiment was performed for Wave I . Other tests of reliability that are frequently used in survey research are tests to measure the internal consistency and tests to measure estimate of test-retest reliability. Reliability tests for internal consistency and test-retest reliability were not performed on the crucial health related variables. Tests for these types of reliability were performed for the predisposing, sociodemographic variables. Because there was no logical inconsistencies overtime for these variables, reliability was assumed. Validity refers to the ability of an item to measure what it is intended to measure. Content validity was addressed in this research by having the survey instruments reviewed by other researchers and then field tested. The results determined if questions were ambiguous and potentially low in content validity. It was also believed that the health interview used in this research would not be perceived by the respondents as personally damaging or threatening to the degree that they would give inaccurate responses. The interview was assumed to have face va I i di ty . There are other issues concerning the validity of the data. The history of health surveys, however, shows that if the limits are recognized a pri ori , health surveys, such as the one utilized in this research, are meaningful indicators of health-service utilization. There

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47 was no way to test the validity of the responses. Theoretically, it would be possible to calculate the validity of some of the survey items by comparing health utilization responses, with medical records or health insurance claims. These comparisons, however, were not available for th i s research. Stati sties The descriptive analysis was performed by utilizing contingency table statistics. The most prevalently used were Chi-square, sign test, and Gamma. As an attempt to reinforce the descriptive findings of the impact of the clinic on the county and for future program planning, clinic utilization was also analyzed by means of discriminant function analysis. The discussion of this analysis is presentee in the following chapter. This chapter has outlined the design and methodology used in this research. The design was a two-stage health survey of adult females presumed To be most knowledgeable of their family's health needs and behaviors. A purposive sample of 195 responaenrs reoresenting approximately one third of the households in the county was selected. The sample was asked questions concerning their own health perceptions and utilization behaviors. They were also asked to be informants for the health perceptions end uTilizaricn behaviors of other members of their families. The items and statistics used in the analyses were described and a discussion of the issues of reliability and validity was presented. Chao+ers I, II and II! have described the conceptual issues of the research and have grouped these issues with relevant research literature and The research questions. These factors have led to a discussion of

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43 an analytical framework with which the issues of the research can be addressed. This chapter has presented the methodological tcols used within the framework. The following chapter presents the culmination of these four chaoters by presenting the research findings.

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CHAPTER V F I ND I NGS Overview Chapter I presented a number of questions that had guided this research. These questions are not formal but are used for the purpose of interpreting The findings. The findings are reported as responses to these questions. The major research question was: will the residents of the county utilize and accept the physician's assistant clinic? To address this question, six specific questions are needed. 1) Who in the community will utilize the clininc? 2) For what illnesses or injuries will they utilize the c I in ic? 5) Will they continue to utilize the clinic over time? 4) Will the clinic be compared favorably to other healthcare services received? 5) Will utilization of the clinic affect the health seeking and utilization behaviors of those in the community? 6) Will the clinic be utilized by all segments of the commun i ty? Before these questions are addressed in detail, a review of the technique for measuring changes-over-time and a discussion of the survey results are presented. It was noted in the previous section that only some of the illnesslevel items changed between the survey waves. It would be simplistic to

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50 state that the changes in i I I nessleve I variables were due solely to the opening of the physician's assistant clinic. Even in a rural, stable community (ike the research county, other factors not measured in this research could have caused the changes to occur. Variables that captured these changes were needed. As described in Chapter IV, by summarizing and creating new variables from the survey data, the needed chanae variables were developed. These variables were then crosstabu lated by whether or not an individual within the family had utilized the physician's assistant clinic. Thus, the two comparison groups are utilizers and nonutilizers of the clinic. The data were then compared to determine if, according to the specific i i I ness1 eve I variable, the utilizers and nonutilizers of the clinic were independent. Sign tests were calculated for the changes in both groups. Since each group, the utilizers and nonutilizers, had equal opportunity for change, the sign change would determine which group changed more significantly. Table 2 presents the general £ ormat for the presentation of these data. TABLE 2 Genera I Format Change in Predisposing, Enabling, and IllnessLevel Variables as a Function of Utilization of the Physician's Assistant Clinic r amiiy Utilized Family Not Utilized Clinic Clinic Change in Positive change Positive change Variables No change No change Negative change Negative change

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51 In the preceding chapter, the sample design was discussed; a brief review is needed. When change variables are presented, the maximum N is 193. These are respondents who participated in both surveys. When data are presented that do not involve change, the maximum N is 278, the 193 who responded to both surveys plus the additional group of 85. Table N T s may fall below these totals because of missing responses. Descriptive Survey Results The results of each survey are compared and discussed within the Andersen-Newman Framework. Predisposing variables. Table 3 depicts the predisposing characteristics of the sample for both survey waves. It can be quickly ascertained that the respondents who are missing from the Wave II survey do not affect the sample characteristics. With respect to the predisposing variables, changes were nonexistent from Wave I to Wave II. This table shows that the sample were primarily white, married, high school graduates who were living in nuclear, complete families within the county for more than twenty years. The respondents have reported themselves to be rural, stable and family oriented. More importantly the sample remained the same with respect to these variables over the year's time. Approximately, 9 percent reported they or their immediate families had received some type of welfare during the past year, 90 percent reported they own at least one car and 60 percent reported ownership of two or more cars and/or trucks. Data on income were collected but determined that farmers, some small business owners, and other selfemployed individuals were reporting only net income, the amount remaining after business costs and depreciations were deducted. Others reported

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TABLE 3 Wave I and Wave II Survey Comparisons of Predisposing Sample Characteristics (Percentages) Age < 35 35 to 64 >65 Race White Black Marital Status Married Si ng le Widowed Separated or Divorced Living Arrangement Nuclear Complete Nuclear Incomplete Alone Length of Time Residing in Gi Ichri st County More than 20 Years 5 to 20 Years Less than 5 Years

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53 gross incomes. No clear, reliable method of making the amounts comparable could be ascertained. Income, as a key variable, was deleted from further ana I ysi s. Enab I i nq van abl es . Table 4 presents a listing of these variables. These health behaviors have remained constant between the two survey waves. There are, however, two interesting findings. The first is that both before and after the clinic opened, 30 percent of the sample had seen a physician. This clearly suggests that the county residents were already high users of health-care services, and that the opening of a new healthcare service did not radically alter this high health-care service rate. The second interesting finding was that the use of patent medicines increased between the survey waves. When this finding was controlled for clinic utilization, no significant difference was found. One explanation is that the Wave II interviewers probably explained more precisely what was meant by patent medicines than did the interviewers in the Wave I survey. Illness-level variables . Table 5 presents the i I I nesslevel variables. The respondents were asked several questions concerning their attitudes and perceptions of their state of health as well as their worry about receiving care. No significant differences were observed between the two survey waves. There are two interesting findings. In Wave II, the perception of receiving enough medical care increased by 13 percent. Secondly, worry about receiving health-care services in an emergency declined in the "often" and "all the time" categories 17 percent, from 28 percent in Wave I to 1 1 percent in Wave II. These findings suggest that there has been some impact of the physician's assistant clinic. The impact is presenred more completely in the next secrion.

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TABLE 4 /ave I and Wave II Survey Comparisons of Enabling, Health Behavior Variables (Percentages) Wave 54 jaw A Physician Yes No 80 20 80 20 Mean Number of Physician Visits 4.5 Hosd ita I i zed Yes No 0.5 39.5 9.5 90.5 Took Prescription Drua Duri na

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TABLE 5 Wave I and Wave il Survey Comparisons of I I Iness-Leve! Variables (Percentages) Poor and very poor Often A I I the Time Have Undetected Disease Never Wave I Wave I I Perceived State of Health Good & excel lent 63 Fa i r 21 Perceived Health Interference w|rh_ D ai ly Activity Never Se I dom I ? Sometimes 17 Often A I I the time 71 29 Perceived Receiving Enough Medical Care Yes No Worry_ Genera I Never Se I dom 2 1 Sometimes 30 Often 47 Occasiona My 23 Often and A I I the Time |Q 71 IS I I 50 55 16 6 I! 13 9 10 19 42 39 30 Receiving Health Care S ervices in an Eme_r_aenry_ Never Occasiona ! ly 25 31 25 7 3 4 66 29 j 227 , 93

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56 Tables 3 and 4 presented a comparison by survey wave of predisposing and enabling variables. These figures show The predisposing variables and the enabling variables shew no dramatic change. Table 5 presented some changes that occurred after the physician's assistant clinic opened for i I I nessleve I variables. Fewer persons perceived themselves to be in poor health and fewer reported that their health interfered with their daily activities. A smaller percentage of the respondents were as worried about receiving medical care in an emergency than during the previous year. Hospitalization and visits to physicians appeared to be the same. Medicine intake, parent medicine, prescription drugs, and nerve pills had all increased during the year. The next section more closely examines These changes by analyzing the differences ; n the : I I ness(eve I variables as a function of family utilization of the clinic. This analysis provides answers to the research questions. Discussion of the Six Specific Questions The f i rsr specific question is: who in the community utilizes the clinic? Two predisposing variables, age of respondent and occupation of male head-of-househol d, are discussed. Tables 5 shows clinic utilization by occupaTion of male head-of-househol d, a predisposing variable. There is a significanT difference between The utilizers and nonuti I izers. The ability To predict utilization by occupation, however, is minimal, Lambda = .10. Additional analysis showed that of those who reported they liked the clinic a great deal, 46 percent were white-collar workers, 23 percent were farmers, 16 percent were craftsmen, 7 percent were operatives, and 8 percent were laborers. Even though the prof sss iona I and white-collar workers indicate a greater liking for the

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57 TABLE 6 Clinic Utilization by Occupation of Male Head-Of-Household Clinic Uti I ization Row Occupation No Yes Total Professional and White Col lar 8 ( 12) 56 (40) 44 Craftsmen Foremen 13 (20) 17 (19) 35 Clerica I Operations 13 (20) 9 (10) 22 Sales Laborers 3 (12) 7 (3) 15 Crafrs Farmers 20 (29) 20 (23) 40 67 39 156 )hi-square = 15.35 Significant p <.0I d.f. = J-

