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GibsonF.H.2003.IndigentclientperceptionsofbarrierstomarriageandfamilytherapyDissertationUniversityofLouisianaatMonroe..pdf
IV. LOUISIANA FAMILY PLANNING
Joseph D. Beasley, M.D., M.P.H.; Ralph F. Frankowski, Ph.D., M.P.H.; and C. Morton Hawkins, D.Sc., M.P.H.
Introduction
THE object of this paper is to givethe reader an operational perspective on the subject of evaluation in ongoing health programs. The term evaluation is used in many senses. It may serve some purpose to delineate several distinct forms of evaluation. To some authors, evaluation is synonymous with the ap- plication of the scientific experimental method in its strictest sense, i.e., evalua- tion implies randomization, replications and local control, or comparison in the application of some treatment, the term "treatment" interpreted in a wide sense. Evaluation then continues along a curi- ous spectrum which touches concepts in the analysis of observational data, pro- gram administration, funding, the inter- action of personnel, facilities and recipi- ents, and may end in a very subjective process which is dependent only on wisps of data. The evaluation process described in this paper is somewhat in the middle of the spectrum. We believe that evaluation should represent the ap- plication of the seientific method to a host of questions which are relevant to program development. The scientific method implies curiosity in problem definition, hypothesis about problem so- lution, gathering of data related to the problem, and then examination of the data in conjunction with the original hypothesis. The process of evaluation is circular and continuous. The process should point out successes and admit to failures.
The Louisiana Program
In order to describe the current eval- uation efforts within the Louisiana Fam-
ily Planning Program, it is necessary to describe the environment in which it evolved and the long-term strategy of the program.
Studies conducted by Beasley and Harter during 1964 and 1965 revealed marked variations in knowledge concern- ing basic reproductive physiology, the ovulatory cycle, and effective means of contraception among social classes in the metropolitan New Orleans area.^ The studies found knowledge about reproduc- tion to be most laeking within the lower socioeconomic group, where approxi- mately 90 per cent of the males and females in the metropolitan area did not understand the relation between the pe- riod of ovulation and fertility. Data from these studies also indicated that approxi- mately 27 per cent of the lower socio- economic population were either sterile or subfecund. Within the fecundable por- tion of this population, it was estimated that 62 per cent had used no method of contraception during their most recent year of cohabitation. Approximately 38 per eent had used some form of contra- ception ; frequently, however, its use was sporadic and in most cases, lower so- cioeconomic couples employed highly in- effective coitally-related methods. There appeared to be no basic motivational blocks to the effective use of family plan- ning techniques; rather, the respondents expressed a strong desire to control fer- tility.
At the time these studies were con- ducted, there were no organized family planning services of any kind available to the lower socioeconomic group in the New Orleans metropolitan area. Neither the charity hospitals nor the public health facilities provided these services.
T812 VOL. 61. NO. 9. A.J.P.H.
EVALUATION OF NATIONAL HEALTH PROGRAMS
Low-income couples who did practice contraception, therefore, did so with their own funds, in most cases employ- ing nonmedical techniques, and in a few cases utilizing medical methods ap- parently prescribed by private physi- cians.^
These and other studies^ led the re- searchers to hypothesize that the indi- gent population's failure to control fer- tility effectively was primarily caused by an inadequate understanding of basic reproductive physiology and contracep- tive methods, and by lack of access to health services that would have provided instruction and care in modern family planning methods. On the basis of pre- liminary data derived from a pilot study in Lincoln Parish, it was further hy- pothesized that an adequately designed patient-oriented family planning program would be utilized by a majority of in- digent families.
Purpose of ihe Program
In the spring of 1966, a group of concerned agencies and institutions* was brought together to establish the Or- leans Parish Family Planning Program. The program aimed at providing family planning services to the indigent popu- lation of the metropolitan area. The program's design was based on (1) studies of social characteristics of the target population, (2) studies of patterns of death and illness within this popula- tion, and (3) operational research con- ducted in Lincoln Parish, a county of 34,700 people.
The first goal of the program was to develop a family planning delivery sys- tem capable of identifying, contacting, educating, and providing all indigent families of the metropolitan area with family planning information and serv- ices, thereby enhancing the system of health services to this group.
The program's second major goal was to accomplish this objective within the
three-year period July 1, 1967 to June 30, 1970.
A third objective was to evaluate the program by measuring its impact on fertility among the target population and its impact on the various obstacles to family health associated with the lack of family planning.
