Studies in Medical Care Administration 3 L,— 1 L :i A: (" \INNOVATIUN IN [OCAL HEALTH SERVICES U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service \Studies in Medical Care Administration, lNNllVATION IN LUBAL HEALTH SERVICES A Study of the Adoption of New Programs by Local Health Departments With Particular Reference to Newer Medical Care Activities by Robert ELMytinger, Dr. P.H. U.S. Department of Health, Education, and Welfare Public Health Service Division of Medical Care Administration Arlington, Virginia 22203 1968 Public Health Service Publication No. 1664—2 February 1968 U.S. GOVERNMENT PRINTING OFFICE, WASHINGTON, DC. For sale by the Superintendent of Do Washington, DC. cuments, U.S. Government Printing Office, 20402—Price 45 cents RA447 C2 M47! wand HEALTH LIBRARY Preface In an era of rapid change in health sciences and health services, it is essential to understand what influences the capacity of health organizations to adapt and innovate. With this report, Dr. Robert Mytinger gives us considerable insight into the underlying determinants of innovativeness in local health departments. The study was conducted by Dr. Mytinger while he was a candidate for the degree of Doctor of Public Health at the School of Public Health, University of California at Los Angeles. The present report is a condensed and edited version of his doctoral disser- tation, prepared by Dr. Mytinger at our request. This report is the second publication on medical care and local health departments to be issued by DMCA, the first, "What 13 Local Health Departments Are Doing in Medical Care” was issued in November 1967. We believe these reports complement each other and that borh will be useful to the field of public health as it develops and expands its involvement in medical care activities. We wish to express our appreciation to Dr. Mytinger for his permission to publish this monograph. JOHN W. CASHMAN, MD, Director, Dis/irion of Medical Care Administration. 00274 iii TABLE OF CONTENTS Page PREFACE ......................................................... iii INTRODUCTION ................................................. 1 I. THE THEORY AND CONCEPT OF INNOVATION ................ 3 Demand for Innovation in Public Health Inevitability of Change Definition of Innovation Generalizations II. BACKGROUND OF THE STUDY ............................... 6 Purpose of the Study The Study Setting Methods of Study Definitions General Findings III. CURRENT INNOVATIONS IN PUBLIC HEALTH ................ 9 Literature Review Practicability and Priority IV. DEGREE OF ADOPTION OF SELECTED NEW PROGRAMS ........ 13 Methods of Study New Programs Details of Seven of the 21 New Programs Temporal Aspect of Adoption Role of Other Agencies in Seven Innovative Programs Plans for Future Adoption of Seven Innovative Programs Derivation of "Innovativeness Score” Degree of Innovativeness V. CORRELATES TO INNOVATIVENESS ........................... 36 Methods of Analysis Previously Demonstrated Correlates to Innovativeness Composite Profile Independent Variables VI. CONDITIONS FOR INNOVATION .............................. 41 Bivariate Analysis of Independent Variables and Total Innovativeness Scores "Style” and Physical Features of Innovative and Non-Innovative Local Health Departments Reasons for Adoption/ Barriers to Engagement Multivariate Analyses Summary vi VII. CONCLUSIONS ............................................... Generalizations from the Data Implications for the Diffusion and Adoption of Innovations by Local Public Health Departments APPENDIX ....................................................... Table . New Program Activities Suggested in Recent Professional Literature 10. 11. 12. 13. 14. 15. 16. 17. 18. LIST OF TABLES for Local Health Department Adoption ........................ Practicability and Priority of New Public Health Programs .......... Practicability and Priority Judgments ............................ Number of New Programs Adopted by Local Health Departments— California, 1964 ........................................... Number of California Local Health Departments, by Type of Engage- ment, in Each of 21 Different New Health Program Innovations . . . . Number and Percent of California Local Health Departments Which were Fully Engaged in 21 Selected New Program Innovations, 1965. . Number of 21 Selected New Program Innovations in Which Cali- fornia Local Health Departments were Engaged, 1965 ............ Number and Priority Rating of 21 New Programs Adopted to Some Degree by 50% or More of California Local Health Departments . . . Number and Practicability of 21 New Programs Adopted to Some Degree by 50% or More of California Local Health Departments . . . Number of Seven New Programs Which Have Been Fully Adopted by California Local Health Departments .......................... Years of Adoption (and Discontinuance) of Seven New Programs by Local Health Departments in California ........................ Involvement of Other Agencies Singly or Jointly with 40 Local Health Departments in Seven New Public Health Innovative Programs ..... Number of Local Health Departments Participating in Seven New Public Health Innovative Programs Which are ConduCted by Agencies Other Than Local Health Departments ................. Number of Local Health Departments Playing Initiatory Roles in the Adoption of New Programs by Other Agencies .................. Number of Non-Engaged Local Health Departments Planning or Desiring to Adopt New Programs ............................ Innovativeness Scores Achieved by California Local Health Departments . . Some Variables Which Have Been Found, in Prior Studies, to Asso— ciate Significantly with Innovativeness ......................... Thirty-Three Independent Variables Descriptive of California Local Health Officers, Local Health Departments, and Communities Served, Which Have Been Retained for Further Analysis .......... Page 10 10 12 15 15 16 17 18 18 21 22 31 31 32 32 34 38 40 Table 19. Characteristics of "The Man” Viewed Against Innovativeness Scores. . . . 20. Tenure of Health Officer and Mean Number of the 21 Study Programs Adopted ................................................. 21. Health Oflicer’s Leadership Status and Mean Number of the 21 Study Programs Adopted ......................................... 22. Characteristics of “The Agency" Viewed Against Innovativeness Score . . 23. Characteristics of "The Place" Viewed Against Innovativeness Score . . . 24. Independent Variables Which Individually Associated Significantly with High Total Innovativeness Scores ........................ 25. Reasons for Full Adoption of Seven New Programs ................. 26. Reasons for Adoption to any Extent of Seven New Programs .......... 27. Six Variables Which Explain 74% of Variance in Innovativeness Scores. . 28. Factor Groupings of 21 New Health Programs .................... 29. Independent Variables Which Best Explain Innovativeness in Five Program Categories ........................................ 30—45. Characteristics of California Local Health Oflicers .................. 46—67. Characteristics of California Local Health Departments .............. 68—78. Characteristics of the Communities and Populations Served by Cali- fornia Local Health Departments .............................. LIST OF FIGURES Figure HH prwsgvewwr H .N Time of Engagement—Alcoholism ................................. Time of Engagement——Accident Prevention .......................... Time of Engagement—Home Nursing Services ....................... Time of Engagement—Early Discovery of Chronic Illness .............. Time of Engagement—Direct Medical Care Services .................. Time of Engagement—Research and Evaluation ...................... Time of Engagement—Family Planning ............................. Cumulative Adoption of Seven Selected New Programs ................ General Innovativeness ........................................... Reasons for Adopting Seven Program Innovations .................... . Barriers to Planning and Reasons for Lack of Desire .................. Barriers to the Adoption of Seven New Programs Reported by Local Health Departments with Highest and Lowest Innovativeness Scores . . . . Page 42 42 42 43 44 45 47 47 53 54 56 64 67 71 Page 23 24 25 26 27 28 29 30 35 48 $1 52 vii INTRODUCTION There are in the United States three major levels at which official and voluntary public health efforts toward health. maintenance and promotion are organized. Nationally, the Public Health Service and national pro- fessional and voluntary health associations serve pri- marily to stimulate, support, guide, and standardize the efforts of lower echelon organizations. State public health departments, and State voluntary headquarters are, in a sense, line organizations which offer varying degrees of direct service. At the same time, they pro- vide stimulatory, supportive and standardizing functions to the local official and voluntary agencies within their purview. On the local scene, one finds an impressive array of official and voluntary health agencies which directly serve the needs of local populations. This is a study of some of the forces which move local official public health departments toward change or innovation in their programs, of the responses which some local health departments have made to these forces, and of selected variables which may serve either to condition a local health department for change or control its reaction to innovative potentialities. The study concerns itself with innovation in general, but innovation as it applies to medical care services has been chosen as the focus. It is traditional that local health officers are often faced with the necessity of starting new programs and getting rid of old unproductive procedures and objectives. Dramatic new clinical and technologic dis. coveries provide new tools for the detection, treatment, and control of illness, the preservation of a healthy environment, and maintenance of wellness. Different, and often new, health hazards and diseases emerge as a result of the changing physical and cultural environ- ment with which health departments must cope. New social attitudes force consideration of new kinds of health services for the population. Thus, the local health officer finds himself beseiged with mandates for change, and with the necessity of deciding upon priorities for his programs. This, then, is the problem of change which faces modern public health. How is the new added to the old, with facilities, money, personnel, and time the scarcest commodities at the disposal of the health officer? What kinds of pressures conspire to prompt a decision to move in one direction and not in others? Is it true that progress and advancement along many new fronts is only for the rich health department—that the rich health de- partments get richer, and the poor ones get poorer? Is it, as some postulate, that progress derives from the "man"—the leader of the program who, despite all odds, manages to give free rein to his imagination and brings to his constituency the best in new pro- grams? It is to these questions, and others subse- quently to be raised, that this study was directed. The major component of the studies reported in these pages is set in California, and derives from that State’s 40-full-time, fully-staffed city and county health departments. The assessment is concerned with new programs which have been adopted by these health departments; it deals with their characteristics, their administrators, and the communities which they serve. These departments differ not only in size, but also in administrative complexion, kinds of populations served, types of health officer backgrounds, training, experience, age, and other characteristics, and in geographic and climatological characteristics. In a study of this nature, a number of topics which might have been explained for their relevance to inno- vation did not receive intensive exploration or scrutiny. Indeed, a number of very salient subjects got much lighter treatment than others, and in some cases treat- ment was deferred. Included among such important matters would be an assessment of the role which organization apmerr or efficiency might play in innovativeness, and the whole question of whether one kind of organizational struc- ture rather than another enhances innovativeness. A number of useful hypotheses relating to these matters deserve study in the setting of organized public health. To an understanding of these questions, careful or- ganizational analysis of structures, and of the systems which operate within and outside them, would be re- quired. Within the limits of the present study, only a superficial examination of the organizational structure of California’s health departments would at best have been possible. I Similarly, important effects on the rate at which local health departments embrace the novel might be found in the role of the private health proferrion: as they impinge on the activities of health departments. The negative attitudes sometimes held by the private medi- cal profession to action by governmental agencies in dealing with health problems have been widely dis- cussed. One observer suggests that, on the basis of economic considerations, moral issues, negative valua- tion of government, and stereotypes of "usual" health officers, "the public health physician has often settled for limited goals in his relations with private practi- tioners, basing his adaptations on the premise that the boundaries of private practice must and will be little affected by his activities”.1 Closely associated with the impact of private medical practice on the potential innovativeness of local health departments, one might usefully speculate as to the effect of the personal philorophic orientation of the health officer and members of his staff on the extent to which innovation in the organization is permitted or encouraged. The philosophical tendency of "the man”—the local health officer—toward liberalism or conservatism, might logically be thought of as having an important bearing on his innovativeness. Despite the fact that the nature of organized social effort, as exemplified in a local health department, might be thought of as recruiting to its ranks those of the more liberal political and philosophical persuasions, it cannot be doubted that among adminiStrators of such public programs, all shades and degrees of social philosophy may be encountered. However, these psycho- social characteristics of local health administrators which might conceivably affect their rate of innovation were not included among the many facets of innovation considered in this study. Thus, it is recognized that an important contribution to the complete understanding of the processes of in- novation in local public health settings would be made by an assessment of some of the foregoing. A reliable understanding of the respective roles which such issues play might well be the focus of subsequent research in this complex subject-matter area. REFERENCES 1. G. Rosen, "Some Substantive Limiting Conditions in Communication Between Health Officers and Medical Practi- tioners". American Journal of Public Heallh, 51:1805—16, December 1961. CHAPTER I THE THEORY AND CONCEPT OF INNOVATION Demand for Innovation in - Public Health Priorities or mandates for new service programs regularly impose themselves upon local public health departments, their staffs, and their administrators, giv- ing rise to new program dimensions and responsibili- ties not already numbered among the array of current services offered. The implied innovations may be thought of as deriving from the following principal sources: 1. new medical knowledge related to diagnosis, eti- ology, treatment, and prevention of illness; 2. changes in the physical environment, arising from bOth natural and man-made phenomena; 3. a shifting epidemiological pattern, wherein hidden dangers come to light when more obvious dangers are removed, as with the emergence of chronic illness pat- terns in the United States which might not have as- sumed their contemporary significance had not infec- tious disease been so largely reduced; 4. new demands for service from voluntary citizen and professional groups, consumer and client groups, or from legislative and other governmental bodies; 5. a changing moral and political base, as may be seen in the widening subscription to the view that med- ical care is a fundamental human right. Confronted as they are on many fronts by potential innovations in the organization and delivery of health services, local health departments may or may not reflect these new dimensions in their services to their communities. Their ability to adopt innovations, and their propensity to do so, would seem to depend upon an interplay among a variety of factors. It has been commonly observed that local health de- partments have been generally unresponsive to chang- ing health program needs. Their tendency to lag behind movements for change—to be late in adopting the new and to delay in grasping the support which the public often willingly offers—was a constant theme in the writings of Joseph Mountin, a public health pioneer of the 1930’s and 1940’s. His feelings on the matter he once summarized thus: "As a rule, health departments have been hesitant about entering the new fields, retaining instead their traditional orientation to communicable disease control, sanitation, and personal hygiene .for the younger groups.” 1 Other contempo- rary writers, too, have addressed themselves to this propensity, for example: “the agency musr . . . inno- vate to keep abreast of its society, or it will be servicing problems ancient in vintage and extinct in significance. . . . Inflexibility is a pathway to extinc- tion, and one must either successfully innovate and progress or simply decline."2 ' It is at the local—the city and county—levels of government in most areas of the United States where one encounters the major share of today’s organized preventive and promotional public health services for the population. Ignoring the fact that about 21% of the counties in the United States today remain without organized local public health service, the disparities between the extent and scope, the quality and effective- ness, of those services which existing local health services offer are significant and obvious.3 Obviously, these indictments cannot be levied solely against local health departments, for not all program innovations suggest an isolated responsibility for change. It has been pointed out, for example, that professional public health does not now have the answer to the question, what should a health department do, but that the answer is part of a larger one: what health services should be provided in a community for its people. The crux of the problem is that "official agency re- sponsibilities have been traditionally . . . only a part of the total community resource available to the in- dividual to protect and promote his health. Two decades ago . . . it was easier to separate out the well-known ‘six essential services’ of the official health agency . . . with the development of new environmental hazards . . . new chemicals . . . drugs . . . the increasing relative importance of degenerative disease, it has been abun- dantly evident that joint community action is needed.” 4 This confused sharing of responsibility for action is a point of differentiation between public health agencies and other governmental and industrial organizations, and this point will be explored more fully when the generalizibility of other researches in innovation is explored in relation to the field of public health. The question of shared responsibilities notwithstand- ing, the fact remains that some people, in some coun- ties and cities, enjoy more and better public health service than their neighbors living in other areas. Some local public health departments, singly, via other or- ganizations, or by partnership, find success in develop- ing and bringing to their communities a wide and imaginative range of public health services, while others retain the flavor of more classical days. Still others even have difficulty maintaining the level of service which characterized the public health move- ment during its earlier epochs. The possibilities of change are frequently countered with apologetics such as "too little money,” or "too conservative a local government,” or "the press of everyday activity precludes taking on anything new." One hears that “other agencies should really do this,” or that “all populations don’t require the same scope of public health service for the optimization of their healt Local health departments represent a unique class of organizations which enjoy, permit, or even require an aetive partnership or sharing of their responsibili- ties by one of several other agencies in their com- munity, both official and voluntary. The responsibility for health promotion and disease prevention is char- acteristically diffused over a wide range of different and autonomous organizations. The question of the proper role of the official health agency quite naturally arises—should it directly "do" public health, should it stimulate others to shoulder their responsibilities, or to what degree should it share the burden with others? The matters which perplex those attempting to effect change in official health organizations relate to a variety of potential influences. For example, what is the impact of consultation (or advocacy of an innovation)? What really is the effect of the availability of funds, or the effect of State and national program emphasis upon the adoption of newer programs at the local level? Does the advent of new technological information and 4 emphasis in professional literature substantially effect the likelihood of a new program’s being adopted at the local level? What are the relative effects of the health officer’s personal characteristics, those of his department, and the nature of the community which he serves? Competition among mandates must cer- tainly control, at least to some extent, the decisions as to which have the higher priority and thus, which are adopted most readily. Which kinds, of mandates, then, by their nature exercise this kind of influence over their eventual adoption by local health authori- ties? This study has been directed towards a partial answer to some of these perplexities. Inevitability of Change Change affects the course and content of cultures and culture generally, and the “futility of attempting to maintain the ttatm qua” is a frequent theme. Whatever the change, and whatever the process by which it comes about, it occurs in a cultural setting and represents a social phenomenon. Wallace5 adds further that "members of a society will ‘learn’ to innovate (and thus effect cultural changes) in pre- cisely those cultural areas in which innovation is apt to be regarded as desirable by society." Murdock 6 holds that "cultural change begins with the process of innovation, the formation of a new habit by a single individual which is subsequently accepted or learned by other members of his society." Cultural change, thus may be thought of as taking place when- ever social behavior persistently deviates from estab- lished cultural habits in any direction, after which time modifications, to bring habits, customs, beliefs, etc., into conformity with the new mode, affect a change in culture. Inasmuch as innovation will shortly be defined as a deviation from former states of affairs, it should be suggested at this point that such deviations, when adopted by, accepted by, or learned by other members of 'a society amount to a change in that culture—thus, innovation is found to be a core concept in cultural change. Definition of Innovation What is innovation? How does it come about and what kinds of people are innovators? Is invention merely a part of broader social change? Are there barriers to innovation and how do these resistances affect the rate at which a given novelty is adopted? If there be resistances, there may also be stimulants to change—can these be identified? Are innovators "different” from others in personal characteristics? The term "innovation" includes principles, methods, techniques, customs, and skills, as well as aspects of the material culture (artifacts and instruments) to which they may be related.7 A number of definitions have been offered as to what constitutes innovation, but the most widely quoted concept comes from Bar- netta who describes an innovation as “any thought, behavior or thing that is new because it is qualita- tively different from existing forms (but comprising elements of common forms) . mental constructs, some of which may be given tangible form or expres- sion.” Innovation is seen, thus, as a reconfiguration of pre-existing elements. Burns and Stalker, Wallace, and Beals and Hoijer condition Barnett’s views by adding that the cultural and situational milieu, idiosyncratic experience, and general cognitive process are involved as well as pre-existing elements, and that beginnings and finite combinations are not always the case—that serendipity and other effects may well be at work. In- novation is seen, then, as a "creative act of man"9 deriving from “individual experience and initiative” 1° and the cultural setting in which the innovative force (man) finds himself.11 Generalizations Some of the relevant literature has been reviewed here and accord has been found with the following generalizations: The components of culture, following some pattern or another but at differing rates, undergo a constant change. Such change is largely technologically based and is dependent upon the assimilation of new methods, devices, implements, customs, etc., by individual men. Such innovations which contribute to changing cultures derive from the minds of men, may be generally thought of as recombined elements from existing cul- tural components, and may come about either by de- sign or by accident. There are a number of stimulants to innovation, most of which are dependent upon satis- fying one or more wants which may be felt by man. Similarly, resistances to the adoption of innovation or to a change in culture are based likewise on the wants of men and the limitations of their particular cultural milieu. Ranking high among the reasons for resistance to change would be t which the new often brings to those in established power positions; the which follows in the wake of the new; and the con- ceptualization of the motives of the change agent which is held by those expected to adopt the new or sub- scribe to it. Regardless of resistances, innovations (and thus cul- tural change) are constantly introduced and adopted, and their acceptance is thought of as being based on the values of the novelty, the kind of advocacy it enjoys, the kind of‘wants or needs being experienced by porential adoptors, and by psychological factors in- herent in those who may or may not accept the new. Thus, innovation is culturally based (the personalities , and felt needs of innovators and adoptors are cul- turally derived) and, in turn, contributes to cultures, their configurations, and components and their changing character. REFERENCES 1. J. Mountin, "Organizing for the Newer Public Health Programs”, Public Health Nurring, October 1950. 