EDITORIALS
tion laws. Although this may be an effective strategy, it is a sigp of our inability to develop effective voluntary programs and can be argued to infringe upon civil liberties. In the absence of a disease eradication program is it to society's advantage to compel immunization by not allowing children to enter school or return to school? Would it have been to society's advantage to have had a compulsory swine flu program in which the right to vote or have a driver's license was suspended untij proof of immunization was presented? Since it is likely that influenza immunization is going to remain voluntary we are going to have to explore further the factors leading people to accept or reject it; and we are going to have to explore strategies for increasing acceptance. Developing less reactogenic vaccines, redefining the high-risk group into categories of relative risk so that programs can focus first on the highest risk individuals, and exploring the use of incentives may all have a role. One thing is certain-if we continue to settle for current rates of participation in influenza vaccine programs we don't really believe in the value of influenza immunization.
STEPHEN C. SCHOENBAUM, MD
Address reprint requests to Dr. Stephen C. Schoenbaum, Department of Medicine, Peter Bent Brigham Hospital, 721 Huntington Avenue, Boston, MA 02115. Dr. Schoenbaum is also affiliated with the Harvard School of Public Health, and is Director of Medical Services at Boston Hospital for Women.
REFERENCES 1. Monto AS and Ross HW: Swine influenza vaccine program in the community: Acceptability, reactions and responses. Am J Public Health 69:233-237, 1979. 2. Boffey PM: Swine flu: were the three deaths in Pittsburgh a coincidence? Science 194:590-591, 648, 1976. 3. Schoenbaum SC, McNeil BJ, Kavet J: The swine-influenza decision. N EngI J Med 295:759-765, 1976. 4. Center for Disease Control, Bureau of Health Education: National survey of public attitudes towards A/New Jersey/76 influenza vaccination: report no. 4. Atlanta, GA. November 30, 1976. 5. Aho WR: Participation of Providence senior citizens in the swine flu inoculation program. RI Med J 60:525-530, 1977. 6. Ennis FA, Tully M, Barry DW, Gordon E: Acceptance of vaccination by the elderly. In P. Selby, ed., Influenza: Virus, Vaccines, and Strategy (Proceedings of a working group on pandemic influenza, Rougemont, January 26-28, 1976). London and New York, Academic Press, 1976.
The Use of Health Surveys in Health Systems Agency Planning At a time when allocation of limited health resources is a major public issue, new or additional insights into the collection of relevant data for health planning are most welcome. Siemiatycki, in a report published in this issue of the Journal,' confirms some previous reports on the comparative effectiveness and costs of various combinations of mail, telephone, and face-to-face interviews in the conduct of community surveys. Of particular interest is the finding that the use of the telephone in such surveys if followed up by household interviews can lead to a high response at a comparatively low cost. Household health surveys-whether local community or multi-county in coverage-can provide useful information for health planning. Survey information can be used to complement data from other sources. Demographic, small-area data are available from the latest Census of Population and Housing printed reports or summary tapes, in which the basic aggregate unit is the enumeration district or the block group with average coverage of about 250 households (but also with great variation).2 Service information is usually available from health agencies, e.g., the number of recipients of a particular health service; resource information would include the amount of money expended on a particular service. These other types of information primarily yield input measures of health services; often, it falls upon the household survey to produce output measures of the effects of varAJPH March, 1979, Vol. 69, No. 3
ious health care strategies on the total community and the relevant health target groups. Furthermore, surveys can be structured to assess the total health and social needs of individuals and families whereas other types of information reflect program data, which, of necessity, are fragments of the whole. The United States, in implementing the National Health Planning and Resources Development Act (PL 93-641), is committed to a policy of health planning at the national, state, and area-wide levels. Although health planning of this kind is a political activity (using the broadest definition of "'political"), it is essential that we apply usable and valid data to allocate resources if we are to promote the goals of improving access to high quality health care at reasonable cost, as projected by the law. The report by Siemiatycki' has implications for those who have responsibility for implementing the Act. One of the pitfalls in planning as performed at the Health Systems Agency (HSA) level is that there may be great variations in the needs for or utilization of health services within a health service area.3 These variations can be taken into account in health planning only if the data currently available through surveys by the National Center for Health Statistics and other federal health programs, including the Cooperative Health Statistics System conducted at the state level, are supplemented by small area surveys. However, Section 1513 (b) of PL 93-641 enjoins the Health 221
EDITORIALS