Operational Plan
The period between July 1966 and Oc- tober 1966 was spent in formulating a plan^ by which such a program could be initiated. Our efforts led, in October 1966, to the formation of a private non- profit corporation, "Family Planning, In- corporated," the agency responsible for implementing the service aspects of the demonstration program and for coordi- nating the activities of the cooperating agencies. This corporate mechanism was chosen because limited available fund- ing required the use of existing resources and personnel with maximum efficiency and a degree of administrative flexibil- ity that did not exist among the organi- zations participating in the program. From October 1966 through April 1967, two major classes of activity were neces- sary. The first was to evaluate existing resources among the participating agen- cies and to develop the mechanisms of coordination necessary between the vari- ous agencies and the program. The sec- ond was to secure funding. These goals were accomplished by April 1967, and the active preparation of facilities, re- cruitment and training of personnel, and other logistics began. The program offi- cially began on June 27, 1967.
The corporation is the agency respon- sible for the development, implementa- tion, and coordination of family plan- ning in the metropolitan New Orleans area (as well as in the state of Louisi- ana). We feel that the results reported in this paper could not have been ac- complished without the administrative cohesiveness and flexibility afforded by
SEPTEMBER, 1971 1813
the corporate mechanism. This mecha- nism allowed us to gather information necessary for making decisions about program operation and about program development and funding. It provided the administrative capacity to deal with over 25 federal, regional, state, and lo- cal agencies that are related to the pro- gram. It also permitted the use of sys- tems analysis, time effort studies and automated data processing, which are crucial elements of modern management technology. Such techniques have not sufficiently applied to the development and implementation of family planning programs in other parts of the U.S. or in the international field. The experience with the corporate mechanism, backed up by consultation and research from universities and other organizations, in- dicates that it would be wise not to dis- count the potential health and demo- graphic effects of family planning pro- grams before we learn how to apply the available technology effectively.
The data to be presented are restricted to the Orleans Parish component of Family Planning, Inc. This is the largest single component of the statewide pro- gram, and began in June 1967.
The New Orleans Standard Metro- politan Statistical Area (SMSA) con- sists of three parishes, or counties: Or- leans Parish, Jefferson Parish, and St. Bernard Parish. Orleans Parish can be identified as the central city of New Orleans; Jefferson and St. Bernard Par- ishes basically form the urban ring. In 1960 the total population of the SMSA was reported to be 868,480 persons (69 per cent white, 31 per cent black) with 72 per cent resident in Orleans Parish. Within Orleans Parish, 63 per cent of Jthe population were classified as white.
As of July 1, 1967, an estimated 210,500 females aged 15 to 44 resided in the SMSA. Information obtained from the 1965 metropolitan New Orleans Sur- vey was applied to this total estimated female population to provide an estimate
of the number of women eligible for the family planning program. The survey indicated that between 16 per cent and 23 per cent of women could be classi- fied as both fertile and belonging to the lower socioeconomic class.* In this group were women with family income under S4,500, education of head of household no more than one year of high school, and occupation of head of household in the service or laborer category, resulting in an estimated 33,700 to 48,400 women who met program eligibility require- ments.
A Summary of the Two-Year Program Response
The Orleans Parish Family Planning Clinic System is composed of a central clinic and three satellite clinics. The central clinic is located at the transpor- tation hub of the city in the immediate vicinity of the two medical schools in the community and the community char- ity hospital. The satellite clinics are lo- cated in a public housing area, and in neighborhoods tbat have been desig- nated as poverty areas. The healtb serv- ices provided are focused on the develop- ment of family planning as an integral component of maternal inter-concep- tional care. Tbe services provided in- clude prenatal care, postpartum care, the prescription and medical supervision of methods for conception control, screen- ing for chronic diseases, social and med- ical counseling.
Table 1 gives tbe total number of program contacts, appointments kept, and number of acceptors of contracep- tive methods during tbe first two years of program operation. In tbis period of time, a total of 24,230 initial contacts were made through tbe program which resulted in 17,459 first admissions to tbe clinic program. As a consequence of their first admission experience 16,762 women adopted some method of family plan-
* The interval reported is computed as a 95 per cent confidenee interval.
1814 VOL. 61. NO. 9, A.J.P.H.
EVALUATION OF NATIONAL HEALTH PROGRAMS
Table 1 Total program response and acceptance rates for the period June 27, 1967-June 30, 1969
Rate per 100 estimated
Rate per 100 program females aged eligible females ••̂ "•• years 15-44 years
50.1-71.9
36.1-51.8
34.6-49.7
Total program eontacts 24,230 11.5
Total first admissions 17,459 8.3
Total aeceptors 16,762 8.0
ning. Participation in the program dur- ing the first two years was highest during the third quarter of the first year of operation.
The response to the program is also presented in Table 1 and is related to both estimates of the total female popu- lation 15-44 and the program-eligible population. Since the inception of the program an estimated 11 per cent of the total female population aged 15-44 has been contacted by the program. This represents an estimated contact rate of between 50.1 and 71.9 contacts per 100 program-eligible women. The acceptance rate is estimated between 34.6 and 49.7 acceptors per 100 eligible women.