2. Henrick L. Blum and Alvin R. Leonard. Public Admin- istration—A Public Health Viewpoint. MacMillan (New York), 1963. 3. Public Health Service, Department of Health, Education and Welfare. Directory of Local Health Unit: (PHS Publica- tion No. 118—1962 Revision). Washington, D..,C 1962. 4. Editorial: "What Should a Health Department Do?” American Journal of Public Health, 52 2841—42, May 1962. 5. Anthony F. C. Wallace. Culture anal Perronality. Random House (New York), 1961. 6. George Peter Murdock, in Man, Culture and Society. (Harry L. Shapiro, ed.) Oxford University Press (New York), 1956. 7. Francis R. Allen, in Technology and Social Change. (John F. Cuber, ed.). Appleton-Century-Crofts (New York), 1957. 8. H. G. Barnett, Innovation. McGraw-Hill (New York), 1953. 9. Margaret T. Hodgen, Change and Hirtory. Wenner-Gren Foundation for Anthropological Research (New York), 1952. 10. T. Veblen. The Instinct of Workmamhip; and The State of The Indurtrial Artr. New York, 1914. 11. Tom Burns and G. M. Stalker, Management of Innova- tion. Tavistock Publications (London), 1961; Wallace, op. cit. CHAPTER II BACKGROUND OF THE STUDY Purpose of the Study This study is specifically directed to the following: 1. Where new program innovations have been adopted by local health departments, a description of the reasons which lie behind their adoption, the bar- riers to adoption or program enlargement which are faced by those who wish to adopt or enlarge, and the reasons for non-adoption on the part of those who do not plan or wish to adopt newer programs; 2. An analysis of selected characteristics descriptive of health administrators, of their organizations, and of their communities, in an effort to discriminate be- tween adopters and non-adopters of new programs; 3. This study’s final objective is to suggest what these data tell about the likelihood of any given local health department’s adopting potential program innova- tions—is it the man, the agency, or the place? To measure alone is not to understand and pressing prob- lems such as the delivery of health service demand an understanding of both the causes and consequences. It is not proposed, however, to offer causal relationships, but rather, it is the aim to develop from such general associations a series of testable hypotheses which will be data-based and statistically documented. The Study Setting The description of current mandates for changes in local health department programs, and the assessment of their relative practicabilities and priorities for adop- tion, preceded the present study and derived from nation-wide samplings of professional literature and the opinion of public health leaders respectively.* While arising from a broader universe, these program innovations, and the subsequent analysis of their prac- * Robert E. Mytinger, "Mandates for Change in Local Health Departments,” Public Health Repartr, Vol. 81, No. 5, May 1966, 442—448. 6 ticability and priority, are referable to the 40, full- time, fully-staffed local health departments in California. The major phase of this research-the field 'studies— specifically embraced these 40 local health departments, but it may be assumed that the findings of this study are true, to a greater or lesser degree, in each of the other states. Methods of Study The data upon which this study is based includes the following general categories: 1. A listing of the major new program innovations facing local health departments for adoption, and an estimate of their relative practicability and priority for adoption;** 2. An assessment of the degree and extent to which local health departments in California are presently en- gaged in 21 such new program innovations. 3. With respect to seven of these 21 innovations; data in depth with respect to the specific operations being conducted by each California local health depart- ment; dates of engagements in each, the role of other community agencies and institutions in each subject program area, coupled with the role which the local health department plays with respect to other involved agencies; reasons for engagement; plans for the future including barriers to future engagement and/ or enlarge- ment, and reasons for non-engagement. . 4. Measurement of selected characteristics, which may be summarized as follows: a. The health admlnlrtrator’r characteristics, in- cluding age, tenure, training and professional employ- ment biography, localite-cosmopolite index, reading habits, intelligence, and a sociometric analysis of inter- relationships among health officers. b. The health department’: characteristics, includ- ** Ihld. ing number and age of staff, length of staff tenure, fiscal measurements, staff mobility, and education and train- ing' policies and motives. ‘ c. The jurirdiction served by the local health de- partment and its characteristics, including size of pop- ulation, density, rural-urban index, white-non-white ratio, educational, income and age attributes of the population, physician-population ratio and geographic location In order to preserve anonymity, departments are identified only by code number. Code numbers were assigned on an arbitrary basis so as to protect the identity of individual departments. Definitions 1. "Health department,” "department,” or "local health department," as used in this and succeeding chapters, refers to those local city and county health departments in California which are administered by a full-time administrator. 2. “Health administrator" refers to those full-time administrators, medical or non-medical, who direct local health departments in California. 3. "Health officer," as used here and in the balance of this report, refers to those full-time medical health adminirtmtor: who direct local health departments in California. General Findings A brief summary of the general conclusions of this study may prove useful to the reader as he reviews and interprets the data which follow. The nature of the community (i.e., its size, economic position, urban character, etc.) plays a significant role in establishing the character of the local health department. Bigness of health department staff and budget seem to be cor- relates of larger communities of an urban nature, in which support and service are spread over a broad population base. While several aspects of the agency— large staffs and budgets, younger staffs which enjoy a degree of cosmopoliteness, etc—are seen to play ap- parently important roles in the adoption of novel pro- grams, it is clear that agency size, maturity, and improvement factors are dependent. in great measure on characteristics of the community served. On the other hand, the reputational characteristics of health officer (inferring cosmopoliteness, accredita- tion and status among his peers) and his local experi- ence more often appear as explanatory variables than either community or agency factors. By and large, the data seem to suggest that the kind of health officer who takes the lead in innovation either seeks (or is sought for) the direction of the larger, more affluent, local health departments. As a consequence, he has then at his disposal the tools with which to satisfy his apparent drive toward novelty. It may seem, therefore, to be “the man"——the local health officer—regardless of setting or agency who might be thought of as the major associate of innovativeness. Taken together, this study suggests that rize—size of community and size of department—is perhaps the most compelling concomitant to innovativeness in overall terms and with respect to the more dramatic or un- usual new programs. Corollary to size, the highly re- puted and locally experienced health officer appears as the leaven which apparently leads to imaginative new programming. Size apparently brings with it the health officer with good reputation and longer local experience. Is it the man, the agency, or the place? No one of these can be said to play a singular role. The man un- questionably requires the tools with which to work, the administrative flexibility which permits trial and error, and the financial position to extend the services of his department. The agency requires support, and to grow in magnitude sufficiently to supply the tools which its innovative direCtor requires, must serve a sufficiently broad population to support its growth. The place, in turn must be large and affluent to support the sizeable local health departments which seek and attract the innovative health office and which provide the ingre- dients for the fulfillment of his innovative tendencies. No information provided here is inconsistent with the basic conclusion that all three—the man, the place, and the agency—are germane to innovativeness. The ideal state of affairs would be an appropriate weight- ing of the several components of this "formula for innovativeness,” but neither the data available nor the statistical procedures permit this. Regression analyses, upon which these conclusions are built, when derived from a crossectional study such as this, present a static picture of a number of abstract relationships. While showing the variables which best associate with the dependent variable—in this case, innovativeness— these analyses present mathematical models which may, or may not be representative of the real-world phe- nomena. While the relationships expressed in the anal- yses presented herein are statistically valid, they show only one-to-one relationships, as between reputation and urbanism, or urbanism and size. The equation may suggest to some that changes in the values of the in- 7 dependent variables (e.g., reputational status) would be followed by a change in the value of the dependent variable, innovativeness. Mathematically, this would probably occur, but it might not necessarily do so in the real world, or to the same degree, or even in the same direCtion, as the equation may be taken to in- dicate. At most, therefore, the conclusions and generaliza- tions whith follow mggen association of variables with innovativeness, but these are not presented as casual relationships. It will necessarily remain for experimental manipulation of such variables, in controlled situations to determine the relative weight or value of the ana- lyzed concomitants to innovativeness. CHAPTER III CURRENT INNOVATIONS IN PUBLIC HEALTH Literature Review Beset as local health administrators are with many mandates, each competing for implementation by local health departments, it was felt that it would be useful to systematically identify the current mandates which cry for adoption. An intuitive approach might have suf- ficed for this purpose, but since this method would lack both system and documentation, it was decided to turn to a survey of recent professional literature for the identification of current mandates for program change.* The papers reviewed treated 36 distinct new program areas or health department program activities. Table 1 presents these data in digested form and subsumes the 36 items under five broad super-categories. One strikingly central thread appears to run strongly throughout the top four or five new priority areas treated in the literature surveyed, and to a lesser ex- tent through all the rest—the concept of the health department as the planner, cooperator, and pivotal agency about which many diverse activities are con- ducted; of the health department as liaison body, leader, stimulator, and appropriately balanced part of the total community health enterprise. To be sure, there was found a wealth of specific new programs which cry for expression in communities, but only in rare cases was there insistence that the health department, per se and independently, plan and do these new things. Rather, the feeling is that modern local health depart- ments, in meeting today’s challenges, should be in the position of reeing that thing: are done, rather than doing. This kind of emphasis is entirely appropriate to the kind; of new programs suggested as innovations, in the sense that the new activities revolve mainly about med- ical, clinical, and administrative activities. These are essentially the kinds of functions which demand team- * For details, 'see Robert E. Mytinger, "Mandates for Change in Local Health Departments,” Public Health Reportr, Vol. 81, No. 5, May 1966, 437—441. work, cooperation, and fullest use of every available resource, as opposed to health department centered programs such as environmental health and laboratory. These new program areas upon which the literature concentrates are also those in which few, if any, legal restrictions either prohibit the participation of others or require specific functions on the part of the health department. This theme has been summarized in the suggestion of two roles for the modern local health department: first, that of provider (food, water, milk, garbage and sewage disposal, insect and animal control, etc., regu- latory activities) along with direct services for medical care, rehabilitation, alcoholism, mental illness, and other needs of the client population; and second, that of watchdog of the community’s health, with freedom and willingness to examine and supervise various util- ity, private and/ or other governmental services, as well as its own activities.‘ Inherent in this role of “watch- dog of the community’s health” is the assumption that the health department has the responsibility of deter- mining the health needs of its community and then, either by direct action or stimulation of others, seeing to it that these needs are met. Practicability and Priority In order to approach the question of practicability and priority of the mandates identified in the literature survey,** a questionnaire seeking the opinion of public health leaders was developed for administration by mail. Table 2 illustrates the practicability/ priority classes and the new programs which fall into each. The questionnaire was sent to leaders of six occu- pational categories and four regional divisions, and the results showed a high degree of agreement among all respondents. In Table 3 opinion by occupation and re- gion is contrasted with over-all ratings of practicability and priority. * “ Ibid. Table 1 New Program Activities Suggested in Recent Professional Literature for Local Health Department Adoption GENERAL COORDINATION, PLANNING AND STUDY Research and evaluation Health aspects of total community planning Joint planning of health programs Planning for comprehensive health care Analysis of community health data Social sciences in health planning Coordination of health resources Planning based on economic considerations Metropolitan planning of area-wide affairs MENTAL HEALTH Mental health organizational center Collaboration with others in mental health Services for ex-mental patients Coordination of mental health activities Suicide prevention Services to meet problems of urban youth ORGANIZATION OF MEDICAL CARE SERVICES Integration and coordination of medical care Organization for comprehensive medical care Assessment of medical care quality Development of rehabilitation facilities Planning for the aging population DELIVERY OF MEDICAL SERVICES Chronic illness early detection Nutrition services Disease eradication as a goal Alcoholism Maternal and child health services Family planning Home nursing services Government employee health services Hearing and speech defect correction ENVIRONMENTAL HEALTH Accident prevention Occupational health Control of ionizing radiation Air pollution Water resources management Noise control Sanitation of medical institutions Table 2 Practicability and Priority of New Public Health Programs (Presented in descending order of practicability and priority) PRACTICABLE—HIGH PRIORITY Health aspects in total community planning Research and evaluation Comprehensive data on health resources Joint planning of health programs Comprehensive maternal and infant care IMPRACTICABLE—HIGH PRIORITY Integration of community health facilities/resources PRACTICABLE—LOW PRIORITY Complete data on state of community’s health Accident prevention Sanitation of medical institutions Water pollution control Eradication of tuberculosis Nutrition Home nursing services Health aspects of housing in urban renewal Air pollution control Services for ex-mental patients Early discovery of chronic illness Health planning based on economic considerations Screening programs for chronic illness detection IMPRACTICABLE—LOW PRIORITY Family planning ' Control of industrial radiation Organizational focus for all mental health services Development of rehabilitation services . Social sciences in health planning/ programs Organizational focus for comprehensive health care Application of eradication philosophy Control of medical radiation Prevention and treatment of alcoholism Programs to meet health problems of aged population Improvement of quality of medical care Provide direct medical care services Prevention/ correction of hearing and speech defects Programs for problems of urban youth Organize delivery of medical care in community Identify / prevent suicide 10 PROGRAM KEY FOR TABLE 3 Item N 0. Program Area 1. wwsmewN 10. 12. 14. 15. l6. 17. 18. 20. 21. 22. 23. 24. 25. 26. 28. 30. 31. 32. 33. 34. 35. 37. 38. 39. 40. Joint planning of health programs with other agencies/ departments. Integration of community health facilities and resources. Assure inclusion of health aspects in total community planning. Provide organizational center for mental health services. Organize services for ex-mental patients. Provide direct medical care services. Organize the delivery of medical care. Programs to improve the quality of medical care. Provide organizational focus for comprehensive health care. Provide planned and continuing research and evaluation. Provide programs aimed at the eradication of tuberculosis. Apply eradication technics and philosophy. Programs for the early discovery of chronic disease. Organize community-wide screening programs for chronic disease. Assure comprehensive maternal and new-born care availability. Surveillance and control over medical radiation. Surveillance and control over industrial radiation. Organize accident prevention programs. Use of social science technics in health planning and program. Programs of family planning, birth control or population control. Reference center for all data on state of community’s health. Comprehensive data on characteristics of community’s health resources and facilities. Home nursing services. Assure presence or development of rehabilitation services. Prevention and treatment of alcoholism. Assure that health problems of aged population are being met. Programs or meet psycho- and medico-social problems of youth. Programs to encourage proper nutrition. Planning of health programs with regard to economic consequences. Air pollution control program. Sanitary surveillance over operations of medical institutions. Prevention and correction of hearing and speech defects/ noise control. Prevention of suicide. Programs related to health aspects of housing in urban renewal areas. Water pollution control program. 