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Dial-a-dietitian : an exploratory study of client use Finlayson, Joan Marjorie 1983

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DIAL-A-DIETITIAN: AN EXPLORATORY STUDY OF CLIENT USE by JOAN MARJORIE FINLAYSON B.He., University Of B r i t i s h Columbia,1953 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department Of Administrative, Adult, And Higher Education We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA August 1983 © Joan Marjorie Finlayson, 1983 In presenting this thesis in p a r t i a l fulfilment of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t freely N available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his or her representatives. It i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of Administrative, Adult, And Higher Education The University of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date: August 24, 1983 i i Abstract This study investigates c l i e n t use of a telephone information service. An exploratory study was undertaken of a D i a l - A - D i e t i t i a n n u t r i t i o n information service to obtain a description of the c a l l e r s , frequency of c a l l e r use of the service, and action taken by the c a l l e r s after receiving the informat ion. The data were obtained from records in the Dial-A-D i e t i t i a n o f f i c e and by interviewing two randomly selected samples of c a l l e r s by telephone one week after they had contacted the service with a question about n u t r i t i o n . Information c o l l e c t e d was age, sex, years spent in school, and perceived health status. Frequency of c a l l e r use was determined by whether a c a l l e r was a f i r s t time c a l l e r or one who had c a l l e d at least once in the past year. The action taken was described as a performance, conduct, or procedure that a person followed after receiving information. The c a l l e r s were described as women with an average age of 51 years who spent 12 or more years in school. They considered their health to be excellent/good. Their n u t r i t i o n a l interests were equally divided between normal and therapeutic n u t r i t i o n . S i x t y - f i v e percent of the c a l l e r s were regular users. Approximately 42% of the c a l l e r s took some i d e n t i f i a b l e action as a result of receiving information from the service. Table of Contents Abstract i i L i s t of Tables v Acknowledgements v i CHAPTER I: INTRODUCTION 1 Nature Of The Problem 2 Purpose Of The Study 5 Plan Of The Study 6 Defini t i o n s For The Study 8 Limitations Of The Study 9 CHAPTER I I : LITERATURE REVIEW 11 Review Of Selected Telephone Information Services 11 Can-Dial 12 Tel-Med 15 D i g i t a l Information Access Line 17 Health Line 18 H i s t o r i c a l Development Of Dia l - A - D i e t i t i a n 19 Vancouver Di a l - A - D i e t i t i a n Service Today 24 CHAPTER I I I : METHODOLOGY 27 Samples For The Study 27 Survey Instrument 31 Data Collections 32 Data Analysis 33 CHAPTER IV: PRESENTATION AND DISCUSSION OF FINDINGS 34 Description Of C a l l e r s 34 Dis t r i b u t i o n Of Callers By Type Of Question 34 Dis t r i b u t i o n Of Callers By Age And Sex 37 Dis t r i b u t i o n Of Callers By Age And Schooling 39 Dis t r i b u t i o n Of Cal l e r s By Perceived Health Status .41 Dis t r i b u t i o n Of Callers By Age, Perceived Health Status And Type Of Question 43 Frequency Of Caller Use 46 Dis t r i b u t i o n Of Callers By Frequency Of Use Of The Service 46 Dis t r i b u t i o n Of Cal l e r s By Age, New And Previous Users And Type Of Question 48 Action Taken 50 Dis t r i b u t i o n Of Cal l e r s By Action Taken 50 Dis t r i b u t i o n Of Callers By Age, New And Previous Users, And Action Taken 52 Dis t r i b u t i o n Of Callers By Age, Type Of Question And Action Taken 54 CHAPTER V: SUMMARY AND CONCLUSIONS 57 Method Of Study 57 Summary Of Major Findings 58 Action Taken By Callers After Receiving Information 58 Description Of The Callers 59 Frequency Of Caller Use 59 Variations In The Samples 59 Seasonal Variation 60 Conclusions 61 Action Taken By Cal l e r s After Receiving Information , 61 Description Of The Cal l e r s 61 Frequency Of Use 64 Variations In The Samples 64 General Conclusions About Telephone Information Services 65 Further Study 67 Cal l e r P r o f i l e 68 Content Of The Questions 69 Service 70 Recommendations 71 BIBLIOGRAPHY ...73 APPENDIX A: Request To The Ca l l e r To Participate In The Study 75 APPENDIX B: Survey Instrument: Facing Sheet And Interview Script 76 APPENDIX C: Di a l - A - D i e t i t i a n Programs And C a l l s 1980-81 Reporting Year .81 APPENDIX D: Caller Source Of Information About The Service 82 APPENDIX E: Total Number Of C a l l s To D i a l - A - D i e t i t i a n , Vancouver 1972-1982 83 APPENDIX F: Di s t r i b u t i o n Of Samples By Age And Sex 84 APPENDIX G: Occupation Of Ca l l e r s • 85 APPENDIX H: Action Taken By Ca l l e r s 86 APPENDIX I: Native Language Of Cal l e r s 87 APPENDIX J: Location Of The C a l l In The Community 88 APPENDIX K: Ease Of Reaching D i a l - A - D i e t i t i a n Service ....89 APPENDIX L: Persons For Whom The Information Was Required 90 V L i s t of Tables 1. Samples For the Study 29 2. Comparison of Ca l l e r s in the Samples with C a l l e r s in the Population 30 3. D i s t r i b u t i o n of Ca l l e r s by Type of Question 35 4. D i s t r i b u t i o n of C a l l e r s by Age and Sex 38 5. D i s t r i b u t i o n of Ca l l e r s by Age and Schooling 40 6. D i s t r i b u t i o n of Ca l l e r s by Perceived Health Status ...42 7. D i s t r i b u t i o n of Ca l l e r s by Age, Perceived Health Status and Type of Question 44 8. D i s t r i b u t i o n of C a l l e r s by Frequency of Use of the Service 47 9. D i s t r i b u t i o n of Ca l l e r s by Age of New and Previous Users and Type of Question 49 10. D i s t r i b u t i o n of Ca l l e r s by Action Taken 51 11. D i s t r i b u t i o n of C a l l e r s by Age of New and Previous Users and Action Taken 53 12. D i s t r i b u t i o n of Ca l l e r s by Age, Type of Question and Action Taken 55 vi Ac knowledqement I would l i k e to thank the many c a l l e r s to Dial-A-D i e t i t i a n who expressed willingness to participate in this study. Their candid comments and enthusiastic responses made the study both possible and enjoyable. I wish to thank Dr. J.E. Thornton, supervisor of the thesis, for his encouragement, patience, and support during the lengthy development of this study. Similarly the author acknowledges indebtedness to Dr. T.J. Sork for consenting to act on the thesis committee and for his pertinent, constructive c r i t i c i s m . In addition appreciation i s expressed to Dr. H.V. Kuhnlein for her guidance during the early stages of the study. Gratitude is expressed to members of the Vancouver D i a l - A - D i e t i t i a n service, M.H. Ottem, S.E. Ross, D.L. Noble, P. Overgaard, A. Campbell, and P.W. Radatzky, for support and encouragement of this project. 1 CHAPTER I INTRODUCTION Di a l - A - D i e t i t i a n , a telephone information service in Vancouver, B r i t i s h Columbia, provides members of the public with n u t r i t i o n information. The service i s supported by the B r i t i s h Columbia D i e t i t i a n s ' and N u t r i t i o n i s t s ' Association, the City of Vancouver Health Department, and the B r i t i s h Columbia Ministry of Health. This telephone service, part of the community health system in B r i t i s h Columbia, employs a d i e t i t i a n to answer enquiries about normal and therapeutic n u t r i t i o n . D i a l - A - D i e t i t i a n services have existed in North America since 1958 when the Detroit D i e t e t i c Association decided to f a c i l i t a t e public n u t r i t i o n education and to combat food misinformation by using the telephone to answer enquiries about n u t r i t i o n (Wagner, Navin, & Huyck, 1960). There were two types of procedures used to receive and answer questions. In one, the c a l l e r l e f t a message on the recording machine, the d i e t i t i a n researched the question and telephoned the c a l l e r within 48 hours and answered the question. This procedure was usually followed when a D i a l - A - D i e t i t i a n service was organized. In the other procedure, the c a l l e r s spoke d i r e c t l y to the d i e t i t i a n who answered the question immediately. This was the procedure followed by the Vancouver D i a l - A - D i e t i t i a n . The B r i t i s h Columbia D i e t i t i a n s ' and N u t r i t i o n i s t s ' Association established a service in Vancouver in 1971 (Campbell, 1977). 2 At the present time the Vancouver service i s interested in establishing a more detailed evaluation procedure to determine effectiveness. The service has collected and recorded the number and subject of c a l l s over the past ten years. This information was s u f f i c i e n t to demonstrate the effectiveness of the service during t h i s time. The service now recognizes the need to obtain additional documented information for the purposes of dir e c t i n g i t s e f f o r t s to that segment of the public that uses i t s services and for continuing accountability to the sponsoring agencies. Documented evidence must be forth-coming i f funds are to be made available in adequate amounts in the future. Prior to the establishment of an evaluation procedure, i t is necessary to obtain some current basic data such as a description of the c a l l e r s , frequency of c a l l e r use of the service, and the usefulness of the information to the c a l l e r . In order to obtain additional information, this exploratory study was undertaken. The data obtained w i l l provide basic information on which to develop an evaluation system for determining effectiveness of the service. This study then, i s an i n i t i a l investigation of c l i e n t use of the Vancouver Dial-A-D i e t i t i a n telephone information service. NATURE OF THE PROBLEM Members of the public, with an interest in their health and general well-being of their families, are constantly seeking n u t r i t i o n information. A recent study (Report on Nutrition Concepts Evaluation Study, 1981) which investigated 3 the public's perception of n u t r i t i o n a l concepts, reported that 80% of the respondents saw a sensible diet as important to them personally. Sensible eating was seen as eating at regular intervals and keeping c a l o r i c intake within an individual predetermined range. Forty percent of the respondents indicated that they had made dietary changes during the past year by consuming less fat and sweets and consuming more f r u i t s and vegetables. This indicates that in addition to an interest in maintaining a sensible d i e t , people report that they are w i l l i n g to make the necessary dietary changes to consume food that promotes health and well-being. In order to make these dietary changes people seek information from many sources. In the above study, adult family members were i d e n t i f i e d as the main source of n u t r i t i o n information. Schools, physicians and the media were i d e n t i f i e d as other sources frequently used. In a study of home learning Kolasa, Wenger, Paolucci, and Bobbitt (1979) found that men contacted l i b r a r i a n s and friends for information and women contacted parents and friends. The subject matter expertise and the a v a i l a b i l i t y of the resource person were the factors that influenced both men and women when seeking information. Thus the contact person's subject knowledge, trusted expertise and convenient placement in the community were factors that generally influenced the use of a resource person. Kolasa et a l . (1979) reported that the three most frequently used resources for information by young families, with members in age from newborn to 34 years, were t e l e v i s i o n (23%), magazines (19%), and newspapers (18%). In 4 middle families, with members ranging in age from 35 years to 54 years, the most frequently used media resources were books (22%), magazines (19%), and t e l e v i s i o n (16%). The older families, with members ranging in age from 55 years and older, used magazines (22%), t e l e v i s i o n (19%) and newspapers (19%). The young and middle families used the telephone for 5% of their information while the older families used i t for 2% of the information. This fiv e percent would represent a s i g n i f i c a n t number of households in the community that would use the telephone as a resource for information. The authors suggested that n u t r i t i o n educators must find acceptable pathways into the family to encourage them to use information systems. This suggests that i t would be useful to use the telephone as a medium for families to obtain information provided that a knowledgeable person or system could be reached. In addition the telephone would meet the requirements of convenience and trusted expertise that was suggested e a r l i e r in the Kolasa et a l . (1979) study. To approach the problem of providing n u t r i t i o n information from the point of view of the providers of the service, Browne and Cooke (1980) suggest that "the public" i s a vague description for people who might use the system and too diverse a group to be the subject of a single service. They suggest that the selection of objectives, methods, and media, suit the c h a r a c t e r i s t i c s of each segment of "the public" that uses a service. Some recommended target groups are sociodemographic segments such as parents of children 5 to 15 years, parents of 5 teenagers s t i l l l i v i n g at home, adults 25 to 65, or adults 65 or older. "Another set of categories might be organized around the extent to which individuals understood and cared about the relationship between diet and health. Another segment might be those who tend towards moderate to heavy exercise or physical work. The target group might also be segmented by l i t e r a c y l e v e l s , income, their exposure to d i f f e r e n t media, and the extent to which individuals are informed and careful consumers. Sociodemographic segments might by divided into ethnic groups; for example Black, Hispanic, Asian, Caucasian, and Middle Eastern" (Brown and Cooke, 1980, p.119-120). Relating this to the use of the telephone i t i s suggested that i t is a medium that could be used to reach s p e c i f i c groups p a r t i c u l a r l y those in the home or workplace. Therefore the nature of the problem of this study i s to determine which segment of the public uses the Vancouver D i a l -A - D i e t i t i a n service. This w i l l provide the basic data for accountability and further development of the service. PURPOSE OF THE STUDY The o v e r a l l purpose of t h i s study was to characterize c l i e n t use of the Dia l - A - D i e t i t i a n telephone service in Vancouver. The main purpose was to determine the action taken by c a l l e r s after receiving the information from Dial-A-D i e t i t i a n . Two secondary purposes were to describe the c a l l e r s to the service and to determine the frequency of c a l l e r use of the service. 