Sources of Patient Referral
First admissions for each year and sources of patient referral are given in
Table 2. The major source of patienis is the postpartum referral system. Estab- lished and maintained by the program, this system accounted for 61 per cent of the total patient load during the two- year period. An additional 19 per cent of the patient load could be attributed to friend or self referrals.
The Family Planning Auxiliary Worker system, which forms the outreach and follow-up component of the pro- gram, accounted for 11 per cent of the total patient load.« Other types of re- ferral, predominantly from established poverty-oriented agencies, accounted for the remaining 10 per cent. These data indicate that in order to establish an effective program, a comprehensive set of contact mechanisms must be created by the operating program to maximize contact with the potential patient popu-
Table 2 First admissions by time period of admission and source of referral
Time period
27 June 1967- 30 June 1968
30 June 1968- 30 June 1969
Total
Per eent
Postpartum
5,452
5,131
10,583
60.6
Source of
Auxiliary outreaeli worker
960
912
1,872
10.7
referral
Self or friend
1,852
1,446
3,298
18.9
Other
942
764
1,706
9.8
Total
9,206
8,253
17,459
Per eent
52.7
47.3
100.0
SEPTEMBER. 1971 1815
Table 3—Categories of initial appointments by percentage of initial ap- pointments kept, period June 27, 1967-June 30, 1969
Type of appointment
First appointment
Second appointment made by phone or mail
Third appointment made at time of home visit
Total
Number of appointments
made
24,230
8,657
2,799
35,686
Number of appointments
kept
14,426
1,907
1,126
17,459
Percentage appointments
kept
59.5
22.0
40.2
48.9
lation. Programs must provide aggres- sive and dynamic outreach systems to reach potential participants.
Table 3 indicates the manner in which appointments to the program were kept. The first column of Table 3 describes three types of clinic appointment. If a woman fails to keep her first clinic ap- pointment, she is subsequently contacted by telephone or mail. If she fails to keep this second appointment, a home visit is made by one of the program's family planning auxiliary workers. This fol- low-up cycle is completed, no further patient contacts are made and the pa- tient's record is closed unless she initiates a reopening at a subsequent date. The exception would be extensive and vigor- ous intervention by health auxiliaries if patients are found to have life-threaten- ing lesions, such as early cancer of the cervix.
Table 3 shows that 60 per cent of the women kept their initial appointments without program assistance in follow-up. The total number of women who kept an appointment was increased from 14,426 to 17,459 or 21 per cent as a re- sult of the follow-up system. Thus, in addition to adequate sources of referral, it should be noted that a large-scale ap- pointment and follow-up system is neces- sary to insure high levels of partici- pation. It is noteworthy that 72 per cent
of all women from the SMSA who were offered appointments to the program eventually kept their appointments. These data substantiate the strong motivation in this population toward participation in the family planning program.
Profile of Patient Characteristics
Table 4 gives a brief comparative profile of demographic and social char- acteristics of women admitted as pa- tients over the two-year period. In sum- mary, a woman entering the program would likely be black (94 per cent); 24 years of age or younger (56 per cent) ; at parity three or less (65 per cent) ; and educated at less than a high school level (69 per cent). She would be char- acterized by a reported history of no previous contraception (45 per cent) or a previous use of only ineffectual con- traceptive methods (30 per cent) ; two or more pregnancies in the last three years (42 per cent) ; a first pregnancy experience below 18 years of age (50 per cent).
It is most likely that a woman entered the program as a result of a postpartum referral (61 per cent) and after enter- ing the program adopted some type of contraceptive (96 per cent). The type of contraceptive most frequently chosen was the Pill (65 per cent).
1816 VOL. 61, NO. 9, A.J.P.H.
EVALUATION OF NATIONAL HEALTH PROGRAMS
In general, the characteristics re- ported above appear to be stable over time. Three exceptions should be noted. First, during the second year of pro- gram operation a 14 per cent decrease was observed in the number of women admitted to the program who had ex- perienced two or more pregnancies in the last three years. The decrease can be partially attributed to the fact that pa- tients admitted during the second year were younger and at a lower parity level than women seen during the first year. Patient recruitment strategies also contributed to this decrease.
The second exception is the type of contraceptive method adopted by patients over the two-year period. There was a 10 per cent decrease in the use of the intrauterine contraceptive device during the second year of the program. During the second year patients tended to choose
the Pill and other methods in prefer- ence to the IUD. Since the Pill requires continuing motivation on the part of the user to be effective, a revision of the educational program in the clinic is presently underway.
The third exception is a small in- crease in white participation in the clinic. Only 4 per cent of total admis- sions during the first year were white women, but during the second year this percentage increased to 7 per cent. The increase in white participation is a re- cent occurrence and possibly an indica- tion of further participation by that group. .