1. Henrick L. Blum and Alvin R. Leonard. Pablic Admin- irtratian—A Public Health Viewpoint. MacMillan (New York), 1963, pg. 46. ll Table 3 PRACTICABILITY AND PRIORITY JUDGMENTS (OPINION SURVEY) x - PnAcncABLE 0: men PRIORITY REGION 0 O ITEM WEST EAST CENTRAL SOUTH TOTAL Lbaltt § 0 u E n awmthum— I2 l4 I5 I6 I7 l8 20 2| 22 23 24 25 26 28 29 3O 3| 32 33 34 37 38 39 4O CHAPTER IV DEGREE OF ADOPTION OF SELECTED NEW PROGRAMS Methods of Study Data concerning the extent and degree to which Cali- fornia’s 40 full-time local health departments engaged (1964—65) in 21 new public health programs were collected. The 21 programs studied were selected from among those which were derived from the survey of professional literature previously reported, 35 of which were also included in the opinion study of practica- bility-priority. Of these 35 new programs, 14 were removed from consideration as inappropriate for this study. The 21 new programs which remained for field study were: 1. Prevention, treatment and/ or rehabilitation of alcoholics among the population; 2. Prevention or reduction of accidents; 3. Home nursing (bedside, therapeutic nursing) services; 4. Early discovery of chronic illness among the population, exclusive of usual and normal venereal disease, tuberculosis, and crippled childrens’ services; 5. Direct, therapeutic, clinical medical care services for some segments of the population, exclusive of venereal disease, and tuberculosis, therapy, well-child conferences, and crippled childrens’ services; 6. Continuing and planned research and evaluation studies, projects, etc.; 7. Family planning, birth control, or population con— trol services; 8. Specific arrangements whereby other agencies and departments of government cooperate with the health department in the joint planning of public health pro- grams; 9. Established channels whereby the health depart- ment assures that health aspects are considered in the total community plans (economic, industrial, and resi- dential development, education, etc. ); 10. Regular availability of social or behavioral sci- entists, either as consultants or staflc members, who participate in program planning and execution; 11. Up-to-the-minute data available, in a readily usable form, as to the state or status of the popula- tion’s health—mortality, morbidity and its causes, ex- tent, severity, etc.; 12. Up-to-date information, of a detailed nature, about the characteristics of all the health and medical resources and facilities in the community; 13. A role in the integration or coordination of health and medical care facilities and resources, to the ,end of assuring comprehensive medical care availability and its organized delivery to all members of the com- munity; 14. Assessment and/ or improvement of the quality of medical care; 15. A specific role in the development of rehabilita- tion services; 16. A role as the organizational center or focus for mental health services in the community; 17. Organized services for mental patients return- ing to the community from mental hospitals; 18. A role in organizing programs to meet specifi- cally the psycho- and medico-social problems of youth in the population; 19. A role in assuring that comprehensive pre- and post-natal care is available to all mothers in the juris- diction and that comprehensive medical care is avail? able for their infants; 20. Prevention and correction of hearing and related speech defects; 21. Identification of potential suicide risks and pre- vention of suicide among them. Data in depth concerning the extent and degree of engagement in the first seven programs, five of which are related to newer medical care activity, were col- 13 lected by personal interviews with each of the 40 health department administrators. For the remaining 14 programs, owing to limitations on the practicality of extending lengthy interview sessions with busy ad- ministrators, data were obtained, often prior to the interview, via a self-rating form which each local health officer completed, rating his department’s en- gagement in the last 14 new programs along a scale ranging fromO (no involvement) to 10 (comprehensive program). Both sets of data are, in effect, health officer self- reported. On the one hand, however, when health offi- cers were asked to self-rate their department’s engage- ment in 14 programs, their assessment of extent of engagement was forced within the confines of a 0—10 scale. In the case of interview data, the investigator had ample opportunity to probe the degree of actual com- mitment to each of the seven programs treated in interview sessions. This opportunity to seek clarifica- tion, to question the health officer directly, is thought to provide a reliable estimate of actual extent of en- gagement in the seven programs covered in the inter- views. One concern with these data, then, is whether local health oflicers tend to over-estimate the extent of their engagement when completion of the self-rating instrument was left to their own consciences. However, when the extent of engagement in seven new programs as determined by personal interview and observation is contrasted with the health officer’s self-reported engagement in 14 others, using Spearman’s rank order correlation, an association (7:.699, significant at the .0001 level) appears between self-reported and inter- view-determined engagement. Furthermore, when a total "score” based on the seven programs included in the interview data is seen against the total “self-rating score” based on the additional 14 programs, an F ratio of 56119 is ob- tained, reflecting a significant association at the .99 level of confidence. There would thus appear a sub- stantial degree of validity in the self-appraisals which form a major part of these data.* V Two methods of quantifying "extent of engagement" * Particularly for the seven programs regarding which de- tailed data has been assembled by interview, independent information—other than the health oflficers’ reports—has also been obtained. The sources of the added appraisals of program existence and vigor were the three Regional Medical Co- ordinators and several program chiefs (e.g., Division of Alco- holic Rehabilitation, the Division of Public Health Nursing, etc.) of the California Department of Public Health. To a great extent, the appraisals gained from these sources support and parallel those derived from the interview determined extent to which departments are engaged in any of the seven programs. 14 were developed. With respecr to the 14 programs about which local health officers self-assessed their engage- ment, a self-rating score of 0—3 was taken to indicate little or no involvement in the activity; a score of 4—7 as indicative of partial engagement; and a score of 8—10 as complete or comprehensive engagement. In the case of the first seven programs, engagement in which was observed and assessed by the investigator through interview, the following point scale was de- veloped for purposes of rating the extent of involve- ment: Operations: 6 points A continuous, regularly scheduled func- tion or operation; 4 points A regular, but sporadic operation, or one limited in area or scope, or a com- ponent of another program; 2 points An irregular, occasional operation; 1 point No operations to this end. Stafl: 6 points A regular, identifiable, and specifically assigned full-time responsibility of one or more staff members; 4 points A specifically assigned duty of one or more staff members which they carry in addition to other responsibilities; 2 points A part of general staff responsibility, not specifically delineated, or an oc- casional responsibility of one or more staff members; 1 point No responsibility held by Staff members. Fundr: 6 points A specific budget allocated for this pur- P056; 4 points Funds from other budget are specifically spent for this purpose; 2 points Some funds are spent, but are nor iden- tifiable as such; 1 point No funds are spent for this function. For each of the seven programs, therefore, a max- imum score of 18 was possible. and a minimum score of 3 could be assigned. The range of 3—5 was taken as indicative of little or no involvement, 6—12 as show- ing partial engagement, and 13—18 as meaning full or complete engagement. New Programs Adopted Table 4 summarizes the number of programs which each local health department in California had either fully, partially, or minimally adopted. Table 5 presents Table 4 Number of New Programs * Adopted by Local Health Departments California—1964 Local Number of Number of Number of health new new new department programs * programs * programs * code fully partially not number adopted adopted adopted 1 4 7 1 0 2 7 12 2 3 5 7 9 4 8 10 1 3 5 1 1 6 4 6 1 3 17 7 1 6 14 8 3 9 9 9 10 6 5 10 9 6 6 1 1 9 7 5 12 1 9 1 1 13 0 8 13 14 1 9 1 1 1 5 12 7 2 16 9 4 8 17 8 8 5 18 9 6 6 19 6 7 8 2 0 7 3 1 1 2 1 3 1 1 7 2 2 3 3 1 5 2 3 6 9 6 24 1 0 4 7 2 5 1 2 4 5 26 7 5 9 2 7 7 10 4 2 8 2 6 13 29 12 8 1 30 6 3 1 2 31 15 2 4 32 4 6 1 1 3 3 2 9 10 34 0 6 14 35 2 7 1 2 36 5 7 9 37 3 4 14 38 3 10 8 39 2 4 15 40 8 8 5 ‘ New Programs include only those 21 encompassed by this study. the same data indicating the number of departments which had adopted each of the 21 new programs by degree of engagement. Table 4 shows that there were no cases in which a single local health department in California had fully, or even partially, adopted all 21 of the new programs studied. No health department had failed to adopt, to some extent, any of the 21 new programs. Although several of the study pro- grams might be thought of as "unpopular,” seven of the new programs had been adopted by more than 75% of California local health departments, at least to some extent. These are the programs which deal with joint planning of health programs, asserting health in total community planning, maintenance of data on com- munity health resources, maintenance of data on the status of the community’s health, a role in the integra- tion of health and medical care facilities and resources, comprehensive maternal and infant care services, and hearing and speech defects. Table 5 Number of CalifOrnia Local Health Departments Engaged in New Health Program Innovations Number of health departments (N=40) New program Fully code New program Not Partially adopt- number * description adopted adopted ed 1 Alcoholism ........... 28 6 6 2 Accident prevention .. . 31 8 1 3 Home nursing ........ 20 5 15 4 Chronic illness detection. 22 12 6 5 Medical care service 15 12 13 6 Research/ evaluation . . . 17 11 12 7 Family planning ...... 27 5 8 8 Joint planning ........ 7 18 15 9 Total community planning ‘ 6 16 18 10 Social sciences ........ 23 10 7 11 Health status data . . . . . 9 16 15 12 Health resources data. . . . 6 12 22 1 3 Integration / coordination 7 2 1 12 14 Quality of medical care . 14 20 6 15 Rehabilitation ........ 1 1 22 7 16 Center for mental health. 19 8 12 17 Ex-mental patients . . . . 22 11 7 18 Problems of youth ..... 17 18 5 19 Comprehensive maternal 3 15 22 2 0 Speech / hearin g ....... 5 1 7 1 8 2 1 Suicide .............. 3 1 4 5 * Program code numbers correspond to listings on p. 13. 15 TABLE 6 HEALTH IN PERCENT OF CALIFORNIA LOCAL WHmH WERE PROGRAM AND NUMBER ENGAGED INNOVATIONS - I965 FULLY DEPARTMENTS SELECTED NEW 2| .835;qu ugugm Luau.» how Emuwo‘fiw 6— 3:25 uumu Hungvofi Houuaoo 5— Emuwnim 59205002 7— 5532323 5 £3. mUfiGSUNU\mumHu—HOA0m HNHOM>N£0£ UmD 7 8:05:00 nus: ”warn—«man >353 we Emumoum L_LLLLLL m7 moot/hum 5H3: “mucus mud—5.53 new maoom n_‘ mmufifiwm Auauaummuunuv 930 132.2: uomufin O_‘ muck—.3 ~30: @333 $5033 503% can animus uo :oHuuouuou\:3u:o>oun 5.3 wazmmu Emuwgm I \ aowuau>mum unawauudw ID 4 8_I.uoouov :95: uaaouzu haunu I— 7_‘ muuuuuma kucwfiuxw wow mmuaiom L 5— :33: 3.5.3353; Eu «0 “a“: mi uaonm :onwsuowpi 3:33 I— 5— mwan—om Aoauaommumnu mwvanvonv wnwmunc 9.85 95.530 Emumoum _ \ usfl muuu=0mou mumu .33qu wcwuwfivuoou can wcauapwuun... 5 33. I— W? huffiuom cofiuw=~m>o can nuuwwmmu wag—53:8 unavaou G—I uuuufiumawv van muwuammw punuo 5:3 man—Sow. vunamam mum mfiwquMQ Juana: B—‘ wauaaman auwnsaaoo H33 a.“ vauugmuou ma :uawufi uwsu amusunm unonfluwmov nuamum uumu “Emu—5 van amumfiuumom vflm Imam Eran—Snowing nuuusgwu :0“qu can 530: akin—5:00 uaonm acaumfiowi “5:32“ _ _ _ _ _ _ 0 www 5 m s o s I o—— I__L_I__L__ 4 2 I. _ w I 349 mkzmzkmddw Ham—L 13.00:. nome=Eum souaomom 12 88 333: 13 038% 3.8:? cognac—u 33m mcmfisa 080$ xxxxxuuxx 15 noun—goon Eoflou< 5:382. ~35: 018 "queue—«mow .38: ~83 11 15 24 27 3500 28 29 18 20 31 2 17 19 23 26 35 37 38. 39 Total . 21 22 DEPARTM ENT NUMBER Years of Adoption (And Discontinuance) of Seven New Programs by Local Health Departments in 3} Bikini—— N Nm—wobAQVUWQmN—UOUO NU—NO‘U—— N—‘— NU—O‘O‘NA #NCDOWUIAO— NNNO‘D‘NNNN—— —0‘0‘— N _ —N—— ONUIOND—DO— bub—-05 IIIIIII Gw—‘D—‘DV-fiO“OUIUQNO)UIOI IIIIIIIIIIIIIIIIIII NO! h‘lo [III 0‘ — NNN ——:b N— —mmAmsIun—u-uoa>—— Table 11 California I949 I950 I'SDISI I9|52 I953 I9|54 I955 I956 I957 I9158 |9l59 |9l60 |9l6l I9162 I9|63 I9l64 lllIllIlIIlIllllIlll IIIIIIIIIIIIIlI IIIIIIIIII A/caho/x’sm Ace/o’em‘ Prevenf/on Home Nursing Serw'ces Ear/y D/scoyery of Chronic ]//ness D/recf Med/'ca/ Care Services Research and E valum‘fon Fem/7y P/ann/ng I | I I T I I I I I I I I I I949 I950 |9|5| I952 I953 I954 I955 I956 I957 I958 I959 I960 I96| I962 I963 I964 TIME OF ENGAGEMENT - ALCOHOLISM ggil96I—I964 Figure 1 pre I949 £§§I949-I952 *“3I953—I956 €35I957—I960 23 TIME OF ENGAGEMENT - ACCIDENT PREVENTION 72/134 gggl949—I952 fifiilgsa—Iess 3:31957—I960 E ...... 3|96l-I964 Figure 2 24 TIME OF ENGAGEMENT - HOME NURSING SERVICES 3:3 a? pre I949 I949 - I952 I953 —|956 I957 - I 960 I96 I - I 964 Figure 3 25 TIME OF ENGAGEMENT—EARLY DISCOVERY OF CHRONIC ILLNESS I949 pre ..... Figure 4 26 TIME OF ENGAGEMENT- DIRECT MEDICAL CARE SERVICES “Gib .4 mg pre I949 ififl949-I952 ”I953—I956 §I957-I960 viileel—I9e4 Figure 5 27 28 TIME OF ENGAGEMENT -RESEARCH AND EVALUATION 3 pre I949 :._____-._ I949- I952 I95 3 -| 9 56 I957—I96O I96 I - I 964 Figure 6 TIME OF ENGAGEMENT - FAMILY PLANNING ‘6‘." “$1; pre I949 J 1949 - 1952 |953 -| 956 I957 - I 960 |96| _ l 964 Figure 7 29 CUMULATIVE ADOPTION OF SEVEN SELECTED NEW PROGRAMS CALIFORNIA LOCAL HEALTH DEPARTMENTS I949‘I964 E 2 40— home nursing .J 3 <2: ° 5 3 z I- . . g 30— direct medical g 2 care research 3 E z m m 0 2 20 I: I" “ w a: a. E , . w family planning o w 2 '— < E I0 -’ .1 g 5 early detection 3 I of chronic illness alcoholism 30 Role of Other Agencies in Seven Innovative Programs The involvement of other agencies and organizations in new and innovative public health programs might be thought of as conditioning the extent or degree to which local health departments directly engage in such novel programs. On the other hand, where other agen- cies are involved in new programs, the role which the local health department plays vi: :1 vi: others war- rants exploration. As a reflection of innovativeness, it is clear that in- volvement in securing the provision of new health program innovations by agencies other than the health department deserves credit. It will be useful in later sections, when innovativeness "scores" are derived for health departments, to include point values for initia- tion of innovations through agencies other than the local health department, and for roles which the health department might be playing in the innovative pro- grams conducted by other agencies. Thus will be taken into account the possible "watchdogging” roles which local health departments in California may have played with respect to the seven new programs presently be- ing considered. With regard to these seven programs, to what extent were other agencies in California communities in- Table 12 Involvement of Other Agencies Singly or Jointly with 40 Local Health Departments in Seven New Public Health Innovative Programs Newprogtams 60 :2 = 'U u 5:5 235%? a 3 2 %5 «Waves 3 :53 e '95 Egfifiefig E < '5. :11 0-8 G 8 a: m Others active: Health department also active 10 S 8 11 22 14 7 Health department inactive ..... 28 31 15 19 17 11 19 No others active: Health department active ....... O 011 5 131 4 Health department inactive ..... 2 4 6 5 0 12 10 volved? Table 12 describes the extent of participation of health departments and other community agencies in connection with the seven programs and shows the number of communities in which others were active in the abrence of health department activity and jointly with health department activity. . These data lead one to wonder about the role which local health departments in California play with respect to the many other agencies in their jurisdictions which are active in these seven innovative programs. Table 13 presents the number of cases where health departments were participating in the programs of other active agencies. Table 13 Number of Local Health Departments Participat- ing in Seven New Public Health Innovative Pro- grams Which are Conducted by Agencies Other Than Local Health Departments New programs E“ In —1 .E" of; .§ m ‘E E c: a :: 'U 8 g 52 u o 5 0—1 a 0-h— _: a —-1 an: a: .2 o E Z t, .8, o c: Q a... u o.) u >. :c o 2-; u (n u :7: § E .32 a § < <: a a: 0% Q 8 a: In Where other agencies are active: Health department participates ..11 7 11 8 13 9 8 Health department passive or non- participatory .27 29 12 22 26 16 18 It would be possible to suggest frOm the data in Tables 12 and 13 that a watchdogging role, at least with respect to surveillance and day-to-day function- ing of other agency programs, developed to only a modest extent with respect to these seven new pro- grams. But then, perhaps continuing participation in such new programs, when their administration is vested in other agencies, is not essential; perhaps the watch- dogging role was played in the stimulation of such other agencies to adopt the new programs. Table 14 presents the data on the role which California local health departments played in initiating innovative pro- grams in other agencies which are currently conduct- ing them. 31 Table 14 Number of Local Health Departments Playing Initiatory Roles in the Adoption of New Programs by Other Agencies New programs E“ (A .2? § o E 8 t: 3 :1 a a E u.9 :1 ‘3 t: if 4: '5. 3 58512-8888: '11 o u ...._u w ._ o G > E 8 u -o 5‘ 9, 3 u 2 0 .l: 3 0 H o a < < a. : U11 2 a ad a. Health department was primary initiator of orherinvolvement.. 2 0 3 0 0 1 5 Health department participated in initiation of other.. 2 0 4 1 1 5 2 ' Health department had no role in initiating ........ 34 36 16 29 38 21 21 It seems clear that in the vast majority of cases where other agencies were engaged in one or more of these innovations, the role of the local health depart- ment in helping mount such programs had been negligible and almost wholly lacking. In a few cases, health departments have played the watchdogging role in establishing extra-health department services (in the fields of alcoholism, family planning, and home nursing services) which are not matched by competing, or at least parallel, health department programs. The ines- capable conclusion persists, however, that by and large, California health departments did either not choose, or did not find it feasible, to play the role of stimulating the development of these seven new programs in other agencies. Furthermore, computations based on the data con— tained in Tables 12 and 14 reveal that in cases where there were other agency programs and no concurrent health department activity (“others active, health de- partment inactive," Table 12), more than 70% of such non-engaged health departments played no role in ini- tiating the activity of extra-health department agencies. This may suggest the possibility that with needs per- haps largely unrecognized by the local health depart- ments in these cases, programs were eventually under— taken by other agencies endeavoring to fill the vacuum. It is apparent that either a considerable amount of "sitting idly by” (or, at best, of unreported behind- the-scenes activity) has been the case in those commu- 32 nities in which other agencies have adopted one or more of these innovations with neither health department initiation nor participation. Plans for Future Adoption of Seven Innovative Programs To round out the picture of program adoptions, it seems appropriate now to turn to plans or desires which health departments may have for future adop- tion of the seven new program areas. An examination of Table 15 reveals that substantial numbers of local health departments which were not presently engaged in the seven new programs studied did, indeed, have either plans or desires for future adoption. Table 15 Number of Non-Engaged Local Health Depart- ments Planning or Desiring to Adopt New Pro- grams New programs in“ a fi 1 'a g g .5 :5, fig .3. e it: 3-2.5 5'5 *3 ‘5: 2 z E I 6-53 5:“? n? m Toral health departments which are-not engaged... 28 31 20 22 15 18 27 Number planning 5 6 4 3 3 2 9 Number desirous of adopting ........ 14 15 10 14 5 9 11 Number with no desire or planning. 9 10 6 5 7 6 7 Derivation of "Innovativeness Score” With adoption of innovative programs being so ob- viously conditioned by the activities of other agencies in the community and by other variables inherent to the health department, the community, and the local government, it becomes apparent that a single measure of engagement in the new program area is not suffi- cient as an index or statement of a department’s gen- eral innovativeness. A better estimate of over-all trends might be an “innovativeness score,” which would ade- quately reflecr the several possible alternatives of either carrying a program forward, seeing that it is being done by others, or planning to do it. From many pos- sible alternatives, a simple point system was devised by which an "innovativeness score” could be derived for each department in the sample. The first set of points assigned were those detailed on page 14, relating to the actual extent or degree of engagement in each of the seven programs under study. To this score, for each of the seven new programs investigated in the field interviews, three additional point values were added, under the following criteria: 1.Planning for future program involvement by health department 5 points A new continuous, regularly scheduled function is being planned; Expansion of present functions into new program areas is being planned, or a limited new program is being planned; Expansion or extension of present func- tions only is being planned, or new personnel are planned for present function; New program being planned of which this new activity will be a compo- nent, or new program will be extra- health department, or new program will be added to present staff respon- sibilities; Planning to assume existing programs from another agency, or to purchase services from another agency/pro- vider; No planning’underway, but desirous of seeing program adopted; No planning underway, and not desirous of seeing program adopted, or not sure whether would like to see it adopted. 2. Health department participation in other agency program(r) 6 points Active support and involvement in other agency, via funds or personnel; Program of other agency administered by health officer or staff member(s); or, conducting program elements by 4 points 3 points 2 points 1 point 1 point — 1 point 5 points contract for another agency; or pur- chasing program service from other agency; 4 points Provide housing, overhead, or other non-personnel non-fiscal support for other programs. 3 points Collaborate actively in the programs of others; provide some staff support; 2 points Coordinate the activities of others; 1 point Cooperate with, refer to, or use program services of other agency; —1 point No relationship or role with other agency(s) active in this program area; 0 points No other agency to participate with. 3. Health department role in initiating activity by other: 6 points Singularly or primarily responsible for moving another or other agency(s) to conduct program; Jointly responsible, with others, for the development of program under the aegis of another agency. 4 points Degree of Innovativeness Based on the scoring criteria outlined above, each local health department was rated for each of the seven individual programs included in the interview phase of the study, and then given an over-all "inno- vativeness score." These data appear in Table 16 and Figure 9. On the basis of over-all scores, it will be noted in Table 16 that the 40 local health departments ranged from a low of 22 to a high of 128. The median score is 69 and the mean score is 69.7. In Figure 9, it is interesting to note confirmation of a tentative hypothesis suggested earlier (Temporal Aspects of Adoption)—namely that high innovativeness scores as- sociate strongly with the metropolitan areas of the state, with the areas where substantial population bases make possible (or require) large local health depart- ments. An occasional and interesting exception may be noted, but the general picture confirms the greater innovativeness of the larger health units. REFERENCES 1. Everett M. Rogers. Diffusion of Innovations. Free Press of Glencoe (New York), 1962, pp. 81—86; 95—98. 2. Ihid. Pp. 152—53. 33 Table 16 Innovativeness Scores (Total and by Program) Achieved by California Local Health Departments Health ‘ Innovative score by program "‘ Total department innovativeness code No. I II III IV V VI VII score 4 ...................... 26 8 21 10 19 24 20 128 11 ...................... 22 11 12 12 16 22 23 118 15 ...................... 14 9 15 7 22 22 28 117 1 ...................... 7 9 1 1 22 9 31 24 113 27 ...................... 9 24 7 29 16 16 11 112 24 ...................... 22 9 26 19 12 3 9 100 29 ...................... 8 10 28 5 22 13 14 100 31 ...................... 15 10 15 6 26 16 5 93 40 ...................... 8 6 18 14 20 15 11 92 10 ...................... 21 7 5 18 17 11 4 83 18 ...................... 8 10 21 7 3 27 7 83 2 ...................... 6 9 13 12 10 17 15 82 8 ...................... 9 7 20 8 6 21 10 81 25 ...................... 23 5 1 11 19 14 7 80 3 ...................... 