6 One objective of the Di a l - A - D i e t i t i a n service i s to provide an information service s p e c i f i c a l l y designed to meet the needs of the general public. However, there is no information collected by the agency that describes the public who use the service or i f the information is useful to the c a l l e r . The study was undertaken to provide background information that could be used as a basis for future investigations of impact or evaluations of the service. This f i r s t exploration of c l i e n t responses is necessary before impact or evaluation study can be done. An impact study would require pre- and post-assessments to determine effectiveness of the service. Therefore t h i s study is to gather information in c l i e n t i d e n t i f i c a t i o n and c l i e n t use of the service. S p e c i f i c a l l y t h i s study w i l l describe the c a l l e r s according to age, sex, years in school, interest as determined by questions asked and perceived health status as reported by the c a l l e r . The study w i l l determine the frequency of c a l l e r use of the service. F i n a l l y , the study w i l l determine i f the c a l l e r took any action as a result of obtaining the information from D i a l - A - D i e t i t i a n . PLAN OF THE STUDY In order to c o l l e c t information for the study, a sample was developed of people who had c a l l e d the service. Names of the c a l l e r s were not requested. However, the c a l l e r was asked to leave a telephone number. While th i s could be considered a 7 means of identifying a person i t was the closest we could get to preserving anonymity and s t i l l contact subjects who had used the service. The telephone interview was used as a method of data c o l l e c t i o n because i t was the medium used by the service, because of the ease of reaching the c a l l e r , and because the conversational method of the interview might provide additional information about the service or c a l l e r s that could be the subject of further investigation. Two samples of c a l l e r s were chosen, about three months apart, to determine i f variation might ex i s t . There might be variation in the composition of each sample according to sex, age, years in school, the d i s t r i b u t i o n between the new and previous users, according to questions asked that i s normal and therapeutic n u t r i t i o n . There might be seasonal variation between samples taken in winter and early spring. Would people, indoors during the winter, tend to ask more therapeutic n u t r i t i o n questions? Would there be a greater interest in normal n u t r i t i o n in early spring when people were a n t i c i p a t i n g a need to reduce their weight? Nutrition Month, held in March, is a p u b l i c i t y a c t i v i t y to promote health through better eating habits. This promotion is sponsored by d i e t e t i c associations, newspapers, and food associations. It might stimulate an increase of normal n u t r i t i o n questions during t h i s period. The d i e t i t i a n s at the service f a c i l i t a t e d the c o l l e c t i o n of data. They asked the c a l l e r s to take part in the study (Appendix A). They recorded the questions and the telephone 8 number of the c a l l e r in the log book. The investigator was allowed access to the log book and pertinent f i l e s in the D i a l -A - D i e t i t i a n o f f i c e . DEFINITIONS FOR THE STUDY For the purposes of this study the following d e f i n i t i o n s w i l l be used. N u t r i t i o n . Nutrition is defined according to the Nutrition Council of the American Medical Association as "the science of food, the nutrients and other substances therein, their action, interaction, and balance in re l a t i o n to health and disease, and the processes by which the organism ingests, absorbs, transports, u t i l i z e s and excretes food substances" (Lagua, Claudio, Theile, 1974, p. 162). Normal Nutri t i o n . Normal Nutrition is defined as the science of food and how the body uses these substances. The nutrients required by the human body are water, protein, carbohydrates, fats, vitamins, and minerals (Gates, 1981). In this study questions from c a l l e r s pertaining to nutrients, c a l o r i e s , food purchasing, preparation and storage are included in the category of normal n u t r i t i o n . Therapeutic N u t r i t i o n . Therapeutic n u t r i t i o n i s defined as the science of food and how the body uses these substances in r e l a t i o n to disease. In thi s study those questions pertaining to diets used because of the presence of a disease or condition are included in the category of therapeutic n u t r i t i o n . 9 Action. Action i s defined as the performance or conduct or procedure that a person follows after receiving information from the service. In thi s study the consumption of a food, preparation of a food, phoning a physician are the application or employment of the information received. Health Status. Health status, defined by the World Health Organization, i s "physical, mental and soc i a l well-being, not merely the absence of disease" (Hopkins, 1979, p.934). In thi s study perceived health status i s the state of health as described by the c a l l e r . New and Previous Users. New users to the service were people who c a l l e d D i a l - A - D i e t i t i a n for the f i r s t time. Previous Users were people who had c a l l e d the service more than once in the past year. LIMITATIONS OF THE STUDY This study i s a preliminary investigation of the u t i l i z a t i o n of a telephone information service. If the c a l l e r s take some action, or apply the information received, or make some behavioral change, then the service can be subjected to further experimental study to determine impact. Burck, Cottingham and Reardon (1973) suggest that the quasi and pre-experimental and non-experimental one sample pre-post designs may be appropriate for preliminary or i n i t i a l investigations of program effectiveness. Liberman (1974) suggests that i t i s important to gain a complete understanding of the c l i e n t responses to current modes of service before struggling with 1 0 more rigorous and d i f f e r e n t experimental approaches. Speer and Tapp (1976) conclude "although i t i s important to be cognizant of the experimental model concepts of internal and external v a l i d i t y and how these effect conclusions and generalization of findings, we recommend that the experimental model per se, be temporarily set aside as the preliminary reference point in i n i t i a l program effectiveness e f f o r t s . Too much developmental work needs to be done to allow us to be blocked by the f e a s i b i l i t y issues in the experimental model" (p. 219). This study was a preliminary investigation of c l i e n t use of the Dial-A-Diet'itian telephone n u t r i t i o n information service and was undertaken to provide basic data that described the c a l l e r s , frequency of use of the service, and action taken after receiving the information. Two di f f e r e n t samples of c a l l e r s were randomly chosen from two d i f f e r e n t seasons of the year. The study was an i n i t i a l investigation of c l i e n t responses. 11 CHAPTER II LITERATURE REVIEW There have been a number of studies of telephone information services reported in the l i t e r a t u r e . Some studies focus on the competency of the individuals providing the services. Other studies focus on the recipient of the services or information. These studies are designed to investigate number and subject of c a l l s , description of c a l l e r s , frequency of use of the service, impact of the information on the behaviour of recipient. This l i t e r a t u r e review i s confined to those studies that focus on individuals who receive health information directed to the public. The f i r s t section reviews studies of selected telephone health information services and the second section. reviews D i a l - A - D i e t i t i a n telephone information services. REVIEW OF SELECTED TELEPHONE INFORMATION SERVICES In the following studies members of the public i d e n t i f i e d their individual interest or need for information and contacted a telephone information service. The four services that are reviewed are Can-Dial, Tel-Med, D i g i t a l Health Information Access Line, and Health Line. Each service i s b r i e f l y discussed according to how the need for the service was i d e n t i f i e d , the assumptions on which the service was based, and the results of surveys or evaluations. 1 2 CAN-DIAL Can-Dial, a project of the Roswell Park Memorial Institute in Buffalo, New York, was a telephone information service of prerecorded lectures about cancer (Wilkinson, Mirand, & Graham, 1977). A telephone operator managed a recording and playback console. Members of the public telephoned and requested a topic, the operator selected the requested cassette and activated the playback mechanism. The need for the service was i d e n t i f i e d because cancer, a major health problem, could be controlled or prevented by early diagnosis. Therefore one approach to l i m i t i n g the spread of the disease would be to increase public awareness of the developing condition and to encourage the use of routine diagnostic screening at the asymptomatic stage or seek medical advice as soon as symptoms appear. Thus there was a need for a service directed to the public to disseminate cancer information that was accessible, accurate, and employed neither scare t a c t i c s nor over optimism. The service was based on the assumption that by increasing public awareness, interest, and knowledge about cancer, early diagnosis would improve health status and thus bring about a decrease in cancer related deaths. To determine i f the Can-Dial program had an impact on the c a l l e r s , Wilkinson et a l . (1977) interviewed a sample of c a l l e r s to determine the reasons for c a l l i n g and the effect on behavior as a result of the c a l l . The demographic data c o l l e c t e d at the time of the c a l l was name, address, telephone number, sex, age, occupation, frequency of use, and source of 1 3 information about the service. In addition, date and time of c a l l , subject and number of tapes requested were also recorded. The results of the study showed that the ratio of male to female c a l l e r s was 2:1. An analysis of age showed that the response was greatest from teenagers. The rate of response was lowest for those 70 years and older. The disturbing implication, according to the authors, was that those at the greatest risk for cancer, the eld e r l y , use the program the least . The respondents were mainly students. Others l i s t e d their occupation as housewife, c l e r i c a l worker, professional and unemployed. It is noted that some of these people would have free time and easy access to a telephone during the day and the researchers implied that s i t u a t i o n a l factors could influence u t i l i z a t i o n of the service. Those using the service were mainly new c a l l e r s (60%). Previous c a l l e r s were 17% of the sample, hangup c a l l s 7% and 16% of the sample was not accounted for in the study. A sample of c a l l e r s was interviewed several weeks after their contact with the service to determine their reasons for c a l l i n g and to ascertain i f any change in their behavior could be attributed to their contact with the program. The authors suggested that a motivating force for contacting the service would be a personal experience with cancer and they found that 53% of the respondents had t h i s experience either as a patient or knowing a patient. Other reasons for c a l l i n g were wanting to quit smoking (23%) and c u r i o s i t y about a cancer problem (23%). Wilkinson et a l . (1977) were interested in the impact 14 that Can-Dial would have on individual behavior. They found that 40% of the c a l l e r s reported some health related change in behavior such as q u i t t i n g smoking or v i s i t i n g a physician. Ten percent reported that they discussed cancer, 11% reported that the information received relieved their anxiety, 40% reported no change in behavior. It is suggested that these results do not indicate long term behavioral change or demonstrate the influence of these changes on health outcomes and thus must be viewed as indicators that behavioral changes could occur. It is further suggested that the study was an exploratory investigation on the use of a telephone information service rather than an impact study as suggested by the authors. An impact study could now be done to determine i f the c a l l e r s continued to abstain from smoking and i f health status improved. Another indicator of the program's impact according to the authors was the knowledge obtained as a result of the c a l l . For t h i s purpose a group of c a l l e r s and non-callers were selected and interviewed and asked to state three warning signs of cancer. More c a l l e r s (60%) than non-callers were able to state three warning signs. It i s suggested that these results be viewed with caution because no baseline data was obtained from the c a l l e r s as to their knowledge of cancer prior to the interview. In summary t h i s study provided baseline data on a telephone information service by describing the c a l l e r s who were young, mainly female students and housewives and who were 1 5 c a l l i n g for the f i r s t time. As a result of the c a l l 40% said they quit smoking or saw a physician. This study provides useful background information for other studies on telephone information service by describing the c a l l e r s and the kind of action taken. It i s suggested that the focus of the services was on interviewees who were concerned about cancer and i t s re l a t i o n to their health. This was a target group, or segment of the public that used a cancer information service. TEL-MED Tel-Med was a health information service in Winston-Salem, North Carolina, sponsored by the Forsyth County Medical Society and the Greater Winston-Salem Chamber of Commerce Foundation (Diseker, Michielutte & Morrison, 1980). C a l l e r s telephoned the service, requested a'taped message which was then played over the telephone. The primary objective of the service was to increase accessabi1ity of health information at no cost to the user and on a 24 hour, 7 day a week basis. Other objectives were to combat r i s i n g health costs by reducing unnecessary v i s i t s to physicians for standardized medical information, to f a c i l i t a t e access to health services for a l l c i t i z e n s where there was a d e f i n i t e need, to help people recognize early signs of i l l n e s s , and to help people find appropriate community resources to deal with their medical problems. 