Table 5 gives the reported marital status of the first admission patients. Of the total first admissions only 51 per cent reported married with husband pres- ent, 18 per cent reported themselves as married but separated, 23 per cent re-
Table 4—Selected
Reported statistic
Total first admission
statistics for first admission patients
Time period 1967-1968
9,206
Time period 1968-1969
8,253
Time period 1967-1969
17,459
Per cent black Per cent 24 years of age or younger Per cent parity 3 or less Per cent less than 12 years of formal education
Contraceptive history Per cent no reported previous use Per cent use of less effective methods only Per cent previous use of Pill or IUD
Per cent 2 or more pregnancies in last 3 years Per cent first pregnancy below age 18 years
Planning status of last pregnancy Per cent taking a chance Per cent planned Per cent method failure
Per cent receiving welfare assistance Per cent unemployed (Patient and husband
were applicable) Per cent postpartum referral Per cent adopting contraception
Per cent Pill Per cent IUD
95.7 55.9 62.4 69.5
40.5 35.0 24.3 48.9 51.7
78.8 11.0 9.0
18.9
37.1 59.2 96.3 62.2 20.1
92.6 57.0 68.0 67.8
48.9 23.7 26.9 35.0 48.9
83.3 10.7 5.2
21.4
38.7 62.0 95.6 67.4 9.8
94.2 56.4 65.1 68.7
44.5 29.6 25.5 42.3 50.4
80.9 10.9 7.2
20.1
37.8 60.5 96.0 64.7 15.3
SEPTEMBER. 1971 1817
Table 5—Reported marital status of first admission patients, period June 27, 1967-June 30, 1969.
Marital status Number Per cent
Never married Married with husband
present Conimon.law marriage Married but separated Divorced Widowed Unknown
Total
4,085 23.4
8,934 646
3,141 420 217 16
51.2 3.7
18.0 2.4 1.2 —
17,459 99.9
ported never having been married, and 8 per cent reported a common-law mar- riage, or being divorced or widowed.
Defalled Characferhfics
Table 6 is a cross-tabulation of re- ported age at first pregnancy and com- pleted years of formal education. Ap- proximately 31 per cent of the patients had at least a high school education, 21 per cent had 8 or fewer years of educa- tion, while 48 per cent reported 9-11 years of formal education. Simultane-
ously, 66 per cent of the patients re- ported a first pregnancy at age 18 years or younger. Moreover, Table 6 indicates the association between years of formal education and age of first pregnancy. As age of pregnancy advances, the total years of formal education increase. While the direction of causality cannot be de- termined from these data, the association is striking and reinforces the urgent need for family planning programs to engage in both research and program develop- ment to determine methods of prevent- ing the initial teenage pregnancy.
Of the total number of women par- ticipating in the program during the first two years of operation, 51 per cent were at parity three or less and below age 25. This indicates that in the population studied family planning pro- grams with this design are capable of reaching families at a critical time in the reproductive age period.
Table 7 compares the contraceptive method used most frequently in the past by clinic participants with the contra- ceptive method selected at the time of first admission. While 45 per cent had previously used no contraceptive, 96 per
Table 6—Reported age at first pregnancy and years of formal education, period ending June 30, 1969
Age at first
pregnancy
13 or under 14-15
16-17 18 19 20 or over Unknown
or not applicable
Total
Per cent
3 or less
10 27 22 17 6
41
1
124
0.7
4-6
52 214 176 64 51
120
7
684
3.9
Years of
7-8
145 917 901 289 200 348
17
2,817
16.1
formal education
9-n
82 1,592 3,590 1,222
727 1,077
78
8,368
47.9
12 or more
5 125 921
1,043 1,043 2,231
66
5,434
31.1
Unknown
2 4 9 3
• 5 5
4
32
0.2
Total
296 2,879 5,619 2,638 2,032 3,822
173
17,459
Per cent
1.7 16.5 32.2 15.1 11.6 21.9
1.0
100.0
1818 VOL. 61. NO. 9. A.J.P.H.
EVALUATION OF NATIONAL HEALTH PROGRAMS
Table 7—Contraceptive method used most frequently in the past compared with method selected at time of first admission
Previous method
None Pill lUD Jelly, cream, foam Other traditional
Total
Per cent
None
385 120
7 60 92
665
3.8
Method
Pill
5,130 3,070
13 1.394 1,682
11,289
64.7
selected at
IUD
932 740 35
464 488
2,659
15.3
first admission
Foam
1,208 483
4 400 485
2,580
14.8
Other traditional
112 46
2 37 69
266
1.5
Total
7.768 4,459
61 2,355 2,816
17,459
100
Per cent
44.5 25.5 0.3
13.5 16.1
100
cent of the patients adopted some method of contraception as a result of their clinic experience.
Several transitions in method use can also be observed in Table 7. First, one notes that nearly two out of three pa- tients selected the Pill. In general, the Pill was the method most often selected, regardless of previous usage. The only exception was in the previous use of the IUD, in ^vhich case the woman was most likely to select the IUD again as her preferred method of contraception.