3 14 19 10 14 3 16 79 5 ...................... 8 9 15 12 20 8 6 78 21 ...................... 23 5 7 3 10 20 8 76 28 ...................... 3 4 19 6 13 10 19 74 35 ...................... 10 7 13 17 10 10 5 72 32 ...................... 4 7 5 12 26 7 9 70 26 ...................... 11 4 10 7 7 20 9 68 23 ...................... 4 5 12 8 12 10 16 67 16 ...................... 10 5 7 7 18 9 5 61 38 ...................... 6 5 13 15 5 9 7 60 39 ...................... 12 3 7 1 25 6 6 60 17 ...................... 6 10 15 5 5 6 5 52 14 ...................... 14 6 11 6 5 5 4 51 9 ...................... 3 5 13 9 8 5 7 50 19 ...................... 6 3 5 4 8 5 19 50 22 ...................... 6 6 5 3 12 4 12 50 20 ...................... 1 3 16 7 12 6 4 49 30 ...................... 5 3 19 7 1 5 8 48 7 ...................... 5 9 3 5 11 4 9 46 36 ...................... 5 7 3 10 7 10 4 46 13 ...................... 7 7 5 4 4 4 6 37 33 ...................... 2 3 8 10 1 ‘6 4 34 37 ...................... 6 5 5 8 1 5 3 33 6 ...................... 5 4 8 3 1 6 4 30 12 ...................... 5 2 6 2 3 4 5 27 34 ...................... 5 2 3 4 4 3 1 22 I == Alcoholism II = Accident prevention . 111 = Home nursing 34 " Program Key IV = Chronic illness V = Medical care VI = Research VII = Family planning GENERAL INNOVATIVENESS Score Range @153 ++ Ioo- I28 + 67 - 93 i 46— GI 22- 37 Figure 9 35 CHAPTER V CORRELATES TO INNOVATIVENESS The preceding chapters have dealt with the defini- tion of innovation generally and in local public health practice, and it is now appropriate to seek answers to some of the puzzles which have directly and indi- rectly been raised throughout the foregoing portions of this report. The possibility of identifying some of the concomitants of innovations was previously raised, with the hope that their discovery might have some pre- dictive value for those advocating or otherwise assert- ing new public health programs. Earlier discussions have led several times to a tentative hypothesis that, in the main, larger health departments which serve ur- banized populations seem generally the more aggres- sive in adopting innovative programs. It is thus the purpose of this chapter to assess the kinds of characteristics which seem to associate with high degrees of innovativeness in local health depart- ments. An examination will be made of whether the adoption of the new tends to associate most strongly with characteristic attributes of "Ike man" (the local health officer), or with some aspects of "tbe agency” (the local health department), or with certain fea- tures of "the place” (the community which the local health department serves). Furthermore, since the re- lationships may be complex, the correlates of inno- vativeness will be more deeply probed in an effort to establish the combination of features of men, agencies, and places which conspire to high innovativeness in local public health practice. Methods Of Analysis A set of exclusions were found necessary before pro- ceeding with the analysis. Originally, the 40 full-time local health departments in California were included in the study sample. Of these, two have been deleted from further analysis, leaving a total sample of 58 to be considered. 36 Of the two departments rejected, one is adminis- tered by a full-time non-medical administrator with a part-time official medical health officer. Inasmuch as variables descriptive of the medical health officer could not be attributed to the full-time, non-medical administrator in this case, the department is not com- parable with Others. In the second case, the local health department presented two distinct drawbacks. It is, first, an organization which during the year of this study absorbed another, nearly equally large, local health department complete with many new and innovative programs. Thus, it would not be proper to "give credit" for such innovations to the absorbing depart- ment. Furthermore, it is an extraordinarily large de- partment, different from all others in the State with regard to size of population, size of staff, and funds available. In this sense, its inclusion causes an unde- sirable skewing of frequency distributions and means. The study called for finding "independent” variables which describe 38 local health departments in California and their local environs, and then viewing these as determinants of innovativeness. It will be recalled that the measure of innovativeness selected for this study is a numeric score (total innovativeness score) for each local health department, based on the actual extent or degree to which that department is engaged in seven selecred new public health programs. It is against this measure—a numeric score based on seven new pro- grams—that the respective characteristics of local health ofl‘icers, their departments, and the communities which they serve will first be viewed. In the next chap- ter, a similar set of numeric innovativeness scores will be introduced which are based upon a series of five program factors which reflect all 21 new programs studied, and the extent of each local health depart- ment’s engagement in the program components of each factor. To summarize, it will be the objective of the re- mainder of this study to view, in progressively difl‘er- ent ways, two sets of measurements against one an- other—33 selected descriptive variables, on the one hand, and innovativeness scores based first on reven programr, and then on 21 programs, on the other hand. The following relationships will be examined: a. First, 33 individual variables will be seen, indi- vidually, against total innovativeness scores (based on seven new programs) to determine whether any of the 35 variables significantly associate with higher scores. b. Next, the 33 variables will be taken as a group, with the assistance of step-wise multiple regression, against total innovativeness scores in an attempt to identify the cluster of independent variables which ac- counts for the greatest percentage of variance in innovativeness scores (based on seven new programs). c. Finally, a new set of innovativeness scores—re- flective this time of engagement in 21 new programs— will be derived through factor analysis. The 33 var- iables will again be taken as a group, using multiple regression analysis, against these factor innovativeness scores with the aim of identifying sets of independent variables which account for the greatest percentage of the variance in the factor innovativeness scores. Thus, differences between types of programs and the vari- ables which most strongly associate with them may be seen. Previously Demonstrated Correlates to Innovativeness A number of other studies have hypothesized a va- riety of individual, organizational, and community characteristics as being correlates of innovativeness. As a point of departure, it would be interesting to com- pare findings of this study with those previously re- ported. Because the design of this investigation was not patterned specifically after those employed in previous work by others, and because it is not wished, as an ex port facto manipulation, to force these data into configurations used by others, no formal replication of other studies will be inferred in the comparisons which follow. Factors related to the innovativeness of a sample of public schools have been analyzed,‘ with the find- ing that 64% of the variation (between schools) in a composite measure of innovativeness was explained by 19 community characteristics. Pierce’s characteris- tics included such factors as the percentage of the adult population having completed the eighth grade, and the percentage having completed college; the ratio of un- skilled workers to the total working population, and the percent of those employed who are business or professional workers; density of population, trends in population change, wealth trends, wealth as measured by taxable real estate and total tax rates; percents of population 50 years of age and over, and of families living in owner occupied dwellings. Others2 have suggested two organizational factors which may influence receptivity to change, the first dealing with the weight of office which top administra- tors may carry, and the second, treating the history of the organization—its atmosphere of good will, feel- ing of mutual confidence, and consideration among members. Stern suggests that retardation of change (in medi- cal science) is, in great measure, assignable to con- servatism in medicine, thus offering other individual characteristics which may correlate with innovative- ness. One other series of personal characteristics offered as being strongly related to the adoption of innova- tion includes age, social status, financial position, specialization, mental ability, cosmopoliteness, usual communication channels used, and opinion leadership status.3 Table 17 presents an organization of some of the better documented correlates to innovativeness which other studies provide. The list is not exhaustive, but only selected variables are presented to provide a framework for this presentation. Selected for this list- ing are only those features of the relevant literature which are congruent with the schedule of data felt possible to collect for this study. Depending upon the researcher or the setting exam- ined, one sees different sets of variables which have been studied and found to relate to innovativeness. However, none of such pre-existing sets of variables has been found to be precisely referrable to innovative- ness in public health settings. Therefore, in this study, the kinds of variables utilized in previous studies have been drawn upon and have been included among the variables measured in connection with each local health department studied. In addition, a variety of other variables thought to be germane to the setting and operation of local health departments were also assessed. The descriptive variables which have been included are divisible into three broad categories: 1. Characteristics of the health officer; 2. Characteristics of the health department as an agency; 3. Characteristics of the community and popula- tion which the local health department serves. 37 Table 17 Some Variables Which Have Been Found, in Prior Studies, to Associate Significantly With Innovativeness "THE MAN" Age: Younger adopters are earlier adopters (Rogers) Long organizational history of innovation associates with organizational innovativeness (Seashore and Bowers) Incumbency: trator (Griffith) Cosmopoliteness: Number of innovations (in schools) inversely pr0portional to tenure of chief adminis- Earlier adopters are more cosmopolite than later adopters (Rogers) Physicians who adopt early have cosmopolite tendencies (Katz) Social Status: Social status, opinion leadership, mental ability and modern rather than traditional norms associate with early adoption (Rogers) Conservatism (in physicians) works as a barrier to innovation (Stern) Weight of top administrator’s oflice enhances innovation (Seashore and Bowers) ”THE AGENCY (or "The Operation”)” Size: More specialized operations are earlier adopters (Rogers) Economic Status: Earlier adopters have a more favorable financial position than later adopters "THE PLACE" Economic Status: Urbanism : Increasing community wealth correlates with school innovativeness (Pierce) Nineteen community characteristics (including education level of the population, density, population change, age of the'population, and value of housing) were found to associate with innovativeness in public schools (Pierce) Composite Profile From the data which are reported in Appendix 1, a rough composite picture of the 1964 “average" Cali- fornia local health officer, of his department, and of his community may be composed. 1. The "Average” Healt/J Officer The profile of an “average” health officer would show him to be 55 years old, with an MPH and cer- tification by the American Board of Preventive Medicine and Public Health, having had nearly 25 years of varied experience, the bulk of which will have been in local public health practice but with about four years of private practice during his career. He will have been in his present position 9.4 years. His official duties take him out of his immediate jurisdiction about once each month and, about once every year and a half, out of California. He keeps up-to-date with the professional literature by reading about six professional and technical journals regularly. He shares a reciprocal personal acquaintance with 24 of the other 40 full- 38 time local health officers in California, and from four to five of the others look upon him as a good source of counsel with regard to new programs. 2. The "Average” Local H ealtb Department The “average" health officer directs a department which has been active for about 30 years, with a staff of nearly 127 workers who are, on the average, about 43 years old and who have been associated with his department about six years. About 7% of staff mem- bers have an MPH degree. The department’s total budget is close to 1.3 million dollars, and from local tax dollars, $2.26 per capita is spent annually for the health services which the department delivers. Thus, about 25% of the budget derives from Other than local tax sources. The incumbent health officer’s predeces- sor served the department for about 71/2 years, and Over the past 13 years the department has had an average of 2.6 changes of health officer. The "aver- age” department encourages advanced training for staff members and makes educational leave available to them, and offers its facilities for the training of student nurses and for public health field training ac- tivities. It probably does not have a residency or lab- oratory training program, however. The department encourages staff members to attend both continuing education and professional meetings, but does not have the facility to help financially with such attendance. More than 30% of the toral staff are apt to be new to the department within the past two years, and over 50% of them have come on the job within the past five years. 3.Tbe ”Average” Community and Population Served The "average” health department serves a commu- nity with about 450,000 people, most of them living in urban settings. The community will have experi- enced a substantial population increase of nearly 50% over the 10-year period of 1950 to 1960. The popula- tion includes about the national average of children under five years of age (11.2%) and somewhat less than usual numbers of the aged, 65 years and over (9.1%). The non-white population which is served is less than the national average. The adult population which is served is less than the national average. The adult population is reasonably well-educated, with 47% of them having completed the eighth grade or better. On the average, families in the jurisdiction have an annual income of about $6,000, and those who own and live in their own homes do so in dwellings valued at somewhat more than $13,000. Not quite half of the community’s general revenue, upon which the de- partment relies for 75% of its budget, comes from property taxes. The community boasts about 125 phy- sicians per 100,000 residents, below national averages, but favorably comparing with them. Independent Variables Subsumed under each of the three major headings previously suggested, the detailed frequency data is presented in the Appendix. No analysis of these data will be made at this juncture. The figures are, of them- selves, important and interesting, and are presented for the sake of information. Later use will be made of .these data in contrasting selected health officer, health department, and community characteristics with over- all innovativeness scores. Fifty-one variables (descriptive of local health offi- cers, their departments, and their communities) were thought to be potential correlates to public health innovativeness. These are presented in Tables 30 through 78 in the Appendix. However, not all of them developed as sufficiently discriminatory or correlative to include them in further analysis. Of the 51 originally measured and reported, 18 variables were rejected for further analysis for the following reasons: 1.Ten variables were not included owing to their lack of dircrimination— distributions were inordi- nately skewed with little or no variability present. 2. Four variables have been rejected because they show very little correlation either with innovativeness scores or with any other variable. 5. Two variables were excluded because data were available on an inrufliciently large number of care: owing to non-response to inquiries. 4. Finally, two variables relating to professional and non-professional staff tenure were rejected in favor of using their combined ualuer reflective of total staff tenure. The combined figure has been adopted because no significant differences are apparent between profes- sional and non-professional staffs in terms of their tenure. Thus, 53 "independent" variables have been retained for further analysis against innovativeness scores (the "dependent" variable). These 35 are detailed in Table 18. It will be noticed that these are subsumed under the general categories employed previously in describ- ing correlates to innovativeness found in other studies which are listed in Table 17. REFERENCES 1. Truman A. Pierce. Controllable Community Cbaracterirtics Related to the Quality of Education. Columbia University Teachers College, Bureau of Publications (New York), 1947, pg. 10. 2. Stanley E. Seashore and David G. Bowers. Changing the Structure and Functioning of an Organization—A Report of a Field Experiment. University of Michigan Press (Ann Arbor), 1963, PP. 46—56. 3. Everett M. Rogers. Diffurion of Innovation:. Free Press of Glencoe (New York), 1962, pp. 171—84. 39 Table 18 Thirty-Three Independent Variables Descriptive of California Local Health Officers, Local Health Departments and Communities Served, Which Have Been Retained for Further Analysis Age: Incumbency : Cosmo politeness : Social Status: Age: Size: Economic Status: Economic Status: Urbanism: “THE MAN" Health officer’s age, Median age of staff Health oflicer’s tenure, Predecessor’s tenure, Mean staff tenure Health officer's professional travel outside jurisdiction during 1964 Health officer’s professional travel outside California during 1964 MPH degree held by health officer Board certification held by health oflicer Opinion leadership status of health officer Breadth of health officer’s acquaintance with peers Length of health officer’s total medical experience Length of health officer’s local public health experience "THE AGENCY” Year health department established Number of full-time staff members Total population served Engagement in residency training Engagement in laboratory training Engagement in nurse training Engagement in field or other training Size of total budget administered by health officer Budgetary provisions for short-term training for staff Budgetary provisions for professional meeting attendance by staff members "THE PLACE” Median income of families in population Value of owner-occupied housing in jurisdiction Physician / population ratio Density of population Percent of population in urban residence Educational level of population (% 8th grade graduates) Percent of population non-white Percent of population under 5 years of age Percent of population 65 years of age and older Growth of population (change between 1950—1960) 40 CHAPTER VI CONDITIONS FOR INNOVATION Bivariate Analysis of Independent Variables and Total Innovativeness Scores The 33 variables in Table 18 will now be explored, individually, to detect cases of significant association with those innovativeness scores which are based on the adoption of seven new programs. The 38 local health departments included in this analysis achieved total innovativeness scores ranging from a low of 22 to a high of 128 points (see Table 16). The mean score was 68.9, with a standard deviation of 26.7. It was decided, for purposes ofz-Jhe following analysis, to designate those local health departments whose scores lie beyond about one standard deviation from the inean as being the extreme cases. On this basis, 16 departments are assigned to the extreme ranges, eight each in the “Very High" (Scores: 92—128) and "Very low” (Scores: 22—46) groups. In the cross tabulations which follow, the remaining 22 cases constitute the "middle” group of scorers. 1. "THE MAN” Thirteen independent variables are subsumed, in Table 18, under "the man" treating such characteristics as age, incumbency, cosmopoliteness, and social status. In Table 19, these are viewed against total innova- tiveness scores. Nine characteristics of "the man” are found, indi- vidually, to associate significantly with higher innova- tiveness scores. Thus, confirmation of the findings of other studies is found with respect to the racial .rtatnr of health officers. It appears from these data (Items h through m, Table 19) that earned professional de- grees, recognition through certification by a national examining board, status among peers both as a leader and as a mutual acquaintance, and the length of local public health experience all associate significantly with innovativeness. Strong corroboration of other studies with respect to cormopolitenerr (Items f, g, Table 19) is also found with significant associations between extra-jurisdic- tional professional travel and high innovativeness scores. It is reasonable to believe that one source of information about new health programs, and stimula- tion to engage in them, certainly comes from inter- personal contacts; and that such contacts are enhanced by increasingly wide travel outside the local jurisdic- tion. While age failed, in this analysis, to show any sig- nificant association with innovativeness (as it has in other studies), the matter of health oflicer tenure (Item c, Table 19) develops as a feature signifi- cantly associated with higher innovativeness scores. While it has been found that in public schools, the number of innovations is inversely proportional to the tenure of the chief administrator,1 the converse seems to hold in the case of local health departments. It would seem logical to suggest that the longer a health officer is incumbent, and the longer his predecessor had been incumbent, the more opportunity there would have been to develop within his department new and imaginative programs. Additional confirmation of this conclusion is provided when the total number of new programs (of the 21 studied) which have been adopted by local health departments is plotted against high and low tenure of the health officer as in Table 20. Apropos opinion leaderrbip (Item h, Table 19) which these data, and other studies, strongly implicate with early innovativeness, substantiation may be found when the extent of opinion leadership is viewed in the light of the average number of 21 new programs which health departments have adopted. As Table 21 shows, the health officers who enjoy high opinion leadership status among their peers tend to be those whose de- partments have adopted the greatest number of new programs. 41 Table 19 Characteristics of "The Man” Viewed Against Innovativeness Scores Total innovativeness score Very Very P ratio high Middle low Age: a. Staf-rr ....................................... 42 + 4 13 6 2.443 <42 4 9 2 (N.S.) b. Health officer ............................... 60 + 3 6 3 0.197 < 60 5 1 6 5 (N.S. ) Incumbency: c. Health officer's tenure (years) .................. 9 + 8 9 2 5.401 < 9 0 13 6 (P < .05 ) d. Predecessor’s tenure (years) ................... 9 + 5 8 1 4.76?) < 9 3 14 7 ( P < .05 ) e. Mean staff tenure (years) ..................... 6.7 + 2 5 4 1.070 < 6.7 6 17 4 (NS. ) Cosmo politeness : f. Professional travel outside jurisdiction ........... 7.5 + 8 11 1 12.944 < 7.5 0 11 7 (P < .05 ) g. Professional travel outside California ............ 2 + 4 3 0 11.705 < 2 4 l9 8 ( P < .05 ) Social Status: h. Opinion leadership citations ................... 9 + 6 5 0 21.143 < 9 2 19 8 (P < .05 ) i. Total years local public health experience ......... 