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Innovation in a public health unit Lugsdin, James Gordon 1981

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INNOVATION IN A PUBLIC HEALTH UNIT by JAMES GORDON LUGSDIN M.D., Queen's U n i v e r s i t y , 1965 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS OF THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF HEALTH CARE AND EPIDEMIOLOGY UNIVERSITY OF BRITISH COLUMBIA acc e p t t h i s t h e s i s as conforming t o the r e q u i r e d s t a n d a r d : THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1981 (c> James Gordon Lugsdin, 19 81 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I agree t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e head o f my department o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 - i -Abstract The impact of introducing a new program into a public health unit was examined by introducing a l i f e s t y l e program, named HHA-PRHU, into the Peace River Health Unit i n B r i t i s h Columbia. The program was i n i t i a t e d without sanction or d i r e c t i o n from the Central O f f i c e c o n t r o l l i n g a l l the health units of the Ministry of Health of B r i t i s h Columbia i n order (i) to i n -vestigate the fate of l o c a l innovation i n health care delivery, ( i i ) to e s t a b l i s h the impediments to such innovation and ( i i i ) to determine ways to remove organizational obstacles i n the i r paths. The l i f e s t y l e program HHA-PRHU used the Health Hazard Appraisal method. This method i s a popular major tool i n the delivery of prospective medicine, a branch of medicine which stresses prevention. The urgent need i n the community for such a l i f e -s t yle program was demonstrated. An analysis of the organizational design of health units showed that they are not designed to foster innovation. Furthermore, i t was shown that l o c a l i n i t i a t i v e i n health units i s d i f f i c u l t to accomplish unless, during the planning process, considera-t i o n i s given to p o l i t i c a l bodies and to the Central O f f i c e . The evaluation of the impact of HHA-PRHU on the Peace River Health Unit was based on observations and perceptions of the Director of the Health Unit, and i t s s t a f f . These observations confirmed that a new program i s not r e a d i l y incorporated into a public health unit when introduced at the l o c a l l e v e l . Methods of s u c c e s s f u l l y introducing new programs o r i g i n a t i n g within a health unit were explored. These methods include ways of r e s t r u c t u r i n g , as well as making better u t i l i z a t i o n of, the e x i s t i n g administrative design. "The c a p a c i t y o f modern man t o c o n t r o l h i s d e s t i n y i n a c h a n g i n g o r g a n i z a t i o n a l s o c i e t y h i n g e s on h i s c o l l e c t i v e a b i l i t y t o change th e key f o r m a l o r g a n i z a t i o n s . " Ronald G. Corwin (1) " I n n o v a t i o n ... i s not so much th e a d o p t i o n o f o b j e c t s by i n d i v i d u a l s as i t i s t h e a c c e p t a n c e o f i d e a s by (people i n ) an o r g a n i z a t i o n . " Andrews and G r e e n f i e l d (2) - i v -DEDICATION Dedicated to my wife Irene and our children Hamish and Michell ACKNOWLEDGMENT I wish to acknowledge the s t a f f of the Peace River Health Unit, Peace River-Liard D i s t r i c t B r i t i s h Columbia, who attempted to adopt a new program into t h e i r busy schedule r e a l i z i n g that the program originated at the l o c a l l e v e l with no central p o l i c y or l e g i s l a t i v e background. The handling of t h i s c o n f l i c t i n an already strained and compromised s i t u a t i o n i s to be commended. I would l i k e to extend my thanks to the thesis committee, Dr. John Milsum, Dr. Charles Laszlo and Dr. Fred Bass for the i r