PUBLIC HEALTH BRIEFS
abortion ancillary services has meticulous records and an experienced legal advisory staff. During the 1977 period, federal abortion funds were available only if the woman's life was endangered by continuing the pregnancy. None of the 971 subsidized abortions performed during this period qualified for federal funds under this provision. Because our study period did not cover the expanded regulations published by the Department of Health, Education, and Welfare on February 14, 1978,4 we could not measure the effect of allowing abortions in situations of "long-lasting physical damage" or in situations where the pregnancy occurred from rape or incest. Several factors may limit our ability to generalize these results to the national level. First, nearly all the subsidized abortions performed in the metropolitan area were in clinics; this contrasts with the national scene where, in 1976, 69 per cent of publicly funded abortions were performed in hospitals.2 In the metropolitan area we studied, the largest public hospital does not perform many abortions, but refers most women requesting pregnancy termination to one of the clinics providing abortion services. One other hospital performs a few subsidized abortions. Second, we examined only the first five months after the funding cutoff. It is possible that
clinics may discontinue subsidies to low-income women if they find that provision of these services are either too expensive or time consuming or drain other essential resources from their facilities.
REFERENCES 1. Department of Health, Education, and Welfare: Reimbursement for Abortions. Federal Register 42:40486, 1977. 2. Lincoln R, Doring-Bradley B. Lindheim BL, and Cotterill MA: The Court, the Congress, and the President: Turning back the clock on the pregnant poor. Fam Plann Perspect 9:207-214, 1977. 3. Cohen IC, Bracken MB: Monthly variation in conceptions leading to induced abortion. Social Biology 24:245-250, 1977. 4. Department of Health, Education, and Welfare: Funding of Abortions. Federal Register 43:4570, 1978. 5. Forrest JD, Tietze C, and Sullivan E: Abortion in the United States, 1976-1977. Fam Plann Perspect 10:271-279, 1978.
ACKNOWLEDGMENTS We wish to thank the following individuals for their contributions to this paper: Howard W. Ory, MD, Carl W. Tyler, Jr., MD, Steven Heartwell, PhD, Charles Warren, PhD, Jerri McNeely, Royda Mescia, Barbara van Norstrand, Barbara Oakes, Patti Osborne, and Gail D. Carpenter.
Cost-Effectiveness Evaluation of a Home Visiting Triage Program for Family Planning in Turkey ROBERT L. BERTERA, MPH, AND LAWRENCE W. GREEN, DRPH
Abstract: Graduate Turkish midwives were trained in triage rules for determining family planning home visit frequency based on risk of couples. In a sample of 542 couples followed for six months, modem contraceptive use increased 22 per cent among high-risk and about 15 per cent among moderate- and low-risk couples. After making assumptions about the fecundity, contraceptive success, and pregnancy complications, the estimated average cost per complication averted was $61 for high-risk, $177 for moderate-risk, and $526 for low-risk couples. (Am J Public Health 69:950-953, 1979.)
Turkey, like many developing countries around the world, faces a critical shortage of personnel for the delivery of health services to its people, especially those residing in rural areas." 2 In 1974, the Ministry of Health and Social Address reprint requests to Lawrence W. Green, DrPH, Professor and Head, Division of Health Education, Department of Health Services Administration, School of Hygiene and Public Health, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD 21205. Mr. Berters is a doctoral student and cardiovascular fellow at JHUSHPH. This paper, submitted to the Journal December 8, 1978, was revised and accepted for publication May 11, 1979.
950
Welfare of the Government of Turkey sought to meet this manpower need by embarking on a midwife training and development program. This paper describes and evaluates the promotion of family planning by 10 midwives working in the Eskisehir Province project during a six-month period in 1976.