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physician's assistant clinic, their utilization is net significantly different from other occupational groups. Additional analysis revealed there was no utilization difference between those who liked the clinic a great deal and those who liked the clinic somewhat. Table 7 presents clinic utilization by age. Age was not a significant factor in clinic utilization. In fact, the percentages of utilizers and nonutilizers in each age group are almost equal. As further explication of this utilization question, the idea that heavy utilizers and needers of health-care services would be more prone to use the clinic was analyzed. No attempt was made to develop a profile of needs assessment for the research county. Health needs for this analysis are defined as health-seeking behavior. Since 80 percent of the sample had sought health care before the clinic had opened, it was assumed these individuals viewed themselves as having a need for health services. It was established from the survey that the majority of respondents perceived they were or had been receiving enough medical care. Because the health-care needs of the research county were already perceived as met, the clinic would then have to replace existing providers or create a new demand for services. In order for the residents of the county to substitute clinic services for existing services, the clinic would have to become an accepted, viable, and preferred provider of health-care services. Table 8 presents clinic utilization by family physician visits. The significant Chi -square is interpreted to mean that the utilizers and nonutilizers are independent groups but, more importantly, the Gamma of .39 implies there is a moderate association between more

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59 15-24 25-34 35-44 45-54 55-64 Over 65 TABLE 7 Clinic Utilization by Respondent's Age CI inic Uti I ization Row Age of Mo Yes Total 4

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TABLE 3 Clinic Uti I i zation by Family Physician Visits Clinic Uti I i zation Row r amily Physician Visits Mo Yes Total of si ,0 /0 None 49 (42) 20 (13) 69 1-5 44 (33) 50 (46) 94 6-10 I i ( 9 ) 13(16) 29 More than 10 13 (II) 22 (20) 35 Tota I 117 110 227 Chi-square = 16.375 Sianificant p = .001 d.f. = 3

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61 physician visits and clinic utilization. This suggests the more individuals use health-care services, the more likely they will utilize the physician's assistant clinic. Table 9 adds a caution to this interpretation. This table presents family physician visits by prospective clinic utilization. The significant Chi-square suggests that prospective utilization plans are independent of family physician visits. The Gamma of -.25 further suggests that the greater the number of physician visits tne lower the prospective clinic utilization, and, further the data indicate that the more visits to a physician a family has, the more likely it is they do not plan to use the clinic. Other survey data verified this implication in that only eight of the respondents reported that a physician ever referred them to the physician's assistant clinic. It may be that the physicians who treat the residents of the research county do not want to lose patients or perhaps these physicians have not accepted the physician's assistant clinic as a viable alternative for healthcare de I i very. Tne second specific question is: for what reasons do the individuals utilize the clinic? The respondents who had utilized the ciinic answered that physicals, checkups, and colds were the reasons they had gone to the clinic. These responses are not soecific enough to address the research question. It was decided this question could be addressed b) examining the changes in certain health factors of the utilizers and nonuti I izers. Table 10 shows there was not significant difference for the utilizers and nonuti I izers of the clinic with respect to change in perceived state of health. The sign test, however, suggests the charge among the utilizers nad a significantly greater

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62 TABLE 9 Family Physician Visits by Prospective Clinic Utilization Family Physician Visits Prospective More Row Utilization None 1-5 5-10 + han 10 Total All Services 15 (46) 22 (25) 5 (18) 3 (9) 45 Some Services II (33) 39 (44) 15 (53) 19 (56) 84 Emergency On I y or Not at Al I 7 (21 ) 28 (3D 3 (29) 12 (35) 55 Total 33 89 28 34 184 Chi -square = 13.423 Significant p< .05 d.f Gamma = . 25

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53 TABLE 10 Change in Perception of State of Health, Preclinic, Postclinic Opening Control led for Clinic Uti I i zation Clinic Uti I i zation Perceived State Row of Health No Yes Total Chi-square = .74 Not significant d.f. = 2 Sign test nonutiiizers Z = 1.21 accept null hypothesis p = .05 utilizers Z = 2.25 reject null hypothesis p = .05 overall Z = 2.719 reject null hypothesis p = .05 Better State of Health 26 (3D 41 (37) 67 Same State of Health 39 (47) 48 (44) 87 Worse State of Health 18 (22) 21 (19) 39 33 NO 193

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64 probability to be positive. Table 11 demonstrates that the perception of health interfering with daily activities was different between utilzers and nonuti I izers. The sign test reports the change for nonutilizers had a significantly greater probability towards more interference. Table 12 shows that perception of receiving enough medical care did not differ be+ween utilizers and nonuti I izers by family clinic-participation. The sign tests indicate the probability for change among both groups was toward a perception of receiving more care during the second year than during the first year. The difference is substantially significant. Table 13 shows there was no difference in general worry by clinic utilization. The sign test indicates the probability for change among both clinic utilizers and nonuti I izers was toward less worry. Table 14 shows that there was a significant difference in worry about receiving emergency medical-care services. The sign test further clarifies the utilizers had a significantly greater probability to be less worried about receiving emergency medical-care services. Although there was some change in worry among the nonuti I izers, the probability of the change being either positive or negative appeared equal and random. Table 15, more clearly shows that utilization of the clinic may have affected specific worry. This table presents the change in worry about having an undetected disease. The sign test indicates the changes between groups is inverse. The nonuti I izers had a significantly greater probability toward more worry than the utilizers.

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65 TABLE ! i Change in Perception of Health Interference with Daiiy Activities, Preclinic, Postclinic Opening Controlled for Clinic Utilization Clinic Uti i fzation Perception of Row Health Interference No Yes Total Less I nterf erence Same Interference More Interference Total 117 110 227 Chi-square = 9.35 Significance p<".0! d . f . = 2 Sign test nonutiiizers Z = 3.37 reject nuii hypothesis p = .05 uti I izers Z = overall Z = 3.99 reject null hypothesis p = .05 15

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66 TA3LE 12 Change in Perception of Receiving Enough Care, Preciinic, Postclinic Opening Controlled for Clinic Utilization Clinic Uti I ization Perception of Row Receiving Enough No Yes Total More Care Than First Year 13 (16) 24 (22) 57 Same Care as First Year 64 (78) 80 (73) 144 Less Care than First Year 5 (6) 5 (5) 10 Total 82 109 Chi -square = 1.23 Mot significant d.f. = 2 Sign test nonutilizers Z = 1.88 reject null hypothesis p = .05 utilizers Z = 3.5 reject null hypothesis p = .05 overall Z = 3.9 reject null hypothesis p = .05

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TABLE 13 Change in Amount of Genera! Worry, Preciinic, Postclinic Opening Controlled for Clinic Utilization Clinic Uti I i zation benera Wnrr Row torry No Yes Total Less Worry 65 (78) 50 (69) 1 15 More Worry 13 (22) 22 (3! ) 40 Total 33 72 |55 Chi -square =1.59 Not significant d.f. = I Sign tesr non utilizer Z = 4.94 reject null hypothesis p = .05 utilizer Z = 3.30 reject null hypothesis p = .05 overall Z = 6.33 reject null hypothesis p = .05

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63 TABLE 14 Change in Amount of Worry about Receiving Emeraency Medical Services, Preciinic, Postciinic Opening Controlled for Ciinic Utilization Clinic Lit i I i zation Worry about Receiving Row Emergency Medical Services No Yes Total Less Worry Same Worry More Worry Total SO 101 Chi-square = 21.175 Significant p<0.00! d.f. = 2 Sign test nonurilizer Z = -.16 accept null hypothesis p = .05 utilizer Z = 6.06 reject null hypotnesis p = .05 overall Z = 4.59 reject null hypothesis p = .05 18

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TABLE 15 Change in Amount of Worry about Having an Undetected Disease, Preclinic, Postciinic Opening Controlled for Clinic Utilization Clinic Uti 1 ization -:? Worry about Having an Undetected Disease No Row Fota! Less Worry Same Worry More Worry 47 21 (14) (60) (26) -%14 (25)

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70 Using bivariate contingency-table analysis and an extension of the binomial test showed that with regard to perceived state of health, health interference with daily activities, perception of receiving emergency medical care, and worry about having an undetected disease that There was an overall significantly positive change for The utilizers of the clinic. The utilization of the clinic demonstrates an inverse relationship with perception of worry about receiving emergency medical services. After a family utilized the clinic, there was a reduction of specific health-related worry. The major reported reasons for clinic utilization were generic. The utilization, however, resulted in significant, positive changes in health perception and worry. Thus, iT was shown that, in addition to direct health care, the utilizers of the clinic had more positive change in health-related perceptions. The Third specific question is: will the county residents continue to utilize the clinic over time? It addresses the continuance of prospective utilization of the clinic. The question in the Wave II survey which addressed prospective utilization is: "Would you go to the medical center in the county seat for all your health-care needs, some of your health-care needs, only in the case of an emergency, or not at all?'' The respondents reported as follows: I would go to the clinic for all healTh-care needs (22 percent), some (46 percent), emergency only (22 percent), and not at a I I (10 percent). These figures raise additional questions. Is there a difference in prospective utilization if one has already utilized the clinic? Do differences in perceived quality of care result in a difference in prospective utilization? Both utilizers and nonuti I izers staTed that their

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71 prospective utilization of the physician's assistant clinic would be for some of their medical care but not for a I I of it. These data suggest that the clinic will be utilized for some of the health-care needs of the commun ity. Table 16 presents utilization with respect to intended future utilization. The clinic utilizers are a significantly different group than the nonutilizers in regard to prospective utilization. The Chisquare is significant at p C .05. The abiliTy to relate actual utilization from prospective utilization is moderately low with Gamma = .24. These data indicate a tendency. Once the clinic is actually utilized, the user is somewhat more likely to return to the clinic for some of his(her) health-care needs. Furthermore, those who used the clinic were quite satisfied with the care rendered. Of those utilizers who liked the clinic a great deal, 90 percent could not list anything they disliked. Consistently, those who utilized the clinic perceived both the cost and quality of care to be the same or berter than their usual place of health-care services. Of those who intended to use the clinic for some or ail of their health-care-service needs, 55 percent perceived the cost of services at the physician's assistant clinic to be less than the cost of services at their usual place of health-care services. These findings suggest that some dissonance of acceptance or nonacceptance by the community of a non licensed primary health provider was resolved after a member of the family had utilized the clinic. The reason for the initial utilization could not be obtained from the survey data. After the utilization of the physician's assistant clinic the user probably fait more favorable about the clinic in that the user was more likely to continue to use the clinic for some of his health-care needs than the nonutilizers.