comments, guidance and d i r e c t i o n throughout the process of planning, implementation and evaluation of the study. - v i -TABLE OF CONTENTS Page Abstract i Dedication i v Acknowledgment v Table of Contents v i L i s t of Figures x i L i s t of Maps x i i L i s t of I l l u s t r a t i o n s x i i i 1.0 INTRODUCTION 1 2.0 STUDY DESIGN AND METHODOLOGY 5 2.1 Introduction 5 2.2 The Method of Introducing HHA-PRHU into the PRHU 6 2.3 The Method of Studying HHA-PRHU i n the PRHU 9 2.3.1 Introduction 9 2.3.2 Items for Examination 10 a) The Outcome of HHA-PRHU 10 b) The Confounding Factors 10 c) The Organizational Chara c t e r i s t i c s 11 2.3.3 Methods of Observation 11 2.3.3.1 The Director's Observations 11 2.3.3.2 The Staff Questionnaire 13 2.4 Concluding Remarks 14 - v i i -Page 3. 0 ORGANIZATIONS AND INNOVATION - AN OVERVIEW 15 3. 1 I n t r o d u c t i o n 15 3. 2 O r g a n i z a t i o n a l S t r u c t u r e 16 3. 3 The O r g a n i z a t i o n and I n n o v a t i o n 19 3. 4 The I n d i v i d u a l and I n n o v a t i o n 21 3. 5 P l a n n i n g and I n n o v a t i o n 25 3. 6 P u b l i c H e a l t h U n i t s and I n n o v a t i o n 28 4. 0 HEALTH HAZARD APPRAISAL, LIFESTYLE MODIFICATION AND PROSPECTIVE MEDICINE 32 4. 1 L i f e s t y l e and D i s e a s e 32 4. 2 P r o s p e c t i v e M e d i c i n e 35 4. 3 H e a l t h Hazard A p p r a i s a l 37 5. 0 THE ORGANIZATIONAL SETTING AND ADMINISTRATIVE DESIGN 41 5. 1 The Peace R i v e r H e a l t h U n i t 41 5. 2 The G e o g r a p h i c a l S e t t i n g and t h e Economy 44 5. 3 S o c i a l S e t t i n g and L i f e s t y l e 45 5. 4 O r g a n i z a t i o n a l D e s i g n 48 6. 0 RESULTS 54 6. 1 I n t r o d u c t i o n 54 6. 2 The Outcome o f HHA-PRHU 55 6. 2.1 The HHA-PRHU P l a n 55 - v i i i -Page 6.2.2 The A c t u a l i z a t i o n o f HHA-PRHU 5 7 6.3 The Confounding F a c t o r s 59 6.3.1 The S u i t a b i l i t y o f HHA-PRHU 59 6.3.2 The Experience and A t t i t u d e s o f S t a f f o f the PRHU 62 6.3.3 The Nature of the E x t e r n a l Environment 64 6.4 The O r g a n i z a t i o n a l C h a r a c t e r i s t i c s 6 5 6.4.1 Leadership 65 6.4.2 The I n t e l l i g e n c e System 66 6.4.3 The D e c i s i o n Making Systems 6 6 6.4.4 The Communication Systems 6 7 6.4.5 M o t i v a t i o n Techniques 67 6.4.6 P l a n n i n g Techniques 67 6.4.7 C o n f l i c t and C o n f l i c t R e s o l u t i o n 68 6.4.8 The C e n t r a l O f f i c e Response 69 6.5 D i s c u s s i o n 70 6.5.1 The S u i t a b i l i t y of HHA-PRHU 71 6.5.2 The Experience and A t t i t u d e s o f S t a f f of the PRHU 72 6.5.3 The Nature of the E x t e r n a l Environment 73 6.5.4 The O r g a n i z a t i o n a l C h a r a c t e r i s t i c s 74 6.5.5 The Role of the D i r e c t o r 75 - i x -Page 7.0 CONCLUSIONS 77 7.1 Introduction 77 7.2 Organizational Design of the PRHU -Deficiencies 77 7.3 Organization Design - How to Innovate in the PRHU 80 7.3.1 Using the Present Organizational Design , 80 7.3.2 Restructuring the Organizational Design 82 7.4 Conclusions 84 APPENDIX A 85 Self-Teaching Questionnaire 86 APPENDIX B 8 8 Post-Implementation Questionnaire 89 APPENDIX C 96 Health Hazard Appraisal Form 97 Computer Printout 99 APPENDIX D 10 3 Dawson Creek and Fort St. John Offices 104 Chetwynd and Fort Nelson Offices 105 Cassiar O f f i c e 106 Project Manager's Directive 107 Central O f f i c e Communication 108 Communication to the Staff of PRHU 109 Letter to the Doctors 110 News Release from PRHU 111 Letter to Resource Persons 112 - x -Page Dawson Creek HHA Waiting Room Display 113 Fort St. John HHA Waiting Room Display 114 Chetwynd HHA Waiting Room Display 115 Cassiar HHA Community Hall Display 116 Dawson Creek Fitness Week A c t i v i t i e s 117 Covering Letter for HHA 118 Form for Tabulating Results of HHA 119 In-Service Education Agenda 121 Dawson Creek Newspaper A r t i c l e , Feb.28, 1979 122 Cassiar Newspaper A r t i c l e , Feb.,1979 124 Dawson Creek Newspaper A r t i c l e , Feb.14, 1979 125 Fitness F e s t i v a l Newspaper Article,May 25,1979 126 Cassiar Newspaper A r t i c l e , March-April, 1979 127 Project Manager's Concerns, Jan.20,1979 128 Project Manager's Update, Jan.22,1979 130 REFERENCES . 