16 A study was conducted in Forsyth County, North Carolina, of a random sample of households to determine the use and effectiveness of Tel-Med (Diseker et a l . , 1980). The respondents were asked (a) i f they were aware of the Tel-Med services, (b) i f they had used i t , (c) whether or not any of the tapes had an effect on their health behavior, (d) their age, marital status, education and family income. Those who were aware of the Tel-Med service were middle aged women who had some college education. Thirty-seven percent of the respondents who had prior knowledge of the service actually used i t , most of these c a l l e r s (80%) had used i t more than once. Repeated usage was dependent upon the usefulness of the information in decision making. The impact of the service on the behavior of the respondents was reported as being encouraged to seek medical and dental care i n i t i a l l y or sooner than they would have otherwise (25%), finding i t unnecessary to see a doctor (30%), following a suggestion on a tape (42%). However, the study f a i l e d to provide information on the suggestions that were on the tapes, or what action the c a l l e r took as a result of t h i s information. It i s suggested that this study was a survey to determine i f people were aware of the service and to provide a p r o f i l e of the user. The study f a i l e d to provide information on the impact of the information on the user. Tel-Med and Can-Dial services both attempted to reach the public. Tel-Med focused the service on the broad subject of health problems. Can-Dial served a smaller target group by 1 7 focusing on those members of the public who were interested in cancer. DIGITAL INFORMATION ACCESS LINE D i g i t a l Information Access Line (DIAL) was a telephone health information service for students at the University of Wisconsin in Madison (Bartlett & Lewis, 1976). Telephone requests were received on a 24 hour per day basis. The requested tape was played over the telephone through the use of a cassette playback unit. The need for the service was i d e n t i f i e d through surveys of students and c l i n i c patients. Many students made unnecessary v i s i t s to the c l i n i c for general health information that could have been provided through other sources. A decision was made to provide this information through a telephone service with the assumption that a student making a c a l l regarding health would be receptive to learning basic concepts of health maintenance and e f f e c t i v e ways of handling current health problems. Ba r t l e t t and Lewis (1976) did a study of the D i g i t a l Information Access Line and reported the subject and number of c a l l s . The subject matter of greatest interest to the students was upper respiratory infections, g a s t r o i n t e s t i n a l conditions, injury, and venereal disease. The questions were tabulated according to those asked by men and those asked by women but the actual number of men and women in the study was not reported so i t is not clear whether the service i s used more by women than men. Frequency of c a l l e r use and impact of the 1 8 service were not reported. This study (Bartlett & Lewis, 1976) is included in the l i t e r a t u r e review as an example of a telephone information service that attempted to provide a program for a target group. In t h i s case the health subjects of interest to university students were i d e n t i f i e d and the service was organized to meet the need. HEALTH LINE Health Line was a patient information service developed by the University of Wisconsin-Extensions's Department of Medical Education and the University of Wisconsin's Center for Health Sciences in Madison. Patients could receive taped messages through their bedside telephone (Bartlett & Meyer, 1976). The purpose of this service was to increase patient understanding of individual health problems and to present the patient with accurate information at the time of hospital stay. The basic assumption of the service was that a patient would be interested in receiving information related to personal treatment procedures. In a study of t h i s service B a r t l e t t and Meyer (1976) reported the subject and number of c a l l s . Usage of the service was higher among women and the users were persons with higher levels of education. No other information was reported. This study i s included in the l i t e r a t u r e review because Health Line was a service targeted to a s p e c i f i c group and in t h i s case, hospitalized patients. 1 9 In summary, these four studies provide some basic data on c a l l e r s to telephone health information services. For instance, c a l l e r s were described as young, female, students, housewives (Wilkinson et a l . , 1977); middle aged women (Diseker et a l . , 1980); women (Bartlett & Meyer, 1976); and students (Bartlett & Lewis, 1976). The frequency of use of the services was not c l e a r l y reported. Wilkinson et a l . (1977), reported that 40% of the c a l l e r s took some action as a result of a c a l l to Can-Dial and Diseker et a l . (1980), reported that 42% followed a suggestion on the tape. However the authors did not c l e a r l y define the suggestions on the tape. The motivation to use the services was influenced by previous experience with cancer in the case of Can-Dial and the usefulness of the information in the case of Tel-Med. These four studies w i l l provide basic background information for the study of the Vancouver D i a l - A - D i e t i t i a n telephone information service. This basic information w i l l be compared to that of the Vancouver system when describing the c a l l e r s and the action taken. HISTORICAL DEVELOPMENT OF DIAL-A-DIETITIAN Di a l - A - D i e t i t i a n started as a project in public relations and community service by the Detroit D i e t e t i c Association on Oct. 1, 1958 (Wagner, Navin & Huyck, 1960). The objectives of the service were to provide the Detroit Dietetic Association with an opportunity to f a c i l i t a t e public n u t r i t i o n education and to combat food misinformation, to offer a unique service to 20 the community, and to use the service for p u b l i c i t y and communication between the lay public and the d i e t e t i c profession. The project was operated from a telephone answering service. C a l l e r s would telephone the service from Monday to Friday during the morning hours and ask a question about normal n u t r i t i o n . The question would be forwarded to the Detroit D i e t e t i c Association and a member would telephone the c a l l e r within 24 hours and answer the question. The telephone was the medium of communication to answer questions, rather than the mailed l e t t e r , because of the opportunity for o r a l exchange to c l a r i f y and extend both the question and the answer, for the ease of the use of both the c a l l e r and the responder, and the value of person to person contact. Financial support was received from the Merrill-Palmer Institute and the Dairy Council of Detroit. The idea of providing n u t r i t i o n information by telephone spread to 19 regional d i e t e t i c assocations with f i n a n c i a l support of the Nutrition Foundation and the guidance of the American Di e t e t i c Association. A study was designed and conducted to evaluate the program organization and the impact of the programs on the communities involved (Wagner, Huyck, & Hinkle, 1965). The impact of the programs was determined by the number and subject of c a l l s and the effectiveness was determined by asking the c a l l e r s i f they were s a t i s f i e d with the service. Wagner et a l . (1965) states in the study: In addition to providing authoritative n u t r i t i o n 21 information in response to the individual telephone requests, D i a l - A - D i e t i t i a n programs serve an unmeasured educational function through the content of the newspaper columns and radio and t e l e v i s i o n interviews to publicize the service. If t h i s is done, then perhaps the program i s functioning as an instrument of n u t r i t i o n education for a greater population than the number of telephone requests would indicate (p.389). A recent study has been done to develop a model to evaluate the use of the telephone as a vehicle for n u t r i t i o n information. The model was then used to evaluate the Roanoke Valley, V i r g i n i a D i a l - A - D i e t i t i a n program (Robbins and Mullis, 1982). The users of t h i s program c a l l a telephone answering service and leave the question and their telephone number. A d i e t i t i a n researches the question and contacts the c a l l e r within 48 hours with the answer. The results of t h i s study indicate that the demographic p r o f i l e of the t y p i c a l c a l l e r is female, over 46 years of age and a homemaker with a college education. The c a l l e r s were s a t i s f i e d with the program and the d i e t i t i a n provided the information that was requested. The c a l l e r s used the information but also f e l t that the information was perceived as useful for the future. The majority of the c a l l s were c l a s s i f i e d as modified diets or nutrient analysis. This study represented an attempt to go beyond the compilation of number and content of c a l l s and to determine the use of the information to the c a l l e r s . The idea of the telephone information service was adopted in Toronto, Canada in 1964 and was based on the p o l i c i e s and procedures of the American D i e t e t i c Association (Bodley, 22 1965b). The Ontario D i e t e t i c Association f e l t i t too had a role in contributing to n u t r i t i o n education of the community. The objectives of the service were to provide an authoritative source of normal n u t r i t i o n information. Bodley (1965a) defined normal n u t r i t i o n as "the current acceptable body of knowledge which deals with the relationship of food to the individual in good health" (p. 13). The subjects considered as normal nu t r i t i o n were the use of Canada's Food Guide in meal planning, use of the guide in the interpretation of n u t r i t i o n a l and food requirements for a l l age levels and ethnic groups, food sources of nutrients, enrichment of foods, buying and storage of foods, food preparation, food fads, regulations concerning food production and marketing. It i s worth noting that d i e t i t i a n s in the United States and Canada o r i g i n a l l y answered questions about normal n u t r i t i o n . However in reviewing the study done by Wagner et a l . (1965), 19% of the questions were about therapeutic n u t r i t i o n . In the topics reported by Bodley (1965a), 11% of the questions were about therapeutic n u t r i t i o n . It was recognized early in the history of D i a l - A - D i e t i t i a n that questions about normal and therapeutic n u t r i t i o n would be asked by c a l l e r s and the service could not be limited to the subject of normal n u t r i t i o n . D i a l - A - D i e t i t i a n started in Vancouver, B r i t i s h Columbia in 1971 as a project of the B r i t i s h Columbia Di e t e t i c Association (Campbell, 1977). It was organized in two phases with f i n a n c i a l support of a Federal Government Local I n i t i a t i v e s 23 Grant. The organizational phase began in January, 1972, with the h i r i n g of five f u l l - t i m e d i e t i t i a n s , three part-time d i e t i t i a n s , a l i b r a r i a n , and a secretary. This staff organized a reference l i b r a r y , volunteer d i e t i t a n s to answer c a l l e r questions, a p u b l i c i t y campaign, and a support system to secure a continuing program. The operational phase began in May, 1972, when the telephone l i n e was open to the public. The staff then consisted of two f u l l - t i m e d i e t i t i a n s , one part-time d i e t i t i a n and one part-time clerk. During the f i r s t months the c a l l s were recorded on the recording machine. The d i e t i t a n s would research the question and return the c a l l . This practice was discontinued because many c a l l e r s refused to state their questions to a machine and would hang up the telephone without leaving the message. The system was changed so that the d i e t i t i a n answered the telephone and spoke d i r e c t l y to the c a l l e r . The recording machine was then used during the lunch breaks, evenings, weekends, and holidays. The service was closed b r i e f l y in A p r i l , 1974, due to lack of funds. Service was resumed in June, 1974, (Campbell, 1977). Today there are three D i a l - A - D i e t i t i a n services in Canada: Edmonton, Alberta; Toronto/Kingston, Ontario; and Vancouver, B r i t i s h Columbia. The Vancouver service i s the largest in North America. Size i s determined by the number of c a l l s per year. The National Advisory Committee of the American Dietetic Association (1982) reported that for the 1980-81 year, there were 37 services in North America with the range of c a l l s from 6 in Finger Lakes, New York, to 3,034 in Boston Massachusetts. 24 The c a l l s in Canada were 484 in Edmonton; 1,528 in Toronto/Kingston; 5,924 in Vancouver (Appendix C). No references were made to the type of answering systems used by these services. VANCOUVER DIAL-A-DIETITIAN SERVICE TODAY Dia l - A - D i e t i t i a n provides direct telephone n u t r i t i o n information to the public in the Greater Vancouver t o l l - f r e e area and indirect service through the media and professionals in other areas of the province (Ross, 1979). The service is staffed by four d i e t i t i a n s who share one full-time p o s i t i o n . One of the staff members acts as the co-ordinator. A d i e t i t i a n i s available to answer questions between the hours of 9 a.m. and 4 p.m. on weekdays. C a l l e r s who telephone at other times of the day or night can leave a message on the recording machine. When the d i e t i t i a n arrives at the o f f i c e the next day she contacts the c a l l e r . The staff of the service is responsible to the D i a l - A - D i e t i t i a n Committee, an advisory committee to the Board of Directors of the B r i t i s h Columbia D i e t i t i a n s ' and N u t r i t i o n i s t s ' Association. The chairman of the committee provides the l i a i s o n between the D i a l - A - D i e t i t i a n staff and the Association (Ross, 1979). Funding for the service comes from three sources. The B r i t i s h Columbia Ministry of Health provides funds for s a l a r i e s and benefits. Funds are received yearly for one full-time d i e t i t i a n position, two days per month for support s t a f f , one month holiday r e l i e f , and employee benefits. The City of 25 Vancouver Health Department provides o f f i c e space and telephone service in the Provincial Health Building on Grant Street in Vancouver. The B r i t i s h Columbia D i e t i t i a n s ' and N u t r i t i o n i s t s ' Association provides equipment, maintenance, l i b r a r y books and journals, reference materials, postage and stationary. D i s t r i b u t i o n of information about the service i s through brochures, a r t i c l e s in the newspapers, telephone book l i s t i n g s , health care professionals, and agency publications (Appendix D). The users of the service are members of the public who telephone for information. D i a l - A - D i e t i t i a n divides the c a l l e r s into several groupings. These are (a) individuals who c a l l for information for themselves, family or friends; (b) professional people who c a l l for information to coun-sel others, (c) media personnel who use the information for radio, t e l e v i s i o n , newspaper and magazine a r t i c l e s ; (d) representatives of other information services such as l i b r a r i e s , and (e) group representatives who are individuals p a r t i c i p a t i n g in volunteer groups and c a l l for information to present to the group. There is no information recorded as to age, sex, educational l e v e l of the c a l l e r or the frequency of use of the service by the c a l l e r . Evaluation of the effectiveness of the service is determined by the number of c a l l s received. The c a l l s have increased from 1,738 in 1972 to 6,084 in 1982 (Ottem, 1982; Ross, 1982; Appendix E). 