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72 TABLE 16 Clinic Uti I i zation by Prospective Clinic Utilization Clinic Uti I i zation Prospective Row Utilization No Yes Total A I I Services 9 (12) 36 (33) 45 Some Services 23 (31) 61 (56) 84 Emergency On ly or Not at A! I 42 (57) 13 (II) 55 Tota I 74 I 1 1 34 Chi-square = 43.295 Significant p«C.05 d.f. = 2 Gamma = .24

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73 A logical additional inquiry was made to determine if the perception of quality of care of clinic utilizers was an important factor in their decision -for prospective utilization. It may be inferred from Table VI that there was a difference of perceived quality of care at the clinic by planned future use of the clinic. Those who intended to utilize the clinic for some or all of their health-care-service needs appeared fo perceive the clinic to be providing the same if not better quality of cere than was otherwise available. Those who did not plan to use the clinic appeared to perceive the quality of care to be the same or worse than the quality of other care. Because so few responded that the care at the clinic was not as good as other providers and so few responded that they do not intend to use the clinic at all, it would be misleading to perform any statistical test on these data. The idea that the health-care needs of the county were being met by the physician's assistant clinic can not be statistically supported with these data. There is an indication that those who have utilized the clinic will continue to. These data also lead to the speculation that the residents were perhaps rigidly entrenched in their previous patterns of health-care-services utilization and they did not perceive the need of the physician's assistant clinic for the major portion of their health-care-service needs. Table 18 presents the change in physician visits by clinic utilization. No differences were shown. It was thought that if there were more physician visits, then there would be lower clinic utilization. It was also thought that if clinic utilizers had an increase in physician visits, then the physician's assistant had identified patients to be referred to physicians for additional specialized treatments, thereby causing these patients' utilization rates of

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74 TABLE 17 Perception of a Physician's Assistant Clinic as Compared to Usual Care Received by Prospective Physician's Assistant Clinic Utilization Perception of Care at Clinic Compared to Usual Care Received Prospective Row Utilization Better Same Not Good Tota A! I Care 8 30 33 Some Care 3 54 3 65 Emergency Care Only 15 3 9 Mot at A I I I I 2 Total 17 90 7 114

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75 TABLE 18 Change in Number of Physician Visits, Preciinic, Postclinic Opening Controlled for Clinic Utilization Clinic Uti I i zation Physician Row Visits No Yes Total More MD Visits Same MD Visits Less MD Visits Total 5! 65 116 Chi-square = 2.73 Not significant d.f. = 2 Sign test nonuriiizer Z -.17 accept null hypothesis p = .05 utilizer Z = -.97 accept null hypothesis p = .05 overall Z = .34 accept null hypothesis p = .05 15

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76 physicians to increase. These arguments cannot be verified in the survey data. The point here is that the residents were already users of heaith services. The survey reported that 80 percent of the informants had utilized some type of health-care service before the clinic had opened. For a county with no health-care services, this is a high percentage. The clinic, then, should not be viewed as the only provider of primary care, it should be viewed as a more convenient alternative. Table 19 presents change in hospitalization by clinic utilization. The utilizers and nonuti I izers are shown to be independent groups. The nonuti I izers, however, had a significantly greater probability for less hospitalization in Wave II than in Wave I. The change in hospitalization ^or utilizers was random. The idea then, that the physician's assistant clinic was functioning as a referral source, is speculative at best. labie 20 presents change in utilization of prescription drugs. There was no difference between the utilizers and nonuti I izers of the physician'.' assistant clinic nor was there any significant probability of the direction of change overall among the groups. As an indicator of preventive medical-care practice, data concerning Pap tests were collected in the surveys. Table 21 shows that there was no significant difference between the physician's assistant clinic utilizers in regard to consistently, yearly, having a Pap test. There was no significant probability of the direction of the change overall. These findings regarding health-care utilization indicate there has been a minimal change which could be attributable to the utilization of the physician's assistant clinic. The reason the clinic had no dramatic affect on the health-seeking behaviors of the respondents during this

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TABLE 19 Change in Amount of Hospitalization, Preciinic, Postclinic Opening Controlled for Clinic Utilization Clinic Uti I izat ion 77 Hosp i ta I i zat ion No Yes KOW Total Less Hospitalization Same Hosp i ta 1 i zat i on More Hospitalization !~ota I 17 (33) (59) (3) Chi-square l o 073 Significant p < 0.00 1 d.f. = 2 Sign test nonut i | i zer uti I i zer over a I I Z = 3.04 reject nuli hypothesis Z = -.04 accept null hypothesis Z = 2.62 rejec+ null hypothesis ( 10) (73) (12) .05 .05 ,05 50 55 227

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TABLE 20 Change in Utilization of Prescription Drugs, Preciinic, Fostciinic Openina Controlled for Clinic Utilization Clinic Ut i i izat ion "78 Ut i I i zat ion of Prescription Drugs No Row fota I Taking More Prescriotion Drugs Taking Same Prescription Druas (7) (80) 90 (7) (32) 14 Taking Less Prescription Drugs (13) 12 (! 23 Totai S3 10 193 Ch i-scuare Sign T es~ nonuti I i zer ut i I i zer overa I i Not significant d. Z 1.21 accept null hypothesis p = Z = -.89 reject null hypothesis p = Z =-1.48 accept null hypothesis p = .05 .05 .05

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T 9 rABLE Change in Having Pap Test, Preciinic, Postclinic Opening Controlled for Clinic Utilization Clinic Uti I i zation Having Row Pap TesT Mo Yes Tota i Had Pap lest Second Year, Not First 12 (15) 9 (8) 2! No Change 60 (72) 85 (77) 145 Had D ao Test Fi rst Year, Not Second i I (13) 16 (15) 27 Fotai 83 MO 193 Chi-square = 1.93 Mot significant d.f. = 2 Sign test ncnutilizer Z = .2! accept null hypothesis p = .05 utilizer Z =-1.40 accept null hypothesis p = .05 overall Z = .36 accept null hypothesis p = .05

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50 research time-frame may be due to the already high health service ut i I i zation. The sixth question is: will the clinic be utilized by all segments of the county? The method for addressing this question is to use the findings thus far reported to make explicit and rest a model of clinic utilization with each wave of survey data. The rationale for this analysis was to attempt a multi factor description of acceptance by the county of the physician's assistant clinic. It was also desired to determine if the collected descriptive data could be interpreted meaningfully by a multivariate statistical technique. 3ecause There are two survey waves, answers to questions regarding who is more likely to use a new health-care service before and after i + was available could be determined and the results then compared. If there are significant differences in the characteristics of tnese two groups, the results would be of interest to health-care planners and policy makers. To this point, the analysis has used bivariate contingency table statistics. Several variables, however, have been, shown to affect utilization of the physician's assistant clinic. They were perceived state o £ health, perceived health interference with daily activity, worry about receiving health care in an emergency, utilization of prescription drugs, family utilization of physician services, perception of receiving enough medical care, occupation of the male head-ofhousehold, and prospective utilization of the physician's assistant clinic. The interaction between these variables has not been explored. A multivariate analysis was undertaken to determine if these variables together would influence physician's assistant clinic utilization.

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81 The multivariate technique chosen was discriminant analysis. The purpose of this analysis was to determine if certain items or factors could predict and classify who would utilize the clinic. Several utilization models were discussed in Chapter II. These models focus on current utilizers of medical services and their illness symptoms. Andersen and Newman state, "The Model should also serve as a guide in the selection of relevant variables to include in the analysis" (1973, p. 106). The objective of discriminant analysis is to develop one or more functions from a given set of variables which will discriminate between members of the various groups. Discriminant analysis derives the function by maximizing the between group differences and minimizing the within group variances. The two groups used in this analysis are those who reported themselves or their families as utilizers of the clinic and those who did not report any utilization. Discriminant analysis provides two kinds of results. First, after a group of variables are found to discriminate between utilizers and nonuti I i zsrs, the analysis selects those variables of a group with the greatest power to discriminate between these utilization categories. Second, the variables selected by the analysis are checked with the observed survey data to determine the percentage of the data that the model predicts. From the data collected before the clinic opened, the discriminant analysis determined that tne greater differences between utilizers and nonuti lizers was a function containing the items, occupation of male head-of-househol d, health interference with daily activities, worry abou" receiving emergency medical care, and distance of home from the

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physician's assistant clinic. This implies that the higher the occupational status, the greater the worry about receiving emergency medical care, and the closer one lives to the clinic, then the more likely one was to use the clinic. These findings are representative of the predisposing, enabling, and i I Inesslevel components of the framework. Table 22 presents the prediction results for Wave I date. The model predicted that, out of the forty-four actual nonuti I i zers, thirty-seven would not utilize the clinic within the first year. It also predicted that, out of the sixty utilizers, forty would utilize the clinic within the first year. This means the nonuti I izers have been accurately identified by these variables 84. I percent of fhe time and utilizers 66.7 percent. The weighted average correctly classified was 74 percent. The discriminant function derived from Wave II data was different. The reason The set of variables has changed is that the differences between variable means for utilizers and nonuti I izers in Wave il are closer to zero than in Wave I. In general, this means that both utilizer and nonuti I izers experienced change during the year. Furthermore, the selecfed set of variables in the Wave I function no longer clearly discriminates differences. Utilizers and nonuti I izers in Wave II car, no longer be classified as different in terms of perception of health, health interference with daily activities, and worry about receiving emergency medical care. Occupation of male head-of-househol d remained a classifying item in Wave II, but the difference added less discriminating power to the function than it did in Wave I.