Systems Agencies to use existing data to the maximum extent practicable. At the present level of funding, HSAs do not have the resources to collect supplementary data independently, even if expressly permitted to do so. To solve this problem, Congress should give serious consideration to the appropriation of supplementary funds for data collection and analysis. This can be justified on the basis of a comparison of the amounts of money spent on health services delivery, and on health systems planning: in 1977 we spent $737 per capita on the delivery of bealth care,4 and only 50 cents per capita, with minor additions from matching funds, on planning the delivery system.5 The average HSA covers a population of about 1 million. If 10 cents per capita were added to the HSA budget nationally, the average HSA would have $100,000 to use for collecting additional data for planning. In allocating these monies a suitable formula should be used to accommodate the special needs of small HSAs since the need for financial assistance is not strictly proportional to population size in the area. This anmount could be used to conduct approximately 4,000 telephone interviews-assuming that $40,000 were spent on personnel and the maintenance of an office, and the rest spent on interviews at $15 per interview if performed in-house, and using reduced-cost telephone service. In many parts of the country, university faculty may well be interested in contributing to the preparation of survey design, and data collection and andlysis because of their own interests in education and
research. Telephone interviews have several disadvantages as well as advantages.6 In the United States we do not generally have the advantage of up-to-date and complete lists of households as is required by law in Canada; a varying proportion of households either do not have telephones or have unlisted numbers; and telephone directories often do not cover the same geographic area that is to be studied. The validity of the responses given over the telephone may, as reported by Siemiatycki,' be limited, but other investigators
have found that there is little or no difference between telephone and face-to-face interviews. In a comparative study of face-to-face and telephone surveys involving 200 different measures, only a few statistlcally significant differences were fouhd between the two approaches.7 The advantages of telephone over face-to-face surveys are the lower cost, and, especially in urban areas, the high level of access to households. On balance, telephone surveys should be seriously considered as a way of reducing the existing gaps in our knowledge of important variables necessary for intelligent health planning. With relatively little increase in expenditure, community data used by HSAs for planning purposes could be improved and the amount of guesswork significantly reduced.
HARRY T. PHILLIPS, MD, DPH ANGELL G. BEZA, AB Address reprint requests to Harry T. Phillips, MD, DPH, Professor, Department of Health Administration, University of North Carolina, School of Public Health, Chapel Hill, NC 27514. Angell G. Beza is Associate Director for Research Design, Institute for Research in Social Science, UNC Chapel Hill.
REFERENCES 1. Siemiatycki J: A comparison of mail, telephone and home interview strategies for household health surveys, Am J Public Health 69:238-245, 1979. 2. U.S. Bureau of the Census. Census Use Study: Data Uses in Health Planning. Report #8, 1970. (See also other health reports in the Census Use Study series.) 3. Wennberg J and Gittelsohn A: Small area variations in health care delivery, Science, 182:1102-1108, 1973. 4. Gibson RM and Fisher CR: National health expenditures, fiscal year 1977, Soc Sec Bull 41:3-20, 1978. 5. National Health Planning and Resources Development Act of 1974 (PL 93-641). Section 1516 (b). 6. Dillman DA: Mail and Telephone Surveys: The Total Design Method. New York: John Wiley and Sons, 1978. 7. Groves RM: Comparing Telephone and Personal Interview Surveys, In: Economic Outlook USA, Summer 1978, pp. 49-51.
Editor's Report: Peer Review As is our wont, we publish this month the names of those who have functioned namelessly as referees of the manuscripts submitted to us during the past calendar year. In 1978 we received 639 papers, somewhat fewer than 20 per cent of which have been or will be published: these figures seem to have stabilized over the past two years. The review process followed by this Journal falls midway between those journals which send all articles out for review and those which send out only a selected few.' For about one out of three papers we receive, a decision (usually not to publish) is made by the Editor, either alone or with the help of the Editorial Board. The remaining papers are sent out to two or more of the referees listed elsewhere in the Journal this month. Their advice is sought, and usually followed; 222
their criticisms and comments are almost always helpful to both the author(s) of the paper and to the Editor on whom the burden of decision rests. The peer review institution has been both criticized and defended, but rarely studied in objective and scientificallyvalid fashion. One of the aspects of peer review, frequently cited in arguments against it, is the lack of concordance between referees. Given three options-Accept, Accept if Revised, Reject-our figures are 57 per cent for complete agreement and 9 per cent for complete disagreement (accept vs. reject). These are rather similar to figures reported from at least one other biomedical journal2 and seem well within the range of reliability of clinical judgments.3 The low level of agreement is far from reassuring, but AJPH March, 1979, Vol. 69, No. 3
tion laws. Although this may be an effective strategy, it is a sigp of our inability to develop effective voluntary programs and can be argued to infringe upon civil liberties. In the absence of a disease eradication program is it to society's advantage to compel immunization by not allowing children to enter school or return to school? Would it have been to society's advantage to have had a compulsory swine flu program in which the right to vote or have a driver's license was suspended untij proof of immunization was presented? Since it is likely that influenza immunization is going to remain voluntary we are going to have to explore further the factors leading people to accept or reject it; and we are going to have to explore strategies for increasing acceptance. Developing less reactogenic vaccines, redefining the high-risk group into categories of relative risk so that programs can focus first on the highest risk individuals, and exploring the use of incentives may all have a role. One thing is certain-if we continue to settle for current rates of participation in influenza vaccine programs we don't really believe in the value of influenza immunization.