12 + 8 13 3 5.345 < 12 0 9 5 (P < .05 ) j. Number reciprocal acquaintances w/ peers ........ 24 + 8 16 3 5.145 < 24 0 6 5 (P < .05 ) k. Health oflicer holds MPH degree ............... Yes 8 10 4 4.245 No 0 12 4 (P < .05 ) 1. Health officer board certified ................... Yes 8 10 4 4.083 No 0 12 4 ( P < .05 ) m. Total years of medical experience ............... 20 + 8 16 6 0.045 < 20 0 6 2 (NS. ) Table 20 Table 21 Tenure of Mean number of the 21 Health ofi‘icer’s Mean number of the 21 health 0 flicer: Itudy program: adopted leaderthip statur: study program: adopted Shorter ................... 10.6 Very high ................. 16.0 Medium ................... 12.1 High ..................... 16.1 Longer .................... 13.6 Medium ................... 12.5 Low ...................... 10.8 42 2. "THE AGENCY" Table 18 presents ten variables which characterize, in one way or another, local health departments in California, and Table 22 views these variables against total innovativeness scores in an effort to establish significant associations which may exist between such individual variables and higher scores. While age of department (Item a, Table 22) shows no significant association, it is clear that five of the six items (Items b through g, Table 22) descriptive of large :ize are found to be associated with innova- tiveness. It would seem from these data that larger health departments, with their concomitantly »larger budgets and stallt of personnel, might be particularly fertile grounds for innovation. There may be little debate that conceptualization and at least initial im- plementation of new programs may well depend on the availability of, and involvement of, adequate num- bers of staff workers. Whether extra-mural training activities such as residency, nurse, and other training contribute to the adoption of the new (owing to extra personnel thus made available perhaps for extraordi- nary activities) or whether they follow as a result of innovativeness, these data cannot demonstrate; they do, however, logically associate with larger size. Thus, this seeming characteristic of highly innovative health departments may be but another expression of their larger size. 3. "THE PLACE” Ten variables were presented in Table 18 as being reflective of the communities which are served by Cali- fornia local health departments. In Table 23, these ten are individually stratified against total innovativeness scores. There is a limited association between community eco- nomic Jtatm and higher innovativeness. While family income does not show a highly significant association, the value of housing (Item a, Table 23) does, and this suggests a tax base which might support local health department budgets of substantial size. Table 22 Characteristics of “The Agency” Viewed Against Innovativeness Score Age: a. Years since health department founded ........ Size: b. Conduct approved residency training .......... c. Conduct other/ field training program ........ i. . d. Number of full-time staff .................... e. Conducr approved laboratory training .......... f. Size of population served ................... g. Conduct nurse training program .............. Economic Status: b. Total budget (in thousands of dollars) ......... i. Budget for short-term staff training ........... j. Budget for professional meeting attendance . . . . Total innovativeness scores Very Very F ratio high Middle low 35 + 3 8 1 0.788 < 35 5 14 7 (N.S.) Yes 7 4 0 15.476 No 1 18 8 (P < .05 ) Yes 8 12 1 8.474 No 0 10 7 (P < .05 ) 40 + 7 17 1 7.322 < 40 1 5 7 (P < .05 ) Yes 6 5 1 5.53 1 No 2 17 7 (P < .05 ) 185M 6 12 0 4.070 <185M 2 10 8 (P<.05) Yes 7 10 3 2.707 No 1 12 5 (N.S.) 400 + 7 15 2 6.811 < 400 1 7 6 (P < .05 ) Yes 5 l7 6 0.313 No 3 5 2 (N .8.) Yes 6 ‘16 5 0.174 No 2 6 3 (N.S.) 43 Table 23 Characteristics of "The Place” Viewed Against Innovativeness Score Total innovativeness scores Very Very F ratio high Middle low Economic Status: * a. Median value housing (in thousands of dollars) .. 12 + 7 15 3 3.305 < 12 1 7 5 (P< .05 ) b. Median family income (in thousands of dollars) . . 6.5 + 6 7 1 2.916 <65 2 15 7 (N.S.) Urbanism: c. Percent population 65 years and older .......... 9% + 1 14 1 6.302 < 9% 7 8 7 (P < .05 ) d. Percent population under 5 years of age ......... 12% + 4 5 4 5.142 < 12 % 4 17 4 (P< .05 ) e. Percent population in urban residence ........... 60% + 6 12 2 3.278 < 60% 2 10 6 (P < .05 ) f. P0pulation per square mile (density) ........... 100+ 6 8 3 2.788 < 100 2 14 5 (N.S.) g. Percent population with 8th grade education ...... 48% + 6 9 2 1.621 <48% 2 13 6 (N.S.) h. Percent population change between 1950—1960 . . . 60% + 5 16 3 1.111 <60% 3 6 5 (N.S.) i. Number physicians per 100,000 population ...... 120+ 5 13 1 0.972 < 120 3 9 7 (N.S.) j. Percent population nonwhite .................. 6% + 3 7 3 0.032 <6% 5 15 5 ( N.S.) " Economic status of population served. Pierce found 19 community characteristics, descrip- tive of degrees of urbanism and diiierent, economic and social levels of urban settings, to be strongly associated with innovativeness in public schools. Of variables in this Study comparable to Pierce’s com- munity characteristics (Items e through h, Table 23), only one (Item e: percent of population residing in urban places)gshows a significant association with health department innovativeness scores. It would seem that insofar as descriptions of "the place” in this study are comparable to Pierce's variables, little im- pact one way or the other is seen on health depart- ment innovativeness.‘ ‘ One kind of variable descriptive of communities, which might logically be thought of as relating obviously to innova- tion, is conspicuous by its absence from the listing in Table 23. This is the matter of local per capita expenditures for public health services, for it is known that such per capita figures fluctuate considerably among localities. This variable was originally included, but it failed to show any correlation either with total innovativeness scores or with any other variable. 44 Four variables thought to be particularly relevant to public health settings were included in the foregoing data. These were percent of population under 5 and over 65 years of age, percent of population nonwhite, and the number of physicians per 100,000 persons (Items c, d, i, and j, Table 23). These variables were felt to be suggestive of special health needs or local capabilities to meet the health requirements of the population. Neither racial composition of the popula- tion nor the physician/ population ratio show signifi- cant association, however. On the other hand, signifi- cant associations with innovativeness score were dem- onstrated for the percentages of population under five and 65 years and older. However, increasing per- centages in these age groups seem to associate with the middle range scores, with the high and low scoring groups remaining undifferentiated on this basis. Thus, these significant associations cannot be taken as sug- gestive of a relationship with higher innovativeness score."‘ In summary, Table 24 lists the 19 independent variables which the foregoing analyses have disclosed as being individually significantly associated with higher innovativeness scores (based on seven new programs). Table 24 Independent Variables Which Individually Associate Significantly with High Total Innovativeness Scores "Tbe Man” Length of tenure Length of preceding health officer’s tenure Number of professional trips outside loCal jurisdiction Number of professional trips outside California MPH degree Certification by Medicine Opinion leadership status Number of reciprocal acquaintanceships with peers Years of local public health experience American Board of Preventive "The Agency" Number of full-time staff members Conduct of residency training Conduct of laboratory training Conduct of nurse training Conduct of field / other training Size of budget “The Place” Size of population Value of owner-occupied housing Percent of population in urban residence "Style” and Physical Feature-s of Innovative and Non-Innovative Local Health Departments Another view of the eight health departments with the highest total innovativeness scores as contrasted with the eight lowest scoring departments might also be considered at this point. Following the field inter- view phase of this study, it became apparent that there “ Had numbers of persons under five years of age, and 65 years and older, rather than percentages, been used, recalling the previously demonstrated association between larger popula- tions and more innovative health departments, an association between these variables and total innovativeness score might have been demonstrated. existed considerable differences between local health departments in California in terms of their physical surroundings, the "feel” one develops about the prem- ises, and the general style of their individual opera- tions. It was expected, therefore, that differences be- tween the highest and lowest scoring departments might be discovered. The impressions upon which the follow- ing brief analysis is based were derived from tran- scripts of field notes that were dictated shortly fol- lowing each visit. In an effort to reduce bias, the stylistic characteristics were reviewed and classified by the investigator without departmental identification and without differentiation between high, middle, or low innovativeness scores. On a number of such stylistic characteristics, there were no clear differences between high and low scor- ing departments. For example, whether certificates and testimonials were conspicuously displayed, certain phys- ical characteristics of health officers, whether offices were open rather than private, or whether offices and administrative quarters are "plush” did not clearly distinguish between the high and low groups. There were, however, three general qualitative characteris- tics which do seem to differentiate one group from the other. Uniformly, the highly innovative departments tended to evoke a business-like aura related perhaps to the newness of the building which houses their headquar- ters. The least innovative departments did not gen- erally convey this impression, but rather shared a common characteristic of being clinical in feel—some even smelled like a hospital or clinic. The offices of the administrators tended to present an interesting contrast. In the highly innovative de— partments were found the better appointed health officer’s office, which gave rise to the impression of its being the base of operations for a working admin- istrator of stature. To the contrary, the least innova- tive health oflicers, by choice or by fate, tended to be found in small and frequently dingy offices—usually neat and orderly, but lacking wholly the trappings as- sociated with the stereotype of modern management. Finally, an aura of self-containment, security, and internal sufi’iciency tended to pervade the highly innova- tive departments, while this seemed not to be the case with the others. Many factors contributed to this im- pression, including, in the innovative departments, depth of stafling so that needed skills are on hand for novel activities, well-trained staffs containing well~developed professional competencies, and a general optimism which suggests that the "know-how” is present and available in the department. It is true that this charac- 45 teristic would normally be expected as a concomitant of large staffs. Earlier analyses have shown the rela- tionship between size of staffs of large departments and higher innovation scores, and we may be observ- ing here symbolic aspects of the consequences of size. Reasons for Adoption/ Barriers to Engagement The next focus of interest turns to the reasons ex- pressed by health administrators for engagement or nonengagement in the seven new programs—reasons which lie behind adoptions and those factors which are perceived to be barriers to future planning. Promo- tive and inhibitive reasoning was elicited in the course of the depth interviews with health administrators. In a few cases, the overt rationale behind adoption, or reasons for nonadop‘ion, or barriers to future adop- tion, were reported by health officers whose tenure had been so brief as to require them to rely on other staff members or departmental hearsay, but in the majority of cases, the data reflects the state of affairs as seen by the administrator who has had to recognize salient barriers and plan to surmount them. Two sets of classifications were established, one treating contributory factors which were reported as lying behind the adopion of an innovation by a local health department; the second treating barriers to plans or desires for adoption of an innovative program and/ or reasons why adoption is not desired. 1.LITERATURE ON ADOPTION OF INNOVA- TION Before analyzing the reasons for adoption of the innovative programs dealt with in this study, it is inter— esting to consider what Barnett has said about the adoption of innovation in general. Whatever resistances there may be, however, change (via the adoption of innovation) does take place, being a moving and in- evitable force. From the point of view of the indi- vidual who innovates, Barnett2 contributes a classifi- cation of several antecedent avenues through which reconfigurations may take place in an individual mind, all of which might be thought of as leading to potential reconfigurations of pre-existing elements. With reference to the act of adopting innovations, the literature suggests four broad classes of effects which may be supportive of adoption or which may contribute to rejection of innovation: The effect of advocacy—Barnett describes several kinds of advocates, and subsumes their respective as. sets under four broad classes: their prestige, their pet- sonality, their personal relations with the adopter, and their majority affiliation. 46 Incentive; to innovation—Barnett includes in his discourses a series of wants which he sees as incentives to adoption: —want for credit; —subliminal wants; ——dependent wants linkages, convergences, compen- sations, or emergences from the satisfaction of other wants) ; —voluntary wants; —creative wants; —-relief and avoidance wants; —the wish for quantitative variation; —vicarious wants, including altruism. Nowelty valuer.——Novelties, or innovations, them- selves would seem to have value as impinging upon their adoption or rejection, and Barnett classifies these under intrinsic and external features inherent in the novelty. Values which are intrinsic to the novelty in- clude the ease of its adoption, its congruence with the adopting culture, its complimentary nature, and its freedom from complication with existing values. Val- ues extrinsic, but of importance to the potential adopter, on the other hand, include compatability, efficiency, cost, advantage, pleasure, mastery required, penalty associated, or repercussions which may be expected. Rogers, subscribing to the majority of these novelty assets as being controlling # factors, adds divisibility (its ability to be adopted on a limited scale) and com- municability (the degree to which results may be dif- fused ro others). For innovation to occur to an individual, Barnett further classifies several conditions for change, many of which have been suggested by others as well.3 These include: —accumulation of ideas upon which innovation may be based; —concentration, or localization of ideas in an indi- vidual mind; ——collab0rative efi’ort, whether formal or informal, drawing from the same cultural pool; ——a conjunction of differences through imitation or compromise; —the expectation of change (emphasized by Blum and Leonard); —lack of dependence upon authority; —where competition among rivals exists (a most pervasive force as described by Burns and Stalker); -——where crisis demands the new; ——Where a dominant correlate is modified, necessitat- ing further modifications (seen also as Ogburn’s cultural lag concept). 2. REASONS FOR ADOPTION With respect to those reasons which seem to lie behind adoption of this study’s innovative programs, the following four broad classes emerged, and each is presented, following by selected sub-categories: * advocacy (external)———by consultants, government, peers, community, vested interests, etc; leaderrbip (internal)——by health officer, staff, or results of other health department operations Such as demonstrations; reroarcer (external )——availability of external re- sources such as funds, new space or equipment, and convenient extensions of other activities as by adjunct or derivation; need—as generally recognized locally, or as de- rived from discrepancies in present services. Table 25 summarizes the responses received from fully engaged departments as to the reasons behind their adoption of new programs. Table 26 includes the same data for all health departments having adopted new programs to any extent. Table 25 Reasons for Full Adoption of Seven New Programs Seven new programs u, i“? a a E, a a g E g §§ E 8 3% g §§e§ a E 3 Reasons 3 <13. m U-8Q8 12° IL“ [3 Advocacy 8 2 5 4 11 10 6 46 Leadership 1 3 12 3 5 13 5 42 Resources 6 l 20 10 11 13 5 66 Need ...... 1 1 5 2 4 1 2 14 It may be noted that the elements relating to ex- ternal resources seem to far outweigh all others as enhancements to the adoption of these seven programs. Of these several resource factors, over half had to do with the availability of special purp05e, categorical, or project funds, or cases in which free or demonstration materials were made available. Thus, the effect of categorial grant programs from State and Federal sources, for example, as instigators of new local health department programming becomes apparent. The avail- ability of Community Health Facilities and Services *A full listing of the classes, and the sub-categories which comprise them, is contained in Appendix 2. Act funds contributed to the development of home nursing and chronic illness programs; special Federal funds for the development of migrant health programs is an example of a resource element which has un- doubtedly helped expand direct medical care servces in local health departments. Table 26 Reasons for Adoption to Any Extent of Seven New Programs Seven new programs 3" no '8 '3 -— G U G g 28 a 38 EEfi “ J: +9 5 0 =31 “ 9, a r? _ § 93 § §§.§2§ E g Reasons «2 <21. m 6-8 a 8:: £3 1-« Advocacy 8 18 6 15 12 17 84 Leadership .. 2 8 13 9 7 26 11 76 Resources 18 39 51 26 22 23 7 166 Need ...... 1 4 4 6 6 1 3 25 Advocacy, overall, apparently has the second most telling effect, with the major impetus derived from sug- gestions received from State consultants, other elements of superior governmental levels, or from the general local public. Specialized personnel of the California De- partment of Public Health regularly relate to most local health departments, particularly via the system of Regional Medical Coordinators. Funnelling through these channels is a steady flow of program consulta- tion and promotion and administrative assistance which has evidently played an important role in the ad0ption of new programs. As regards leadership, by far the most potent influ- ence has apparently been the health oflicer’s personal interest in, or conviction of, the desirability of the new program. Frequently during interviews, local health officers told of their abiding and deep interest in a given activity. When such analysis is extended to all local health departments, including those engaged even in partial program: in these seven new areas, the same ranking of broad categories applies: first resources, then advo- cacy, leadership, and finally, need. There are, however, some differences which become apparent when this broader number is viewed as in Table 26. For example, the most compelling resource factor is that in which the new program is seen as a natural adjunct to other services or programs. 47 48 REASONS FOR ADOPTING SEVEN PROGRAM INNOVATIONS (CALIFORNIA LOCAL HEALTH DEPARTMENTS) _ _ N N 01 OI 8 o 01 O 01 O OI TOTAL NUMBER OF CATEGORY COMPONENT CITATIONS O LIOIN m ALCOHOLISM ..——-ACCI DENT PREV. --------- ~I'IOME NU RSI NG WNOHRONIO DISEASE MMEDIOAL GARE woooooRESEARCH _.-._FANILY PLANNING I I ADVOCACY LEADER SHIP (EXTERN AL) (INTERNAL) RESOURCES NEED (EXTERNAL) MAJOR CATEGORIES OF REASONS Figure 10 As discussed previously in connection with the prac- ticability of adoption of new programs, it was sug- gested that those which enjoy a rating of "practicable” for adoption are, by and large, new programs which could easily become adjuncrs to other, perhaps more traditional, health department activity. By the same token, they might be natural derivatives from other, on-going activities which, when adopted, would not be viewed as radical changes but rather as expansions. Several cases were observed during the field studies, for example, where new home nursing programs were accomplished by simply extending the duties of public health nurses into this service area and simultaneously reducing the size of their case load. As regards advocacy, more than half the reasons mainly center either in recommendations received from State consultants or from other departments or persons or agencies in the local government, with the effect of community willingness dropping somewhat in im- portance. In terms of the leadership category, the personal interest and conviction of the health officer seems to continue to play an important role, but again, subordinate to either resource and advocacy factors. The data discussed in the foregoing section is graphi- cally presented in Figure 10, which illustrates the ma- jor categories of reasons for adoption of new programs. 5. LITERATURE ON RESISTANCE TO INNOVA- TION Nimkoff, Seashore and Bowers, Wallace, Spicer and Stern have treated the matter of resistance to cultural change and to the adoption of innovation. In general, two main classes of resistance to change may be sum- marized, and these relate to difficulties in making in- ventions and resistances to the use of innovations. Difficulties in making inventions may arise from: disparities in cultural storehouses (not everyone has the same raw materials from which to work in construct- ing the new); limited knowledge (technologic deficit); incompletely used mental abilities to perceive recon- figurations possible; and organizational maladaptations to the new. On the other hand, resistances to the use of inno- vations may owe to: their cost; cultural habits which preclude the use of the new; lack of demand for the new; tendency of society to trend toward balance and resist all upsetting forces; vested interests (including perceived threats to power positions of persons and groups) and the protective motives of those whose values are challenged; inability of recipient culture to participate in decisions to adopt; the fact that partici- pation by recipient culture in decision to adopt is alien to their culture; personal conservatism. Other barriers to change have been suggested, such as the sacredness of the old.4 In the context of formal organizations, Seashore and Bowers5 rephrase several of the foregoing and suggest. three compelling factors which induce resistance to change: —lack of plan or system into which new methods or devices can be systematically inserted; —the concomitant effect of change in one compo- nent of an organization upon all other related components; also seen by Wallis6 as “the in- evitable effect on an entire, interrelated culture, which an innovation effects”; —the controlling effect which an organization's (external) environment has on its internal structure and operations. In addition to these, Barnard’ singles out three others from a formal organizational point of view, which in- clude: —inability of knowing in advance an innovation's value; —the press of routine and inability to adopt many new things at once; —the donor’s irresponsibility for the consequences of his novelty. Apparently, individual characteristics of innovators and their nature as human variantsa help to account for much resistance as well. Dexter“ suggests that "personalities tend to be more or less integrated; and unorthodoxy in one field may well be accompanied by unorthodoxes in others. . . Veblen was not only a scoffer at classical economics; he was personally sar- castic.” The theme of the unconventionality of the innovator has been echoed by others,” and all have discussed those aspects of history which suggest that "being first” has its attendant hazards. Being first, however, may not be the sin; it may rather be that he who tends to be first tends to be different, in ways “objectionable” to the rest of society. 