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83 TABLE 22 Discriminant Functions for Wave Prediction Results No. of Predicted Group Membership Actual Group Cases Nonutilizer utilizer Nonuti I izers 44 37 7 Utilizers 60 20 40 Percent of "Grouped" Cases Correctly Classified: 74.04 percen:

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34 The discriminant function that determined the greatest difference between utilizers and nonutilizers in Wave I! was a function composed of prospective utilization, distance from home to clinic, and perception of receiving enough care. The utilizers used the clinic if they intended to use the clinic for some or a I I of their health-care needs, lived close to the clinic, and perceived that they were receiving enough medical care. Table 23 presents the prediction results. These variables were able to accurately predict nonuti I i zation 31 percent of the time and utilization 65.6 percent of the time. The segments of the framework represented were distance from the clinic, an enabling component, and perception of enough care, an i I i ness-level component. The predisposing component was no longer included. Tables 24 and 25 depict the comparison of the means of the selected variables for Wave I and Wave II. Tables 26 and 27 depict the comparison of selected variables by utilizer and nonutilizers. These four tables delineate tne items and their importance in The d iscr iminante functions. The data have shown the clinic has not gained its share of potential utilizers in the county. The results of the discriminant analysis isolated predictive determinants of potential utilizers. The policy makers of the clinic mus + decide if this is the segment of the county that they want to serve. This chapter presented the results and the interpretations of the survey findings. Six specific questions were addressed. The composition of each survey was presented. The lack of change or impact of the survey items was demonstrated, as each of the six specific questions was addressed. The conclusion drawn from these analyses addressed the

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85 TABLE 23 Discriminant Funciions for Wave Prediction Results No. of Predicted Group Membership Actual Group Cases Nonutilizer Utilizer Nonuti I izers 42 34 8 Utilizers 64 22 42 Percent of "Grouped" Cases Correctly Classified: 71.70 percent

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36 TABLE 24 Comparison of Wave I and Wave II Variable Means for Nonutilizers Variab les Wave I Wave I I Occupation 3.0682 2.9286 Marital Status 1 .0682 1 .0000 Perceived State of Health 1.3132 1.3571 Perception of Health 1.3182 1.7857 I nterference Worry About Emergency 1.5909 1.6667 Health Care Services Use of Prescription Drugs 1.6364 1.6190 Perception of Enough Care 1.2045 1.1667 Sector 2.4773 2.4524 Family Physician Visits 0.8636 1.6667

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87 TABLE 25 Comparison of Wave I and Wave Variable Means for Utilizers Variables Wave I Wave I I Occupation 2.3167 2.3906 Marital Status 1 . 0333 1.0156 Perceived State of Health 1.3500 1.3125 Perception of Health 1.5167 1.7188 I nterf erence Worry About Emergency 2.1333 1.5000 Health Care Services Use of Prescription Drugs 1.6000 1.5469 Perception of Enough Care 1.2500 1.0469 oector 1.8667 1.8750 Family Physician Visits 0.9333 1.5625

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Table 26 Wave I Variable Means by U" Vari ab I es Ncnut i I i zer Jti I izers Occupation Marital Status Perceived State of Health Perception of Health I nterf erence Worry About Emergency Health Care Services Use of Prescription Drugs Perception of Enough Care Sector Family Physician Visits 3. 0682 1.0682 1 .3132 1 . 3 1 82 1 .5909 1 .6564 1 .2045 2.4773 0.8636 2.3167 1.0333 1 .3500 1 .6167 2.1333 1.6000 1 .2500 1 .8667 0.9833

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39 TABLE 27 Wave II Variable Means by Utilization Variables Nonutilizers Utilizers Occupation 2.9266 2.3906 Marital Status 1.0000 1.0156 Perceived State of Health 1.3571 1.3125 Perception, of Health 1.7357 1.7138 I nterf erence Worry About Emergency 1.6667 1.5000 Health Care Services Use of Prescription Drugs 1.6190 1.5459 Percept ion of Enough Care 1.1667 1.0469 Sector 2.4524 1.3750 Family Physician Visits 1.666/ 1.5625 Prospective Utilization 2.6429 1.3281

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90 the major research question which asked, did the county accept, as measured by clinic utilization, the physician's assistant clinic as a viable source of primary health-care delivery. In addition to bivariate analysis, a multivariate analysis was undertaken. The latter analysis is limited by the data. The items used in the discriminant analysis are primarily ordinal. It would be erroneous to discuss the magnitude of the items in each function. A discussion of the direction of each variable, however, is valid. The analysis does list the ranking of the response categories. For example, the Wave I discriminant function demonstrated that occuDation of the male head-of -household was a key variable in the pattern of utilization. The higher the occupation score then, the greater the prediction of clinic utilization. This means that white-collar workers are more prone to use the clinic. Because of the limitations of the data, it does not mean that whitecollar workers have an exact mathematical probability of using the clinic that is greater than the other occupational groups. The findings and interpretations are assembled and discussed in the next chapter, Summary and Conclusions.

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CHAPTER VI SUMMARY AND CONCLUSIONS This research describes the impact of a physician's assistant clinic on the health practices of a rural county in the southeastern United States. The county had no practicing physician within its boundaries. The major research question was: is the physician's assistant clinic accepted as a source of primary health, care by the community's residents as measured by clinic utilization? This question and its corollaries were addressed through the analysis of health survey data. The major question was answered in general with several qualifications. Based on this impact-evaluation research, the mere availability of a new health care service does not significantly impact a population. A premise for this research and the creation of the physician's assistant clinic was, a community without its own healrh care services would, after the establishing of an innovative health provider clinic, be able to meet irs health service demands. This premise was wrong in that both surveys snowed that 80 percent of its citizens were already in and utilizing an exisxing primary health care system at seme level within the last year. To demonstrate the imoact of this new health care provider, the choice of this county was a poor one. This high base biased nonusers in a number of ways: i) they may not have perceived a need for this health care service;

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92 2) they may not have perceived the need to try a different type of health care service; 3) they may have been satisfied with their existing health care and they did not want to alter it; 4) the clinic gave a sense of security tc the residents but the clinic was not strong enough to cause a change in their health seeking behavior; 5) those residents who sought health-care services had become accustomed to seeking Them in the nearby urban area. The seeming lack of residents substituting the clinic for their normal place of receiving health care may in fact be due to time. Perhaps individuals take a time period longer then one year to begin to substitute the clinic for their usual health-care-service mode. Also, since it was determined that once a family utilizes the clinic, the family has a oositive attitude toward using it again, it may simply be that some of the residents of the county have not had a need for the health-care services that they perceive are available at the clinic. The conceptual framework, as the guide for the analysis, was a model of health-care utiiizaticn. Several guiding questions operational i zed the general research question into more descriptive components. These questions each addressed a related but separate issue of the evaluation of the physician's assistant clinic. The data were aggregated into comparison groups of utilizers and nonuti I izers. The first specific question determined who utilized the clinic. Of the predisposing variables, the primary descriptor of clinic utilization was the occupation of the male head-of-househol d. Occupation

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was used as an indicator of social class. The white-collar workers, the middle and upper classes, were more prone to use the clinic than the lower classss of the county. Typically, the upper and middle classes use health service more routinely. These classes have traditionally been motivated to try, new commodities and products. These individuals are socialized into keeping up with the Jones's and being first on The block to have a new product. The physician's assistant may have been considered by some as a new product. The enabling variables, the degree of previous health-care utilization, was also examined as a description of utilization. Heavy utilizers, those who utilize health services more than The national average, may also be more inclined to use the clinic. This was not always the case. Heavy utilizers of all health services were shown to have used the clinic but heavy utilizers of just physicians did not nor did they plan to utilize the clinic for most of their health-service needs. The heavy utilization of physicians tnen, affected the prospective clinic utilization. Perhaps physicians in the neighboring counties feel that they will lose some of their frequent patients, and may not be referring these patients to the clinic. The second question attempted to determine for what specific illnesses the county residents UTilized the clinic. The data shewed residents of the county primarily go to the clinic for minor, routine services. That is to be expected as this fact is also true for family practitioners, the traditional primary health-care provider. The utilizers of the clinic, however, had changed with regard to the illnesslevel variables of perceived state of health and health interference with their daily activities, more positively than did nonuti I izers. Both

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94 groups showed a positive change toward receiving more care. The utilizers, however, were less worried about receiving emergency health-care and about having an undetected disease. The idea that improvements in the health perceptions of the county occurred because of the opening of the physician's assistant clinic was partially demonsTrated. There were more positive changes, less illness in year 2 than in year 1, in the illness level variables of the individuals who had been utilizers of the clinic. These changes, however, could not be directly attributed to the clinic. Because the utilizers and nonutilizer groups were not significantly different on these variables, it was deduced that the positive changes were attributable to clinic uti I i zat ion. The Third question addressed the continued use of the clinic by the county. These findings point out that once the clinic is utilized, residents plan to use it again for some but not all of their health service needs. In addition, when the individual uses the clinic he will be satisfied, in general with the service, ana in particular with the quality of c^re received. The fourth question addressed the comparison of the clinic to other providers of health care. The utilizers favored the clinic in comparison to other health services with respect to the clinic's geographical location, its cost, the ease in getting an appointment, and the ease in talking about their medical problems with clinic staff. The nonusers systematically did not respond to these questions. Since the utilizers seem satisfied with the quality and convenience of care given at the clinic, the nonusers may also be satisfied when they do use the clinic. It appears then, that getting county residents to use the clinic is the major hurdle. Once that objective is reached, the individual will be satisfied with the services at the clinic.

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95 At this point in time, the use of the clinic did not seem to affect The utilization of other health services. This was the concern of the fifth question. No difference could be detected between utilizers and nonutilizers of the clinic with regard to physician visits, drug use, or rap tests. There was less hospitalization for clinic nonutilizers. This is explained in that these individuals are in general nonusers of most services. If this group does not go to hospitals, they probably will not go to a clinic. Thus, the clinic is net a substitute or replacement health service for the county. It is an alternative service where minor medical problems may be treated with satisfaction. The last question determined which segments within the county utilized the clinic. This was done through discriminant analysis. This analysis demonstrated that all three components of the Andersen-Newman framework, the predisposing, enabling and illness level variables, were descriptive of health service utilization only before the opening of the clinic. After the opening of the clinic, the predisposing or sociodemograph ic variables were no longer the descriptors of clinic utilizers. The enabling and illness-level variables, however, did remain important descriptors. One possible explanation of why the sociodemograph ic variables were not descriptors of clinic utilization is that the county was very homogeneous with respect to these variables. The descriptive analysis of clinic utilization verified the AndersenNewman framework of health service utilization conceptually. The framework is a general base for beginning an examination of both actual and prospective utilization of health service. Not every variable is necessary in every particular situation, but the categories of variables are important.