STEPHEN C. SCHOENBAUM, MD
Address reprint requests to Dr. Stephen C. Schoenbaum, Department of Medicine, Peter Bent Brigham Hospital, 721 Huntington Avenue, Boston, MA 02115. Dr. Schoenbaum is also affiliated with the Harvard School of Public Health, and is Director of Medical Services at Boston Hospital for Women.
REFERENCES 1. Monto AS and Ross HW: Swine influenza vaccine program in the community: Acceptability, reactions and responses. Am J Public Health 69:233-237, 1979. 2. Boffey PM: Swine flu: were the three deaths in Pittsburgh a coincidence? Science 194:590-591, 648, 1976. 3. Schoenbaum SC, McNeil BJ, Kavet J: The swine-influenza decision. N EngI J Med 295:759-765, 1976. 4. Center for Disease Control, Bureau of Health Education: National survey of public attitudes towards A/New Jersey/76 influenza vaccination: report no. 4. Atlanta, GA. November 30, 1976. 5. Aho WR: Participation of Providence senior citizens in the swine flu inoculation program. RI Med J 60:525-530, 1977. 6. Ennis FA, Tully M, Barry DW, Gordon E: Acceptance of vaccination by the elderly. In P. Selby, ed., Influenza: Virus, Vaccines, and Strategy (Proceedings of a working group on pandemic influenza, Rougemont, January 26-28, 1976). London and New York, Academic Press, 1976.
The Use of Health Surveys in Health Systems Agency Planning At a time when allocation of limited health resources is a major public issue, new or additional insights into the collection of relevant data for health planning are most welcome. Siemiatycki, in a report published in this issue of the Journal,' confirms some previous reports on the comparative effectiveness and costs of various combinations of mail, telephone, and face-to-face interviews in the conduct of community surveys. Of particular interest is the finding that the use of the telephone in such surveys if followed up by household interviews can lead to a high response at a comparatively low cost. Household health surveys-whether local community or multi-county in coverage-can provide useful information for health planning. Survey information can be used to complement data from other sources. Demographic, small-area data are available from the latest Census of Population and Housing printed reports or summary tapes, in which the basic aggregate unit is the enumeration district or the block group with average coverage of about 250 households (but also with great variation).2 Service information is usually available from health agencies, e.g., the number of recipients of a particular health service; resource information would include the amount of money expended on a particular service. These other types of information primarily yield input measures of health services; often, it falls upon the household survey to produce output measures of the effects of varAJPH March, 1979, Vol. 69, No. 3
ious health care strategies on the total community and the relevant health target groups. Furthermore, surveys can be structured to assess the total health and social needs of individuals and families whereas other types of information reflect program data, which, of necessity, are fragments of the whole. The United States, in implementing the National Health Planning and Resources Development Act (PL 93-641), is committed to a policy of health planning at the national, state, and area-wide levels. Although health planning of this kind is a political activity (using the broadest definition of "'political"), it is essential that we apply usable and valid data to allocate resources if we are to promote the goals of improving access to high quality health care at reasonable cost, as projected by the law. The report by Siemiatycki' has implications for those who have responsibility for implementing the Act. One of the pitfalls in planning as performed at the Health Systems Agency (HSA) level is that there may be great variations in the needs for or utilization of health services within a health service area.3 These variations can be taken into account in health planning only if the data currently available through surveys by the National Center for Health Statistics and other federal health programs, including the Cooperative Health Statistics System conducted at the state level, are supplemented by small area surveys. However, Section 1513 (b) of PL 93-641 enjoins the Health 221
EDITORIALS