The general trend of the patient popu- lation was toward adoption of efEective
methods (Pill or IUD) and abandon- ment of more traditional methods. For example, in the past only 26 per cent reported using an effective method as compared with 80 per cent adopting an effective method after admission to the clinic program.
Black and White Participation Tables 8 and 9 represent an attempt to
estimate clinic participation rates in re- lation to the estimated number of women who can be classified as financially eligi- ble for admission to the program. The data presented in these tables are re-
Table 8—Estimated participation of financially eligible black women* in the Orleans Parish Family Planning Program
1.
2.
3.
4.
5.
6.
Eligibility, admissions. and general fertility
Estimated number of financially eligible women
First admissions
Per cent of financially eligible women admitted
General fertility (1967)
Per cent of total births (1967)
Estimated participation rate
15-19
7,076
2,775
39.2
139.0
27.6
20-24
5,733
4,471
80.0
210.5
33.9
Age
25-29
4,777
2,944
61.6
155.3
20.8
group
30-34
4,158
1,600
38.5
88.7
10.4
12,951/(29,795) (67.2) = 6 4 . 7
35-39
4,018
828
20.6
46.7
5.3
per 100
40-44
4,033
333
8.3
17.5
2.0
Total
29,795
12,951
43.5
119.5
100.0
eligible women
* Data rcstricled to Orleans Parish residents only.
SEPTEMBER, 1971 1819
Table 9—Estimated participation of financially eligible white women* in the Orleans Parish Family Planning Program
1.
2.
3.
4.
5.
6.
Eligibility, admissions. and general fertility
Estimated number of financially eligible women
First admissions
Per cent of financially eligible women admitted
General fertility (1967)
Per cent of total births (1967)
Estimated participation rate
15-19
2,126
129
0.8
51.8
14.7
20-24
2,252
226
1.3
140.1
42.2
Age
25-29
1,875
168
1.2
95.7
24.0
group
30-34
1,404
86
0.8
58.2
10.9
676/(10,757) (67.2) = 9 . 4 per
35-39
1,400
48
0.5
35.2
6.6
4 0 ^ 4
1,700
19
0.1
6.5
1.5
Total
10,757
676
0.8
69.5
100.0
100 eligible women
* Data restricted to Orleans Parish residents oniy.
stricted to women who are residents of the city of New Orleans.
Row 1 of Table 8 gives 1967 mid-year estimates, by age groups, of the number of financially eligible black women in New Orleans. The procedures and as- sumptions for the computations in Tables 8 and 9 are given in Table 10. Row 2 gives the number of first admis- sion by age group. These are first ad- missions who named New Orleans as their place of residence, and the age grouping refers to the patient's age at admission. Row 3 gives the percentages of financially eligible women admitted to the program. Row 4 gives estimated age-specific fertility rates for the entire black population in 1967, and row 5 is the percentage distribution of these births by age of mother.
From row 3 of Table 8 it is esti- mated that 44 per cent of the black financially eligible population was ad- mitted to the program during the first two years. In more depth, the age-spe- cific percentages indicated that the greatest impact occurred in the age group 20-24. It is also interesting to note that the age-specific admission rates, are ranked in the same order as the baseline age-specific fertility rates. The admission rates also appear to be con-
sistent with the percentage distribution of births with one exception, which oc- curs in the age group 15-19. On a per- centage basis this group accounted for 28 per cent of the total black births in 1967. Thus, relative to age groupings, the 15-19 group ranked second in the distribution of births, third in general fertility, and third in admission. The program's admission policy is giving par- ticular attention to the unmarried teen- ager. A similar re-examination should occur in all existing programs and in public policy regarding admission of unmarried teenagers to family planning programs.
Table 9 gives similar data for the white population. Table 9 indicates that only 0.8 per cent of the financially eligi- ble white population enrolled in the clinic program. However, even with the small number of patients, it is interesting to note that the admission rates are di- rectly associated with both the age-spe- cific fertility rates and the percentage distribution of white births for the year 1967.
Row 6 in Tables 8 and 9 is an at- tempt to relate first admission patients to the total number of eligible women in New Orleans. A correction factor of about % was applied to the total num-
1820 VOL. 61. NO. 9, A.J.P.H.
EVALUATION OF NATIONAL HEALTH PROGRAMS
ber ol financially eligible women in order to correct this figure for the num- ber of women who would be classified as not available for participation in the family planning program. The correc- tion factor was derived from three years of contact experience in the Lincoln Parish Family Planning Program. It accounts for the number of women cur- rently pregnant, desiring a pregnancy, sterile, etc. When this factor is applied to the total number of financially eligi- ble women, the results yield a partici- pation rate of 65 per 100 eligible women
for the black population as contrasted with a participation rate of 9 per 100 for the white lower-income patients in the clinic program.