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96 This study has also verified the belief that every county must have its own practicing primary health-care provider is mistaken. The history of rural health care has depicted a situation whereby rural physicians have been and are leaving these areas to pursue more rewarding careers in metropolitan areas. The Hill-Burton Act of 1945 and its modifications within the p3sr thirty years had led to several problems for the late 1970s. This act provided moneys for the construction of health-care facilities chiefly in rural and underserved areas. The result of the Hill-Burton Act is that there are now several newly built rural hospitals that have neither professional staff nor patients. Staff are more attracted to metropolitan areas and patients are attracted to medical facilities in nearby cities. The existence of these HillBurton hospitals has presented several problems. The hospitals are underutilized. As a solution to the underut i I i zaticn and in order to more completely use the ancillary services of these hospitals, seme are turning a proportion of their acute beds into skilled nursing faci I ity beds. The findings of this research and the modifications underway at some Hill-Burton hospitals demonstrate that The provision of facilities, e.g., hospital beds to rural areas may not be the best approach To rural health-care delivery. With the increase in automobile ownership and the improvement of highways, the access to health-care providers should now be measured in time; not miles or county borders. Hospitals were shown not to be the correct solution. The solution is perhaps for the provision of thoroughly prepared and equipped health emergency teams and facilities. These teams and their equipment would be far less costly than the construction, staffing and maintenance of a small rural hospital or clinic and perhaps even more efficient and effective.

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97 Although the community impact of the clinic was not statistically significant, several other goals were reached. First, the clinic did provide a training site and trial clinical exoerience for an experiment dealing with the potential uses of physician's assistants. Second, the clinic did take some of the routine service burden away from the providers in nearby counties. Third, the clinic did satisfy the community need for security in having a health-care provider available for emergencies. In this rural agricultural community, the residents now worry less about being able to receive health-care service in an emergency. The cafa did not indicate that this was a community which was not being serviced by health-care providers. The data did suggest that the clinic added a sense of security and an element of convenience to county residents. There are several research designs with which to evaluate an action program. The program, the process, the outcome, and the impact of the action program can each be separately evaluated. This research was limited to an impact design. The impact of the physician's assistant clinic appeared marginal. The result need not reflect on the program, the process, or the outcome evaluations. If the other evaluations were carried out, a more complete evaluation of the physician's assistant wouid be ascertained, which may aid in explaining the marginal impact of the clinic on the county as shown in this research. Every day, grants and contracts are awarded by governmental and private agencies to investigate the various aspects of the health-care system. The investigations are typically the result cf societal demands on these agencies to demonstrate That every individual within society can exercise his right to health-care prevision. The creation, design

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98 and functioning of the physician's assistant clinic have all been developed within the past ten years. It is a wise decision to monitor this and any new health-care provider to determine its feasibility in the ever-enlarging health-care system. The monitoring will provide necessary feedback for the upgrading, continuance, and discontinuance of new programs. This initial descriptive analysis was able to determine deductively some additional research questions that should be addressed by policy makers and health-service researchers before a new health program begins. Without the type of descriptive research as conducted in this study, these questions may never have surfaced. Unless these questions are answered, modifications of the health-care system, which undoubtedly will be forthcoming at great expense, may oe undertaken with marginal values to both The community and societal systems. These questions are: was it determined that the community needs a comprehensive health-care orovider? A needs assessment study would provide the answer to this question. Was it determined that there was evidence of support for the utilization of the new service; that is, would there be referrals from the existing health-care system as well as from the lay-referral network? Did ~ne community want this new service or were they satisifed with the existing but seemingly inconvenient health-care system? Is there a design to create a legitimate market for the new service? Who would underwrite the cost of the new service: that is, would the new service be eligible for third-party payments and could the community afford the new service? Would the new service be financially selfsupporting or would it be dependent on another health organization for support? Would the new service, in meeting the needs o* the community

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99 be utilitzed to its capacity? It is the contention of this author that if extensive planning were done, based on the responses to these or similar questions, the new programs may have an impact on their intended population. The health service would provide and maintain healthy and contributing mempers of the community.

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APPENDIX A GILCHRIST COUNTY HEALTH STUDY QUESTIONNAIRE (WAVE I )

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101 3 I LChPs [ ST COUNTY HEALTH STUDY QUESTIONNAIRE (FHASE i } ) Name Address 3) In general, how would you say your health has been during i he !as _ I 2 months? excel lent J_ good 2 fair _3 peer £ very bad 3. ? 5_ 4) Does your health interfere with your daily activities? never i rarely 2 sometimes 3_ often _£ all ~he rime 5_ ? c_ ) Accut now many times in the pasr 12 months « /• yes; wnar were you seen ~zr\ 1) Hew many times did you nave re be 12 months? 1 I 2 2 5. 3-4 4_ Ove 35 Did you go for a yearly checkup by a deef months even Though you were feeling well? yes i no 2_ 9) How often are you worried or nervous? never I seiccm 2 sometimes 3 ofts or a:jrt no me i asr i The t

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10) Are you new faking regularly any medicine presc yes J_ no 2_ 11) If yes, new many are you taking? 1 e d by a 102 lector? 7 -K -re ycu currently using regularly any nc 'ion mec i c i net :r ncme ran /es 5) If yes, new many ere you taking :ver n.re ycu presenri/ using any nerve pi i Is: yes J_ no 2_ Were you pregnant during the iast 12 monrns? yes I no 2 1 '. ) nave vol ;d (.female; With Co vcu ~nink that you are pr-. asi i months . enouqn mec M . A . -,o, why no" 9; What is your present marital status? single J_ carried 2_ widowed _5 sepa living i o g e t n e r o : / !Q) Who else lives am heme with /ou?

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103 Health Perceotions Has anyone I i v i ng d i seases? 45) Tubercu losi s the house ever had any one o f +no t.. 3 S T 9 s 9 ? yes i 47) Hear Disease yes _i_ no 2_ ? 3_ 43) High 3 iced Pressure yes \_ no 2 ? 3. 49) Low Bioca or Anemia ?UJ jiauccrn: .cw i A/ou:d I i K9 to asK you some quesnons aoour wnera you .vcuio go to get meaicai attention if you felt that you or a member of your family needed i + . What wou ! d you do: ever and were cougn i ng up olcod? r yourself j_ regular family doctor 2_ specialist (M.D.) _3 university hosptTal _£ other hospital _p_ druggist c_ puolic health nurse J_ friend or relative _8 faith healer or minister 9 other 10 ? II N.A. 12 vcu nac *ake car?

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104 f you twisted your ankle and it was s later? fami Iv M.D. 2 se I r _l_ un i vers i ty hosp f ta I 4 ofr,er has ec i a i i si ju i re swo I i en a dav "'JOG ! st o i o nea ,rse fnenc cr relative 2 :ea ler or If you had bleecing between periods 'if post-menopausa I , rurrner vag i na i b I eec i ng )? self _i_ family M.D. _2 specialist (M.D.j 5_ university hospital _£ other hospital _5 druggist^ public health nurse ~riend or relative _3_ fairh healer or minister 9_ ether _H3 ? i i N . A . I 2 your cnilaren developed a men ? l o~her heso ita j_ un i vers i Ty puul is nea I t h nurse er oTner oeaan losing 'weight wimoi -yi ju tecame very deoressec •ami ly M.u. un i vers i Ty >ub I i c nea I tn nur: ie 3 faith healer cr

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If you had a suacen heart attack? se I f J_ family M.D. 2 specialism 3_ university hcsci otner rose i fa! _5 jruggist 6_ public health nurse 2 relative _3 faith healer or minister 9_ other j_3_ ? N.A. \2_ If you had a -ever and a running nose? self I family M.D. 2 soecialist 3 university nosoi 105 orner nospital 5. crugg i relative c_ faith nealer N.A. j_2 My, I wou I i just I i ke to /our rami i /. ChecK whether aerson is? olcCK _i_ wnite _2 other Check sex of person Check mileage from city ii within mown I CI mile; cue I i c nea urse 7 friend or ask you a few ger iuestions aacum you J. 1-cG miles d over Z'J mi les new old are you r some co i I ece t year of school you ccmoleted? some high school 3_ nigh school graduate 4_ col leas oracuafe 5 some post-qraduate (includinq masters) 7 PHD cr equivalent ler 9 N.A. !

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i 06 54) row oig was ~r,e town where ycu scent most of your childhood? rural (under 2,000) j_ big town (2, COO1 0,000) 2 small city ( 10,000-100,000) 2 o i g city (over 100, CCC) £ ? 5_ N.A. I 55) How many years have you lived in GilchrisT County? under 2 years J_ 2-5 years 2_ 5-2C years 5_ over 20 years £ 53) Does your rami iv nave a car or Truck? yes £ no 2 ? _3 N.A. £ i f yes, hew many? I j_ 2 2_ 3 £ ever 3 £ ? £ Are ycu presently employed full-time (ever 30 Incurs! yes J_ no 2 ? £ N.A. £ if yes, .vna~ do ycu dc? is your nuscana presently emp I yes i no 2 ? 3 N.A. 4 yes, h; :sj '..^ It nc, hew long has he been unemployed? under i year i 1-5 years 2 5-10 yea years £ 3) About hew much jo ycu and your rami unoer 3, CCC £ 3,CCC-5,999 2_ 6,C over 15,000 5 ? 5 N.A. 7 eacn, year? ? 3 10,000-15,000 -i

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107 74) Dees your family presently nave any health insurance? yes j_ no 2_ ? _3 N.A. 4_ 75) If yes, what type? Blue Cross-Blue Shield j_ Private other 2_ Medicare 5. Medicaid 4_ I 2, 3 5_ 2 J 35 3i47 ? 3_ N.A. 9 75) If income under S3, GOG, are you currently receiving any income from a welfare agency? yes _!_ no 2 ? 2 N A 1 How many community or civic or be I one to? ? ? 0: -i or iver 5 ^ and 7c u r husband ? 6 N.A. 2 Check general appearance of living rocm. nea !" J_ reasonably we I I kept 2_ somewhat sloppy 3_ very sloppy _£ shambles 5_ now much go you worry about net being able to get medical case of an emergency for you or /our family? oasional ly £ otten _o a row mucn :o you worry that you or a memcer or your fami ly may nave a disease that nasn't been found by a doctor yet? never I occasional ly 2_ often 3_ all rne time 4 ? 5_

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-her Adu I f (over I 5 out ot scnool ) 21 ) Check if person i husband J_ other Name ^e (she) 5-34 2 24) n genera ! , how ,-jo\j,'\6 you say his (her) hes 33T I 2 moruns? ;xcs! lenr I -cod 2 fair 3 ocor 4 vs d over b> th has been during The -3) Joes nis (ner; nea lever . rareiv iTertere w ^neTimes j About now many rimes in The last 12 months by an M.D.? Tas ne (sne) ceen seen 5 r yes, whar ,va: 23) Hcvi many ~imes did ne (sne! iasT i2'mcnTns? ncsD i Ta |. jun no The 23) uio ne (sne J go tor a yearly checKup 12 months even Though he (sne) was f-; yes _i_ no 2 ? 5. 3C) How often does he (she) get worried : never i se!:cm 2_ sometimes _3 c 3!) Is ne (she) taking regularly any med yes i no 2 ? 3 by a 10 the las" nervous; -en £ all the time 2 ? :ines eraser i bed by a doc

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109 32) If yes, hew many is he (she) faking? I 1 2 2 5 3_ 4-5 £ over 5 5_ ? b_ 35) Is he currently using regularly any non-prescription medici home remedies? yes J_ no 2 ? 3_ 4-3 £ over 5 5_ ? 5_ 34) if yes, now many is he taking? I j_ 2 2 3 3 4-5 £ over 5 3_ ? 5 55) Is ne presently taking any nerve pills? 36) Co you think that he is presently receiving enouch medical < yes I no 2 ? 3 wny ?