The Home Visiting Triage Method A simple method was developed for classifying all eligible couples (married, with the wife between the ages of 15 and 49) into one of three priority groups. Midwives were trained to assign couples to priority groups on the basis of two easily determined risk factors: the probability of having a future pregnancy and the probability of experiencing a pregnancy-related complication.* Couples were defined as being at high risk of having a future pregnancy when they had a living child less than four years of age or when the woman was currently pregnant. This rule was derived from the observation that approximately 80 per cent of all births occur to women who had given birth during the previous four years.3 Couples were defined as being at high risk of having a pregnancy-related complication when the woman had five or more live births. AJPH September 1979, Vol. 69, No. 9
PUBLIC HEALTH BRIEFS
The application of these two criteria leads to the assignment of couples into one of three priority groups: * First priority couples are at high risk of an additional pregnancy and at high risk of a pregnancy-related complication; * Second priority couples are at high risk of an additional pregnancy but at low risk of a pregnancy-related complication; * Third priority couples are at low risk of an additional pregnancy and at low risk of a pregnancy-related complication. A fourth potential priority group-low risk of pregnancy and high risk of a complication was not used as it was a relatively rare combination. The 10 project midwives classified couples after initial home visits to all households in their assigned work area, completing this task within a month. At the same time, they gathered baseline information on contraceptive use and began family planning education activities. Ideally, Priority 1 couples were supposed to be visited once a month, Priority 2 couples every three months, and Priority 3 couples once a year. During home visits, midwives provided family planning education and information, supplies (condoms to any couple and pills to women having a physician's prescription) and referral to health centers for ItDs; in addition, midwives discharged a number of other maternal and child health responsibilities during home visits.3 The project area of 30,000 people is located in the Anatolian plateau province of Eskisehir, 220 km northwest of the capital city of Ankara. It represents the developing regions of the country which are beginning to experience the growth of light industries near the towns and the mechanization of some agricultural practices in the farm areas. Approximately 60 per cent of the population resides in rural areas while the remaining 40 per cent resides in moderate sized towns. The overall literacy rate is about 53 per cent (70 per cent of the males and 37 per cent of the females).
scribed 2); third priority couples received 2.0 (vs. the prescribed 0.5). Apparently the midwives were not able to comply with the prescribed number of home visits for each priority group but were using the risk-priority concept to some extent in allocating home visiting time. This suggests that it will be necessary to reinforce the ideal of concentrating home visits on higher risk groups, while expending only the minimum prescribed effort on lower risk groups by periodic refresher training and ongoing supervision. In the six-month study period, use of modern contraceptives (pill, IUD, condom or foam) rose 22 per cent among Priority I couples, 14 per cent among Priority 2 couples, and 15 per cent among Priority 3 couples (Table 1). For each priority group there is a consistent and significant trend for these shifts to modern methods of contraception to be much more pronounced in the younger age groups than in the older groups. There were corresponding declines in the numbers of couples using no contraception or traditional methods (douche, lemon juice, or withdrawal). Figure 1 presents the cumulative proportion of family planning adopters according to age in each priority group, before and after the home visiting program was initiated. These distributions appear to approximate the S-shaped curve which has been demonstrated as a useful tool for describing the adoption and diffusion of various innovations over time.4' 5 Figure I also suggests that the diffusion of modern family planning methods was already under way before the home visiting program began; the cumulative proportion of couples using a modern method at month 1 ranged from 26 per cent to 48 per cent in the three priority groups. Thus, the home visiting program was addressing itself in general to later rather than earlier adopters. The home visiting program was adapted to the needs of later adopters since it provided regular interpersonal contacts, brought contraceptive samples to the home, and continued reinforcement and follow-up even after a couple adopted a modern contraceptive method.
Evaluation Design and Methods Cost Effectiveness Comparisons A sample of 542 couples was randomly selected from the 3,400 eligible couples listed on the project's household list. The home visit records on the sample couples were audited after the initial home visit (Month 1) and again after six months of regular home visiting by the 10 project midwives (Month 6). The audits were carried out by central office staff during regular field visits to midwives, but the midwives were not aware of which codples in their case-loads were being followed for the evaluation. Information collected included priority status, number of home visits made, contraceptive use, and demographic characteristics.