26 In summary, five studies of telephone health information services which focus on the recipient have been reviewed. Users of these services were mainly women. Ages of c a l l e r s varied from teenage to middle age. Many c a l l e r s l i s t e d their occupation as student or housewife. Some c a l l e r s had a college education. Frequency of use of the services varied and no conclusions can be drawn from the information given in the studies. The impact of the information on the behaviour of the recipient was reported as q u i t t i n g smoking or seeing a physician. It was speculated in two of the studies that a motivation to use the service might be a personal involvement with the subject such as cancer or involvement when a decision has to be made such as seeking medical attention. These were not followed through and investigated in the studies. This l i t e r a t u r e review provides guidelines for the study of the Vancouver D i a l - A - D i e t i t i a n service for age, sex, and educational background of c a l l e r s . It does not provide much information on the frequency of use of the service. It provides a beginning for a study of the usefulness of the information to the c a l l e r . 27 CHAPTER III METHODOLOGY The purpose of thi s study was to characterize c l i e n t use of the Dia l - A - D i e t i t i a n telephone information service in Vancouver, B r i t i s h Columbia. The main purpose was to determine the action taken by the c a l l e r after receiving information from the service. The two secondary purposes were to describe the c a l l e r s and to determine the frequency of use of the service. Two samples were selected, and an interview s c r i p t prepared. SAMPLES FOR THE STUDY The data for the study were coll e c t e d by interviewing c a l l e r s to Di a l - A - D i e t i t i a n telephone service in Vancouver, B r i t i s h Columbia. The data were coll e c t e d from two samples. Sample A was col l e c t e d in January/February, 1982 and Sample B in March/April 1982. Two samples were coll e c t e d to see i f there were any differences that might be attributed to the season of winter or early spring. The two samples would also be l i k e l y to be more representative over time. The d i e t i t i a n routinely asked each c a l l e r to parti c i p a t e in the study (Appendix A). The d i e t i t i a n recorded the telephone number of those w i l l i n g to be interviewed. She also noted those unwilling to be interviewed for the study. 28 The interviewer numbered the c a l l s posted in the log book, chose a number from a table of random numbers, selected that c a l l e r and every t h i r d c a l l e r to be interviewed. In Sample A, 66% of the c a l l e r s chosen were interviewed and in Sample B, 37% of the c a l l e r s chosen were interviewed ( Table 1 ). In Sample A, 128 c a l l e r s were randomly selected for interviews. Of this group, 96 were w i l l i n g to be interviewed by the d i e t i t i a n . Eighty-five interviews were actually completed, 11 did not answer the telephone after four repeated c a l l s to the number at various times of the day; and three were rejected because of extreme reluctance to answer the questions and general lack of interest in the interview. Therefore the usable responses from Sample A were 82 (64%). In Sample B, 138 c a l l e r s were randomly selected for interviews. Fifty-one interviews were actually completed, 69 did not answer the telephone after four repeated c a l l s at various times of the day over a period of several days. Thus the usable responses for Sample B were 51 (37%). The data from the D i a l - A - D i e t i t i a n log i s presented as a comparison for the sample periods of January/February and March/April to indicate that the samples drawn are representative of the population ( Table 2 ). 29 Table 1 Samples For the Study Sample A 1 N % Interviewed 82 64.0 Interviewed and Rejected 3 2.3 Not home 11 8.6 Unwilling to be Interviewed 32 25.0 Call e r s Selected for Interviews 128 99.9 2 Sample B 3 N Interviewed 51 37.0 Interviewed and Rejected Not home 69 50.0 Unwilling to be Interviewed 18 13.0 Call e r s Selected for Interviews 138 100.0 1. Total c a l l e r s in the population for January/February were 384. 2. Due to rounding of percentages, t o t a l does not equal 1 00%. 3. Total c a l l e r s in the population for March/April were 413. 30 Table 2 Comparison of Ca l l e r s in the Samples with C a l l e r s in the Population Populat ion Jan/Feb Sample A Jan/Feb Sample A Individuals 1 Professionals 2 Media 3 Other Services" Group Representative 5 Total c a l l s for period N % 340 88.5 40 10.4 3 0.8 1 0.3 N % 119 93.0 9 7.0 384 100.0 128 100.0 Populat ion Mar/Apr Sample B Mar/Apr Sample B Individuals 1 Professionals 2 Media 3 Other Services" Group Representative 5 Total c a l l s for period N % 381 92.3 25 6.0 1 0.2 6 1.5 N % 123 89.1 12 8.7 1 0.7 1 0.7 1 0.7 413 100.0 138 99.9 s 1. Individuals are people who c a l l e d the service for themselves, family or friends. 2. Professionals counseled others in dietary matters. 3. Media persons used the information for t e l e v i s i o n , radio and newspaper a r t i c l e s . 4. Individuals from other services that provide information to the general public. 5. Individuals who c a l l e d for information to present to their volunteer group. 6. Due to rounding of percentages, t o t a l does not equal 100%. Source: From "Dial-A-Dietitian Log," January and A p r i l 1982. 31 SURVEY INSTRUMENT A facing sheet and interview script were prepared to record each interview (Appendix B). The following information was recorded on the facing sheet: the telephone number of the c a l l e r , willingness/unwillingness to be interviewed, c a l l e r category, and the question they had asked the d i e t i t i a n . The facing sheet was then attached to the interview s c r i p t for recording the interview. Each interview s c r i p t was numbered. The interview s c r i p t was p i l o t tested prior to the study. Ten c a l l e r s to the telephone service were randomly chosen. Eight interviews were completed and two c a l l e r s did not answer the telephone after repeated c a l l s to the number. Information gathered from the p i l o t interviews were age range of 30 to 89 years, sex of c a l l e r s was 7 female and 1 male, 4 new users and 4 previous users, 2 asked questions about normal n u t r i t i o n and 6 about therapeutic n u t r i t i o n , 5 people took some action and 3 did not. These interviews lasted 5 to 7 minutes. The c a l l e r s remembered c a l l i n g D i a l - A - D i e t i t i a n and were w i l l i n g to be interviewed. The interview s c r i p t was then revised to include the exact age rather than the range, and to include a section giving participants the opportunity of making comments, coding of the interview s c r i p t . 32 DATA COLLECTIONS The data were collected by telephone interviews conducted by the author who is a d i e t i t i a n but not employed by Dial-A-D i e t i t i a n . The interview was conducted one week after the c a l l e r had telephoned D i a l - A - D i e t i t i a n with a question. The responses to the interview questions were recorded on the interview s c r i p t . The telephone was used to interview the c a l l e r s because of the ease of reaching the c a l l e r and because i t was the medium they used to contact D i a l - A - D i e t i t i a n . Because this was an exploratory study the interview method (rather than the mailed questionnaire) was used. The interview might bring forth other questions, or insights or information that might require further investigation by the service. The interview s c r i p t contained five sections. The f i r s t two sections contained questions on how the c a l l e r located and used the service. These questions were asked to determine c a l l e r use, ease of reaching the service and the source of information about the service. The t h i r d section contained questions about the reasons for c a l l i n g the service and the number of persons who would be reached with the information. These questions were asked to determine why the c a l l e r chose to telephone D i a l - A - D i e t i t i a n rather than use another source of information. An attempt was made to determine i f the c a l l e r passed the information on to others. The fourth section contained questions about the action taken by the c a l l e r s after receiving the information. This question was asked to determine the use of the information by the c a l l e r . The f i f t h 33 section contained personal questions to obtain demographic data as to the age of the c a l l e r , number of years spent in school, present occupation, native language and perceived health status. DATA ANALYSIS The data, co l l e c t e d from the interview s c r i p t s , were tabulated and cross tabulated and are presented in Tables 3 to 12. The Chi square s t a t i s t i c was used to test for s i g n i f i c a n t differences between samples. The l e v e l of significance was .05. The Chi square s t a t i s t i c i s based on the idea that no actual differences exist between the observed frequencies and the expected frequencies. If a value of Chi square i s equal to or greater than the c r i t i c a l value required for significance for the appropriate degrees of freedom then the n u l l hypothesis (that no difference exists) i s rejected and differences between the observed and the expected frequencies are s i g n i f i c a n t and cannot be explained by sample fluctuation (Ferguson, 1980). In summary, two d i f f e r e n t samples of c a l l e r s to Dial-A-D i e t i t i a n were interviewed and the data recorded on an interview s c r i p t . The data were tabulated and cross tabulated. The Chi square s t a t i s t i c was used to determine s i g n i f i c a n t differences between and within the samples. 34 CHAPTER IV PRESENTATION AND DISCUSSION OF FINDINGS The objectives of the study were to describe the c a l l e r s to D i a l - A - D i e t i t i a n telephone service, characterize c a l l e r use of the service, and determine the action taken by the c a l l e r after receiving information from the service. In addition there was a need to determine i f there were differences between the two samples that could lead to speculation about seasonal va r i a t i o n and/or the effect of Nutrition Month held in March. A Chi square s t a t i s t i c at the .05 le v e l was used to determine i f there were differences within or between the samples. DESCRIPTION OF CALLERS The c a l l e r s were described according to the type of question asked, age, sex, years spent in school, and perceived health status. This information i s presented in Tables 3 to 6. DISTRIBUTION OF CALLERS BY TYPE OF QUESTION The information on the d i s t r i b u t i o n of the samples by type of question asked of those selected to be interviewed i s presented in Table 3 . Individuals in each sample were divided into three groups: those actually interviewed, those unwilling to be interviewed, and those not at home after repeated c a l l s to the number. Questions were divided into two subject categories of normal and therapeutic n u t r i t i o n . The 35 Table 3 Dis t r i b u t i o n of Cal l e r s by Type of Question Normal 1 Nutrition Therapeut. N u t r i t i o n 2 'Total Sample A Interviewed Unwill to be Interviewed Not Home3 Total N % 42 32.8 21 16.4 6 4.7 N % 43 33.6 11 8.6 5 3.9 N % 85 66.4 32 25.0 11 8.6 69 53.9 59 46.1 128 100.0 Sample B Interviewed Unwill to be Interviewed Not Home Total N % 27 19.6 10 7.2 39 28.3 N % 24 17.4 8 5.8 30 21.7 N % 51 37.0 18 13.0 69 50.0 76 55.1 62 44.9 138 100.0 1. Normal nu t r i t i o n included questions about c a l o r i e and nutrient content of food, about food storage, safety and preparation. 2. Therapeutic n u t r i t i o n included questions about foods for prescribed diets such as diabetic d i e t s , gluten free d i e t s . 3. C a l l e r s who did not answer the telephone after 4 repeated c a l l s to the number at various times of the day over the course of several days. No c a l l s were made at night. = 2.65, df = 5, n.s. 36 information i s presented to see i f there were any differences between groups as to type of question asked. Those actually interviewed were 85 (66%) in Sample A and 51 in Sample B (37%). Those unwilling to be interviewed were people who said they would be absent from home during the interview period, those unable to leave a number for an interview c a l l , and those who refused for reasons not s p e c i f i e d . Those unwilling to be interviewed were 32 (25%) in Sample A and 18 (13%) in Sample B. Those "Not at Home" when c a l l e d were people who did not answer the telephone after four repeated c a l l s to the number over a period of several days. C a l l e r s "Not at Home" represented 11 (8.6%) in Sample A and 69 (50%) in Sample B. A l l c a l l s were made during the day between 9 a.m. and 5 p.m. unless the c a l l e r asked to be interviewed in the evening. The types of questions asked of D i a l - A - D i e t i t i a n were grouped into the categories of normal and therapeutic n u t r i t i o n . Normal n u t r i t i o n questions were designated as those about c a l o r i c content of food, food storage, safety and preparation. Those questions designated as therapeutic n u t r i t i o n were related to c l i n i c a l diets or were modified d i e t s . The results presented in Table 3 suggest that questions asked by those interviewed were approximately evenly divided between normal and therapeutic n u t r i t i o n . There was no s i g n i f i c a n t difference between samples when tested by means of a Chi square. 