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APPENDIX 3 GILCHRIST COUNTY HEALTH STUDY QUESTIONNAIRE (WAVE I I ) 10

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111 GILCHRIST C017.TY HEALTH STUDY QUESTIONNAIRE (FHASE II) Department of Cocniur.lt y Health and Far.ily Medicine University of Florida Intoi-vie'* idcintif ication number Family Nane Election District Attempts to interview: (Date, tine, outcome, Interviewer) Week of interview 1. Who lives with you SAME AGE SEX RELATIONSHIP TOTALS ___ 4 OF ADULTS __ 4 OF CHILDREN . . _ FAMILY SIZE Check who was interviewed

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Col. 1 # of Adults * of Children family size family composition i 17-18 1 12 Identification •; 2-4

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7. How often are you v/orried or nervous? Would you say . . . Have you received Radical care or a physical frcn i anyone in the oast, 12 nonths? | ?-& Are you now taUina rep^larly any medicine orescribed bv a doctor' [f yes, How manv different Prescriptions? 1.0. Arc you currently usin^. regularly any r.onprescript ion medicine or here remedies? i 1. never l 2 . seldc-n i 3. soneCir.es I 4. often i S. don' t know 1 9. not applicable 1. yes 2. no S . don ' t know 9. not applicable 1. yes 2 . no 3. don't Vno'.' 9. not aoniicable 1. 1 2. 2 3. 3 4. 4-5 5. over 5 S. dor.' c Xr.ow 9. not aoDlicable 1. yes I 2. no | 8 . don ' C '.-now I 9. not applicable 29 If yes. How nar.y different ones are vou taltiiw? 5. over 5 3. don' t '-now 9. not applicable Are you presently tahins nerve oills? 7 ore you presrnan Last 12 nontha 13. Have you had a Pap (female) i test in the past 12 months'? j 14. Do you think that you are presently receiving enough nedical care? If no, Why not? 32 34 35-35 37-33 1. ves 2 . no 3. don' C know i 9. not applicable 1. yes 7. . no 3. don' t '-now i 9 . not applicable I G. don' t know 9 . not asplicable 1.

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15. Do you kr.au about the Medical Center in Trenton? 1. yes 2. no 8. don't V.r.ow ?. not aDnllcable Have' you ever been to the Medical Ci.'.ter yourself as a patient? If no, Probe : ; 7hy not? Li3t reasons: If yes, Probe: 1. For what? 2. Hou nany tines? (Include house calls) 2y vhoin ware you treated at the Medical Center? List: Do you know his name? List: 41-42 ; 43-44 i : : J 45-46 47-48 ! I ! 49-50 I I i 51 I I 52 53 1. vet 3. don't r.r.ov ?. not applicable EXACT yfJMESR 1. M.D. 2. P. A. 3. combination 3. don' t !aou ?. not aoDlicabls 1. yes 2 . no 3. don' t know 9. not aoolica'oie 17. 13. Hoc nany tines in the past year have you been seen by a doctor other than at the Medical Center? If yes , '.7ho were the7 ? IThat for? VJhere? EXACT t-TUMBER 56-57 58-59 60-61 62-63 64-65 .'£. don t '.enow ?S. not anplicabl ;ho (1) '•That (1)_ '•here (1) -ho (2) \-hat (2)

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CARD "TIMBER 1 15 '-•hat for? 5-6 rr ho (2) LS. T:3ve you been a patient in the hosnital during the nast 12 ^.onchs? If yes, when? "no sent you to z: hospital? 9-10 11 12-13 14-15 16-17 "hat (2) "here (2) 1. yes 2 . no 3 . den ' t 'enow 9. not anoiicable Kb en (1) niere (1) For what (1) "ho (1) 'nnen (2) Where (2) Code for nore than 24-25 26-27 23-29 ur what (2) r-?ho (2) 20. Are you currently beins seen by anyone for health reasons? I: yes, by vhoa? For vhat? Tor how long? !7hat is heir.?; done? Vhere? 33-34 35-36 37-33 39-40 41-42 43-44 9. not applicable List: "net? ( 1 ) '.-hat

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1 16 THIS SET CF QUESTIONS DEALS 'HT 1 .! T5IE "TEALTH 23. ''oulci you say that your husband's health has been better, '..-orse, or the same as last year? 51 BESS OF YOUR HOUSEHOLD. EXACT ag: "hat is your husband's a;>e?

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3o you chin!; that your husband is presently receiving enough tiedical If no, vhy not? 53 59-60 30. Has your husband received nedical care or a physical fron anyone in Che Dasc 12 months? Has your husband beer, to che Medical Cancer as a pacienc? If no, ?robe : 'Thy noc? List raasons : If yes , Probe : 1. 7or what? List: 2. Ha" r.any ti^.es? (Include house calls) 1. yes 2 . no 3. don't knov ". noc applicable Lisc: 17 x . ves 2. n„ don ' t know noc applicable 62 63-64 65-66 67-63 59-70 71-72 1. ves 2. no 8. don't know ?. not anplicable EXACT NUMBER 33. By whom vas he Cteaced at Che Medical Center? List:

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'"hac for? "here? Probe: Eiergencv ?.con r ."se Has your husband sought medic.il '--elp fron any sources ocher Chan the tfedical Center or a doctor In the past 12 -onths? If yes, '-.'ho vas it? r "r.ac for? '.'here? 35. Has your husband been a pati&nc in the hosoical during the oast 12 months? If yes , when? !J here? For what? T "no sent bin to the hosDital? 16-17 13-19 -21 23-24 25-26 27-2S 29-30 35 35-37 38-3? 40-41 42-43 (4-45 46-47 Hi List: '.
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36. Is ycur husband currently beinp, seen for health reasons? If yes, by tvhon? "cr './hat? For how long? '--"hat is beins; dene? '•'he r e ? 52 53-54 55-56 57-5J 61-61 65-66 67-63 71-7; 1. yes 7. . no 3. don ' t know 9. not applicable List: "hora (1) "hat (I) 1 19 iow icr-.p. (1) !Jcne (1) 'There (1) List : ''hen (2) "hac (2) ^ow lonR (2) 3one (2) "here (2) CARD :-~!J?'Pr.R ID SUIQES

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120 TH2 MEXT SERIES CF QUESTIONS ASKS ABOUT THE 37. How many children are presently livinp at hone with vcu? 3-6 ,TK C" YOUR CHILDRE". I EXACT i.TTirER 33. Are there any children in | the house who you would sav are sick nore often than n:ost children their ase? I 7 If yes, how many? 3-9 j I. yes 2 . no I 8. don ' C bou 9. r.ot applicable ixjc: raer 40. nave any of vour cnildren received nedical care or a physical from anyone in the ?ast 12 months? Have any of your children been to the "edical Center as oatients? If no, Probe: '-Thy not? List reasons : 10 If yes, Probe: 1. Eor What? List reasons: 12-13 14-15 13-17 1 . ves 2 . no 8. den ' t know 9. not applicable 1. yes 2. no 3. don't know 9. not applicable

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121

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121 CAKD HIRC5I 43. Ho^.' many of your children are currently beir.2 seen for health reasons? If yes, by when? For what? For hou long? !/hat is being done? 'Tiere? 2-4 14-15 15-17 13-19 !2-23 List: '.-Thorn (1) './ha t

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123 T"E ;-:ett sf.t hf ouestiws deals "tt: j thk other asclt 'rprrER.s n» toos household. OTHER AEULT-FTRST-OLD'vST 44. "hat i3 his/her relationship to you? 126-27 '-That Is his /'her as;e?

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124 52. Is he/she presently ta!'ir nerve cilia? 30 53. Bo you think Chat he/she presently receivlrtz encu
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25 If. vea, "no «as it? t r nat for? vr here did he/she ->o? Probe: Er.ereencv Room Vse 71-72 List: Kho (1) -.at for? (1) .ere did he °e (1) CA.HD NX": 1 '."" S-6 9-10 -lac for (2) lere did he so (2) £7. In the nast vear has he/she received rr.edical Hein fron any sources other than the "edical Canter or a doctor? If yes, ,r ho '-ras it? "hat for? '."here did he/she ^o? 1. ves 2. no 8. don't know 9 . not aooiicabla I List: I "ho (I) 14-15 13-1? :>-2i Vhat for

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I ? more than 2 tines, list exact number. 35-36 37-3* £1-42 "hen (2) '•'here (2) for what (2) Vho (2) F.TACT J-fUMr-ES 25 Is he/she current!'' heiri" seen tor any health reasons: If ;'es, 3y vhor.2 For vhat? For how Ion j? '^hac is bein
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127 •to mpv/j SFT OF nU7.STI0r!S DEALS ''ITH T'TE OTKF." ADULT ^tP'SF.R^ I" T YOUR 'OUSSKOLD. ASITLT-UST-Y.'"'' -OEST 60. ;j hat is his/her relationship to VOU? .