Results During the six-month study period, the first priority couples received an average of 3.3 home visits (vs. the prescribed 6); second priority couples received 2.6 (vs. the preA.JPH September 1979, Vol. 69, No. 9
The average costs per new family planning adopter are
$30 for Priority I couples, $33 for Priority 2 couples, and $43 for Priority 3 couples (Table 2). The comparison suggests that a home visiting program which focuses on higher risk subgroups in a target population can be relatively cost-effective in recruiting adopters from higher risk groups. The six-month follow-up period of this study was not a sufficient time to obtain information on pregnancies and pregnancy-related complications. Some of the variables needed to figure these costs (differing according to Priority group) are illustrated and given an estimated value in Table 2. With the assumptions made, the estimated cost of averting a complication is $61 among the higher risk, Priority 1 couples, $177 among moderate risk, Priority 2 couples, and $526 among the lower risk, Priority 3 couples, as shown in Table 2. The outcome of this hypothetical exercise indicates that the allocation of home visiting time to the higher risk 951
PUBLIC HEALTH BRIEFS
TABLE 1-Distribution of Contraceptive Use by Method, Study Month, Priority Group, and Age of Woman Contraceptive Method and Study Month Modem Method Priority Group and Age of Woman
Month 1
Month 6
Total Sample N
N
(%)
N
16 34 16 66
3 17 7 27
(19) (50) (44) (41)
189 51 5 245
91 25 2 118
48
7 30 22 59
Priority 1 Ages 15-29 30-39 40-49 Total Priority 2 Ages 15-29 3G-39 40-49 Total Priority 3 Ages 15-29 30-39 40-49 Total Total Sample
97 86 231 542
Traditional or No Method Month 1
Month 6
(%)
Per Cent Change
N
(%)
N
(%)
Per Cent Change
5 21 7 33
(31) (62) (44) (50)
+66 +24 0 +22
13 17 9
39
(81) (50) (56) (59)
11 13 9 33
(69) (38) (56) (50)
-15 -24 0 -15
(48) (49) (40) (48)
105 27 2 134
(56) (53) (40) (55)
+15 +8 0 +14
98 26 3 127
(52) (51) (60) (52)
84 i11
(44) (48) (60) (45)
-14 -8 0 -13
(15) (31) (26) (26)
7 36 25 68
(15) (37) (29) (29)
0 +20 +14 +15
41 67 64 172
(85) (69) (74) (74)
41 61 61 163
(85)
0 -9 -5 -5
24 3
(63) (71) (71)
NOTE: Shifts to the more effective contraceptive methods were statistically significant by the Wilcoxon test of ordered comparisons for categorical data (S = 6297, p < .05).
couples is the most cost-effective way of utilizing this type of personnel in recruiting new adopters.
Discussion This study demonstrates the feasibility and suggests cost-effectiveness advantages of an outreach program that concentrates on high-risk couples by applying triage rules to determine program priorities. Moderate risk couples who are represented in the second priority group will be an important
Priority 1-High Risk z u60 0.. Xo 50 o
60
0-O 30
M
onth4
1
20
e
eto
ope
dpigaMdr
otaetv
25
I 24 2934 39 4449 AGE
30
Mo-3h
4
20 10
10
I 19Mot15 D
o
40
Month 1
< 10
FIUE1Cmltv
Priority 3-Low Risk
-
40
22933944192230
>W20 n20
Priority 2-Moderate Risk .-Month 6
50D 50
Month 620
40
group to follow-up as they could move into the Priority 1 group as their parity increases. Home visiting among the lower risk, Priority 3 couples beyond the minimum prescribed level, however, would not be a cost-effective outreach activity. Unless other benefits could be demonstrated or less costly recruitment techniques developed, home visiting time should be shifted from the lower risk couples to the higher risk couples. As the climate for cost containment becomes more and more pervasive, the opportunities for applying similar triage rules to other public health programs should be explored.7
19 24 29 343944 49
AGE
ehdb
Mrorith6tts Age 'of
1-5 1924 29 343944 49 I
AGE FIGURE 1-Cumulative Per Cent ef Couples Adopting a Modern Contraceptive Method by Priority Status, Age of Women and Study Month (N = 542) 952
AJPH September 1979, Vol. 69, No. 9
PUBLIC HEALTH BRIEFS TABLE 2-Cost Effectiveness Information for the Midwife Home Visiting Program by Priority Group Priority Group Cost-Effectiveness Information*
Cost Per Adopter (Experiential) Number of Couples in Sample Number of Home Visits Number of Modern Method Adopters Cost Per Adopter Cost Per Complication Averted (Estimated) Estimated Fecundity Rate Estimated Contraceptive Success Rate Estimated Pregnancy Complication Rate Estimated Number of Complications Averted Estimated Cost Per Complication Averted
Priority 1
Priority 2
Priority 3
66 218 6 $30
245 632 16 $33
231 471 9 $43
100% 75% 66% 2.97 $61
75% 75% 33% 2.97 $177
50% 75% 22% .74 $526
*Cost Information Common to All Three Priority Groups: Midwife hourly salary is $1.10; Average length of a home visit is .75 hours; and the average cost of a home visit is $.83
REFERENCES 1. Bryant J: Health in the Developing World. Ithaca, New York: Cornell University Press, 1969. 2. Taylor CE, Dirican R, Deuschle KW: Health Manpower Planning in Turkey. Baltimore, Johns Hopkins University Press, 1968. 3. Bertera RL, Ustunoglu N: Training village midwives for family planning services delivery in rural Turkey. Boston: The Pathfinder Fund, Pathpaper #1, July 1977. 4. Green LW: Diffusion and adoption of innovations related to cardiovascular risk behavior in the public: In Enelow J, Henderson JB, (Eds): Applying Behavioral Science to Cardiovascular Risk. New York: American Heart Association, 1975.