4. BARRIERS TO ENGAGEMENT With respect to barriers to plans and desires or rea- sons for non-entry, a somewhat different categoriza- tion of factors was needed. The major classifications“ which were used are the following: —Health department: a. staff b. organization —Community: a. opposition b. demand c. physical peculiarities * A detailed listing of barriers to innovation which health officers perceived is contained in Appendix 3. 49 —Government: a. local board (supervisors, city council, etc.) b. funds c. other —Other agencies and organizations —Need and appropriateness Figure 11 summarizes the data wherein the fre- quency with which given barrier categories were cited by health officers during interviews are plotted, by new program area, for each of the three classes of respond- ing health officers; those planning to adopt, those not planning but desiring to adopt, and those with neither planr nor desire to adopt.* A close similarity may be noted between the frequency with which certain cate- gories are cited by planners, desirers, and non-desirers, as well as the occasional striking difference which pre- sents itself. For example, with reference to the barrier category identified in the graphs as "staff,” it may be noted that in the case of five of the seven new programs included, planners, desirers, and non-desirers perceive this prob- lem with the same salience. While non-derirerr (Figure 11: the dotted line) conform closely with the other categories of respond- ents in most cases, the overwhelming reason which they cite for non-desire for adoption of medical care programs lies in the barrier class called “other agen- cies.” This would suggest that the roles presently played in California by county hospitals, and other or- ganized medical services outside the health department, are effectively inhibiting some local health officers from even expressing a desire to engage his department in medical services. Speculation at this point could sug- gest that a substantial behind-the-scenes role is played by the private medical community with regard to such medical "other agencies,” and that this role, rather than the other agency per se, is in fact the inhibiting force. In short, it might be questioned whether the role of the local private medical community is not the un- articulated reason in back of the ostensible reasons perceived by, or at any rate, reported by respondents in this study. It was decided to compare the eight most innovative health departments (highest total innovativeness scores) with the eight least innovative (lowest total innovative- ness scores) in terms of the kinds of barriers which their respective health officers perceive as being effec- tive inhibitors to innovation. *For details, see Robert E. Mytinger, "Barriers to the Adop- tion of New Programs Perceived by Local Health Oflicers,” Public Health Reportr, Vol. 82, No. l. 50 When the kinds of barriers reported by the most innovative local health departments are contrasted with those cited by the least innovative, it appears that each group of health departments apparently perceives al- most every barrier to the same extent. As Figure 12 presents these data, it is clear that there is one issue which presents a significant difference between high and low innovators, and this relates again to the role of other agencies as a barrier. The least innovative departments perceive this barrier as the most signifi- cant to them, while it ranks well down in importance for the most innovative departments. This suggests that the administrators most deeply engaged in new pro- grams may have found ways of surmounting or circum- venting this kind of barrier, while those with less ex- perience in establishing novel activities feel considerably more anxiety on this score. To a somewhat lesser extent, departments with low total innovativeness scores perceive matters of unmet need (which include technologic deficits) as a more significant barrier than did the high-scoring group. Multivariate Analyses The earlier analyses of relationships between indi- vidual items leave several deficits. While illustrating individual associations, no information as to sets of items which may be strongly interrelated is given. A more sophisticated analysis would attempt to under- stand the role played in innovation (as represented by innovativenes scores), by reduced sets or groupings of variables. In such a case, each of the variables within a set would hear high correlation with one another and lOWer correlations with the variables in other sets. Statistical methods which permit the simultaneous han- dling of reneral variables are useful in achieving this objective, and such multivariate techniques have been employed here. In the sections which follow, three separate yet pro- gressive attempts have been made to reduce the data to manageable proportions while retaining essential meaning. Two separate multiple regression analyses were made, interspaced with one factor analysis, as follows: Arrociation of 33 Independent Variable; will) Total Innovatiienerr reores First, the 33 independent variables, descriptive of local health officers, their departments, and their com- munities (see Table 19) were regressed, a: a group, against toral innovativeness scores based on seven new programs. mm_mOOw._.Oo £410 20:.— 20:45 42 Jab mwflro mow—Du amqom .m» 024 waéOafio .z<20 mug—b : 85mm ..,.,...,‘.x,,:.,.,...\..\.:..HAndy/1.x“.V/A... mmo_>mmm mmO¢ M310 29.... 202.48 ouwz mmIPo murcb m9“?— omm w Iommmn_ ._.Zmo_oo< mo_>mmm ozamaz 220: “$53 “a. v.9: mo“. mzomfim w czEzfin. a a GELLIO SVM HEIHHVS SEWLL :IO 'ON 51 30 N 0| 5 NUMBER OF TIMES BARRIER WAS CITED "' 5 52 FIGURE |2 BARRIERS TO THE ADOPTION OF SEVEN NEW PROGRAMS REPORTED BY LOCAL HEALTH DEPARTMENTS WITH HIGHEST AND LOWEST INNOVATIVESS SCORES \ ——HIGHEST scones (a) I \ \ ---—LOWEST scoass (8) I \ STAFF ORGAN- O ”’08- DEMAND PHYS. BOARD FUNDS OTHER OTHER NEED IZATION ITI ON DHAR. OOV'T. AOOYS. BARRIER CATEGORIES Figure 12 Factor Analyrir of 21 New H ealtly Program: An attempt, with the assistance of factor analysis, was made to understand how the 21 new programs in- cluded in this study grouped themselves into more or less homogenous sets. Once such sets had been estab- lished, it was possible to assign a "score" for each health department for each set of new programs, thus providing another "innovativeness score” on program factors, based this time on all 21 new programs. Anociation of 33 Independent Variable: with Five Program Factor: Finally, using the 33 variables as in the first step above, these characteristics were regressed, again as a group, against the program factor score: based on 21 programs which were developed from the factor analysis. 1.ASSOCIATION OF 33 INDEPENDENT VARI- ABLES WITH TOTAL INNOVATIVENESS SCORES It will be recalled, when 33 independent variables were each separately stratified on total innovativeness scores, F ratios indicating significance at the 5% level or better appeared for 19 variables (Table 24). Looked at as a group, these variables seemed to suggest that a combination of characteristics which relate to the health officer's reputation and experience, to the size characteristics of the health department and, to some degree, to "urbanistic” characteristics of communities, tend to bring higher total innovative- ness scores. This tentative conclusion appeared to be confirmed by the results of the first step-wise multiple regression analysis. When the 33 individual variables were regressed against total innovativeness scores (based on seven programs), a total of six variables taken together were seen to account for 74% of the variation in innovative- ness scores. Table 27 presents these variables. Table 27 Six Variables Which Explain 74% of Variance in Innovativeness Scores Health officer’s professional trips out of California Health officer’s opinion leadership status among peers Size of the health department budget The conduct of residency training The conducr of field and other training programs Percent of population living in urban residence Table 27 clearly shows that much of the variance in innovativeness scores is accounted for by health officer reputational characteristics, health department size feature, and community urbanistic tendencies. From this analysis, it appears that the direction of effect of these components is the same; that is, higher status ratings for the health officer, larger health departments, and more urban settings. Specula- tion might suggest that the variable relating to ur- banism in the listing above may well be the primary component of the equation. There seems to be, in fact, a predictive quality to this tentative conclusion. For example, when the 38 local health departments are examined individually, one discovers that only six of them meet all the requirements of being highly reputa- tional, highly urbanistic, and high in the size component simultaneously. These six departments, in terms of over-all innovativeness score, fall within the top ten, and five of them are included among the top six on the innovativeness score. Intuitive reasoning applied at this point would sug- gest that the persuasive feature of the equation (repu- tation + size + urbanism) is the matter of health department size. Large health departments, with large stafl‘s, budgets, a substantial training activity, etc., are characteristically those which are associated with ur- banized areas. With respect to the reputational char- acteristics of the health officer, these might be thought of as deriving from his direction of a large, prom- inent, and visible health department (owing to its ur- banistic nature and size) or from acclaim which his greater innovativeness may have brought. Speculation at this point might center about whether it may not be organizationally possible to take ad- vantage of these thoughts so as to provide a broader base for innovation. The question arises about the possi- bility of regrouping smaller health units in some fashion into larger ones, serving in turn broader and larger groupings of people, so that the apparently greater innovative qualities of the local health unit might be enhanced. It might be argued that it is the innovative health officer (who holds the higher reputational status) who is ultimately responsible for the adoption of new pro- grams by local health departments. True though this may be, it would appear from these data that with few exceptions, reputational status is a concomitant of administering a large unit. At least in California, it would appear that smaller units (with a few excep- tions) have not been able to recruit (or retain) the health officer with enhanced reputational status; or viewed another way, the local departments have not provided the basis upon which their health officer might have established a higher status. 53 Table 28 Factor Groupings of 21 New Health Programs Factor Factor I (Administrative) : loading Integration/ coordination of health facilities/ resources ........................................ 0.67 Improvement of quality of medical care .................................................... .66 Maintenance of complete data on community’s health status ................................... .63 Joint planning of health programs with others ............................................... .50 Use of behavioral sciences in public health programs ......................................... .50 Prevention/ correction of hearing/ speech defects .................... , ......................... .47 Assuring that health aspects are included in overall community planning ...................... .42 *Home nursing services .................................................................. .42 Factor 11 (Limited knowledge) : *Accident prevention ................................................................... .76 *Early detection of chronic illness ......................................................... .69 Factor III (Basic, traditional) : Maintenance of complete data on health resources/ facilities .................................... .79 Assuring availability of comprehensive maternal and newborn health services to all mothers and infants .................................................................. .54 Factor IV (Medical-psychiatric) : Services for ex-mental patients ........................................................... .80 Providing focus for community mental health services ........................................ .79 Suicide prevention ..................................................................... .70 Development of rehabilitation services ..................................................... .51 Programs for psycho- and medico-social problems of youth .................................... .49 *Direct medical care services ............................................................. .45 Factor V (Contentious): *Research and evaluation ................................................................ .79 *Alcoholism prevention, treatment, and rehabilitation ........................................ .64 *Family planning ....................................................................... .54 * Those programs which are starred with an asterisk (*) are those seven whose scores were derived from interview data (innovativeness scores). For the remaining 14 programs, scores were derived from the self-rating instrument which health officers completed. With reference to the factor groupings which appear above, it may be noted that scoring methodology (inter- view-based scores as opposed to self-rating scores) did not affect the dispersion of programs within the five factors. 2. FACTOR ANALYSIS OF 21 NEW HEALTH PRO- GRAMS Factor analysis"‘ was employed, using innovativeness scores which the 58 study departments achieved for the " The factor analysis which was performed included a prin- cipal component solution and an orthogonal rotation of the factor matrix. The data upon which the analysis is based in- cluded innovativeness scores assigned to each of 38 local health departments based on their extent of involvement in seven study programs, and the score assigned to each for 14 additional programs via the health officer's self-rating of extent to which his department is engaged in those 14 new programs. Twenty- one scores were thus used for each health department in the sample. The analysis discloses those groups of new programs which are most highly intercorrelated on the basis of these scores. 54 21 new public health programs originally included in this study. This analysis disclosed five factors into which the 21 programs seemed best to divide. Table 28 presents these program factors, with their com- ponent program items and appropriate factor loadings which describe the general importance of each item in each factor. 3. ASSOCIATION OF 33 INDEPENDENT VARIA— BLES WITH FIVE PROGRAM FACTORS When the 35 individual independent variables de- scriptive of local health officers, their departments, and communities are collectively regressed on each of the five program factors * described in the preceding section, some differences between kinds of programs and the sets of variables which best explain their variance appear. Table 29 presents the data from these five analyses. One advantage of multiple regression analysis is its facility of handling a great number of interre- lated variables. The results of such analysis suggest only those variables which seem bert to explain the dependent phenomenon, and it is in this light that Table 29 should be viewed. The generalizations based on these analyses which follow, while tending to bear out the previous tentative conclusions relating to size. urbanism, and reputational status as concomitants of innovativeness generally, also illustrate some signifi- cant differences between types of programs and the kinds of independent variables which explain the max- imum of variance in each. a. ”Adminirtmtive” progrmm. High scores (indi— cative of high adoption) for these kinds of programs seem most strongly related with settings where a high proportion of the population lives in urban residence. This suggests an abundance of governmental and vol- untary agencies as in a large municipality. While ef- fective liaison (implicit in most of the programs sub- sumed under this factor) between elements of bu- reaucratic structures is a problem which is magnified in such complex settings, the sheer number of choices for cooperation and administrative arrangements might be thought of as contributing to the adoption of such programs by local health departments in such settings. Large staffs are commonly associated with the large units which are developed to serve the needs of highly * For purposes of this multiple regression analysis, program factor scorer were used as the dependent variables. The individual scores which each of the 38 local health departments achieved for each of the components of each program factor (Table 28) were standardized, to assure that all variables were treated equally and that differences in scoring methods (footnote, Table 28) were taken into account. Because the nature of the data does not warrant the most refined statistical treatment, factor scores were not used. The score (either assigned by inter- view or by self-rating) which each department achieved for each program was standardized using the following equation: X1 ) —- —— —— X (ZSHD 2 . 10 + 50 SD. Five sets of standard scores were thus evolved, one for each of the five program factors. These scores reflect the extent to which local health departments have adopted programs subsumed under the five program factors presented in Table 28. urbanized populations. Furthermore, it seems likely that a large staff would be essential to affect adminis- trative cooperation with many other agencies and de- partments, and to the execution of programs which are essentially administrative in nature. The variable, "conduct of field or other extra-mural training,” which associates with departments engaged in "administra- tive" type programs, would seem to be another re- flection of large departmental size, and this relation- ship has been previously suggested. b."Limiterl knowledge” programr. Here it is inter- esting to note the suggestion that the high status health officer variable begins to appear with other variables in having an association with the adoption of such risk-bearing programs. The data further suggest that such programs have found greatest adoption in places where staffs are younger, for an inverse relationship for the staff age variable is indicated by the analysis. Perhaps this implies that younger staffs are more flex- ible and willing to engage in newer activities. Perhaps a younger staff is but a concomitant of larger staffs, possibly with high turnover rates, and thus there is a considerable infusion of young and more venturesome individuals. Large cities, dense suburbs, or cities peripheral to metropolitan centers are suggested by some of the var- iables which explain the bulk of variance in this pro- gram factor. It may be that these settings offer a concen‘rated need, with perhaps higher rates of chronic illness, accidents, etc. The analysis suggests that per- centage of population which is nonwhite works in- versely to other variables, possibly implying (in con- nection with higher family incomes) the development of such "limited knowledge” programs in more homog- enous, higher income populations such as those char- acteristically found in densely settled suburban areas and peripheral cities. Many of these locales also have a larger proportion of older persons. In the context of this type of program, three community variables (homogeneity, family income, and dense settlement) are seen coming into play which did not previously show a significant association (as individual variables) with total innovativeness scores based on seven pro- grams. This may suggest that these aspects of the setting are important considerations in the adoption of this specific class of program, while they play little or no significant role in the introduction of other types of programs. c."Barr'c” programs. The main impression from the data associated with engagement in this .type of new 55 Table 29 Independent Variables Which Best Explain Innovativeness in Five Program Categories Percent of variation Type of innovative program Main independent variables . . . (dependent variable) utilized 1 m innovativeness explained 1. "Administrative” type programs: a. integration/ coordination; + Size of staff ....................... 49 b. quality of medical care improvement; + Field/ other training c. data on health status; + Short~term training budget d. utilization of social sciences; + Percent of population in urban residence e. joint planning; f. health aspects of total planning; g. hearing and speech; h. home nursing. 2. "Limited knowledge” type programs: a. accident prevention; + Opinion leadership status ............. 70 b. early discovery of chronic illness. ‘ Age of staff + Density of p0pulation ‘ Median family income ' Percent non-white 3. "Basic” type programs: a. data on health resources/ facilities; + Length of health officer’s experience . . . . 31 b. comprehensive maternal/ infant services + Field/ other training ‘ Median family income + Median value of housing 4. ”Medical" or clinical type programs: a. services for ex-mental patients; ' Health officer’s board certification ...... 61 b. center for community mental health servs; + Health officer’s out-of-state professional c. sucide prevention; travel d. development of rehabilitation services; + Residence training program e. psycho/medico-social problems of youth; + Budget for professional meeting attendance f. direct medical care services. + Physician / population ratio in jurisdiction 5. "Contentious" type programs: a. research / evaluation; + Field/ other training ................. 