37 DISTRIBUTION OF CALLERS BY AGE AND SEX The age and sex of c a l l e r s i s presented in Table 4 and Appendix F. The ages ranged from 20 to 77 years in Sample A and 22 to 73 years in Sample B. The median age of c a l l e r s interviewed in Sample A was 58 years and in Sample B was 53 years. The mean age was s l i g h t l y lower being 52 years in Sample A and 50 years in Sample B. This was similar to the finding of Robbins and Mullis (1982) whose c a l l e r s to the Roanoke D i a l - A - D i e t i t i a n service had an average age of 46 years. Diseker et a l . (1980) reported that middle aged women were the largest group of c a l l e r s to Tel-Med. However, Wilkinson et a l . (1977) reported that teenagers c a l l e d the Can-Dial service most often. In comparing those 50 years and over with those 49 years and under, 38% of the c a l l e r s were 49 years and under and 62% were 50 years and over in Sample A. In Sample B, there was a more even d i s t r i b u t i o n of age. In Sample B, 47% were 49 years and under and 53% were 50 years and over. It was necessary to collapse the frequency d i s t r i b u t i o n s to calcuate the Chi square because some of the c e l l s were less than one. There was no s i g n i f i c a n t difference between samples or within samples. Robbins and Mullis (1982) found an even d i s t r i b u t i o n of age with 50% of c a l l e r s 49 years and under and 50% of c a l l e r s 50 years and over. 38 Table 4 Dis t r i b u t i o n of Callers by Age and Sex Female N % Male N % Total N % Sample A 20-49 Years 50-79 Years Total Not Reported 2 27 35.5 44 57.9 2 2.6 3 3.9 29 38.1 47 61.8 71 93.4 5 6.5 76 99.91 6 Sample B 20-49 Years 50-79 Years Total Not Reported 2 22 45.0 23 46.9 1 2.0 3 6.1 23 47.0 26 53.0 45 91.9 4 8.1 49 100.0 6 1. Due to rounding of percentages, t o t a l does not equal 1 00%. 2. Not reported because age not given by respondents X 2 = 1.05, df = 3, n.s. 39 Approximately 92% of the c a l l e r s were women in both samples. This i s consistent with the findings of Robbins and Mullis (1982) who found that 91% of the c a l l e r s were women and with Wagner et a l . (i960) who found 98% were women. It i s noted that there was an absence of teenagers and the very old from both samples in the current study and i t i s suggested that others take r e s p o n s i b i l i t y for their care. Many of the c a l l e r s l i s t e d their occupation as housewife. They may be the care givers to these two groups (Appendix G). Robbins and Mull i s (1980) found that 43% of their c a l l e r s were homemakers and 22% of the c a l l e r s were r e t i r e d giving a t o t a l of 65% of c a l l e r s who would be "home" and l i k e l y to use a telephone information service. This i s not consistent with the findings of Wilkinson et a l . (1977) whose c a l l e r s were students (52%). Housewives and the r e t i r e d were 23% of the c a l l e r s . DISTRIBUTION OF CALLERS BY AGE AND SCHOOLING The education l e v e l of c a l l e r s , as reported by the number of years in school, i s given in Table 5 . In Samples A and B respectively 74% and 71% had attended school for 12 or more years. In comparing age and years spent in school we find that 38% of the c a l l e r s 49 years and under and 37% of the c a l l e r s 50 years and over in Sample A had 12 or more years in school. However in Sample B, 43% of the c a l l e r s 49 years and under and 29% of the c a l l e r s 50 years and over had 12 or more years in school. There were more Table 5 Dis t r i b u t i o n of Callers by Age and School Sample A N % Age: 20-49 years Years of Schooling 8-9 1 1.4 10-11 12-13 14 18.9 14-15 6 8.1 16+ 8 10.8 Age: 50-79 years Years of Schooling 8-9 8 10.8 10-11 10 13.5 12-13 14 18.9 14-15 3 4.1 16+ 10 13.5 Total 74 100.0 Not Reported 1 8 Sample B N % Age: 20-49 years Years of Schooling 8-9 1 2.0 10-11 3 6.1 12-13 19 38.8 14-15 16+ 2 4.1 Age: 50-79 years Years of Schooling 8-9 4 8.2 10-11 6 12.3 12-13 10 20.4 14-15 1 2.0 16+ 3 6.1 Total 49 100.0 Not Reported 1 2 Not reported because age not given by respondents. 41 c a l l e r s in the 49 years and under group in Sample B that had 12 or more years in school. Robbins and M u l l i s (1980) reported that 94% of the c a l l e r s to the Roanoke Di a l - A - D i e t i t i a n service had a high school or higher l e v e l of education. DISTRIBUTION OF CALLERS BY PERCEIVED HEALTH STATUS Ca l l e r s were asked to rate their health in one of four categories: excellent, good, f a i r , or poor. The perceived health status of c a l l e r s i s given in Table 6 . During the interviews the c a l l e r s had d i f f i c u l t y c l a s s i f y i n g their health between good or excellent and between f a i r or poor. It seemed to the interviewer that two categories of perceived health status would best describe that of the c a l l e r s and excellent/good and fair/poor were established. Those c a l l e r s rating their health in the excellent/good category were 81% and 77% in Samples A and B respectively. Clearly c a l l e r s to the service considered themselves to be in good health. There was no s i g n i f i c a n t difference between the samples for perceived health status. Table 6 Dis t r i b u t i o n of Ca l l e r s by Perceived Health Status Sample A N % Excellent/Good 63 80.8 Fair/Poor 15 19.2 Total 78 100.0 Not Reported 1 4 Sample B N % Excellent/Good 39 76.5 Fair/Poor 12 23.5 Total 51 100.0 1. Not reported because age not given by respondents. X 2 = 0.32, df = 1, n.s. 43 DISTRIBUTION OF CALLERS BY AGE, PERCEIVED HEALTH  STATUS AND TYPE OF QUESTION A subsequent comparison was made of age, perceived health status and type of question ( Table 7 ). In comparing the 49 years and under group with the 50 years and over group according to question, we f i n d that in both samples the 49 years and under group consider their health to be excellent/good and asked more questions about normal n u t r i t i o n . This finding seems consistent with the fact that the younger age group would be interested in a normal diet for health maintenance and would not l i k e l y have serious health problems. The 50 years and over group considered themselves in excellent/good health and asked more question about therapeutic n u t r i t i o n . Some of these c a l l e r s were on c l i n i c a l diets and had questions of a therapeutic nature. A higher proportion of the c a l l e r s in the 50 years and over group (18%) in both samples considered themselves in fair/poor health. This again r e f l e c t s the greater interest of the 50 years and over group in questions of therapeutic n u t r i t i o n . There were s i g n i f i c a n t differences in Sample A as indicated by the Chi square value at the .01 l e v e l of sign i f i c a n c e . In Sample A the 49 years and under group in excellent/good health asked more questions about normal n u t r i t i o n while the 50 years and over group asked more questions about therapeutic n u t r i t i o n . 44 Table 7 Di s t r i b u t i o n of Callers by Age, Perceived Health Status and Type of Question Normal Nutrition Therapeut. Nutrition Total Sample A 20-49 Years Ex/Good Health Fair/Pr Health 50-79 Years Ex/Good Health Fair/Pr Health Total Not Reported 2 N % 22 28.9 1 1.3 9 11.8 6 7.9 N % 6 7.8 24 31.6 8 10.5 N % 28 36.7 1 1.3 33 43.4 14 18.4 38 49.9 38 49.9 76 99.81 6 Sample B 20-49 Years Ex/Good Health Fair/Pr Health 50-79 Years Ex/Good Health Fair/Pr Health Total Not Reported 2 N % 14 28.6 1 2.0 7 14.3 3 6.1 N % 7 14.3 1 2.0 10 20.4 6 12.2 N % 21 42.9 2 4.0 17 34.7 9 18.3 25 51.0 24 48.9 49 99.91 2 1. Due to rounding of percentages, t o t a l does not equal 100%. 2. Not reported because age not given by respondents Sample A, x 2 = 16.74, df = 3, p > .01 Sample B, x 2 = 3.82, df = 3, n.s. 45 In Sample B the d i s t r i b u t i o n of questions between normal and therapeutic n u t r i t i o n was as expected. One explanation for the difference might be the influence of the season. For instance, Sample A was col l e c t e d in January/February when c a l l e r s were indoors, possibly i l l or depressed and may have more concern about diet and health at that time of year. Although the "subject content" of the o r i g i n a l question asked of D i a l - A - D i e t i t i a n was not part of t h i s study i t i s noted these questions involved diets for minor stomach problems, ulcers, general complaints about d i e t . In summary the D i a l - A - D i e t i t i a n telephone service answers questions about normal and therapeutic n u t r i t i o n . The questions were approximately equally divided between the two categories. The sociodemographic segment of the public that uses t h i s service range in age from 20 to 77 years. Ninety-two percent of both samples were women. In both samples the •education l e v e l was high school or higher. C a l l e r s perceived their health to be excellent/good. These results are similar to those found by Robbins and Mullis (1982) in a study of the Roanoke, V i r g i n i a , D i a l - A - D i e t i t i a n service where the t y p i c a l c a l l e r was a 46 year old homemaker with a college education. The results d i f f e r from Wilkinson et a l . (1977) who found that c a l l e r s to a cancer information service were teenagers. There were no s i g n i f i c a n t differences between samples for type of question, age, sex, and health status. There was a s i g n i f i c a n t difference in one sample for age, perceived health status and type of question where the 49 years and under age 46 group asked more questions about normal n u t r i t i o n than expected and the 50 years and over asked more questions about therapeutic n u t r i t i o n than expected. FREQUENCY OF CALLER USE The second objective of the study was to determine the frequency of c a l l e r use. This information is presented in Tables 8 and 9. DISTRIBUTION OF CALLERS BY FREQUENCY OF USE OF THE SERVICE Of those c a l l e r s interviewed, 35% and 37% in Samples A and B respectively were new c a l l e r s ( Table 8 ). It would appear that there was a regular c l i e n t e l e of previous users of approximately 65%. As both samples were similar, time of year of data c o l l e c t i o n did not appear to influence the r e l a t i o n s h i p between new and previous users. There was no s i g n i f i c a n t difference between the samples when tested by means of the Chi square s t a t i s t i c . The interviewer found that c a l l e r s considered the service a convenient source of information p a r t i c u l a r l y i f their question was not complex enough to warrant a c a l l to the physician or outpatient d i e t i t i a n , yet the c a l l e r needed an answer. Where c l a r i f i c a t i o n of a diet was required the d i e t i t i a n at the service provided this information. It would appear that the service i s a link between the professional in the hospital or c l i n i c and members of the public. Table 8 Di s t r i b u t i o n of Ca l l e r s by Frequency of Use of the Service Sample A N % New Users 29 35.4 Previous Users 53 64.6 Total 82 100.0 Sample B N % New Users 19 37.3 Previous Users 32 62.7 Total 51 100.0 X 2 = 0.03, df = 1, n.s. 48 This service is one facet of the community health system network and i t s function is to provide c l a r i f i c a t i o n of or additional information to that already provided by the physician and the hospital d i e t i t i a n and through other sources of n u t r i t i o n information. DISTRIBUTION OF CALLERS BY AGE, NEW AND PREVIOUS USERS AND TYPE  OF QUESTION The d i s t r i b u t i o n of samples by age and New Users and Previous Users is presented in Table 9 . There was a s i g n i f i c a n t difference in Sample A as indicated by the Chi square value at the .01 l e v e l of signi f i c a n c e . There appears to be a trend that both New and Previous Users in the 50 years and over group asked more questions about therapeutic n u t r i t i o n . S i x t y - f i v e percent of the c a l l e r s had used Dial-A-D i e t i t i a n previously. Younger users, both new and previous, asked more questions about normal n u t r i t i o n than older users. 49 Table D i s t r i b u t i o n of Callers by Users and Type 9 Age of New and Previous of Question Normal Therapeut. Total Nutrition Nutrition Sample A N % N % N % 2 0 - 4 9 Years New Users 9 11.8 3 4 . 0 1 2 15. 8 Prev Users 1 3 17.1 4 5.3 1 7 2 2 . 4 5 0 - 7 9 Years New Users 2 2 .6 1 4 18.4 1.6 21 . 0 Prev Users 1 3 17.1 18 2 3 . 7 31 4 0 . 8 Total 37 4 8 . 6 39 51 .4 76 100 . 0 Not Reported 1 6 Sample B N % N % N % 2 0 - 4 9 years New Users 8 16 .3 3 6.1 1 1 2 2 . 4 Prev Users 8 16 .3 4 8 .2 1 2 2 4 . 5 5 0 - 7 9 years New Users 1 2 .0 6 12 .3 7 14. 3 Prev Users 9 18.4 10 2 0 . 4 19 3 8 . 8 Total 26 5 3 . 0 23 4 7 . 0 49 100 . 0 Not Reported 1 2 1. Not reported because age not given by respondents. Sample A x 2 = 2 6 . 0 1 , df = 3 , p_< • 0 1 Sample B x 2 = 7 . 0 5 , df=3 , n.s. 50 ACTION TAKEN The t h i r d objective of the study was to determine the action taken by the c a l l e r after receiving information from the service. The data are presented in Tables 10 to 12. DISTRIBUTION OF CALLERS BY ACTION TAKEN As a result of receiving information from the service the number of people who took action was 37 (45%) in Sample A and 20 (39%) in Sample B ( Table 10 ; Appendix H). There was no s i g n i f i c a n t difference between samples as indicated by the Chi square s t a t i s t i c at the .05 l e v e l of s i g n i f i c a n c e . Action was the performance, conduct or procedure that a person followed after receiving information from the d i e t i t i a n at the service. One performance that was considered an action was actually eating food. For example th i s was described as eating the spe c i f i e d bland diet foods for a hiatus hernia and ulcer, eating r i c o t t a cheese after obtaining the exchange value, and eating oranges for breakfast. Another kind of action was the preparation of a food. For example th i s was described as the successful preparation of Yorkshire pudding for a diabetic, and preparation of a low fat topping for a dessert. Another way of taking action was to contact another source for information or to provide information to others. For example, th i s was described as obtaining Table 10 Di s t r i b u t i o n of Callers by Action Taken Sample A N % Action Taken 37 45.1 No Action Taken 45 54.8 Total 82 99.91 Sample B N % Action Taken 20 39.2 No Action Taken 31 60.7 Total 51 99.91 Due to rounding, totals do not equal 100% X2 = 0.45, df = 1, n.s. 52 an a r t i c l e from the l i b r a r y , phoning a physician, and writing and d e l i v e r i n g a speech. The findings in the current study are consistent with those of Wilkinson et a l . (1977) who found that 40% of the respondents to a cancer information service reported some form of behavior such as q u i t t i n g smoking or seeing a physician about a symptom. The c a l l e r s who took no action reported they did nothing with the information, just wanted to know, were curious about the service, or wanted the information for someone else. Again, the Wilkinson et a l . (1977) study reported that 10% discussed the information with others, 11% had anxiety relieved, and 40% f e l t the c a l l resulted in no action. These results were consistent with the current study where 55% and 61% in Samples A and B respectively took no action (Table 10; Appendix H). DISTRIBUTION OF CALLERS BY AGE, NEW AND PREVIOUS  USERS, AND ACTION TAKEN A comparison was made of age of New and Previous Users and action taken ( Table 11 ). There was no s i g n i f i c a n t difference between samples as indicated by the Chi sqare s t a t i s t i c at the .05 l e v e l of sig n i f i c a n c e . In Sample A 32% of the 50 years and over group took action as compared to 17% of those 49 years and under. In Sample B, 29% of the older group and 10% of the younger group took action. When a comparison i s made between New and Previous Users in Sample A, Previous Users (28%) take action more often than New Users (21%). In Sample B, 53 Table 11 Dis t r i b u t i o n of C a l l e r s by Age of New and Previous Users and Action Taken Act ion No Act ion Total Sample A 20-49 Years N % N % N % New Users 7 9.2 5 6.6 12 15. 