5. Rogers EM, Shoemaker FF: Communication of Innovations. New York: The Free Press, 1971. 6. Rogers EM: Communication Strategies for Family Planning. New York: The Free Press, 1973. 7. Green LW: Toward cost-benefit evaluations of health education: Some concepts, methods, and examples. Health Educ Monogr 2(Suppl.):34-64, 1974.
ACKNOWLEDGMENT The original work on this project was supported by The Pathfinder Fund. Preparation of this analysis and manuscript was supported by NIH Research Training Grant T32-HL-07180.
7th Energy Technology Conference and Exposition, 1980 Call for Papers The 7th Energy Technology Conference and Exposition, to be held March 24-26, 1980, Sheraton Washington Hotel, Washington, DC, has issued a call for papers. Persons interested in presenting a paper should submit three copies of the paper's title, abstract and author's biography to the Conference headquarters prior to September 10, 1979. All papers must be new and must not have been previously presented at a national meeting. The Conference is the world's largest forum of discussion and interaction for the international energy community. Total attendance should exceed 10,000 and will include key energy decision-makers from around the nation. Papers to be submitted for consideration should focus on the application of technology to satisfy the world's energy needs, and should not dwell on basics but be oriented to a well-informed audience. Papers are currently being reviewed and accepted for the conference. For further details, contact the Program Chairman, 7th Energy Technology Conference, c/o Govemnment Institutes, Inc., 4733 Bethesda Avenue, NW, Washington, DC 20014, phone: 301/656-1090.
AJPH September 1979, Vol. 69, No. 9
953
abortion ancillary services has meticulous records and an experienced legal advisory staff. During the 1977 period, federal abortion funds were available only if the woman's life was endangered by continuing the pregnancy. None of the 971 subsidized abortions performed during this period qualified for federal funds under this provision. Because our study period did not cover the expanded regulations published by the Department of Health, Education, and Welfare on February 14, 1978,4 we could not measure the effect of allowing abortions in situations of "long-lasting physical damage" or in situations where the pregnancy occurred from rape or incest. Several factors may limit our ability to generalize these results to the national level. First, nearly all the subsidized abortions performed in the metropolitan area were in clinics; this contrasts with the national scene where, in 1976, 69 per cent of publicly funded abortions were performed in hospitals.2 In the metropolitan area we studied, the largest public hospital does not perform many abortions, but refers most women requesting pregnancy termination to one of the clinics providing abortion services. One other hospital performs a few subsidized abortions. Second, we examined only the first five months after the funding cutoff. It is possible that
clinics may discontinue subsidies to low-income women if they find that provision of these services are either too expensive or time consuming or drain other essential resources from their facilities.
REFERENCES 1. Department of Health, Education, and Welfare: Reimbursement for Abortions. Federal Register 42:40486, 1977. 2. Lincoln R, Doring-Bradley B. Lindheim BL, and Cotterill MA: The Court, the Congress, and the President: Turning back the clock on the pregnant poor. Fam Plann Perspect 9:207-214, 1977. 3. Cohen IC, Bracken MB: Monthly variation in conceptions leading to induced abortion. Social Biology 24:245-250, 1977. 4. Department of Health, Education, and Welfare: Funding of Abortions. Federal Register 43:4570, 1978. 5. Forrest JD, Tietze C, and Sullivan E: Abortion in the United States, 1976-1977. Fam Plann Perspect 10:271-279, 1978.
ACKNOWLEDGMENTS We wish to thank the following individuals for their contributions to this paper: Howard W. Ory, MD, Carl W. Tyler, Jr., MD, Steven Heartwell, PhD, Charles Warren, PhD, Jerri McNeely, Royda Mescia, Barbara van Norstrand, Barbara Oakes, Patti Osborne, and Gail D. Carpenter.