Table 10 describes the procedures and assumptions necessary for the computa- tions given in Tables 8 and 9. Table 10 is given to alert the reader to limita- tions in the interpretation of these data. We believe the data presented adequately reflects the levels of need and clinic uti- lization in New Orleans. Data from the 1970 census will certainly remove some of the present uncertainties.
Table 10—Procedures and assumptions for the computations presented in Tables 8 and 9
1. The distribution of women 15^4 years of age by five-year age groupings was obtained for Orleans Parish, 1967, from estimates provided by the Division of Business and Economie Re- search, Louisiana State University in New Orleans (LSUNO). These projections are based on a cohort survival technique from numbers of women by race and age as given in the 1950 and 1960 U.S. Censuses. Details may be found in the publication, "The Population of Louisiana: Projections by Race, Sex and Age," Population Study No. 1, LSUNO, February, 1968.
2. The population projections were reduced in eaeh age eategory by applying the per cent of families in Orleans Parish classified as poor, by race. The per cent of families classified as poor was 25.6 per cent for the parish as a whole, 50.1 per cent black and 13.4 per cent white. These data were obtained from the Office of Economic Opportunity Infonnation Center, Com- munity Profile as reported in the publication, "Statistical Abstract of Louisiana," LSUNO, Third edition, 1969. (Row 1, Tables 8 and 9).
3. Under the OfSce of Economic Opportunity criteria for economic status, an individual is con- sidered poor if his personal income or the income of the family to which he belongs inade- quately provides for his subsistence. The exact criteria were those developed by the Social Security Administration. The classification is based upon 1960 U.S. Census data for Orleans Parish.
4. Row 2, Tables 8 and 9, gives the number of women by age admitted for the first time to the Orleans Parish Family Planning Program. These women were reported residents of Orleans Parish and the age grouping is given at the time of admission.
5. When the number of women admitted is divided by the number of estimated financially eligible women, an age-specific admission percentage was computed. This percentage does not take into account any qualifying factors relative to eligibility other than financial criteria. (Row 3, Tables 8 and 9.) The data reported in row 3 are valid only on the assumption that all first admissions (numerator) are of the financially eligibility population [denominator]).
6. Rows 4 and 5, Tables 8 and 9, give the estimated age-specific fertility and per cent distribu- tion of births, by age of mother, for the general population, 1967. This data reflects Orleans Parish only.
7. The estimated participation rate was computed for each population by applying an estimate of the number of women currently not available for service due to factors such as pregnancy, sterility, sensitivity, no need, etc. This percentage estimate is based upon data reported in the publication, "Family Planning and the Reduction of Fertility and Illegitimacy: A Pre- liminary Report on a Rural Southern Program," Beasley, J. D. and Parrish, V. W., Social Biology, June 1969. This is a local estimate and reflects the best local data available.
SEPTEMBER, 1971 1821
Table 11—Selected first admission statis- tics by ctlinic composition of the pa- tient population (period ending 30 June 1969)
Reported statistic
Total first admissions Per cent 24 years of age
or younger Per cent parity 3 or less Per cent less than 12 years
of formal education
Black
16,451
56.5 64.8
68.2
White
998
55.0 69.9
77.0
Contraceptive history Per eent no reported
previous use Per cent use of less
effective methods only Per cent previous use
of Pill or IUD Per cent 2 or more pregnancies
in the last 3 years Per cent age of first pregnancy
less than 18 years
Planning status of last pregnancy
Per cent taking a chance Per cent planned Per cent method failure
Per cent receiving welfare assistance
Per cent unemployment Per cent postpartum referral
Per cent adopting contraception
Per cent Pill Per cent IUD
44.2
29.9
25.6
42.2
50.0
81.5 10.3 7.3
20.1 38.1 60.8
96.5 64.8 15.2
49.1
25.7
25.3
44.4
57.7
71.9 20.9 5.9
19.9 33.5 57.5
91.5 62.3 15.8
Table 11 gives a brief comparison of patient characteristics by ethnic compo- sition. The data presented do not pro- vide any characteristics which appre- ciably differentiate the two groups be- yond the variable of classification. The typical white patient was slightly older and at a lower parity than the black patient. The white patient had, in gen- eral, fewer years of formal education and less contraceptive experience than her black counterpart. The white patient also became pregnant at an earlier age; however, it was more likely that her most recent pregnancy was planned.
Both groups reported approximately the same level of welfare assistance, but the white patient reported a shghtly better employment status. Lastly, the typical white patient was reluctant to use con- traceptives, but when a method was ac- cepted, the most prohable choice was the Pill.
Thus the data reveal the basic dimen- sions of similarity among the patients' social, economic and medical poverty.