8 Prev Users 6 7.9 1 1 14.5 1 7 22. 4 50-79 Years New Users 9 11.8 7 9.2 16 21 . 0 Prev Users 1 5 19.7 16 21.1 31 40. 8 Total 37 48.6 39 51 .4 76 100. 0 Not Reported 1 6 Sample B 20-49 years New Users N 1 % 2.0 N 10 % 20.4 N 1 1 % 22. 4 Prev Users 4 8.2 8 16.3 1 2 24. 5 50-79 years New Users 4 8.2 3 6.1 7 14. 3 Prev Users 10 20.4 9 18.4 19 38. 8 Total 19 38.8 30 61 .2 49 100. 0 Not Reported 1 2 1. Not reported because age not given by respondents. Sample A x 2 = 2.06, df=3, £<.05 Sample B x 2 = 6.77, df = 3, p_<.05 54 Previous Users (29%) take action more often than New Users (10%). It i s concluded the c a l l e r s who take action more often were in the 50 years and over group and were Previous Users. DISTRIBUTION OF CALLERS BY AGE, TYPE OF QUESTION  AND ACTION TAKEN A comparison was made of age, type of question and action taken ( Table 12 ). There were s i g n i f i c a n t differences between samples and within samples as indicated by the Chi square s t a t i s t i c at the .05 l e v e l of signi f i c a n c e . In Sample A c a l l e r s who took action more often than expected were in the 50 years and . over age group asking questions about therapeutic n u t r i t i o n . In Sample B the results were as expected for this age group. Within Sample B more c a l l e r s in the 49 years and under age group asked questions about normal n u t r i t i o n but took no action than expected. No conclusions can be drawn from this comparison. In summary, in Samples A and B an average of 42% of the c a l l e r s took action and indicated this by reporting eating a food, preparing a food, contacting another source for information or presenting a speech to others. Those who took action most often were in the 50 years and over age group and were Previous C a l l e r s . 55 Table 12 Di s t r i b u t i o n of Callers by Age, Type of Question and Action Taken Normal Therapeut. Total Nutr i t ion Nutrition Sample A N % N % N % 20-49 Years Act ion 1 0 13.2 3 3.9 1 3 17. 1 NO Action 1 3 17.1 3 3.9 1 6 21 . 0 50-79 Years Action 4 5.3 20 26.3 24 31 . 6 NO Action 1 1 14.5 1 2 15.8 23 30. 3 Total 38 50. 1 38 49.9 76 100. 0 Not Reported 1 6 Sample B N % N % N % 20-49 years Action 2 4.1 3 6.1 5 10. 2 NO Action 1 4 28.5 4 8.2 18 36. 7 50-79 years Action 8 16.3 6 12.3 1 4 28. 6 NO Action 2 4. 1 10 20.4 1 2 24. 5 Total 26 53.0 23 47.0 49 100. 0 Not Reported 1 2 1. Not reported because age not given by respondents. Sample A x 2 = 20.66, df = 3, p_<«u1 Sample B x 2= 11.23, df=3, p<.0l 56 In summary the c a l l e r s to D i a l - A - D i e t i t i a n were women with an age range of 20 to 77 years, a mean age of 51 years and in excellent/good health. They spent 12 or more years in school. S i x t y - f i v e percent of the c a l l e r s were regular users. An average of Samples A and B indicates that 42% of the c a l l e r s took some action as a result of receiving information from the d i e t i t i a n at the service and reported the performance, conduct or procedure. Those that took action most often were in the 50 years and over age group and Previous Users. There was no s i g n i f i c a n t difference between samples for age, sex, perceived health status, frequency of use of the service and action taken. There were s i g n i f i c a n t differences within Sample A for age, perceived health status and type of question; age, New and Previous Users and type of question; age, type of question and action taken. However, there was a tendency in the winter months, when Sample A was taken, for the younger c a l l e r s to ask more questions about normal n u t r i t i o n and the older c a l l e r s to ask more questions about therapeutic n u t r i t i o n than expected. 57 CHAPTER V SUMMARY AND CONCLUSIONS This study was an i n i t i a l investigation of c l i e n t use of the D i a l - A - D i e t i t i a n telephone service. It was an exploratory study undertaken for the purposes of providing the service with some basic information so that e f f o r t s could be directed to that segment of the public that telephones for n u t r i t i o n information and for continuing accountability to the sponsoring agencies. The main purpose was to determine i f the c a l l e r s used the information they received. The two secondary purposes were to obtain a description of that segment of the public that uses the service as well as to determine i f a proportion of the c a l l e r s were previous users and thus a regular c l i e n t e l e . Data for t h i s study were gathered through telephone interviews of c a l l e r s to D i a l - A - D i e t i t i a n . The following i s a summary of the method of study, major findings, conclusions, suggestions for further study, and recommendations. METHOD OF STUDY Two samples of c a l l e r s were chosen in two di f f e r e n t time periods and interviewed by telephone. The number of usable responses in Samples A and B respectively were 82 and 51. The second sample of c a l l e r s provided a comparison group. The data were recorded on telephone interview s c r i p t s and then tabulated and cross tabulated to determine action taken by c a l l e r s after receiving information, a description of c a l l e r s , and frequency 58 of c a l l e r use. To determine variation in samples, the Chi square s t a t i s t i c was used to test for s i g n i f i c a n t differences within and between samples for (a) type of question asked by those selected to be interviewed, (b) age and sex, (c) perceived health status, (d) age and perceived health status and type of question, (e) frequency of c a l l e r use of the service, (f) age and new and previous users, and (g) age, action taken and type of question. SUMMARY OF MAJOR FINDINGS ACTION TAKEN BY CALLERS AFTER RECEIVING INFORMATION The main purpose .of the study was to determine i f the c a l l e r s used the information they received. Approximately 42% of the c a l l e r s reported they used the information and indicated t h i s by describing the action taken. These actions were described as eating a food, preparing a food, contacting another source for information, or de l i v e r i n g a speech with the information. Those who took action tended to be in the 50 years and over age group and previous users (see Tables 10 to 12) . 59 DESCRIPTION OF THE CALLERS A secondary purpose of the study was to describe the c a l l e r s to the service. Their age ranged from 20 to 77 years with an average age of 51 years. Ninety-two percent of the c a l l e r s were women who reported their occupation as housewives. The absence of teenagers and the very old was observed in both samples. The c a l l e r s spent 12 or more years in school. The c a l l e r s considered their health to be excellent/good (see Tables 3 to 6). FREQUENCY OF CALLER USE The second subpurpose of the current study was to determine the frequency of c a l l e r use of the service. From this investigation 65% of the c a l l e r s were regular users (see Tables 8 and 9). VARIATIONS IN THE SAMPLES There were no s i g n i f i c a n t differences between samples as indicated by the Chi square s t a t i s t i c at the .05 le v e l of significance for type of question asked by those selected to be interviewed, by age and sex, by perceived health status, by frequency of use of the service, and by action taken. However, there was a s i g n i f i c a n t difference within Sample A for age, perceived health status and type of question. Those c a l l e r s 49 years and under in excellent/good health asked more questions about normal n u t r i t i o n than expected. Those on the 50 years 60 and over age group asked more questions about therapeutic n u t r i t i o n than expected (see Table 7). There was a s i g n i f i c a n t difference within Sample A for age of New and Previous Users and type of question. There appeared to be a trend that both New and Previous Users in the 50 years and over age group asked more questions about therapeutic n u t r i t i o n (see Table 9). There was a s i g n i f i c a n t difference between the two samples for age, type of question, and action taken. In Sample A, c a l l e r s took action more often than expected i f they were in the 50 years and over age group asking questions about therapeutic n u t r i t i o n . In Sample B, c a l l e r s took action in the numbers expected. However, within Sample B, more c a l l e r s in the 49 years and under asked more questions about normal n u t r i t i o n but took no action, than had been expected (see Table 12) . SEASONAL VARIATION There was speculation that there could be a seasonal variation in type of question asked. For instance i t was speculated that there might be more interest in therapeutic n u t r i t i o n in the winter, when Sample A was taken and more interest in normal n u t r i t i o n in the spring when Sample B was taken. The results indicate that this was not the case. In both samples, the c a l l e r s asked an equal number of normal and therapeutic n u t r i t i o n questions. However, within the winter sample, younger c a l l e r s asked more questions about normal 61 nu t r i t i o n and less about therapeutic n u t r i t i o n and conversly the older c a l l e r s asked more questions about therapeutic n u t r i t i o n and less about normal n u t r i t i o n . There was speculation that Nutrition Month might influence the type of question asked. This was not the case. CONCLUSIONS ACTION TAKEN BY CALLERS AFTER RECEIVING INFORMATION One indicator of effectiveness was to determine i f the c a l l e r s a c t u ally used the information. It is concluded from thi s study that approximately 42% of the c a l l e r s used the information by reporting some performance, conduct or procedure. This finding, that c a l l e r s actually used the information, provides basic data and a beginning from which to develop a study to determine the impact of the information on the behavior of the c a l l e r . DESCRIPTION OF THE CALLERS Di a l - A - D i e t i t i a n provides n u t r i t i o n information to any person in B r i t i s h Columbia who c a l l s the service. However, only a segment of the public was i d e n t i f i e d as using the service. These people were mostly women who ranged in age from 20 to 77 years with a mean age of 51 years and who considered themselves in excellent/good health. They spent 12 or more years in school and l i s t e d t h e i r occupation as housewives. 62 Their interests were evenly divided between normal and therapeutic n u t r i t i o n . Having described the users and their interests i t is speculated that the focus of D i a l - A - D i e t i t i a n was in three general areas. One area of focus was on the person who c a l l s most often not only for herself but for others in her care. This focus includes not only the c a l l e r but also those that might be influenced by the actions of this i n d i v i d u a l . In the current study, the person who c a l l e d most often was the housewife or care giver. There was an absence of teenagers and the very old from the samples. These two age groups may have been looked aft e r by the housewife or care giver. It i s suggested that the c a l l e r s were segments of the public. For instance parents of very young children, parents of school age children, young adults, adults 25 to 65 years, adults 65 and over were some of the groupings. A second area or focus was around the extent to which the individual understood and cared about the relationship of diet to health and were interested in discussion and exchange of information. It was evident during the interviews that many c a l l e r s were very knowledgeable about both normal and therapeutic n u t r i t i o n as i t applied to themselves and their families. These individuals showed a great deal of interest and concern about eating a sensible diet suitable to their individual s i t u a t i o n . In t h i s study the c a l l e r s described their health as excellent/good and thus could be considered a well segment of the public. The findings in this study also indicated that the c a l l e r s had spent 12 or more years in school 63 and they indicated some knowledge of diet and health. It was evident during the interviews that c a l l e r s had information and experience that could be added to that of the d i e t i t i a n at the service. This working together of d i e t i t i a n and c a l l e r is part of the exchange of information which is a feature of the service. A t h i r d area of focus for the service was on the content of the questions. These were i d e n t i f i e d in the study as normal and therapeutic n u t r i t i o n . The service had both younger c a l l e r s interested in health maintenance and the older c a l l e r s interested in modified diets for health maintenance. This recognition of the focusing of the service would now permit the design of a system that more clos e l y meets the needs of the users and the professional and monetary resources of D i a l - A - D i e t i t i a n . It must be emphasized that targeting or focusing or segmentation means that the service can s t i l l be available to serve the public but e f f o r t is directed to those members who use the service frequently. D i a l - A - D i e t i t i a n is one part of the B r i t i s h Columbia health care system and i t is recognized that there are other services that provide n u t r i t i o n information. The function of D i a l - A - D i e t i t i a n in t h i s system is to answer enquiries from that portion of the public who request n u t r i t i o n information through the use of the telephone. 