59 b. alcoholism; + Health ofl'icer’s out-of-state professional c. family planning. travel + Size of budget + Budget for professional meeting attendance ' Median value of housing ‘ + a directly increasing relationship between the variable and program innovativeness score. an inverse relationship. ll 56 activity is one of older, more experienced health offi- cers leading respected departments in economically well-off areas. The variables reflective of health officers’ total experience, and higher values of housing in the community, suggest a stable, conservative environment together with a stable, conservative health officer, and this characteristic seems more important to adoption of "basic” program extensions than it does to overall innovativeness. d. "Medical” or "Clinical” type programr. As with the risk-bearing programs clustered in factor 11, one high status health officer variable appears as strongly associated, together with a department whose clinical depth has been acknowledged by vesting it with ap- proval for residency training. Fewer physicians in pri- vate practice per unit of population are suggested, and it might be assumed that where physicians are not so numerous as elsewhere, their practices are sufficiently busy as to preclude overconcern with the entry of official health agencies into aspects of medical care. This is the only new program factor where the matter of medical population enters as an associated variable. A degree of cosmopoliteness on the part of the health officer and his staff implied (out-of—state pro- fessional travel and budget for professional meeting attendance), from which may develop new ideas or stimulation to enter into such new programs as this factor includes. e. "Contentiour" programr. As with medical and limited-knowledge programs, a status feature associ- ated with the health officer is implied in connection with engagement in this program area. The aspect of status indicated is cosmopoliteness (out-of-State pro- fessional travel by the health officer), and this seems to be shared with staff members by virtue of some flexibility in funding their attendance at professional meetings. It may well be a result of these characteris- tics that stimulation to enter, and information about, such new program activities develop. The association of contentious programs with health departments hav- ing larger budgets (suggesting in turn, larger staffs) might be explained on the basis that such activities are, to a degree, divisible and thus might be tried incon- spicuously within the limits of available funds without spotlighting them with special appropriations. Large budgets, likewise, provide a degree of flexibility to the health officer for unobtrusive experimentation, and it would seem logical that such facility might be impor- tant to the development of the contentious or "ques- tionable” programs such as those which comprise Fac- tor V. Summary The data presented in this chapter have shown a consistent pattern of health officer, health department, and community characteristics which significantly as- sociate with greater innovativeness. When the relationship between innovativeness and a series of 33 individual descriptive items was demon- strated, it was found that innovative health officers tend to be stable, cosmopolite, of high status, and with lengthy local experience. The departments most heavily committed to novel programs were seen to be the larger ones, in terms of personnel and money, and they were found to be serving large urbanized popu- lation groups. This picture was further borne out when the same 33 characteristics were viewed, collectively, against to- tal innovativeness scores. Reputational features of the health officer were found to be correlates of greater innovativeness jointly with size and urbanistic charac- teristics of the departments and communities. However, when the 35 variables were viewed against five different "types” of novel programs, it was shown that some aspects of the pattern described above ap- prarently associate most strongly with certain kinds of programs and not with others. Characteristics of locali- ties whrch connote urbanism were, it is true, found to be an important concomitant of innovativeness irre- spective of type of new program. The several variables which depict "bigness” of health departments, however, were found to be primarily associated with new pro- grams characterized by their "limited knowledge,” their contentiousness, or their administrative flavor. Thus, it was seen that programs which are essentially novel extensions of basic activities, and those devoted to clinical, medical, or psychiatric activities, are not necessarily associated primarily with large health de- partments. Likewise, the several attributes of health officers which might be subsumed as his “reputational status” seem to be important concomitants of innovations dealing in the areas of limited knowledge, contentiousness, and medical-psychiatric activity. As in the case above, basic program innovations are not seen as requiring the fea- tures of reputation; administrative programs of a novel nature seem similarly independent of such status char- acteristics. It would thus seem that although urbanistic ten- dencies are associated generally with innovativeness, as novel programs become more "risky” or as they in- volve departures into unorthodox areas, the features 57 of the health officer which contribute to his reputa— tional status and the characteristics of health depart- ments associated with larger size enter as important conditioners of innovativeness. REFERENCES 1. Daniel Griffith, in Innovation in Education (Matthew B. Miles, ed.). Bureau of Publications, Teachers College, Columbia University (New York), 1964, pp. 425—35. 2. H. G. Barnett, Innovation. McGraw-Hill (New York), 1953, Pp. 188—224. 3. Tom Burns and G. M. Stalker, Management of Innova- tion. Tavistock Publications (London), 1961; He'nrick L. Blum and Alvin R. Leonard. Puhlic Administration—A Public Health Viewpoint. MacMillan (New York), 1963; William F. Ogburn, in Technology and Social Change. (John F. Cuber, ed.) Appleton-Century-Crofts (New York), 1957. 4. Lewis A. Dexter, in Studies in Leadership (Leadership and Democratic Action). (Alvin W. Gouldner, ed.) Harper (New York), 1945, pp. 592—600; Meyer F. Nimkofl, in Technology and Social Change. (John F. Cuber, ed.) Appleton- Century-Crofts (New York), 1957; Chester Barnard (Com- 58 ments on Lewis A. Dexter, in Studies in Leadership). (Alvin W. Gouldner, ed.), Harper (New York), 1950; Bernhard J. Stern, Social Factors in Medical Progress. Columbia University Press (New York), 1927. 5. Stanley E. Seashore and David G. Bowers. Changing the Structure and Functioning of an Organization—A Report of a Field Experiment. University of Michigan Press (Ann Arbor), 1963, PP. 45—56. 6. Wilson D. Wallis. Culture and Progress. McGraw-Hill (New York 1930, pp. 9—12. 7. Chester Barnard, op. cit., pp. 601—03. 8. Everett M. Rogers. Difiusion of Innovations. Free Press of Glencoe (New York), 1962. 9. Lewis A. Dexter, op. cit. 10. H. G. Barnett, op. cit.,“ Bernhard J. Stern, op. cit.; Everett M. Rogers, op. cit. CHAPTER VII CONCLUSIONS Public health as it has evolved in the 20th century has developed mainly as a result of two major and interrelated forces—technologic advance and a develop- ing social consciousness. The veryagenciesNWhich this report discusses—ciland county health departments— grew from early eflortsmem- selves fromtke perio 1C ravage‘s’ro‘fruep‘idemics. As the philosophy of dEfEH’s’é‘hgaimt the ills of Others changed to a concern for ”@ghealrlmandlell-Abeinggfmrhers; as technologic armament provided the understanding of, and facility for, effective prevention and treatment of illness; and as crusaders, shocked by the social ills rampant in 19th-century America, took up their respec- tive banners—there culminated a movement to establish professional and scientific public health organizations. First at the city level, then the State, then the Federal, and finally the county level, there has come in the past century a steady procession of increasingly complex and competent health authorities to deal with the health problems of the population.* These trends continue to the present day, with the continuing deveIOpment of official and voluntary health organizations with a continually changing social out- look tending toward recognition of health as a priceless and undeniable "right" of every human regardless of station and with an ever-increasing abundance of tech- nologic progress in medical and engineering sciences. Until the mid-20th century, the overwhelming aim of organized public health was to perfect itself, and to extend basic services which had developed out of the earliest attempts to control epidemic disease—c01- lection of vital records, quarantine, isolation, and later immunization, special attention to the health of chil- dren, improvement and control of the physical environ- ment, and education of the public in matters of hygiene. The past has been characterized by the pre- " True local health organization may be thought of as be- ginning with the New York Metropolitan Health Act of 1866. sentation of a need, by social change forcing atten- tion to new issues, and by the provision of technologic tools with which to meet the needs. For the future, it can hardly be doubted that social change will continue, despite efforts to contain it and retain the status quo. Technologic development shows little sign of weakening," with many feeling it has far outstripped ability to translate the fruits of scientific achievement into practice. And there is little rationale in believing that needs for new health services will diminish, if the emergence of the chronic and degen- erative diseases which have made their recent and dra- matic impact on the minds of scientists and the public alike serves as example. . The time seems at hand when bona fide change in public health programs—through the adoption of in— novative programs and activities—is required to keep abreast of social demand for action, to faithfully and effectively use the new tools being provided, and to meet the new and different problems of preserving and promoring the health of the people. The era of im- proving the old has given way to the era of adopting the new. Many older and more traditional activities have virtually outworn their usefulness, as in the case of early concepts of disinfection and quarantine. Many functions are conducted in traditional ways despite newer "streamlined” techniques (e.g., replacing the rou- tines of milk or food inspection or school health exam- inations with perhaps better, quick-screening techniques which might give warning of those places or persons requiring individual attention). As the old is either discarded or more efficiently main- tained, the opportunity to begin to meet emergent problems appears. This is not to suggest that the only way new problems can be met is by the discard of the old; importantly, expansion is suggested not only to assure the adequate maintenance of desirable elements of older functions, but to guarantee needed and rapid expansion into newer areas of endeavor. 59 It would appear, from the tenor of the literature and the nature of newer health problems, that more than ever future public health efforts will be adminis- trative innovations. With social structure becoming more complex, highly developed administrative skills will be required to blend the efforts of oflicial health agencies with those of others or to stimulate the de- velopment of roles for others. With needs pressing with increasing frequency, no longer can the public health profession patiently await the development of tech- nologic knowledge—it must rather plan for contribut- ing to it. And with social change so great a determinant of the roles which public health may be permitted to play, official health departments would seem to have the responsibility of being in the vanguard of those who stimulate and support the needed change. Thus, innovation—the adoption of the new and the restructuring of the old—is, today, perhaps the most important function of the health administrator. For those who seek to induce change—advocates, crusad- ers, leaders, surrogates—insight into the correlates of innovation seems essential. For those who administra- tively control or guide the development of this na- tion’s health services, an understanding of the struc- tures most conducive to change seems important. The contributions of the present research would seem to lie partly in the data descriptive of new pro- grams, the extent to which they have been adopted by local health departments in one State, and the char— acteristics of California’s local health departments, their administrators, and the communities which they serve. These matters have been treated fully in the preced- ing chapters. Generalizations from the Data It was the purpose of this study to develop tenta- tive, yet data-dOCumented hypotheses for future study. To this end, a series of generalizations have been found to flow naturally from the data presented in the fore- going chapters. These are presented on the following page as a basis for further study of local public health departments, and of their complex relationships with other public and private agencies in terms of innova- tion. For purposes of clarity, rather than dogmatism, the generalizations have been phrased in violation of the general rules of conservatism in drawing conclu- sions. The tentative hypotheses which have been presented above should be of interest to administrators, upon whose shoulders the burden of innovation falls; to those advocating innovations; and to those planning or other- wise guiding the development of local health services. 60 It is to these three groups—administrators, advocates, and planners—that the following concluding comments are directed. Although they may be taken by some as recommendations, they are presented here as the prin- cipal implications which the data comprising this study seems to contain: Implications for the Diffusion and Adoption of Innovations by Local Public Health Departments 1.1mplicati0m for Adminirtratorr of Local Health Department: A more general recognition of the philosophy that the local health department, per re, need not "do” every desirable public health program seems indicated. Judging from the innovative activities of some health departments reported in this study, it is not unreason- able to suggest that broader involvement of and stim- ulation of other agencies in providing needed new health services has been found a useful and valuable expedi- ent. Teamwork between the official health agency, which retains its legal and moral role as “watchdog," and other community agencies is implicit here. It seems evident that the local health department has the obli- gation to act as the medical conscience of the com- munity in playing the role of prime mover (directly or indirectly) in developing needed services internally or under other auspices where indicated, as well as the duty of maintaining surveillance and some control over the, quality and scope of such services. On the basis of the experience of highly innovative departments reported in this study, less preoccupation with presumed barriers to the adoption of new pro- grams seems indicated. For example, lack of funds, the historic involvement of other agencies in the given pro- gram, or the pressures of other vested interests have not proved insurmountable barriers to some. Yet, to- day these matters are reported as effective inhibitors to the adoption of many new and worthwhile pro- grams by many local health departments. It would seem that the important role of local health depart- ments is the organization of all facilities and resources which are needed to bring to the population the neces- sary health services to maintain optimal health. The fact that funds may not be directly available to a local health department need not, necessarily, preclude the delivery of the desired service to the community. The fact that vocal and powerful minorities militate against the development of useful and needed health services should not dissuade the health administrator from serv- ing, by one route or another, the needs of his clientele. GEN ERALIZATIONS A. THE MAN, THE AGENCY, AND THE PLACE 1. The Local Health Oflicer a. Health officers with higher reputational status are those who lead the larger local health departments. b. Local health officers with higher reputational status will be more innovative than other local health officers. C. Cosmopolite local health officers are more innovative than their localite counterparts. (1. Older, more generally experienced local health officers restrict their innovations to corollaries of basic public health programs. e. Local health officers who are opinion leaders tend to adopt programs in which there is limited knowledge, or lack of successful precedent, and those which are contentious. 2. The Local Health Department a. Larger local health departments are more innovative than smaller ones. b. Health departments with a history of stability of health officer in terms of his tenure will adopt a greater number of innovations than those with less stability. c. Local health departments with younger staffs will adopt more radical innovations. d. Local health departments which conduct extra-mural training activities are more innovative than those which do not. 3. The Community a. Highest innovation will occur in jurisdictions comprising, or immediately adjacent to, major metropolitan centers. ‘13. THE PROGRAMS 1. Characterirticr of Innovative Pro grams a. The priority of a proposed program innovation, as seen by advocates and the profession generally, is related to the extent to which it is adopted. b. The practicability of a proposed program innovation, as seen by advocates and the profession generally, bears less relationship to the extent to which it is adopted than does priority. c. Innovative programs which may be adopted on a limited scale will be adopted more frequently by local health departments which have larger budgets and staffs. d. The adoption of programs which are contentious depends mainly on a locally experienced health officer with high reputational status who heads a large local health department. e. The adoption of medical care programs depends on a large, cosmopolite, and younger-staffed health depart- ment. f. Greater adoption of medical care programs will occur in areas with lower proportions of private practicing physicians. g. Programs about which there is limited knowledge or few successful precedents will be adopted more fre- quently in communities where urbanism and homogeneity characteristics of the population require attention to such problems. C. BARRIERS TO ADOPTION AND REASONS FOR ADOPTION OF INNOVATIONS 1. Barrier: a. Local health departments generally face and perceive the same barriers to innovation. b. Non-innovative local health departments perceive the role of other agencies as a barrier to innovation more acutely than do highly innovative departments. 2. Keaton; for Adoption a. Availability of external resources is the most compelling general reason for the adoption of new public health programs by local health departments. b. Advocacy plays a secondary role as a reason for adoption of public health innovations by local health de- partments. 61 Thus, several possibilities for action suggest themselves. Anxieties about barriers might be replaced with atten- tion to seeing that health needs are met by whatever resources can most efficiently and effectively do so, inferring that the health department need not neces- sarily consider itself the only resource through which needed services can be developed. Where vested inter- ests assert significant inhibitions to change and develop- ment, the mobilization of support from countervailing forces would seem an important function of the local health department. This step, it must be recognized, may often require the health administrator to divorce himself from social roles consistent with his medical background which, by their very nature, may dictate against the desired change. 2.1mplicationr for Tbore Planning or Guiding the De— velopment of Local H ealtla Service: Larger and better budgeted local health departments have been seen in this study as being high innovators. This suggests attention to a broadened population base for the support of local health departments as well as to increases in present levels of support. While it is true that most basic health services need to be deliv- ered where the people live, it does not necessarily hold that such services need to be adminirtered at the most fundamental local level. Planning, management and control can be centralized, and it would appear to be desirable to do so where such central administration would be able to serve a broader population base with an increased scope of innovative services. Important also seems to be the enhancement and im- provement of graduate training for public health ad- ministrators at all levels, for it has been demonstrated here that the better professionally prepared adminis- trators apparently yield a more abundant crop of in- novative programs. Additionally, as health departments grow in size, complexity, and scope, better trained administrators will be continually needed to meet the problems of management and organization which will undOubtedly develop. Every effort to develop for local health administra- tors, and their staffs, opportunities to meet with others, to view the programs of others, and to learn the intri- cacies of new technologic contributions seems indi- cated, for the more cosmopolitan the administrator and his staff become, the greater seems to be the inno- vative potential. By the same token, efforts to main- tain permanency of tenure of health officers would seem to offer important rewards in increased inno- vativeness. 3.1mplicationr for five Advocate; of Innovation: It has been shown, in this study and others before 62 it, that opinion leaders are the early innovators. This suggests special attention to placing new pilor or dem- onstration programs, which may be viewed as innova- tions, in the departments headed by the opinion leaders. It would seem that this maneuver would first enhance the rate of initial diffusion and, second, provide a chan- nel for diffusion to others. It might be debated that scarce demonstration funds should be allocated to the smaller, more “needy” health units which, without such special subsidy, would lack the capability to entering new program areas. However, behind many of the in- novative programs considered in this study (e.g., home nursing services and chronic illness detection) there have been ample funds available to the smaller, less affluent units. Despite this fact, visible programs in such areas have appeared mainly in the larger units. It would appear that innovations may best be intro- duced through the larger local health departments, owing to their better financial position, their higher reputational health officers, larger staffs, and the di- versity of populations which they serve. The foregoing suggests that advocacy, during the diffusion stages of a given innovation, may best come from local health officers with higher reputational status (i.e., administrators of large local health depart- ments) who have "tried” or adopted the new program. Some previous research has suggested that the rate of adoption is directly proportional to the intensity of advocacy from the supra-system.1 In the present case, it is suggested that the early innovators may constitute the most effective supra-system within the social struc- ture of organized local public health, for among the early innovators are found the opinion-leading, highly reputational local health officers who head larger de- partments with capabilities for attempting the new. Opportunistic aspects of any new innovation should apparently be emphasized, and in one of its most basic senses, this implies financial support. It may be worth observing that today’s era is one of health subsidy, deriving from higher governmental sources. The fact seems to be that if an innovation is worthwhile but beyond the fiscal ability of local appropriations, sup- port from other sources on a relatively stable basis may be the simplest and most efficient way of intro- ducing and maintaining the novelty. The long-term trend in grant-in-aid health programs has shown clearly that outside pump-priming money has enhanced local initiative. In the first place, new aCtivities and programs are implemented which, without special support, might not have been. More0ver, local funding for general health programs and the continuation of new programs as well appears to have continued to increase in the face of increasing amounts of outside financing. Out- nancing but rather has stimulated increasing local ap- side financing has not, apparently, replaced local fi- propriations. REFERENCES 1. Daniel Griffith, in Innovation in Education (Matthew B. Miles, ed.). Bureau of Publications, Teachers College, Columbia University (New York), 1964. 63 HEALTH OFFICERS 1.CHARACTERISTICS OF CALIFORNIA LOCAL Table 30 Age of California Full-Time Local Health Officers, in Years, Calculated as of the 1964 Anniversary Date Range: 35—67; Mean 55 Age: Number 3 5—44 ...................... 8 45—56 ...................... 19 5 7—67 ...................... 1 3 Total ..................... 4—0. Table 31 Number of Full-Time Local Health Offices Holding MPH Degree (California: 1964) Number MPH degree .................... 22 No MPH degree ................. 18 Total .................... 4—0 Table 32 Board Certification by American Board of Preventive Medicine and Public Health Held by Full-Time Local Health Officers (California: 1964) Number Certified ........................ 23 Not certified .................... 