Cost-Effectiveness Evaluation of a Home Visiting Triage Program for Family Planning in Turkey ROBERT L. BERTERA, MPH, AND LAWRENCE W. GREEN, DRPH
Abstract: Graduate Turkish midwives were trained in triage rules for determining family planning home visit frequency based on risk of couples. In a sample of 542 couples followed for six months, modem contraceptive use increased 22 per cent among high-risk and about 15 per cent among moderate- and low-risk couples. After making assumptions about the fecundity, contraceptive success, and pregnancy complications, the estimated average cost per complication averted was $61 for high-risk, $177 for moderate-risk, and $526 for low-risk couples. (Am J Public Health 69:950-953, 1979.)
Turkey, like many developing countries around the world, faces a critical shortage of personnel for the delivery of health services to its people, especially those residing in rural areas." 2 In 1974, the Ministry of Health and Social Address reprint requests to Lawrence W. Green, DrPH, Professor and Head, Division of Health Education, Department of Health Services Administration, School of Hygiene and Public Health, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD 21205. Mr. Berters is a doctoral student and cardiovascular fellow at JHUSHPH. This paper, submitted to the Journal December 8, 1978, was revised and accepted for publication May 11, 1979.
950
Welfare of the Government of Turkey sought to meet this manpower need by embarking on a midwife training and development program. This paper describes and evaluates the promotion of family planning by 10 midwives working in the Eskisehir Province project during a six-month period in 1976.
The Home Visiting Triage Method A simple method was developed for classifying all eligible couples (married, with the wife between the ages of 15 and 49) into one of three priority groups. Midwives were trained to assign couples to priority groups on the basis of two easily determined risk factors: the probability of having a future pregnancy and the probability of experiencing a pregnancy-related complication.* Couples were defined as being at high risk of having a future pregnancy when they had a living child less than four years of age or when the woman was currently pregnant. This rule was derived from the observation that approximately 80 per cent of all births occur to women who had given birth during the previous four years.3 Couples were defined as being at high risk of having a pregnancy-related complication when the woman had five or more live births. AJPH September 1979, Vol. 69, No. 9
PUBLIC HEALTH BRIEFS
The application of these two criteria leads to the assignment of couples into one of three priority groups: * First priority couples are at high risk of an additional pregnancy and at high risk of a pregnancy-related complication; * Second priority couples are at high risk of an additional pregnancy but at low risk of a pregnancy-related complication; * Third priority couples are at low risk of an additional pregnancy and at low risk of a pregnancy-related complication. A fourth potential priority group-low risk of pregnancy and high risk of a complication was not used as it was a relatively rare combination. The 10 project midwives classified couples after initial home visits to all households in their assigned work area, completing this task within a month. At the same time, they gathered baseline information on contraceptive use and began family planning education activities. Ideally, Priority 1 couples were supposed to be visited once a month, Priority 2 couples every three months, and Priority 3 couples once a year. During home visits, midwives provided family planning education and information, supplies (condoms to any couple and pills to women having a physician's prescription) and referral to health centers for ItDs; in addition, midwives discharged a number of other maternal and child health responsibilities during home visits.3 The project area of 30,000 people is located in the Anatolian plateau province of Eskisehir, 220 km northwest of the capital city of Ankara. It represents the developing regions of the country which are beginning to experience the growth of light industries near the towns and the mechanization of some agricultural practices in the farm areas. Approximately 60 per cent of the population resides in rural areas while the remaining 40 per cent resides in moderate sized towns. The overall literacy rate is about 53 per cent (70 per cent of the males and 37 per cent of the females).