Continuity of Patient and Program
Within the context of a family plan- ning program, a partial measure of the program's performance can be obtained through analysis of the patterns of con- traceptive practice of women participat- ing in the program. To this end, a study of 3,187 women who adopted a contra- ceptive method in the program was con- ducted. This study included all women who were first admissions to the program between June 27, 1967 and January 1, 1968. The period of observation for this cohort extended to January 1, 1969. The period of use analyzed began with the initiation of contraception and terminated with any one of the follow- ing five statuses: (1) not pregnant and using contraception at the end ol the period of observation; (2) accidental pregnancy while using contraception; (3) discontinuation of eontraception for personal reasons; (4) discontinuation of contraception for medical reasons; and (5) loss to follow-up. Some of the re- sults of this study are reported in Table 12. From these data it can be observed that the cumulative probability of a woman successfully using clinic-managed contraception for 12 months is 0.83. The 18-month cumulative probability of con- tinued contraception is 0.74. In other words, we estimate that three out of four women admitted to the program will he active contraceptors 18 months later. Thus, both contact and continuity with patient population have been established by the program.
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EVALUATION OF NATIONAL HEALTH PROGRAMS
Discussion
The metropolitan New Orleans Family Planning Research and Demonstration Program was predicated on:
1. Demographic and social studies of medically indigent patients who were to be the primary recipients of the services.
2. Studies of the availability and usage of existing health services and resources.
3. A detailed evaluation of all fa- cilities and resources which could be used in the implementation of a fam- ily planning program.
4. Operational research was imple-
mented in 1964 in one county with a population of 34,700, which was used as a research area where prob- lems of program design could be tested in a small population in order to gain some indication of their ap- plicability to a metropolitan area of over one million. As a result of this development and consideration of be- havioral, political, social, and admin- istrative variables, the program design for New Orleans was developed. These research findings indicated that cri- teria which required priority were decision-making in the program which could be adopted to serve the needs of the patients; and design and ad-
Table 12—Monthly and cumulative probabilities of the continued use of clinic-super- vised contraception—all methods of contraception
Ordinal month
1 2 3 4 5 6 7 8 9
10 11
12 13 14 15 16 17 18
Women exposed to the risk of termination at start of
ordinal month*
3,187 3,065 2,950 2,846 2,757 2,674 2,605 2,520 2,450 2,374 2,306 2,245 2,158 1,687 1,217
860 509 231
Adjusted number of
women exposed to termination during ordinal
montht
3,144.5 3,031.5 2,925.0 2,823.5 2,739.0 2,658.5 2,585.5 2,502.5 2,429.0 2,355.5 2,291.5 2,220.5 1,936.5 1,458.0 1,047.5
693.0 374.5 117.0
Number of terminations
observed during ordinal
montht
37 48 54 44 47 38 46 35 34 31 32 38 28 12 18 17 9 3
Probabilities ot continuation
Monthly
0.99 0.98 0.98 0.98 0.98 0.99 0.98 0.99 0.99 0.99 0.99 0.98 0.99 0.99 0.98 0.98 0.98 0.97
Cumulative
0.99 0.97 0.95 0.94 0.92 0.91 0.89 0.88 0.87 0.86 0.85 0.83 0.82 0.81 0.80 0.78 0.76 0.74
Standard error of cumulative probability of continuation
0.002 0.003 0.004 0.004 0.005 0.005 0.006 0.006 0.006 0.006 0.006 0.007 0.007 0.007 0.008 0.009 0.011
0.015
* Women admitted to the program between June 27. 1967 and January 1, 1968 and followed to January 1, 1969 or to their point of termination with the program.
t Numher of cases adjusted for women lost to follow-up or withdrawn from the study. J Terminations in this category include: (1) accidental pregnancy while using contraception; (2) discontinuation
of contraception for personal reasons; (3) discontinuation of contraception for medical reasons.
SEPTEMBER, 1971 1823
ministration of the program to en- hance the patient's privacy and indi- viduality while respecting her intelli- gence and freedom of conscience. This latter would help patients realize their desire to increase the quality of their own lives and that of their children's. Insofar as possible, this program has been administered with these criteria as guidelines. In short, the program was designed to meet the needs of
• patients.
Our studies indicated that the major problems we faced in implementing a family planning program in an area of over one million people were organiza- tional, not motivational on the part of prospective patients. This conclusion im- plied two principles to be built into the design of the program and its admin- istration. The first was to solve the an- ticipated problem of utilizing a variety of talents; hence we recognized from the start that this multifaceted problem would require a multidisciplinary team working cohesively. The second princi- ple was the need to develop a unique structure combining versatility, flexibil- ity, and manpower in an effective manner.
5. After careful study of the data, it was decided that the most flexible, versatile administrative mechanism possible would be a private nonprofit corporation. Such a corporation was established and has been used to de- velop the capacity and test the ap- plicability of concepts used in mod- ern management technology to deci- sion-making processes involved in the development, administration, and evaluation of the program. The corpo- ration has been a highly successful mechanism to this point. As long as the requirements of Items 1 and 2 are met, there may be a variety of in- stitutional and organizational mecha- nisms which could be used to prop- erly develop family planning pro- grams. It is our opinion, however.
that programs which do not consider the factors delineated in Items 1 and 2 will not be successful in achieving their objectives.