PAGE 138

123 If ves, he.' nar.y is he/she

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129 lo'-r r.any tires in the -a".t year has he/s .'. licen seen jv doctors other than at t'-i= "edical Cnr.ter? I f yes, '";.o ;:as it? "hat for? '"lore did he/she <"o? Probe : "rr.erp.ency Room Use 73. In the oast vesr has he/she received -.edical helo fror ar.y sources other than the ,: vical Center or a doctor 9 I' ,/es, V'.-.o '.'as it? ,7 hac for? T fti.\re did be/she ',0? 33-34 3536 37-33 39-40 0.-42 43-44 4^.-40 52-53 34-55 56-57 Has he/she been a natient ir the hosoital durina the nast 12 months? If ves, "hen? '•here? For 'rhat? ,T ho sent hin/b.er to the hosoital? 6i-e: 65-f>t 67-63 ! fi?-70 98. don t bff Jf, not 3?">lic3ble List: "ho (1) "hat for (1)

PAGE 140

130

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76. "OR ALL ?-gp^nF»T-: Ho'; did you hear a '-out the "edical Center? List: 23-2 r 3 rt -31 131 ';o you ".ave Cr.R teieor.or.e number someplace in case vou need it? 32 _o you kjio'i '.t~.o is resnonsible for the new medical center beinz ooened here in Trenton? If yes, 'Tho? Do vou biou '*ho else? 23 7 q . Have vou ever called the "ed~ ! ical Center for nedic?.l advice? "xclude :na'-ir.s> anointments. 80. Have you ever had a housecall from the Medical Center? ''(>. never ieari of it 01. familv r 2. friends 03. net/snaner 04. M.D. referral 05. ta! en thera in an emergency Ofi, school ^7. other n 3. don' t r>:-°.r.ber 93. don't know Q 9. not apnlicabie °. don ' t knot r 0. not anolicaole 3 . don ' t knot-; ?. noc aooiicable 1. yes 2. no 3 . don ' t know 5. not aoplicab] 35 3. •-'on't kno?-? 9. not aooiicabl FOR T'-'OSE ,r: 0SE FAMILIES U"0 T&l MFDICAL CCTTKR IN rRE-TMM 31.

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132 CTIS S"CTIC' ASitS YOU TO CO"? AM THS "EPICAL .CT-.TT'? I 1 PLACES YOU MIft'TI GO E0". "EDICAL CARP ASK ALL PJSS'OirWTS ! , "ith repard co ho" eas 1 ' it is to set co che office for medical care, how mjuI
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9*. "o" much do vou worry about not bein? able to -jet medical care in case of ar. emerpencv for you or for vour family? • ''ould vou say. . . 53 Hot-' such do you worrv chat vou or a menber of vour fanily r.av hav» a disease chat has not been found by a doctor yec? "ould vou sav... 54 Ir you vere to use the "'edical Center a-e treated bv any particular person there? If yes , ;ho? List: low AI Ketli If the respondent "0"S "QT i : ";cu HVi, substitute '-'us>;Cedercuist, if still no recognition, substitute Car-/ lexroat. Substitute Physician Assistanc. I If yes, what do you call hin? Ho you know his training? If yes, what is it? (Can you describe it?) 54. How do vou Chink other Teonl; you know in the county like the Medical Center? !7 culd you say . . . List: 95. Has a physician nade anv consents to you or to your family abouc the Medical Center in Trenton? It yes, list renly. 2. OCCASIONALLY 3. OFT 5 "*' 4. AIL. OF T"F Tt"» 3. don't '-.now ?. not annlicable 133 1. ••1\~R 2. OCCASIONALLY 3. GFT^! V 4. .ALL HE TI'3 C. don ' t know 9. not aDolicable i 3. don't know I 9. not apolicable j 1. AL SENT | 2. GAP.Y ?EXROAT 3. '.'J'O'.l CEDF'VrilST 6. DR. REYT.'OLCS 7. OTHER I 3 . don ' t know 9. not aoolicabie yes HAMPS ves PHYSICIAN ASS1 don t Icr.o" not annlicabls

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13^ 96. '>.o in vour fanily usually decides that sor.eone should see a doctor? List: 1. t 'ot:-:e?. 2. FAT"fR 3. C'-'ILD 4. G3A M DPAS£HT 5. individual cokc 6. ot!:lti 2. don ' C i;now P. not applicable THIS LAST SECTION IS GENERAL lV:0^:'k~lOV. AXl'T THE -AMIL'i 97. ,r hat vas the last year of school that vou ccr.nleced? 93. Are you presently er.ploved? If yes, what do you do? j 1. yes, full time I 2. yes , art time J 3. no ! 8. don' t know j 9. not applicable i I List: 190, 101. 192. CARD NUMBER

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135 8 . don ' c know 9. not applicable 2. no 3. don't know 9 _

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136 RKSPONDPn 3ACKCROUr3 CHARACTERISTICS "0= 21 1. 31ack 2. "hite 3. Ocher 106 . Sex 3?. Male Fenalc 107. How bi« «as the to'-r. where i vou soer.t your childhood? '; 103. How tiar.y years have yau lived in Gilchrist: Cour.ty? 109. Chech annroxinate reiieane fro:", ho-.e to Trenton. 1. rural under 2,000 2. bis to«n 2-10,000 3. small city 10-100,000 4. bic, city over 100,000 3. don't Vr.o'-? 9. not applicable 1. under 2 years 2. 2-5 years 3. 5-2C years 4. over 20 years 5. dcn't know 1. 0-10 miles 2. 10.1 to 20 niles 3. over 20 miles 3. don't know

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BIBLIOGRAPHY Adamson, T.E. "Critical Issues in the Use of Physician Associates and Assistants." American Journal of Public Health , 51:1765-79 (September, 1971). '" "" " " Aday, L.A., and Andersen, R. Access to Medical Care . Ann Arbor: Health Administration Press, 1975. American Medical Association. Essentials of an Approved Program for the Assistant to the Primary Care Physician . Chicago: American Medical Association, 1971. Andersen, R. A Behavioral Model of Families' Use of Healrh Services . Research Series No. 25. Chicago Center for Health Administration Studies, University of Chicago, 1968. Andersen, R., et al. Expenditures fcr Ferscnal Health Services : National Trends and Variation — 1955-1970 . Washington: Bureau of Health Services Research and Evaluation: U.S. Department of Health, Education and Welfare Publication Mo. (HRA) 74-3105, 1975. Andersen, R. and Newman, J.F. "Societal and Individual Determinants of Medical Care Utilization in the United States." The Mi I bank Memorial Fund Quarterly , 51:95-120 (Winter, 1973). Anderson, J.Q., and Bartkus, D.E. "Choice of Medical Care: A Behavioral Model of Health and Illness Behavior." Journal of Health & Social Behavior , 14:343-362 (December, 1973). Anderson, J.G. "Causal Models and Social Indicators: Toward the Development of Social Systems Model." American Socio logical Rev i ew , 33:235-301 (June, 1974). '"" ~ """" Andreoli, K.G. "A Look at the Physician's Assistant." American Journal of Nursing , 72:710-3 (April, 1972). Backstrom, C.H., and Hursh, G.D. Survey Research . Chicago: Northwestern University Press, 1963. Ballenger, M.D. "The Physician's Assistant. Legal Considerations." Hospitals , 45:58-61 (June I, 1971). Beck, R.G. "Economic Class and Access to Physician Services Under Public Medical Care Insurance." International Journal of Health Services , 3:341-345 (Summer, 1973). 137

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38 Bergen, S.S., and Clapp, R.W. '' D hysician Assistants' Training. A Model for Human Resources Development." Journal of the Medical Society of Mew Jersey , 69:251-3 (March, 1972). Blalock, H.M. Social Statistics . New York: McGraw-Hill Eook Company, Inc., I960. Bodenheimer, T.S. "Patterns of American Ambulatory Care." I nqu i ry , 3:26-35 (September, 1970). Bonrnstedt, G.W. "Reliability and Validity Assessment in Attitude Measurement." in Gene F. Summers, Attitude Measurement . Chicago: Rand McNa I I y & Company, pp. 30-99, 1970. Borland, 3.L., Williams, F.E., and Taylor, D. "A Survey of Attitudes of Physicians on Proper Use of Physician's Assistants." Health Service Report , 87:467-72 (May, 1972). Brook, R.H. "A Study of Methodologic Problems Associated with Assessment of Quality of Care," (Ph.D. dissertation, The Johns Hopkins University, 1972). Chen, M.K. "Access to Health Care: A Preliminary Model." National Center for Health Services Research and Development, 1973. Coe, P.M., and F ichtenbaum, L. "Utilization of Physician Assistants: Some Implications for Medical Pracrice." Medical Care , 10:497-504 (November-December, 1972). Coser, L.A. The Functions of Social Conflict . Mew York: The Free p ress, 1956. Davidson, G.E. "Nursing Service." Hospita Is , 45:127-30 (April I, 1971). Demaria, W.J., et a I . "Evaluation of the Marine Physician Assistant Program," HSMHA Health Report , 36:195-20! (March, 1971). Donabedian, A. AspecTs of 'Medical Care Administration . Cambridge: Harvard University Press, 1973. Ennes, H. "Toward a Constructive Appraisal of Community Health Services." American Journal of Public Health , 47:5-6 (November, I 957) . Estes, E.H., Jr., and Howard, D.R. "Paramedical Personnel in the DistriDUTion of Health Care." Archives of Internal Medicine , 127:70-2 (January, 1971). Estes, E.H., Jr. "Physician's Assistants." AORN Journal , 15:95-100 (January, 1972).

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139 Estes, E.H., Jr. "Teaching Medical Assistants for the Doctor." Medical Progress through Techno logy , 1:196-200 (February, 1973). Etzioni, A., and Lehman, E. "Some Dangers in Valid Social Measurement." Annals of American Academy of Political and Social Sciences , 373:1-15 (September, 1967). Fleck, A. "Evaluation as a Logical Process." Canadian Journal of Pub I ic Health , 52:135 (May, 1961). -look, E.E. and Sanazaro, P.J. Health Services Research and R&D In Perspective . Ann Arbor: Health Administration Press, 1973. Ford, l.C. "Physician's Assistant: Why, Who and How?." AORM Journal , 15:41-50 (Apri I, 1972). Freeborn, D.K. and Greenlich, M.R. "Evaluation of the Performance of Ambulatory Care Systems' Research Equipments anc Opportunities." Medical Care , 11:63-75 (March-April Supoiement, 1973) . Greenberg, B., and Mattison, R.F. "The Ways and Wherefores of Program Evaluation." Canadian Journal of Public Health , 46:293 (July, 1955). Greenberg, E.M. "Evaluating the Effectiveness of Mental Health Services." Milbank Memorial Fund Quarterly , 44:20-49 (January, I 965) . Hawiey, P.R. "Evaluation of the Duality of Patients Csre." American Journal of Public Healxh , 45:153 (December, 1955). Henry, R.A. "Use of Physician's Assistants in Gilchrist County, Florida." Health Service Report , 37:537-92 (Ocrober, 1972). Hershberger, S. "Revamping the Health Care Team." Journal of Obstetric, Gynecologic and Neonatal Nursing , 2:54-7 (MarchApril, 1973). Herzog, E. Some Guidelines for Evaluative Research . U.S. Department of Health, Education and Welfare, Washington, D.C., 1959. Hoi I ingshead, A. "Medical Sociology: A Brief Review." Health and Society , 51:531-42, 1973. Horsley, A.W., and Aschenbrener, T.D. "Physician's Assistant Training Program: Questions and Answers." Journal of Iowa Medical Society , 63:155-5 (April, 1973). Hutchinson, G.3. "Evaluation of Preventive Services." Journal of Chronic Diseases , 11:497 (May, I960).