64 FREQUENCY OF USE It i s concluded that D i a l - A - D i e t i t i a n is an established service with a regular group of c a l l e r s of approximately 65%. However the service continues to expand with a group of new c a l l e r s of approximately 35%. C a l l e r s found that using the telephone was a convenient accessible method of contacting a knowledgeable person and many of the new c a l l e r s indicated that they would c a l l again. Regular c a l l e r s reported that the telephone contact with the d i e t i t i a n was an opportunity to discuss and c l a r i f y information. The c a l l e r s provided the service with insights into current n u t r i t i o n concerns of the community. This exchange kept the d i e t i t i a n in touch with community nu t r i t i o n information needs. Dia l - A - D i e t i t i a n could be seen as a l i a i s o n between the community and the sponsoring agencies, B r i t i s h Columbia D i e t i t i a n s ' and N u t r i t i o n i s t s ' Association, B r i t i s h Columbia Ministry of Health, and the City of Vancouver Health Department, for determining the n u t r i t i o n information needs of the community. VARIATIONS IN THE SAMPLES There was a v a r i a t i o n between samples for age, perceived health status and type of question. The younger c a l l e r s considered themselves in excellent/good health and tended to ask more questions about normal n u t r i t i o n when age, perceived health status and type of question was compared with that of the older c a l l e r s . This seems consistent with the fact that 65 the younger segment of the public would be interested in normal diet and health maintenance and physical fitness and would not have many health problems. The older c a l l e r s also considered themselves in excellent/good health and asked more questions about therapeutic n u t r i t i o n . This i s probably due to the fact that many c a l l e r s were following therapeutic diets at the time. There was a variation between samples for age, new and previous users and type of question. The younger users tended to ask more questions about normal n u t r i t i o n . They were both New and Previous Users. The interviewer found that the younger c a l l e r s often requested the c a l o r i c value of s p e c f i f i c foods or were curious about the service and asked basic questions. There appears to be a trend that the older Previous User asked questions about therapeutic n u t r i t i o n . There was a variation between samples for age, action taken and type of question. It is suggested that those who took action were the older c a l l e r s who were Previous Users. GENERAL CONCLUSIONS ABOUT TELEPHONE INFORMATION SERVICES A telephone health information service i s a reference center providing s p e c i f i c factual information to c a l l e r s . In the telephone service under study the c a l l e r spoke d i r e c t l y to the person providing the information. It is r e c a l l e d from the l i t e r a t u r e review that in another type of service the c a l l e r s requested a taped message from a telephone operator. It i s suggested that the second type of service provides information only and does not answer questions and c l a r i f y information as 66 is done in the service in the current study. Both systems have a place in the telephone information network. The taped message is useful for c a l l e r s who want a s p e c i f i c fact or general information on a subject. On the other hand, the direct access to a professional person is useful when a c a l l e r wants to c l a r i f y , extend or discuss information. A telephone information service could be viewed as the f i r s t contact or one of the contacts in the search for information. Some c a l l e r s in the current study expressed t h i s reason for c a l l i n g . It i s suggested that a telephone information service is part of a larger information service which includes professional people, schools, l i b r a r i e s as well as parents and friends. It should be noted that the current study was about a telephone information service rather than a telephone counselling service such as used in c r i s i s intervention. In c r i s i s intervention the counsellor l i s t e n s and then a s s i s t s the c a l l e r in determining the action to take to resolve the c r i s i s and often contacts the c a l l e r at a later time to determine i f the problem was resolved. In the telephone information service the professional l i s t e n s to the problem, suggests a solution but makes no attempt to ascertain the uses of the information. The medium of the telephone allows the c a l l e r to remain anonymous and to have control over what information to reveal. The voice i s the only clue to the c a l l e r ' s state of anxiety or mood. There is no opportunity to see the c a l l e r and to assess the physical appearance. The c a l l e r can chose the time to c a l l 67 and can terminate the conversation when desired. In the current study, c a l l e r s often reported that the telephone was a convenient medium to use to obtain information. They did not have to make an appointment or tr a v e l to another place. One concern that was mentioned by several c a l l e r s was that the person answering the questions about diet may not have enough information about the state of health of the enquirer and thus may not be able to provide suitable information. For instance, the professional w i l l not know i f the c a l l e r has a disease or condition unless this information i s communicated during the conversation and there could be the p o s s i b i l i t y of giving the c a l l e r unsuitable information. Because the c a l l e r i s not physically v i s i b l e there i s no opportunity for the professional to assess the person's appearance or mannerisms that may give a clue to the state of health or mood of the c a l l e r and thus prompt the professional to ask appropriate questions. In general telephone information services are a reference center that are convenient and accessible and allow the c a l l e r anonymity i f desired. FURTHER STUDY This study was undertaken to provide basic information on the Vancouver D i a l - A - D i e t i t i a n telephone service so that a systematic evaluation could be developed. In addition to the basic information provided in the current study, three broad 68 areas for on-going study are suggested: (a) the development of a c a l l e r p r o f i l e , (b) an examination of the content of the questions, (c) and an examination of the service i t s e l f . CALLER PROFILE Current p r o f i l e s of the c a l l e r s need to be maintained. Data for t h i s purpose could be colle c t e d in two stages. For instance at the time of the i n i t i a l c a l l , the d i e t i t i a n could ask the c a l l e r s for name, address, telephone number, sex, age, new or previous user of the service. There is also a need to ask the c a l l e r for whom the'information i s required because i t may be requested for another person. In the current study an attempt was made to gather t h i s information (Appendix L). The d i e t i t i a n would also have to know of any special diet or physiological condition of the person for whom the information was required. In addition, date, time of c a l l , question asked and content of reply could also be recorded. The information could be recorded on tape or on special forms in the log book. The second stage of data c o l l e c t i o n would be to send a questionnaire to each 25th c a l l e r . Information requested could be the reason for c a l l i n g , sources of information about the service and use of the information. An alternative to the questionnaire would be telephone interviews four times per year with a systematic group of c a l l e r s . 69 An analysis of the data should include (a) the relationship of age, perceived health status, time of year and question asked; (b) age, new or previous user, time of year and question asked; (c) age, new or previous user, time of year and action taken. In the current study tentative conclusions were drawn from these relationships but further investigation is necessary. Two other sets of information were co l l e c t e d for the current study which may be useful for.further study. They were location of the c a l l in the community (Appendix J) and native language of the c a l l e r (Appendix I ) . C o l l e c t i o n and analysis of the foregoing would provide the service with a p r o f i l e of the c a l l e r . CONTENT OF THE QUESTIONS A d i f f e r e n t area for study would be to examine the content of the questions. This information would provide the data to focus the service on the extent the individual understood and cared about the relationship of diet to health. The d i e t i t i a n recording the question could ask the c a l l e r some routine questions to determine the sense of the persons knowledge of nut r i t i o n and to rate the complexity of the question according to a predetermined c r i t e r i a . Questions might pertain to menu pattern, food eaten each day. The d i e t i t i a n would then record the answer given to the c a l l e r . At a later date the d i e t i t i a n would contact the c a l l e r to obtain information on the use of the information and a p r o f i l e of the c a l l e r . This would provide some information as to the c a l l e r ' s knowledge of 70 n u t r i t i o n , provide a record of the replies to the questions, the use of the information by the c a l l e r s and basic demographic information. The service may find that simple questions and answers could be put on tape and offered on another l i n e . This would be similar to the systems described in the l i t e r a t u r e review. The d i e t i t i a n would then be able to spend the time with c a l l e r s who asked more complex questions. This focus would be an extension of the present Vancouver D i a l - A - D i e t i t i a n system. SERVICE A t h i r d and d i f f e r e n t area of study would be the service i t s e l f . There are several approaches that might be taken. One would be to examine n u t r i t i o n information services in B r i t i s h Columbia with emphasis on the place of D i a l - A - D i e t i t i a n in t h i s system. An examination of the relationships, functions and l i m i t a t i o n s of this telephone service within the larger information network. A second approach to the study of the service would be to examine the legal implications of giving health information over the telephone. The investigation could include both the r e s p o n s i b i l i t i e s of D i a l - A - D i e t i t i a n to the c a l l e r and the r e s p o n s i b i l i t i e s of the c a l l e r to the d i e t i t i a n in the exchange of information. 71 Another approach to the study of the service would be an investigation of the professional and personal q u a l i t i e s , education and experience, required to be a D i a l - A - D i e t i t i a n and how these are the same or d i f f e r e n t to those required for other s p e c i a l t i e s in d i e t e t i c s . Another approach would be an investigation of o f f i c e organization and management and the use of professional and material resources to meet the objectives of D i a l - A - D i e t i t i a n . In the current study c a l l e r s were asked about the ease of reaching the service (Appendix K). This could be extended to the c a l l e r s a t i s f a c t i o n about the a v a i l a b i l i t y of the service on the one hand and the actual provision of the service on the other. These are several d i f f e r e n t , approaches that should be taken to continue the examination of the D i a l - A - D i e t i t i a n service as a health information source to the people of B r i t i s h Columbia. RECOMMENDATIONS The following recommendations are made to the Dial-A-D i e t i t i a n Telephone Service to a s s i s t them in d i r e c t i n g their e f f o r t s to that segment of the public that uses the service and for continuing accountability to the sponsoring agencies. 1. It i s recommended that there be a clear description of the c a l l e r s . The c o l l e c t i o n of information could include the sex of the c a l l e r , frequency of use of the service, some indication of age such as young 72 mother, grandmother, some indication of position such as c l i n i c supervisor, doctor, outpatient d i e t i t i a n , or other description that i s appropriate to describe the users of the service. It i s recommended that both the question and the reply be recorded. This could be recorded on tape. It i s recommended that a s t r a t i f i e d sample of c a l l e r s be contacted on a regular basis to document c l i e n t s a t i s f a c t i o n with the service as well as to determine i f the c a l l e r s understood and used the information. This information could be co l l e c t e d with questionnaires. It i s recommended that the questions be analysed to determine trends or n u t r i t i o n interests of c a l l e r s . This information could be forwarded to the Continuing Education Committee of the B r i t i s h Columbia D i e t i t i a n s ' and N u t r i t i o n i s t s ' Association as subjects for continuing education programs. It i s recommended that D i a l - A - D i e t i t i a n c l e a r l y define i t s role in the larger framework of community n u t r i t i o n and then communicate th i s to the sponsoring agenc i e s . It i s recommended that the B r i t i s h Columbia D i e t i t i a n s ' and N u t r i t i o n i s t s ' Association examine the legal implications of giving n u t r i t i o n information over the telephone. 73 BIBLIOGRAPHY Ba r t l e t t , M.H., & Lewis, W.R. Closing the health information gap in a university student community by telephone access to taped messages. American College Health Association  Journal, 1976, 24, 301-306. B a r t l e t t , M.H. & Meyer, T.C. Patients receive current concise health information by telephone. Journal of the  American Health Association, 1976, 5_0, 79-82. Bodley, M.A. D i a l - A - D i e t i t i a n service in metropolitan Toronto. Canadian Nutrition Notes, 1965, 2J_, 13-16. (a) Bodley, M.A. D i a l - A - D i e t i t i a n . Canadian Food Journal, 1965, 6, 24-35. (b) Brown, K.H. & Cooke, T.M. The general public. Journal of  Nutrition Education Supplement, 1980, J_2, 117-120. Burck, H., Cottingham, H., & Reardon, R. Counselling and accountability: methods and c r i t i q u e . New York: Pergamon Press, 1973. Campbell, A. D i a l - A - D i e t i t i a n : A unique service provided by the B r i t i s h Columbia Di e t e t i c Association. Journal of the  Canadian Dietetic Association, 1977, 38, 63-66. Diseker, R.A., Michielutte, R. & Morrison, V. Use and reported effectiveness of Tel-Med: A telephone health information system. American Journal of Public Health, 1980, 70, 229-234. Ferguson, G.A. S t a t i s t i c a l analysis in psychology and  education (5th ed.). New York: McGraw-Hi11, 1981. Gates, J. Basic Foods. New York: Holt, Rinehart and Winston, 1981 . Hopkins, C.E. Patients outcome measures. In G.K. Chacko (ed.), Health handbook, an international reference on care  and cure. New York: North Holland Publishing Company, 1 979. Kolasa, K., Wenger, A., Paolucci, B., & Bobbitt, N. Home-based learning - Implications for n u t r i t i o n educators. Journal of Nutrition Education, 1979, 19-21. Lagua, R.T., Claudio, V.S., & Thiele, V.F. Nutrition and diet  therapy reference dictionary. St. Louis: C.V. Mosby Co., 1974. 