scribed 2); third priority couples received 2.0 (vs. the prescribed 0.5). Apparently the midwives were not able to comply with the prescribed number of home visits for each priority group but were using the risk-priority concept to some extent in allocating home visiting time. This suggests that it will be necessary to reinforce the ideal of concentrating home visits on higher risk groups, while expending only the minimum prescribed effort on lower risk groups by periodic refresher training and ongoing supervision. In the six-month study period, use of modern contraceptives (pill, IUD, condom or foam) rose 22 per cent among Priority I couples, 14 per cent among Priority 2 couples, and 15 per cent among Priority 3 couples (Table 1). For each priority group there is a consistent and significant trend for these shifts to modern methods of contraception to be much more pronounced in the younger age groups than in the older groups. There were corresponding declines in the numbers of couples using no contraception or traditional methods (douche, lemon juice, or withdrawal). Figure 1 presents the cumulative proportion of family planning adopters according to age in each priority group, before and after the home visiting program was initiated. These distributions appear to approximate the S-shaped curve which has been demonstrated as a useful tool for describing the adoption and diffusion of various innovations over time.4' 5 Figure I also suggests that the diffusion of modern family planning methods was already under way before the home visiting program began; the cumulative proportion of couples using a modern method at month 1 ranged from 26 per cent to 48 per cent in the three priority groups. Thus, the home visiting program was addressing itself in general to later rather than earlier adopters. The home visiting program was adapted to the needs of later adopters since it provided regular interpersonal contacts, brought contraceptive samples to the home, and continued reinforcement and follow-up even after a couple adopted a modern contraceptive method.
Evaluation Design and Methods Cost Effectiveness Comparisons A sample of 542 couples was randomly selected from the 3,400 eligible couples listed on the project's household list. The home visit records on the sample couples were audited after the initial home visit (Month 1) and again after six months of regular home visiting by the 10 project midwives (Month 6). The audits were carried out by central office staff during regular field visits to midwives, but the midwives were not aware of which codples in their case-loads were being followed for the evaluation. Information collected included priority status, number of home visits made, contraceptive use, and demographic characteristics.
Results During the six-month study period, the first priority couples received an average of 3.3 home visits (vs. the prescribed 6); second priority couples received 2.6 (vs. the preA.JPH September 1979, Vol. 69, No. 9
The average costs per new family planning adopter are
$30 for Priority I couples, $33 for Priority 2 couples, and $43 for Priority 3 couples (Table 2). The comparison suggests that a home visiting program which focuses on higher risk subgroups in a target population can be relatively cost-effective in recruiting adopters from higher risk groups. The six-month follow-up period of this study was not a sufficient time to obtain information on pregnancies and pregnancy-related complications. Some of the variables needed to figure these costs (differing according to Priority group) are illustrated and given an estimated value in Table 2. With the assumptions made, the estimated cost of averting a complication is $61 among the higher risk, Priority 1 couples, $177 among moderate risk, Priority 2 couples, and $526 among the lower risk, Priority 3 couples, as shown in Table 2. The outcome of this hypothetical exercise indicates that the allocation of home visiting time to the higher risk 951
PUBLIC HEALTH BRIEFS
TABLE 1-Distribution of Contraceptive Use by Method, Study Month, Priority Group, and Age of Woman Contraceptive Method and Study Month Modem Method Priority Group and Age of Woman
Month 1
Month 6
Total Sample N
N
(%)
N
16 34 16 66
3 17 7 27
(19) (50) (44) (41)
189 51 5 245
91 25 2 118
48
7 30 22 59
Priority 1 Ages 15-29 30-39 40-49 Total Priority 2 Ages 15-29 3G-39 40-49 Total Priority 3 Ages 15-29 30-39 40-49 Total Total Sample
97 86 231 542
Traditional or No Method Month 1
Month 6
(%)
Per Cent Change
N
(%)
N
(%)
Per Cent Change
5 21 7 33
(31) (62) (44) (50)
+66 +24 0 +22
13 17 9
39
(81) (50) (56) (59)
11 13 9 33
(69) (38) (56) (50)
-15 -24 0 -15
(48) (49) (40) (48)
105 27 2 134
(56) (53) (40) (55)
+15 +8 0 +14
98 26 3 127
(52) (51) (60) (52)
84 i11
(44) (48) (60) (45)
-14 -8 0 -13
(15) (31) (26) (26)
7 36 25 68
(15) (37) (29) (29)
0 +20 +14 +15
41 67 64 172
(85) (69) (74) (74)
41 61 61 163
(85)
0 -9 -5 -5
24 3
(63) (71) (71)
NOTE: Shifts to the more effective contraceptive methods were statistically significant by the Wilcoxon test of ordered comparisons for categorical data (S = 6297, p < .05).
couples is the most cost-effective way of utilizing this type of personnel in recruiting new adopters.