Systems Agencies to use existing data to the maximum extent practicable. At the present level of funding, HSAs do not have the resources to collect supplementary data independently, even if expressly permitted to do so. To solve this problem, Congress should give serious consideration to the appropriation of supplementary funds for data collection and analysis. This can be justified on the basis of a comparison of the amounts of money spent on health services delivery, and on health systems planning: in 1977 we spent $737 per capita on the delivery of bealth care,4 and only 50 cents per capita, with minor additions from matching funds, on planning the delivery system.5 The average HSA covers a population of about 1 million. If 10 cents per capita were added to the HSA budget nationally, the average HSA would have $100,000 to use for collecting additional data for planning. In allocating these monies a suitable formula should be used to accommodate the special needs of small HSAs since the need for financial assistance is not strictly proportional to population size in the area. This anmount could be used to conduct approximately 4,000 telephone interviews-assuming that $40,000 were spent on personnel and the maintenance of an office, and the rest spent on interviews at $15 per interview if performed in-house, and using reduced-cost telephone service. In many parts of the country, university faculty may well be interested in contributing to the preparation of survey design, and data collection and andlysis because of their own interests in education and
research. Telephone interviews have several disadvantages as well as advantages.6 In the United States we do not generally have the advantage of up-to-date and complete lists of households as is required by law in Canada; a varying proportion of households either do not have telephones or have unlisted numbers; and telephone directories often do not cover the same geographic area that is to be studied. The validity of the responses given over the telephone may, as reported by Siemiatycki,' be limited, but other investigators
have found that there is little or no difference between telephone and face-to-face interviews. In a comparative study of face-to-face and telephone surveys involving 200 different measures, only a few statistlcally significant differences were fouhd between the two approaches.7 The advantages of telephone over face-to-face surveys are the lower cost, and, especially in urban areas, the high level of access to households. On balance, telephone surveys should be seriously considered as a way of reducing the existing gaps in our knowledge of important variables necessary for intelligent health planning. With relatively little increase in expenditure, community data used by HSAs for planning purposes could be improved and the amount of guesswork significantly reduced.
HARRY T. PHILLIPS, MD, DPH ANGELL G. BEZA, AB Address reprint requests to Harry T. Phillips, MD, DPH, Professor, Department of Health Administration, University of North Carolina, School of Public Health, Chapel Hill, NC 27514. Angell G. Beza is Associate Director for Research Design, Institute for Research in Social Science, UNC Chapel Hill.
REFERENCES 1. Siemiatycki J: A comparison of mail, telephone and home interview strategies for household health surveys, Am J Public Health 69:238-245, 1979. 2. U.S. Bureau of the Census. Census Use Study: Data Uses in Health Planning. Report #8, 1970. (See also other health reports in the Census Use Study series.) 3. Wennberg J and Gittelsohn A: Small area variations in health care delivery, Science, 182:1102-1108, 1973. 4. Gibson RM and Fisher CR: National health expenditures, fiscal year 1977, Soc Sec Bull 41:3-20, 1978. 5. National Health Planning and Resources Development Act of 1974 (PL 93-641). Section 1516 (b). 6. Dillman DA: Mail and Telephone Surveys: The Total Design Method. New York: John Wiley and Sons, 1978. 7. Groves RM: Comparing Telephone and Personal Interview Surveys, In: Economic Outlook USA, Summer 1978, pp. 49-51.
Editor's Report: Peer Review As is our wont, we publish this month the names of those who have functioned namelessly as referees of the manuscripts submitted to us during the past calendar year. In 1978 we received 639 papers, somewhat fewer than 20 per cent of which have been or will be published: these figures seem to have stabilized over the past two years. The review process followed by this Journal falls midway between those journals which send all articles out for review and those which send out only a selected few.' For about one out of three papers we receive, a decision (usually not to publish) is made by the Editor, either alone or with the help of the Editorial Board. The remaining papers are sent out to two or more of the referees listed elsewhere in the Journal this month. Their advice is sought, and usually followed; 222
their criticisms and comments are almost always helpful to both the author(s) of the paper and to the Editor on whom the burden of decision rests. The peer review institution has been both criticized and defended, but rarely studied in objective and scientificallyvalid fashion. One of the aspects of peer review, frequently cited in arguments against it, is the lack of concordance between referees. Given three options-Accept, Accept if Revised, Reject-our figures are 57 per cent for complete agreement and 9 per cent for complete disagreement (accept vs. reject). These are rather similar to figures reported from at least one other biomedical journal2 and seem well within the range of reliability of clinical judgments.3 The low level of agreement is far from reassuring, but AJPH March, 1979, Vol. 69, No. 3