74 Liberman, R. Behavioral measurement in a community health center. In P. Davidson, F. Clark & R. Liberman (eds.), Evaluation of behavioral programs in community,  r e s i d e n t i a l and school settings. Champaign, 111: Research Press, 1974. Ottem, M. Co-ordinator, D i a l - A - D i e t i t i a n , Vancouver, B r i t i s h Columbia. Personal communication, January, 1982. Report on n u t r i t i o n concepts evaluation study. Nutrition  Planning, 1981, 4, 42. (Abstract) Robbins, J.C., & M u l l i s , R.M. The development of a model to be u t i l i z e d in the evaluation of the telephone as a vehicle for n u t r i t i o n information. Proceedings of the  Twenty-third Annual Conference of Adult Education Research , 1982, 175-184. Ross, S.E. Summary information to accompany application for Ministry of Health grant. D i a l - A - D i e t i t i a n , Vancouver, B r i t i s h Columbia, 1979. (a) Ross, S.E. A p r o v i n c i a l model to improve the n u t r i t i o n a l knowledge and practices of B r i t i s h Columbia residents. D i a l - A - D i e t i t i a n , Vancouver, B r i t i s h Columbia, 1982. (b) Speer, D.C. & Tapp, J.C. Evaluation of mental health service effectiveness. American Journal of Orthopsychiatry, 1976, 46, 217-228. Wagner, M.G., Huyck, M.C., & Hinkle, M.M. Evaluation of the D i a l - A - D i e t i t i a n program. Journal of the American  D i e t e t i c Association, 1965, 47, 381-390. Wagner, M.G., Navin, E.P., & Huyck, M.C. D i a l - A - D i e t i t i a n . Journal of the American D i e t e t i c Association, 1960, 37, 219-221. Wallin, P.F., Callahan, L.V., Roberts, G., Robbins, J. D i a l -A - D i e t i t i a n programs and c a l l s 1980-81 reporting year. D i a l - A - D i e t i t i a n Newsletter, August, 1982. Wilkinson, G.S., Mirand, E.A., & Graham, S. Cancer information by telephone: A two year evaluation. Health  Education Monographs, 1977, 5, 251-263. 75 APPENDIX A  REQUEST TO THE CALLER TO PARTICIPATE IN THE STUDY The study data were coll e c t e d by interviewing the c a l l e r s to D i a l - A - D i e t i t i a n Telephone Service. The d i e t i t i a n on duty at the service asked the c a l l e r "We have a graduate student from the University doing a study on the use of our service. She would l i k e to do a phone interview with some of our c a l l e r s within the next week or two. Would you be w i l l i n g to be interviewed i f she should c a l l ? It would take about ten minutes. When is the best time for her to c a l l you? Whom should she ask for? Your telephone number? Thankyou for your help." APPENDIX B SURVEY INSTRUMENT: FACING SHEET AND INTERVIEW SCRIPT FACING SHEET Name ( i f given) F1 W i l l i n g to be interviewed YES 1 NO 2 F2 Caller Category A Media 1 B Counselors 2 C Other Service 3 D Group Rep 4 E Individuals 5 F3 Question Normal Nut/Food Comp 1 Therapeutic Nut 2 Misc 3 Real Value 4 Food Safety 5 Contrv Heal Fds 6 Food Storage 7 Food Prep 8 Budgeting 9 Food Addit Ethnic Foods 1 2 77 INTERVIEW SCRIPT "Hello, could I speak to I am c a l l i n g about the D i a l - A - D i e t i t i a n Telephone Service. The d i e t i t i a n t e l l s me that you are w i l l i n g to be interviewed and that is why I am c a l l i n g you." (pause) I have been asked to interview some of the c a l l e r s to D i a l - A - D i e t i t i a n because they are interested in improving their service. The purpose of the study i s to obtain information on how the D i a l - A - D i e t i t i a n Service is used by i t s c a l l e r s . " (pause) The information that you can give us w i l l be valuable. We keep thi s information c o n f i d e n t i a l . Please feel free to stop the interview at any time. The interview w i l l take 7 to 10 minutes. The f i r s t set of questions is about how you located and used D i a l - A - D i e t i t i a n . " 1 . Have you used D i a l - A - D i e t i t i a n before? YES 1 NO 2 Can you t e l l me the number of times in the l a s t year? ONCE 1 TWICE 2 THREE 3 2. Can you t e l l me where you f i r s t found out about Dial-A-Dietitian? TELEPHONE DIRECTORY 1 NEWSPAPER 2 BROCHURES 3 TV/RADIO 4 DIETITIAN 5 DOCTOR 6 NURSE 7 FRIENDS/RELATIVES 8 OTHER 9 3. When you t r i e d to phone D i a l - A - D i e t i t i a n l a s t week, were you able to get through on the f i r s t d i a l attempt? YES 1 NO 2 How many time did you have to d i a l before you were able to get through? TWO 1 THREE 2 FOUR+ 3 Were you able to talk to the d i e t i t i a n immediately or did you leave a message on the tape recorder? DIRECTLY 1 TAPE 2 Did you mind leaving a message on the recorder? YES 1 NO 2 If you l e f t a message, how long was i t before the d i e t i t i a n contacted you? SAME DAY 1 NEXT DAY 2 NOT AT ALL 3 Were you s a t i s f i e d with t h i s procedure? YES 1 NO 2 78 (Reasons for Calling) "Now I have some questions about your reasons for c a l l i n g D i a l - A - D i e t i t i a n . " 4. Can you t e l l me your reasons for c a l l i n g Dial-A-D i e t i t i a n ? 5. Where else do you think t h i s information i s available? 6. Did you try t h i s source YES 1 NO 2 7. How many people were reached with this information? Was i t yourself, your c h i l d , your family, your friend, your readers, your l i s t e n e r s , your viewers? YOURSELF 1 CHILD 2 FAMILY 3 FRIEND 4 READERS 5 LISTENERS 6 VIEWERS 7 OTHERS 8 (Use of information) 8. "With the information you obtained from Di a l - A - D i e t i t i a n could you t e l l me how you used the information? CHANGE YOUR MEAL PATTERN What changes did you make? SUBSTITUTED ONE FOOD FOR ANOTHER What foods did you substitute? ADDED FOODS TO YOUR DIET What foods did you add? LEFT FOODS OUT OF YOUR DIET What foods did you leave out? MADE AN APPOINTMENT WITH THE DOCTOR VISITED A DOCTOR CONTACTED ANOTHER AGENCY WROTE AN ARTICLE UPDATED FILES NOTHING YET OTHER "If you have not had time to use the information, how do you plan to use i t . " (Information about c a l l e r s ) 9. "In the last question we would l i k e some background information about yourself. This information, along with a l l the rest you have given me w i l l be treated 7 9 c o n f i d e n t i a l l y . We are always interested in knowing more about our c a l l e r s and who uses the service." "I have five questions to ask you. One deals with your health, one with your age, occupation, years you spent in school and your native language." The f i r s t question is about your health. In general do you consider that your health i s : EXCELLENT 1 GOOD 2 FAIR 3 POOR 4 HOW OLD ARE YOU WHAT IS YOUR OCCUPATION HOW MANY YEARS DID YOU SPEND IN SCHOOL WHAT IS YOUR NATIVE LANGUAGE "Thank you very much." Have you any other comments that you think would be useful to Dial-A-Dietitian? "I would l i k e to thank you for your assistance and hope that D i a l - A - D i e t i t i a n can be of use in the future. I've enjoyed talking to you." 80 POST INTERVIEW ASSESSMENT P1. Sex of Respondent. FEMALE 1 MALE P2. Was there a language problem that made i t d i f f i c u l t to interview the respondent? YES 1 NO 2 P3. Was there any other problem that made i t d i f f i c u l t to interview the respondent? YES 1 NO 2 P4. The respondents understanding of the questions was: EXCELLENT 1 GOOD 2 FAIR 3 POOR 4 P5. The respondent's a b i l i t y to express self was: ART with d i f f i c u l t y Ex Voc 1 2 3 lim vocab 4 P6. How great was the respondent's interest in the interview? Very Hi 1 Above Avg 2 Avg 3 Below Avg 4 Very low 5 P7. The mood of the conversation as indicated by the respondent was: EASY 1 2 3 RUSHED/ANXIOUS 4 P8. During the interview did the respondent ask how much longer the interview would last? YES 1 NO 2 P9. Was the interview interrupted? YES 1 NO 2 P10. Knowledge of n u t r i t i o n that came through was Very High 1 Above Avg 2 Avg 3 Below Avg 4 Very Low 5 PI 1. Length of c a l l ? 7-10 Minutes 1 OVER 10 2 P12. General Impressions PI 3. LOCATION 81 APPENDIX C DIAL-A-DIETITIAN PROGRAMS AND CALLS 1980-81 REPORTING YEAR Arizona, Phoenix 1210 C a l i f o r n i a , San Diego 373 Georgia, Atlanta 240 Georgia, Augusta 45 Idaho, Boise No records I l l i n o i s , Waukegan 89 Indiana, Indianapolis No Records Kentucky, Bluegrass 357 Kentucky, Lexington 175 Louisiana, Lafayette 102 Massachusetts, Boston 3034 Michigan, Detroit 412 Minnesota, Minneapolis 20 Missouri, Kansas City 1318 Montana, Missoula 222 North Dakota, Bismark 398 New Mexico, Roswell 48 New York, Finger Lakes 6 New York, Rochestor 289 Ohio, Akron 194 Ohio, Cincinnati 583 Ohio, Columbus 289 Ohio, Dayton 325 Ohio, Toledo 98 Pennsylvania, Berks County 204 Pennsylvania, Philadelphia 980 Tennessee, Chattanooga 346 Tennessee, Knoxville 262 Tennessee, Memphis No Response Tennessee, Nashville 458 Texas, Dallas 358 Texas, Houston 804 Texas, Fort Worth No Response V i r g i n i a , Roanoke 605 West V i r g i n i a , Charleston 56 Wisconsin, Madison 531 Wisconsin, Milwaukee 437 Canada, Alberta/Edmonton 484 Canada, Toronto/Kingston 1528 Canada, Vancouver/British Columbia 5924 Source: From "Dial-A-Dietitian Newsletter of the National Advisory Committee" by P.F. Wallen, L.V. Callahan, G. Roberts, and J. Robbins, August, 1982. 82 APPENDIX D CALLER SOURCE OF INFORMATION ABOUT THE SERVICE Sample A N Health Professionals 1 19 23.1 Newspaper 16 19.5 Telephone Directory 9 11.0 Friends/Relatives 7 8.5 Organizations 2 7 8.5 Miscellaneous Sources 3 14 17.1 Don't Remember 10 12.2 Total 82 99.9 Sample B Health Professionals 1 Newspaper Telephone Directory Friends/Relat ives Organizations 2 Miscellaneous Sources 3 Don't Remember N 10 1 1 5 7 3 6 9 19.6 21 .6 9.8 13.7 5 1 1 1 7 9 8 6 Total 51 1 00.0 (1) Health professionals were d i e t i t i a n s , public health nurses, physicians. (2) Organizations were TOPS, Weight Watchers, Action B.C., Canadian Diabetic Association, Fitness group, Calorie Counting Club, Seventh Day Adventists. (3) Miscellaneous sources were t e l e v i s i o n , radio, educational i n s t i t u t i o n s , l i b r a r y , booklets, health food store, Edith Adams Cottage. 83 APPENDIX E TOTAL NUMBER OF CALLS TO PIAL-A-DIETITIAN, VANCOUVER 1972-1982 Year of Service A p r i l 1-March 31 Total Number of C a l l s 1972-73 1 ,738 1973-74 2, 378 1974-75 1,813 1975-76 4, 263 1976-77 5,249 1977-78 5,622 1978-79 5,642 1979-80 5,741 1980-81 5,953 1981-82 6,084 Source: "A Pro v i n c i a l Model to Improve the Nutrition Knowledge and Practices of B r i t i s h Columbia Residents" by S.E. Ross, Dial-A-D i e t i t i a n , Vancouver, 1982. 84 APPENDIX F  DISTRIBUTION OF SAMPLES BY AGE AND SEX Female Male Total Sample A 20-29 Years 30-39 Years. 40-49 Years 50-59 Years 60-69 Years 70-79 Years Total Not Reported 2 N % 9 11.8 10 13.2 8 10.5 13 17.1 24 31.6 7 9.2 N % 1 1.3 1 1.3 1 1.3 2 2.6 N % 9 11.8 11 14.5 9 11.8 14 18.4 26 34.2 7 9.2 71 93.4 5 6.5 76 99.91 6 Sample B 20-29 Years 30-39 Years 40-49 Years 50-59 Years 60-69 Years 70-79 Years Total Not Reported 2 N % 11 22.5 4 8.2 7 14.3 8 16.3 12 24.5 3 6.1 N % 1 2.0 2 4.1 1 2.0 N % 12 24.5 4 8.2 7 14.3 10 20.4 13 26.5 3 6.1 45 91.9 4 8.1 49 100.0 2 (1) Due to rounding of percentages, t o t a l does not equal 100% (2) Not reported because age not given by respondents. 85 APPENDIX G OCCUPATION OF CALLERS Sample A N % Housewi fe 40 50.6 Nurse 7 8.9 Retired 5 6.3 Clerk 4 5.1 Librar ian 2 2.5 Teacher 2 2.5 D i e t i t i a n 2 2.5 Student 2 2.5 Others 1 15 19.0 Total 79 99.92 Not Reported 3 Sample B N % Housewife 35 71 .4 Retired 6 12.2 Clerk 6 12.2 Others 1 2 4.1 Total 49 99.92 Not Reported 2 (1) In Sample A others were bus driver, manager, a i r l i n e p i l o t , dancer, disabled person, housekeeper, s o c i a l worker, a r t i s t , volunteer, music teacher, pharmacist, cook, physiotherapist, police o f f i c e r , home economist. In Sample B others were hairdresser, small business owner. (2) Due to rounding of percentages, t o t a l does not equal 100%. 8 6 APPENDIX H ACTION TAKEN BY CALLERS Sample A Act ion: ate yogurt, dried f r u i t s , cottage cheese, spinach, eggs and milk, aspartame, r i c o t t a cheese, oranges and grapefruit, s a l t free cheese, popcorn, Perrier water. prepared soup with milk, low fat topping, bread, cake for a diabetic, vegetables without s a l t , meal of lean meat and f r u i t . contacted doctor, outpatient d i e t i t i a n . wrote and delivered speech obtained a r t i c l e from l i b r a r y . fed baby. No Action: nothing, just wanted to know, relieved anxiety, substituted low c a l o r i e foods for high c a l o r i e foods (not s p e c i f i c ) . Sample B Action: ate "equal", clamato and orange juice, bran, aspartame, r o l l e d oats, kiwi f r u i t , milk. prepared yorkshire pudding for diabetic, soup from leeks, foods with bran, wheat free muf f ins. contacted pharmacist, doctor. fed c h i l d vegetables suggested, fed baby cream of wheat. read labels to determine hydrogenation of f a t . No Action: wanted to know, nothing, relieved anxiety. 87 APPENDIX I NATIVE LANGUAGE OF CALLERS Sample A N % English 69 84. 1 German 3 3.7 Dutch 1 1 .2 Ukrainian 3 3.7 It a l i a n 1 1 .2 Japanese 1 1 .2 Chinese 1 1 .2 Not Reported 3 3.7 Total 82 100.0 Sample B N % English 49 96. 1 Slavic 1 2.0 Not Reported 1 2.0 Total 51 100.11 (1) Due to rounding of percentages, t o t a l does not equal 100%. 88 APPENDIX J LOCATION OF THE CALL IN THE COMMUNITY Sample A N 32 1 2 9 5 1 4 10 5-Vancouver Burnaby North Vancouver Richmond New Westminster, Coquitlam P. Coquitlam, P. Moody North Delta, Surrey, Langley White Rock, Maple Ridge 39.°0 14.6 11.0 6.1 17.1 12.2 Total 82 100.0 Sample B N 21 4 4 3 7 1 2 9-Vancouver Burnaby North Vancouver Richmond New Westminster, Coquitlam P. Coquitlam, P. Moody North Delta, Surrey, Langley White Rock, Maple Ridge •5 41.2 7.8 7.8 5.9 13.7 23.5 Total 51 99.91 (1) Due to rounding of percentages, t o t a l does not equal 100%. APPENDIX K EASE OF REACHING DIAL-A-DIETITIAN SERVICE Sample A N % Reached Service on F i r s t Attempt Yes 44 53.6 No 36 44.0 Don't Remember 2 2.4 Total 82 100.0 Sample B N % Reached Service on F i r s t Attempt Yes 21 41.2 No 30 58.8 Don't Remember — — Total 51 100.0 90 APPENDIX L  PERSONS FOR WHOM THE INFORMATION  WAS REQUIRED Sample A N % C a l l e r 48 58.5 Family 27 32.9 Friend 6 7.3 Li steners 1 1 .2 Total 82 99.91 Sample B N ' % Caller 26 51 .0 Family 23 45.0 Friend 1 2.0 Readers 1 2.0 Total 51 1 00.0 (1) Due to rounding of percentages, t o t a l does not equal 100% 

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