6. Our studies indicated that there was a marked lack of information concerning reproductive physiology and contraceptive technology in this metropolitan area of over one million: there were no available organized services designed to meet the needs of patients: and there was no adequate health delivery system for the popula- tion in which we could incorporate family planning. For these reasons we worked with the cooperating and par- ticipating organizations to design a system for the delivery of health care. Such a system had to be developed before a family planning program with the elements we have specified could be implemented and sustained; hence we placed great emphasis on creating the delivery system. Family planning was offered first, then pre- natal care to be supplemented by many other components of primary health care as priorities dictated. All of our studies indicated that there was strong motivation among the lower socioeconomic population, and especially among the economically de- prived black population, for family planning services.
7. Summaries evaluating the results of lower socioeconomic patients' par- ticipation during the first two years of the metropolitan New Orleans study have been presented in detail in the text. However, it is important to em- phasize the following points:
(a) From the initiation of the Orleans Parish program on July 1, 1967 through June 30, 1969, 17,459 families have become active participants in tbe program.
(b) An estimated 74 per cent of all pa- tients who entered the program during the first six months of operation are continuing active contraceptors 18 months after ad. mission.
(c) Over 95 per cent of the 17,459 fami- lies are from the black segment of the
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EVALUATION OF NATIONAL HEALTH PROGRAMS
lower socioeconomic section of the popula- tion.
(d) We estimate that the greatest ac- ceptance of the program is in the 20-24 age group in the black female population of New Orleans.
(e) The probability of a black patient participating in the program has been six times as great as that of a white patient from a lower socioeconomic group.
These data indieate that there is in- deed not only willingness to accept family planning but motivation and desire for these services among the lower socioeconomic population when the services are offered in an acceptable manner. If services are made avail- able to the lower sociocconomie seg- ment of the population in the manner described, we believe that similar levels of acceptance can be achieved throughout the nation. In short, the problem lies in the lack of an effec- tive primary system for the delivery of health care to the indigent. What is needed is a system to provide in- formation about family planning and the means to deliver health care and family planning services.
Other Evaluafion Techniques
In addition to the types of evaluative data presented above a sampling of types of investigations in wbicb researchers in the program are currently engaged are:
1. method specific and non-method specific use-effectiveness and extended use-effectiveness studies through the application of multiple decrement life tables;
2. a cost-benefit analysis of the Or-
leans Parish component of the pro- gram;
3. a determination of family struc- ture, interpersonal communication and fertility decisions;
4. the program effects on child spacing, and;
5. trend analyses of selected vital rates for the clinic eligible popula- tion.
REFERENCES
1. The reports of these studies are: Beasley, Joseph D.: TIarter, Carl L.; and Fischer, Ann. Attitudes and Knowledge Relevant to Family Planning Among New Orleans Negro Women. A.J.P.H. 56,11:1847-1857 (Nov.), 1966; Harter, Carl L. Male Fer- tility in New Orleans. Demography 5,1: 61-78, 1968.
2. Beasley, Joseph D., and Harter, Carl L. Introducing Family Planninpc Clinics to Louisiana. Children 14,5:188-192 (Sept.- Oct.), 1967.
3. Beasley, Joseph D.; Harter, Carl L.; and McCalister, Donald V. Aspects of Family Planning Among Low Income High-Risk Mothers. Advances in Planned Parenthood: Proceedings of the Third and Fourth Annual Meeting of the Amer. ASTOC. of Planned Parenthood Physicians, Amster- dam: Excerpta Med. Foundation, Intenn- tional Congress Series No. 138, TT, 197-204. 1967.
4. The complete list of particinatiuf; and co- operating acencies and institutions is de- scribed in: Beaslev, Joseph D.: Frankowski, Ralph F.: and Hawkins. C. Morton. The Orleans Parish Familv Planning Demon- stration Proftram. Milbank Mem. Fund Quart. 47.3 Pt. 1. 225-253 (July), 1969.
5. Beaslev, Joseph D. The View from Louisi- ana. Familv Planning Perspectives 1,1: 2-15 fSnringi, 1969.
6. A fuller description of the auxiliary worker system is contained in Beasley, Frankowski and Hawkins, op. cit.
Dr. Beasley is direetor of the Health Services Researeh Department, Tiilane University, 1430 Tulane Ave., New Orteans, La. 70112. Dr. Frankowski and Dr. Hawkins are with the University of Texas at Houston, School of Public Health, P.O. Box 20186, Astrodome Station, Houston, Tex. 77025.
This paper was presented before the Joint Session of the Statistics, Community Health Planning, Maternal and Child Health, Mental Health, Occupational Health, and Public Health Nursing Sections of the Ameriean Puhlic Health Association at the Ninety-Eighth Annual Meeting in Houston, Tex., on October 27, 1970.
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