Nov 19, 1970 - Research Support Grant from the U.S. Public Health. Service, The Allen ... Nutrition Education Program (EFNEP) of the Maryland. Cooperative ...
recently postpartum, factors which are associated with increased rates of expulsion.3 The rate of medical removals is lower than the Barbados or Cooperative Study rates. This may be attributable to the vital role that the nurse-midwife and health educators of the Community Health Program played in patient support and education. The difference in rates of nonmedical removal is primarily due to the ill patients not planning additional pregnancies, which were contraindicated by their disease. It is important to recognize that this study was carried out in the context of a comprehensive clinical program, where midwives worked under supervision. In such settings the acceptance and continuation of family planning methods are undoubtedly enhanced. The sobering finding that less than 5 per cent of the women in the target population accepted the device even though modern methods of health education were used, however, confinns the findings of others4 that rural Haitians are not particularly desirous of this method of family planning at the present time. The authors expect this to change as infant and child mortality rates continue to fall. A CKNOWLEDGMENT
The valuable technical assistance of J. Adrien Hilaire, MD, Patricia Forsman, MD, Linda Driskill, MScHyg, and other members of the staff of the Albert Schweitzer Hospital in Deschapelles, Haiti, is gratefully acknowledged.
References 1. Berggren, W. L., and Berggren, G. M. Changing Incidence of Fatal Tetanus of the Newborn. Am. J. Trop. Med. Hyg. 20:491-494, 1971. 2. Tietze, C. Intrauterine Contraception: Recommended Procedures for Data Analysis. Stud. Fam. Plann. 18 (suppl.): 1-6, 1967. 3. Potter, R., et al. IUD Effectiveness in the Taichung Medical Study. Stud. Fam. Plann. 18:13-20, 1967. 4. Stycos, J. M. Haitian Attitudes Towards Family Size. In Human Organization, pp. 42-47, 1964. 5. Tietze, C. Intrauterine Contraception: A Research Report. Stud. Fam. Plann. 36:11-12, 1968. 6. Vaillant, H. W., et al. Insertion of Lippes Loop by Nurse-Midwives and Doctors. Br. Med. J. 3:671-674, 1968. 7. Natality Statistics Analysis, United States, 1965-1967. Public Health Service Publication No. 1000-Series 21. p. 13, November 19, 1970. Dr. Berggren is Research Associate, Department of Population Sciences, Harvard School of Public Health, Boston, Massachusetts 02115. Dr. Vaillant is Visiting Lecturer, Department of Population Sciences, Harvard School of Public Health. Dr. Garnier is Assistant Director, Community Health Service, Albert Schweitzer Hospital, Deschapelles, Haiti. This study was supported by a General Research Support Grant from the U.S. Public Health Service, The Allen Foundation, Pathfinder Fund, the Rockefeller Foundation, and the Colonial Research Institute. Portions of this study were presented in Port-au-Prince, Haiti, in September, 1971, at the National Family Planning Seminar.
A 3-Year, Longitudinal Study of the Impact of Nutrition Aides on the Knowledge, Attitudes, and Practices of Rural Poor Homemakers LAWRENCE W. GREEN, DrPH VIRGINIA Li WANG, MPH, PhD PAUL H. EPHROSS, PhD
Introduction This paper presents the final results from a 3-year, longitudinal evaluation of indigenous aides working with rural poor homemakers in the Expanded Food and Nutrition Education Program (EFNEP) of the Maryland Cooperative Extension Service. The primary focus of this evaluation is on the question of diminishing returns in cost effectiveness of home visits as an educational method. How 722 AJPH JULY, 1974, Vol. 64, No. 7
long should aides continue visiting individual homemakers: 1 year, 2 years, or more?
Background The EFNEP of the Extension Service has been subjected to the scrutiny of large scale, nationwide evaluations of its performancel and its impact.2 As an
innovative deployment of indigenous aides, serving in its first 2 years over 600,000 families (2.9 million people) with an average income of $2,700, one-third of which is spent on food, the program commands serious evaluative attention.