17 Total .................... 4—0 ‘ The tables were calculated as of the end of 1964. In some cases the data are incomplete, as will be apparent from the "total” in the tables. 64 Table 33 Employment Hirtory of California Full-Time Local Health Ofi‘icers (total professional employment) Range: 4—45; Mean: 14.9 Years: Number 4—1 0 ....................... 7 1 1—20 ...................... 10 2 1—30 ...................... 17 3 1—40 ...................... 5 41—50 ...................... 1 Total .................... 40 Total years of experience, past medical school, internship and residency which health officer has had, calculated as of the end of 1964. ' Table 34 Employment Hirtory of California Full-Time Local Health Officers (total local public health experience) ' Range: less than 1—38; Mean: 13.2 Yeurr: Number Less than 1—11 ............... 15 12—19 ...................... 14 20—29 ...................... 9 30—39 ...................... 2 Total .................... 40 Total years of local public health department experience which health officer has had, calculated as of the end of 1964. Table 35 Employment Hirtory of California Full-Time Local Health Officers (total State public health experience) Range: 0—14; Mean: 3.3 Year: Number 0—1 ........................ 33 1.5—4.5 ..................... 4 4 6—140 .................... 3 Total ..................... :13 4 Table 36 ’ Employment History of California Full-Time Local Health Oflicers (total national public health experience) Range: 0-33; Mean: 1.6 Years: Number 0—3 ........................ 37 4-33 ....................... 3 Total .................... 4—0 # fi fir * Table 37 Employment History of California Full-Time Local Health Officers (total military medical experience) Years: Number 0—2 ........................ 28 . 3—12 ....................... 9 12—27 ...................... 3 1 Total .................... 40 i‘ * I! II: Table 38 Employment Hirtory of California Full-Time Local Health Oflicers (total private pracrice experience) ( Range: 0—35; Mean: 3.9 Years: Number 0—3 ........................ 30 . 4—12 ....................... 7 12—35 ...................... 3 Total .................... E Table 39 Incumbency of Full-Time Local Health Officers in Present Position (California: 1964) Range: .5—25; Mean: 9.4 ' Years: Number 0.5—3 ...................... 1 7 4—1 2 ....................... 1 l - 12—20 ...................... 9 2 1—2 5 ...................... 3 Total .................... 40 Table 40 Number of Trips, on Oflicial or Professional Business, Which California Full-Time Local Health Officers Made During 1964 Outside Their Jurisdiction (in major met- ropolitan areas, this figure includes only trips outside that area) Range: 0—52; Mean: 12.4 Table 41 Number of Tripr, on Official or Professional Business Which California Full-Time Local Health Officers Made During 1964, Outside the State of California Range: 0-5; Mean: .75 Trrpr Number 0 .......................... 2 5 1—2 ........................ 12 3—5 ........................ 3 Total .................... 715 65 Table 42 Number of Proferrional and Technical Publications, of a Regular or Periodic Nature (Journals, etc), Which California Full-Time Local Health Officers Report as Regularly Read Range: 0—15; Mean: 1.9 Journals: Number 0 .......................... 3 1—3 ........................ 12 4—6 ........................ 15 7—1 5 ....................... 1 0 Total .................... 40 The six most commonly reported professional jour- nals which full-time local health officers in California read include: 1.Journal of the American Medical Association— 33 regularly read. 2.American Journal of Public Health—31 regularly read. 3. Public Health Reports (DHEW)——29 regularly read. 4. California's Health (CSDPH)—15 regularly read. 5.New England Journal of Medicine—15 regularly read. 6. California’s Medicine (CMA)—12 regularly read. I! it is It Table 43 Reciprocal Acquaintancerbips Which California’s Full- Time Local Health Officers Have With Other California Local Health Officers (1964) (number of others whom health officers report being acquainted with who also report acquaintance with him) Range: 4—25; Mean: 24 Acquaintances: Number 0—10 ....................... 4 11—20 ...................... 7 21—30 ...................... 15 31—40 ...................... 12 Total .................... 38 66 Table 44 Opionion Leadership Stutur of California’s Full-Time Local Health Officers as Professional Counsel to Other Local Health Officers (1964) (number of times health officer was cited as resource person to whom another local health officer might turn for professional c0unsel, with reciprocal citations—which may be biased by friendship factor——deleted) Range: 0—2; Mean: 4.4 Citatiom.‘ Number 0—4 ........................ 26 5—9 ........................ 4 10—15 ...................... 5 16—20 ...................... 2 2 1—25 ...................... 1 Total .................... 3 Table 45 "Mental Ability” of California’s Full-Time Local Health Officers as Reflected by Score on Cloze Procedure Instrument (1964) Score: Number 8—1 1 ....................... 2 12—14 ...................... 4 15—17 ...................... 8 18—20 ...................... 12 21—23 ...................... 5 24—26 ...................... 1 Total ..................... 32 2.CHARACTERISTICS OF CALIFORNIA LOCAL HEALTH DEPARTMENTS I Table 46 Region of California in Which Full-Time Local Health Departments are Located Region: Number North ...................... 6 Central Coast ................ 14 Central Valley ............... 10 South ...................... 10 Total .................... 4O Divisions are based on arbitrary segmentation of counties in California. It is 5* it ‘ Table 47 Year in Which California’s Full-Time Local Health De- ‘ partments Were Established (age in years in 1964) Range: 1880—1957; Mean: 1934 Year Established: Number 1880—1919 .................. 3 1920—1929 .................. 10 1950—1939 .................. 10 1940—1949 .................. 11 ‘ 1950—1957 .................. 4 Total .................... 4—0 ' ii is 1'! lfi Table 48 Total Staff Employed by Full-Time Local Health De- partments (California: 1964) Range: 7—1,705; Mean: 126.7 Employees: Number 0—111 ...................... 34 200—399 .................... 4 400—over ................... 1 Total .................... 35 . Table 49 Age of Staff Members Employed by Full-Time Local \ Health Departments (California: 1964) Range of median ages: 33—52; Mean of median ages: 42.7 Age: Number 33-39 ...................... 9 40—45 ...................... 20 46—50 ...................... 7 51—52 ...................... 3 Total .................... 39 Table 50 Length of Staff Arrociatt'on with Full-Time Local Health Departments (California: 1964) Range: 4.2-9.9; Mean: 6.2 years Years: Number 0—4.4 ...................... 3 4.5-5.9 ..................... 20 6.0—7.4 ..................... 4 7.5—8.9 ..................... 6 9.0—9.9 ..................... 3 Total .................... 36 Table 51 Length of Staff Anociation with Full—Time Local Health Departments (California: 1964) (professional staff only) Number 5.5 years or less .................. 12 More than 5.5 years ............... 15 Total ..................... 37 Table 52 Length of Stafi‘ Arrotiation with Full-Time Local Health Departments (California: 1964) (nonprofes- sional, or other, staff) Number 5.5 years or less .................. 16 More than 5.5 years ............... 11 Total .................... 2—7 67 Table 53 Percent of Professional Staff Members Holding MPH Degrees Employed by Full-Time Local Health Depart- ments (California: 1964) Percent MPH: Number 0 .......................... 7 1—5 ........................ 1 1 6—10 ....................... 14 1 1— l 5 ...................... 5 16—20 ...................... 2 Total .................... 37 Table 54 Total Budget Administered by Full-Time Local Health Departments (California: 1964) Range: $62,761—$15,318,691; Mean: $1,356,973 Badger Number $62,761—$99,999 ............. 1 $100,000—$ 5 00,000 ........... 14 $500,000—$1,000,000 ......... 10 $1,000,001—$2,000,000 ........ 8 $2 ,000,00 1—$4,000,000 ........ 5 $4,000,001—above ............ 1 Total .................... 40 Total health department budget, which includes all funds administered by the health officer during the fiscal period July 1, 1964—]une 30, 1965. Table 55 Per Capita Health Expenditures Derivative from Local Tax Sources in Jurisdictions Served by Full-Time Local Health Departments (California: 1964) Range: $100—$505; Mean: $2.26 Per capita expenditurer: N umber $ 1.00—$ 1.49 ................. 7 $ 1.50—$ 1.99 ................. 7 $2 .00—$2 .49 ................. 12 $2. 50—15299 ................. 8 $50045 3. 5 0 ................. 3 $3.5 O—above ................. 3 Total .................... 40 Figures do not reflect State and Federal subventions, grants, and categorical funds, voluntary and philanthropic contribu- tions. Figure is for fiscal period July 1, 1964—June 30, 1965. 68 Table 56 Incumbency of Predecessors of Full-Time Local Health Officers (California) Range: .33—30; Mean: 7.6 Yearr: N umber 33-29 ..................... 1 3 3—8.9 ...................... l 1 9—149 ..................... 9 15—20 ...................... 4 2 1—over .................... 2 Total ..................... 39 It is interesting to turn attention to the rate of health officer turnover in California local health departments. During the period of 1951—1964, as calculated from the 1951, 1953, 1954, 1955, 1956, 1957, 1958, 1960, and 1962 revisions of the Public Health Service "Di- rectory of Local Health Departments,” full-time local health departments in California experienced the fol- lowing degrees of leadership changeover: Number of Number of changes: department: 0 .......................... 14 1 .......................... 10 2 .......................... 5 3 .......................... 2 4 .......................... 7 5 .......................... 2 When these data are seen against the number of new and innovative programs in which departments are engaged, the following picture emerges: Mean rmm ber of new program: m Number of health ofi‘icer changes: which engaged 0 .......................... 6.0 1 .......................... 6.0 2 .......................... 5.2 3—5 ........................ 5.0 Table 57 Educational Policy and Program of Full-Time Local Health Departments (California: 1964) (encouragement of advanced academic education for staff) ' Number Encourages ...................... 28 Does not encourage ............... 12 Total .................... 4—0 Table 58 Educational Policy and Program of Full-Time Local Health Departments (California: 1964) (provides for , educational leave for staff members) Number Yes ............................ 3 1 6 N0 ............................ 9 Total .................... E ‘ a it a a: Table 59 Educational Policy and Program of Full-Time Local Health Departments (California: 1964) (approved resi- dency in public health) Number Yes ............................ 10 ‘ No ............................ 30 Total .................... 46 The health department has an approved public health resi- dency program regardless of whether the resident position is currently filled or not. Table 60 Educational Policy and Program of Full-Time Local Health Departments (California: 1964) (approved public health laboratory training program) Number . Yes ............................ 13 No ............................ 27 Total .................... E The health department has an approved program for the training of public health laboratory technologists, regardless of whether the positions are currently filled or not. Table 61 Educational Policy and Program of Full-Time Local Health Departments (California: 1964) (participating with a school of nursing for on-the—job training of nursing students in public health nursing) Number Yes ............................ 21 No ............................ 19 Toral .................... 5 Table 62 Educational Policy and Program of Full-Time Local Health Departments (California: 1964) (department used for field and other special training) Number Yes ............................ 23 No ............................ 17 Total .................... 4—0 Table 63 Educational Policy and Program of Full-Time Local Health Departments (California: 1964) (encourage- ment of, and fiscal support for, staff member contin- uing education) Number Encourages, provides support ....... 12 Encourages, does not provide support . 28 Does not encourage ............... 0 Total .................... E Table 64 Educational Policy and Program of Full-Time Local Health Departments (California: 1964) (encouragement of, and fiscal support for, staff member attendance at professional meetings) Number Encourages, provides support ....... 13 Encourages, does not provide support . 27 Does not encourage ............... 0 Total .................... E 69 Table 65 Health Department Staff Turnover (additions or replace- ments over past 2 years) in Full-Time Local Health Departments (California: 1964) Number Professional staff : 30 percent or less new within past 2 years ............... 8 More than 30 percent new within past 2 years .......... 19 Total .................... 2—7 Other staff: 30 percent or less new within past 2 years ................ 11 More than 30 percent new within past 2 years ......... 16 Total .................... 2—7 All staflr combined: 50 percent or less new within past 2 years ............... 11 More than 30 percent new within past 2 years ......... 25 Total .................... g3 70 Table 66 Health Department Staff Turnover (additions or replace- ments over past 5 years) in Full-Time Local Health Departments (California: 1960) Number Professional staff: 50 percent or less new within past 5 years ............... 6 More than 50 percent new within past 5 years ......... 21 Total .................... 27 Other staff: 50 percent or less new within past 5 years ................ 8 More than 50 percent new within past 5 years ......... 19 Total .................... 2—7 All staflc combined: 50 percent or less new within past 5 years ................ 8 More than 50 percent new within past 5 years ......... 28 Total .................... % Table 67 Ratio of Professional to Clerical Staff in Full-Time Local Health Departments (California: 1964) Number 2.0 professional to 1 clerical or less . . 12 More than 2 professionals to 1 clerical 15 Toral .................... 27 3. CHARACTERISTICS OF THE COMMUNITIES AND POPULATIONS SERVED BY CALIFORNIA LOCAL HEALTH DEPARTMENTS Table 68 Total Population Served by Full-Time Local Health De- partments (California: 1960) Range: 18,000—6,376,542; Mean: 453,107 Population: N um ber 18,000—99,999 ............... 12 100,000—299,999 ............. 12 300,000—599,999 ............. 9 600,000—899,999 ............. 3 900,000—0ver ................ 4 Total .................... 40 Source: County and City Data Book, 1962, Bureau of the Census, Washington, DC, and where available, most recent local population estimate as ofiered by responding health oflficer. Table 69 Density of Population (population per square mile) Served by Full-Time Local Health Departments (Cal- ifornia: 1960) Range: 11—16,42 5 / square miles; Mean: 1, 1 88/ square mile Number 100 or less ...................... 22 More than 100 ................... 18 Total .................... 4—0 Table 70 Percent of Population in Urban Residence in Jurisdic- tions Served by Full-Time Local Health Departments (California: 1960) Range: 34.7—100 percent; Mean: 67.7 percent Percent urban: Number 30—49 ...................... 10 5 0—69 ...................... 14 70—89 ...................... 7 90—99 ...................... 5 100 ........................ 4 Total .................... 40 Source: See Table 68. Table 71 Trend in Population Change in Jurisdictions Served by Full-Time Local Health Departments (California: 1950—1960) Range: 45—2256 percent; Mean: 49.1 percent Percent change: Number —4.5—0 ...................... 2 1—30 ....................... 15 3 1—59 ...................... 9 60-89 ...................... 1 1 90—above ................... 3 Total .................... 40 Population increase or decrease between 1950 and 1960, expressed as a percentage. Source: See Table 68. Table 72 Percentage of Population under 5 Year: of Age in Juris- dictions Served by Full-Time Local Health Departments (California: 1960) Range: 7.9—135 percent; Mean: 11.2 percent Percent under 5: Number 75—104 ........... 7,. ........ 12 10.5—11.9 .......... ’ ......... l 4 12.0—13.5 ................... 14 Total .................... :10 Table 73 Percent of Population 65 Year: of Age and Over in Jurisdictions Served by Full-Time Local Health Depart- ments (California: 1960) Range: 55—191 percent; Mean: 9.1 percent Percent 65 and older: Number 5.5—7.4 ..................... 15 75—104 .................... 14 10.5—14.9 ................... 10 15.0—19.1 ................... 1 Total .................... 40 Source: See Table 68. 71 Table 74 Percent of Population Whit/J i1 NonWbite in Juris- dictions Served by Full-Time Local Health Depart- ments (California: 1960) Range: 1.4—26.2 percent; Mean: 6.2 percent Percent nonwhite: N um her 1 .4—2 .9 ..................... 6 3.0—5 .9 ..................... 10 6.0-8.9 ..................... 7 9.0— 17.9 .................... 6 1 8.0—over ................... 2 Total .................... 40 Table 75 Percent of Population with High School Education or Better in Jurisdictions Served by Full-Time Local Health Departments (California: 1960) Range: 32.6—67.5 percent; Mean: 47.0 percent Percent H .S . or better: Number 32.0—39.9 ................... 8 40.0—47.9 ................... 14 480—5 5 .9 ................... 1 3 56.0—67.5 ................... 5 Total .................... 40 Table 76 Median Family Income in Jurisdictions Served by Full- Time Local Health Departments (California: 1960) Range: $4,596—$8,110; Mean: $6,166 Income: Number $45 00—$4,999 ............... 4 355,000—315,999 ............... 16 teem—$6,999 ............... 13 $7,000—$7,999 ............... 5 $8,000—0ver ................. 2 Total .................... 40 Source: See Table 68. 72 Table 77 Median Value of Owner-Occupied Dwelling: in Juris- diCtions Served by Full-Time Local Health Depart- ments (California: 1960) Range: $8,800—320,200; Mean: $13,326 Value dwellings: Number $8,500—$ 10,499 .............. 5 $10,500—$13,499 ............. 19 $13,500—$16,499 ............. 10 35 16,5 00—over ................ 6 Total .................... 40 Value figures based on respondent’s estimate of the sales value of the property (house and land) in April 1960. Source: See Table 68. It i it ’I‘ Table 78 Pbyrician Population Ratio in Jurisdictions Served by Full-Time Local Health Departments (California: 1964) Range: 49—320/100,000 population; Mean: 125.8/100,000 Pbyrician/I 00,000 population: Number 40—89 ...................... 12 90—1 19 ..................... 12 1 20—1 79 .................... 1 1 ISO—above .................. 5 Total .................... 40 Ratio of the number of licensed physicians reported in the jurisdiction of the health department per 100,000 population. Source: California Board of Medical Examiners, Annual Report, 1964, Sacramento, California. APPENDIX 2 Reasons For Local Health Department Adoption of New or Innovative Programs ADVOCACY: _ State consultants or expert counsel recommended; participation or engagement invited by another agency; CCLHO advocated; experiences of peers suggested; State government, or national emphasis, stimulated interest, support, demand; Other department or person or agency in local government called for or stimulated this service; Private physician’s call for this service; Requests from interest or willingness to participate, by general public or from community voluntary, spe- cial-interest commercial groups, etc.; mmpow> G. Experiences of other departments suggested desirability or stimulated engagement. LEADERSHIP: H. Health officer's personal interest; conviction of desirability; derivative from his prior experience in another position; I. Stalf administrative personnel promoted the program; J. General interest on part of one or more components of general staff; K. Successful pi10t or demonstration program or other related health department experience led to present activity. OPPORTUNISM: L. Derivative from other activities; contributory to other objectives; M. A natural adjunct to Other services or programs under health officer’s administration; N. Additional space, new facilities or equipment, improved working environment made possible; 0. Pre-existing agency withdrew; health department re-organized; functions of another agency assumed by' merger; P. Special purpose, categorical, or project funds were available; free or demonstration materials made available; Q. Th° time was propitious; an opportunity appeared. NEED: R. A discrepancy existed in service between portions of the jurisdiction; S. An area of obvious need, as indicated by observation, study, etc. 73 HEALTH DEPARTMENT COMMUNITY 74 APPENDIX 3 Barriers to Plans or Desires for Entry Into New Program Areas STAFF Insufficient personnel; short-staffed, can’t recruit, no time; . Staff lacks technical competencies required; No specialized personnel; no one to administer/ plan program; . Routine duties too demanding; other activities more pressing; . Time needed for integration into present staff activities; . Staff member(s) / health officer antagonistic/ disinterested; . Staff/ health officer interested only in certain components. ummewmg—n ORGANIZATION 8. Department not large enough or equipped to do this; 9. No space is available for this program—space shortage; 10. Would require specific assignment of responsibility to department; 11. Uncertain future organization; dependent on reorganization; 12. Dependent on success of present demonstration. OPPOSITION 13. Community groups antagonistic; 14. Medical profession/ society/ physicians antagonistic or need convincing; 15. Business interests antagonistic. DEMAND 16. No community interest; social/ emotional climate not right, no demand; no mandate. PHYSICAL CHARACTERISTICS ‘17. Physical distances between population centers makes collaboration difficult. {-4 Z E Z g 2 W U <5 do mm EC 0 fl m 0% 5‘2 235 9-: < LOCAL BOARD 18 . Reluctant to accept funds; fear of need to take over future financing locally; 19. Political antagonism against "frill" spending/ program; holding the budget line; conservatism; 20 . Supervisors won’t approve; on record as disapproving, need convincing. FUNDS 21. Awaiting the availability of funds; funds not presently available; 22. Would require project money; no local tax funds for new programs. OTHER 23. Awaiting needed State or national leadership, legislation, requirement and/0r special funds; 24. Don’t have legal authority to conduct essential components such as charging for services, of this program. 25. This function has been preempted by another agency; 26. Health department unwilling to ally with other agency in this program; 27. Other agencies fearful of our entry into this area; 28. Other agencies unwilling to accept the program as health department wants it; 29. Other agency, presently doing program, is resistant to health department intervention; 30. Other agency should do this; not an appropriate health department function as seen in this jurisdiction; 31. Other agency(s) already doing it satisfactorily; 32. Awaiting development of relations with another local agency; 33. Awaiting development of this or a related program in another agency or in health department; 34. Awaiting withdrawal of another agency from this program area or transfer. 35. N0t much of a problem yet in this jurisdiction; 36. Those in need already getting the service they require——present program satisfactory; 37. Other things more important; low priority for this program; 38. Lack of data on needs; 39. Awaiting study, survey, research results/ reports; 40. A local program will not answer this problem; 41. Technologic knowledge is lacking; doubt that available means are effective; 42. The time is not propitious—timing. {y U.S, Government Printing Office: 1968 0—278-331 75 mm (025725u51 Public Health Service Publication No. 1664—2 :3 In