Discussion This study demonstrates the feasibility and suggests cost-effectiveness advantages of an outreach program that concentrates on high-risk couples by applying triage rules to determine program priorities. Moderate risk couples who are represented in the second priority group will be an important
Priority 1-High Risk z u60 0.. Xo 50 o
60
0-O 30
M
onth4
1
20
e
eto
ope
dpigaMdr
otaetv
25
I 24 2934 39 4449 AGE
30
Mo-3h
4
20 10
10
I 19Mot15 D
o
40
Month 1
< 10
FIUE1Cmltv
Priority 3-Low Risk
-
40
22933944192230
>W20 n20
Priority 2-Moderate Risk .-Month 6
50D 50
Month 620
40
group to follow-up as they could move into the Priority 1 group as their parity increases. Home visiting among the lower risk, Priority 3 couples beyond the minimum prescribed level, however, would not be a cost-effective outreach activity. Unless other benefits could be demonstrated or less costly recruitment techniques developed, home visiting time should be shifted from the lower risk couples to the higher risk couples. As the climate for cost containment becomes more and more pervasive, the opportunities for applying similar triage rules to other public health programs should be explored.7
19 24 29 343944 49
AGE
ehdb
Mrorith6tts Age 'of
1-5 1924 29 343944 49 I
AGE FIGURE 1-Cumulative Per Cent ef Couples Adopting a Modern Contraceptive Method by Priority Status, Age of Women and Study Month (N = 542) 952
AJPH September 1979, Vol. 69, No. 9
PUBLIC HEALTH BRIEFS TABLE 2-Cost Effectiveness Information for the Midwife Home Visiting Program by Priority Group Priority Group Cost-Effectiveness Information*
Cost Per Adopter (Experiential) Number of Couples in Sample Number of Home Visits Number of Modern Method Adopters Cost Per Adopter Cost Per Complication Averted (Estimated) Estimated Fecundity Rate Estimated Contraceptive Success Rate Estimated Pregnancy Complication Rate Estimated Number of Complications Averted Estimated Cost Per Complication Averted
Priority 1
Priority 2
Priority 3
66 218 6 $30
245 632 16 $33
231 471 9 $43
100% 75% 66% 2.97 $61
75% 75% 33% 2.97 $177
50% 75% 22% .74 $526
*Cost Information Common to All Three Priority Groups: Midwife hourly salary is $1.10; Average length of a home visit is .75 hours; and the average cost of a home visit is $.83
REFERENCES 1. Bryant J: Health in the Developing World. Ithaca, New York: Cornell University Press, 1969. 2. Taylor CE, Dirican R, Deuschle KW: Health Manpower Planning in Turkey. Baltimore, Johns Hopkins University Press, 1968. 3. Bertera RL, Ustunoglu N: Training village midwives for family planning services delivery in rural Turkey. Boston: The Pathfinder Fund, Pathpaper #1, July 1977. 4. Green LW: Diffusion and adoption of innovations related to cardiovascular risk behavior in the public: In Enelow J, Henderson JB, (Eds): Applying Behavioral Science to Cardiovascular Risk. New York: American Heart Association, 1975.
5. Rogers EM, Shoemaker FF: Communication of Innovations. New York: The Free Press, 1971. 6. Rogers EM: Communication Strategies for Family Planning. New York: The Free Press, 1973. 7. Green LW: Toward cost-benefit evaluations of health education: Some concepts, methods, and examples. Health Educ Monogr 2(Suppl.):34-64, 1974.
ACKNOWLEDGMENT The original work on this project was supported by The Pathfinder Fund. Preparation of this analysis and manuscript was supported by NIH Research Training Grant T32-HL-07180.
7th Energy Technology Conference and Exposition, 1980 Call for Papers The 7th Energy Technology Conference and Exposition, to be held March 24-26, 1980, Sheraton Washington Hotel, Washington, DC, has issued a call for papers. Persons interested in presenting a paper should submit three copies of the paper's title, abstract and author's biography to the Conference headquarters prior to September 10, 1979. All papers must be new and must not have been previously presented at a national meeting. The Conference is the world's largest forum of discussion and interaction for the international energy community. Total attendance should exceed 10,000 and will include key energy decision-makers from around the nation. Papers to be submitted for consideration should focus on the application of technology to satisfy the world's energy needs, and should not dwell on basics but be oriented to a well-informed audience. Papers are currently being reviewed and accepted for the conference. For further details, contact the Program Chairman, 7th Energy Technology Conference, c/o Govemnment Institutes, Inc., 4733 Bethesda Avenue, NW, Washington, DC 20014, phone: 301/656-1090.
AJPH September 1979, Vol. 69, No. 9
953