Purpose and Design of the Study This paper summarizes our analysis of the third and final stage of a longitudinal study of the Maryland EFNEP in two rural counties-one Appalachian and primarily white, the other on the Chesapeake delta (Eastern Shore) and primarily black-with a combined panel of 93 homemakers who had been retained in the program for 2 to 3 years (combining the two counties and racial groups because earlier analyses revealed few substantial differences between them).3 In addition, this study includes a matched control group of 58 "friends" who were designated by the homemakers but were not participants in the EFNEP. The original design of the longitudinal study is described in a previous monograph,4 but logistical problems forced modifications in the sampling which is described below. The main intent of this presentation is to supplement the earlier evaluations of EFNEP by examining the neglected issues of (1) appropriate criteria and standards of comparison, (2) the point of diminishing returns in continuing visits to homemakers, and (3) the broader impact of the program on selected health variables. There are two experimental and two comparison groups in this study. One experimental group consists of 49 EFNEP homemakers still being visited by aides after 3 years in the program. The second experimental group consists of 44 homemakers who have been progressed out of the program after the end of their second year. The two experimental groups are derived from a 50 per cent random sample of EFNEP homemakers in two Maryland counties. The control groups consist of matched samples of 34 designated friends of the first experimental group and 24 friends of the second experimental group. All data are from interviews conducted in the homes by trained persons unrelated to the program. Homemakers were interviewed in 1970, 1971, and 1972 to determine shifts in their knowledge, attitudes, and nutritional practices as well as related health and child-rearing practices. Questionnaires completed by aides in 1970 and 1972 and various service records also were analyzed. Variable improvements in knowledge, attitudes, and practices are documented and specific program components are evaluated. Effectiveness of the EFNEP is shown in relation to limited objectives.
contact, and that continuing home visits with the same homemakers in the third year are of minimal value. Original gains of the first year are not lost, but further gains are not apparent after the second year of home visits. Comparisons included, in addition to nutritional indicators, seven criteria of adequate referrals for health care, seven criteria of adequate knowledge of health care resources, and 12 criteria of preventive health behavior. The cumulative evidence of numerous comparisons between continued homemakers and others lead us to assert certain conclusions with greater confidence than we might have from a more controlled study of a narrower range of data. We are prepared to assert on the basis of these data that the third year of continuing home visits with the same homemakers has been of minimal, if any, value beyond the achievements with these homemakers in the first 2 years. There definitely is not a straight line progression in knowledge, attitudes, or behavior from the first through the third year, and there probably is not enough progression of any kind to justify continuing investment in the same families rather than starting with new ones by the end of the second year. This is not to say, however, that continued home visits have no potential. We have identified some particular problems which might respond to a shift in educational methodology and focus in the second year. Specifically, we have suggested that the strong emotional support provided by the aide in the first year has tended to produce an optimistic but passive and dependent homemaker whose own initiative in planning and coping has been abdicated to the aide and to other external forces. We propose that greater emphasis be given to the training of aides in techniques that control, rather than create, dependence by rewarding the homemaker for initiative. The aide, like any professional worker, must guard against the addictive relationship in which client and helper are meeting succorance and nurturance needs symbiotically. If the aide fails to see the lack of growth that we have documented in the client's third year, then she has probably fallen prey to this kind of relationship. We have further suggested that the point of diminishing returns may be partly a function of the limited scope of the program's objectives. Additional progress in nutritional practices beyond a certain point may depend on meeting certain other needs first. Our data indicate that some gains are lost in the third year while some other major concerns and needs, namely health, remain unmet. The homemaker apparently loses interest in new recipes and balanced meals as her health needs become intensified. Whether there is a cause-effect relationship between the two and which precedes the other are not so important as the apparent need for the program to deal with both in a comprehensive rather than categorical way.
Findings and Conclusions The longitudinal data on nutritional, attitudinal, and behavioral effects indicate that the impact of the aide on homemaker improvement diminishes after the first year of
References 1. Synectics Corporation. Program Performance 1971: Expanded Food and Nutrition Education Program. U.S. PUBLIC HEALTH BRIEFS 723
Department of Agriculture, Extension Service, Washington, DC, May, 1971. 2. Marketing Economics Division. Impact of the Expanded Food and Nutrition Education Program on Low-Income Families: An In-Depth Analysis, Report No. 200. U.S. Department of Agriculture, EconomicResearch Service, Washington, DC, February, 1972. 3. Wang, V. L., and Ephross, P. H. Poor But Not Forgotten, Monogr. No. 1. University of Maryland, Cooperative Extension Service, College Park, 1970. 4. Wang, V. L., Green, L. W., and Ephross, P. H. Not Forgotten But Still Poor, Monogr. No. 2. University of
Maryland, Cooperative Extension Service, College Park, 1972.