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140 James, G., and Helleboe, H. "Evaluation During the Development of a Public Health Program in Chronic Diseases." American Journal of Public Health , 45:149 (February, 1955). Johnson, T.M. "The Mew Curer: Anthropological Perspectives in the Training of Physician's AssistanTS." (Ph.D. dissertation, University of Florida, 1976). Lambertsen, E.G. "Perspective on the Physician's Assistant." Murs i nc Outlook , 20:32-6 (January, 1972). Lave, J. P., et a I . "The Physician's Assistant. Exploration of the Concept." Hospitals , 45:42-51 (June I, 1971). Lemkan, P.V., and Pasamanick, B. "Problems in Evaluation of Mental Health Programs." American Journal of Orthopsychiatry , 27:55 (January, 1957) . Lewis, C.E. "The Physician's Assistant. Acceptance of Physician's Assistants." Hospitals , 45:62-4 (June I, 1971). Litman, T.J. " D ublic Perceptions fo the Physicians' Assistant — A Survey of the Attitudes and Opinions of Rural Iowa and Minnesota Residents." American Journal of Public Health , 62:343-6 (March, 1972). Lohrenz, F.N. "The Marshfield Clinic Physician-Assistant Concept. Critical Evaluation of Advantages, Disadvantages and Prospects." Mew England Journal of Medicine , 284-301-4 (February II, 1971). ' MacMahon, 3., Pugh, T.F., Hutchinson, G.B. "Principles in the Evaluation of Community Mental Health Programs." American Journal of Pub I ic Health , 51:963-5 (July, 1961). McKinlay, J. 3. Research Methods in Health Care . Mew York: PRODIST, 1973. McKinlay, J. 3. "Some Approaches and Problems in the Study of the Use of Services An Overview." Journal of Health and Social Behavior , 13:115-152 (June, 1971). M.echa n i c , D . Public Expectations and Health Care: Essays on the Changing Organization of Health Services . Mew York: John Wiley and Sons, 1972. Merton, R.K. Social Theory and Social Structure . Glencoe, Illinois: Free Press, 1957. Miale, J.E. "Caring for the Surgical Patient." Hospitals , 45:72-4 (July I, 1971).

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Nie, M.H., et a ! . Statistical Package for the Social Sciences . New York; McGraw-Hill Book Company, 1970. Nolan, L.C., and Nolan, G.H. "Status of the New Health Care Providers: The Physician's Assistants." Medical Care Peview , 32:430-56 (Apri I, 1975). Onion, O.K., and Schulten, T. "The Physician Assistant in Maine: Two Pending Proposals." Journal of the Maine Medical Association , 64:93-101 (May, 1973). Oppenheim, A.N. Questionnaire Design and Attitude Measurement . New York: Basic Books, 1966. 'Toole, R. The Organization, Management and Tactics of Social Research . Cambridge: Schenkman, 1971. Parsons, T. The Social System . New York: The Free Press, 1951. Paul, 3.D. "Social Science in Public Health." American .journal of Pub I ic Health , 46:1390 (November, 1956). Phillips, D.L., and Clancy, K.J. "Some Effects of 'Social Desirability' in Survey Studies." American Journal of Sociology , 77:921-940 (March, 1972). ~~ ~ ' "' ' "Physician Visits: Volume and Interval Since Last Visit. United States 1971." Vital and Health Statistics , Series 10, No. 97, U.S. Department of Health, Education and Welfare, Washington, D.C. (March, 1975). "Physician's Assistant Jury Still Out." American Medical News , 18:1 (January 27, 1975). "The Physician's Assistants. A Visit to Bowman Gray." RN , 33:34-5 (October, 1970) . Richardson, E.L. "Meeting the Nation's Health Manpower Needs." Journal of Medical Education , 47:3-9 (January, 1972). Rcemer, Milton I. "Historical Perspective of Health Services in Rural America." in Rural Health Services: Organization, DeI i very, and Use , edited by E. Hassinger and L.R. Whiting. Ames, Iowa: The Iowa State University Press, 1976. Rogers, D.E. "Shattuck Lecture — The American Health Care Scene." New England Journal of Medicine , 238:1377-1583 (June 23, 1973). Rogers, H.L. "Physician Assistants and Medical Practice." Journal of the Medical Association of Georgia , 61:133 (April, 1972).

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142 Roghmann, K.J. "Looking for the Medical Care Crisis in Utilization Data." Inquiry , 11:232-91 (December, 1974). Roghmann, K.J., and Haggerty, R.J. "Measuring the Use of Health Services by Household Interview: A Comparison of Procedures Used in Three Child Health Surveys." International Journal of Epidemiology , 3:71-71 (1974). Rosenberg, M. The Logic of Survey Analysis . New York: Basic Books, 1963. Rosenberg, S. "Use of Physician Associates." American Journal of Pub I ic Health , 62:465-6 (April, 1972). Rossi, P. "Booby Traps and Pitfalls in the Evaluation of Social Action Programs." Proceedincs of American Statistical AssociationSocial Science Section , (1966). Rotnberg, J.S. "Nurse and Physician's Assistant: Issues and Relationships." Nursing Outlook , 21:154-3 (March, 1973). Sadler, A., Sadler, B., and Bliss, A. The Physician's Assistant: Today and Tomorrow . New Haven: Yale University Press, 1972. Schwab, J. J., et a I . "Community Mental Health Evaluation: An Assessment of Needs and Services." submitted for publication i n Eva I uation . Shaw, B.L. "New Man in Town: The P. A." RN, 33:33 (October, 1970). Shortell, S. "Patterns of Med i ca i Care: Issues of Access, Cost, and Continuity." Paper presented at Center for Health Administration Studies, Chicago (April 5, 1973). Smith, R.A. "MEDEX — An Operational and Replicated Manpower Program: Increasing the Delivery of Health Services." American Journal of Public Health , 62:1563-5 (December, 1972). Sterling, T.D., and Pollack, S.V. Introduction to Statistical Data Process i nq . Enclewood Cliffs, New Jersey: Prentice-Hall, inc., 1968. Stone, L.A., and Bassett, G.R. "The MEDEX Medical Occupation Concept in Subjective Medical Occupation Professional Multidimensional Space." Psychological Reports , 31:167-74 (August, 1972). Strunk, H.K. "Patients Attitudes Towards Physician Assistant." Ca I i fornia Medici ne, 118:73-77 (June, 1973).

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143 Stuart, R.S., et a 1 , "The Training and Role of Physicians' Assistants in the Army Medical Department.'' Mi I i tary Med ici ne , 138:227-30 (April, 1973). Suchman, E.A. Evaluative Research . New York: Russell Sage, 1957. Suchman, E.A. "Medical Deprivation." American Journal of Orthopsychiatry , 36:665-72 (July, 1966). ~ " Suchman, E.A. "Social Patterns of Illness and Medical Care." Journa I of Health and Human Behavior , 6:2-16 (Spring, 1965). The Utilization of Health Services: Indices and Correlates, A Research Bi b I ioqraphy . The National Center for Health Services Research and Development, Department of Health, Education and Welfare, Health Services and Mental Health Administration, Washington, D.C., 1972. U.S. Department of Health, Education and Welfare. Health: United States 1975 , Rockville, Maryland: U.S. Department of Health, Education and Welfare, Public Health Service, Health Resources Administration, National Center for Health Statistics, 1975. U.S. Department of Health, Education and Welfare. "Comparison of Hospitalization Reporting in Three Survey Procedures." V i ta I and Health Statistics , Series 2, Number IS, (July, 1965). Van de Geer, J. P. Introduction to Multivariate Analysis for the Social Sciences . San Francisco: W.H. Freeman and Company, 1971. Wa r he i t , G . J . , et a I . Planning for Change: Needs Assessment Approaches . The National Institute of Mental Health, no date. We i s s , C . H . Evaluating Action Programs: Readings in Social Action and Education . Boston: Aliyn and Bacon, Inc., 1972. Weiss, C.H. Evaluation Research . Englewood Cliffs, New Jersey: Prentice-Hall, 1972. Young, L.S. "Physician's Assistants and the Law." Nursing Outlook , 20:56-41 (January, 1972). Zborowski, M. "Cultural Components in Response to Pain." Journa I of Social Issues , 8: 16-30 (Fall, 1952). Zeitlin, I ,M. Rethinking Sociology . New York: App I eton-CenturyCrofts, 1973.

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BIOGRAPHICAL SKETCH Robert Edmund 3urke was born in Boston, March 31, 1947. He graduated from Boston College High Scnool and attended Boston College where he received both his A. 3. and M.A. in Sociology. Before pursuing further graduate studies, he was an instructor at The College of Saint Teresa in Winona, Minnesota. He entered the Ph.D. program in Sociology at the University of Florida the fall of 1971, with Medical Sociology as his major area of concentration. While at the University of Florida, he served as President of Beta Chapter of Alpha Kappa Delta, the National Sociology Honorary. Since 1974, Mr. Burke has been Senior Analyst for the Research and Development acitivity of Medicus Systems Corporation . 14<

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I certify that I ha*/e read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. George WaTheit, Ph.D. Professor of Sociology I certify that I have read this study and that in my opinion it conforms fo acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor cf Philosophy. / M**1 ijVxS^Hi&)^ Felix Serardo, Ph.D. rofessor of Sociology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. /I Wi I bur Bock, Ph.'D. Associate Professor cf Sociology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is ful !y adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. /seph Vandiver, Ph.D. Professor cf Sociology

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! certify that I have read this study and That in my opinion it conforms to acceptable standards of scholarly presentation and is ful adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Otto vcn Mering, Ph.D. Professor of Anthna^iogy This dissertation was submitted to the Graduate Faculty of the Department of Sociology in the College of Arts and Sciences and to the Graduate Council, and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philisophy. Dean, Graduate School

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iiilff.