Dr. Green is Associate Professor, Department of Public Health Administration, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland 21205. Dr. Wang is Health Education Specialist, Cooperative Extension Service, and Dr. Ephross is Chairman, Social Strategy Concentration, School of Social Work and Community Planning, University of Maryland, College Park, Maryland 20742. This paper was presented before the Food and Nutrition Section, Centennial Meeting of the American Public Health Association, Atlantic City, November 16, 1972. This study was conducted under the auspices of the Cooperative Extension Service, University of Maryland, College Park, Maryland 20742.
Illegitimacy Ratios in Large U.S. Cities: Determinants and Implications MURRAY GENDELL, PhD JEAN VAN DER TAK, MA Since the illegitimacy ratio (out of wedlock births/all births) only requires data on births, it is far more readily available and used to judge the level and trend of illegitimacy than the illegitimacy rate (out of wedlock births/unmarried women of childbearing age). Unfortunately, differentials and trends in the ratio are often misinterpreted, because the nature of the measure is not adequately understood. The essential difference is that the ratio, but not the rate, is strongly influenced by differences or changes in the number of women at risk of illegitimate births and in marital fertility, since the latter comprises the vast majority of all births in most societies (about 90 per cent in the U.S.). During the past 15 years in the U.S., marital fertility has fallen, slowly at first, more rapidly later. Also, the large cohorts of postwar babies began to reach childbearing age during this time, greatly swelling the number of young unmarried women. Consequently, the rise in the illegitimacy ratio accelerated. However, during the 1960s the rise in the illegitimacy rate decelerated. Indeed, among nonwhite women the rate declined. Nevertheless, it has been argued by public health officials that the swift rise in the ratio reflected increased promiscuity often exacerbated by restrictions on the distribution of birth control devices and information to unmarried women under 21 years of age. It is the aim of this analysis to contribute to a better understanding of the measures of extramarital fertility. Even if the facts were to indicate-as they do at this time-that there is little that public health agencies can do to arrest the increase in the illegitimacy ratio, a better understanding of its determinants should help to avoid 724 AJPH JULY, 1974, Vol. 64, No. 7
misleading causal interpretation and perhaps, as a consequence, misdirected public health programs. Just such a misinterpretation of the ratio in the District of Columbia, which doubled from 20 to 41 per cent between 1960 and 1970, led us to make this analysis for the District and nine other major cities containing large numbers of blacks. The requisite data were most fully available for Washington. Between 1960 and 1970 in that city, the following demographic changes took place: of all women 15 to 44 years of age, the percentage (1) unmarried (i.e., single, widowed, and divorced) increased from 40 to 51, more so among nonwhites than white; and (2) the percentage nonwhite, with must higher illegitimacy ratios than whites, climbed from 58 to 74; (3) whereas 31 per cent of nonwhite women in 1960 were less than 25 years old, at which age illegitimacy rates are relatively high, 43 per cent were that young by 1970. (4) in all age-color categories, marital fertility fell by at least one-third. Overall, per 1000 wives 15 to 44 years of age there were 155 births in 1960, but only 100 in 1970; (5) despite a decline in the illegitimacy rate from 114 to 92 births per 1000 unmarried women 15 to 44 years old among nonwhites, the rate for all unmarried women 15 to 44 increased from 58 to 66. This resulted mainly from the sharp increase in the relative number of nonwhite women 15 to 44 (point 2, above). As the data for Baltimore, Chicago, Cleveland, Detroit, Houston, New Orleans, Philadelphia, and Washington indicate, illegitimacy ratios in large cities (ranging in these cities from 12 to 33 per cent in 1968) were substantially greater than for the whole country (10 per cent in 1968).