131 - x i -LIST OF FIGURES FIGURE Page 1 Time Li n e f o r O v e r a l l P l a n n i n g 7 2 A Conceptual Model f o r the A n a l y s i s of P l a n n i n g Behaviour 26 3 Causes o f Death by Health Risks 33 4 H e a l t h Hazard A p p r a i s a l and the N a t u r a l H i s t o r y of Disease 36 5 UBC H e a l t h Hazard A p p r a i s a l System 39 6 M i n i s t r y of Health 49 7 Community Health O r g a n i z a t i o n 50 - x i i -LIST OF MAPS B r i t i s h Columbia Health Units T e r r i t o r i a l Map with Distances Between Subunits - x i i i -LIST OF ILLUSTRATIONS ILLUSTRATION Page 1 Dawson Creek and F o r t S t . John O f f i c e s 104 2 Chetwynd and F o r t Nelson O f f i c e s 105 3 C a s s i a r O f f i c e 106 4 Dawson Creek HHA Wai t i n g Room D i s p l a y 113 5 F o r t St. John HHA Waiting Room D i s p l a y 114 6 Chetwynd HHA Wai t i n g Room D i s p l a y 115 7 C a s s i a r HHA Community H a l l D i s p l a y 116 8 Dawson Creek F i t n e s s Week A c t i v i t i e s 117 - 1 -1.0 Introduction In 1979, i n my capacity as Director and Medical Health O f f i c e r of the Peace River Health Unit (PRHU)* i n B r i t i s h Columbia, I introduced the Health Hazard Appraisal (HHA) method of L i f e s t y l e Modification into the e x i s t i n g system of health care delivery. My aim was to accomplish t h i s without sanction or d i r e c t i o n from the Central O f f i c e c o n t r o l l i n g a l l the health units i n the Ministry of Health i n order to investigate the fate of l o c a l i n i t i a t i v e i n health care delivery. In p a r t i c u l a r I set out to es t a b l i s h the impediments to such i n i t i a t i v e s and ways to remove organizational obstacles to t h e i r paths. In Chapter 2 the objectives, design and methodology of the study are presented. The method of introduc-ing HHA into the PRHU as part of a new program, HHA-PRHU, i s d e t a i l e d . The items chosen for observing the impact * A public health unit i s a corporation, agency or government body sta f f e d by professional health workers and support s t a f f responsible for the provision of public health programs within a geographical j u r i s d i c -t i o n . H i s t o r i c a l l y , under the P r o v i n c i a l Health Acts, geographical e n t i t i e s were i d e n t i f i e d as "Public Health Units." In several provinces t h i s term has been replaced by terms such as "region," " d i s t r i c t , " "municipal depart-ments," etc. For the purpose of t h i s study the term "Public Health Unit" i s used s o l e l y for ease of interp r e t a t i o n ( 3 ) . - 2 -o f HHA-PRHU on t h e PRHU a r e d e s c r i b e d . These i t e m s a r e o b s e r v e d by r e c o r d i n g p e r c e p t i o n s made by m y s e l f as an o b s e r v e r , and by a q u e s t i o n n a i r e completed by t h e s t a f f o f t h e PRHU. In Chapter 3 an o v e r v i e w o f change i s p r e s e n t e d . F i r s t , o r g a n i z a t i o n a l c h a r a c t e r i s t i c s and t h e o r g a n i z a t i o n a l a b i l i t y t o i n n o v a t e a r e r e v i e w e d . S e c o n d l y , t h e e f f e c t o f change on t h e i n d i v i d u a l i s d i s c u s s e d . T h i r d l y , t h e p l a n n i n g p r o c e s s and r e l a t i o n s h i p o f p l a n n i n g t o t h e i m p l e m e n t a t i o n o f change a r e examined. F i n a l l y , t h e o r g a n i z a t i o n a l d e s i g n o f p u b l i c h e a l t h u n i t s w i t h r e -s p e c t t o t h e i r a b i l i t y t o i n n o v a t e i s d i s c u s s e d . I n C h a p t e r 4 t h e H e a l t h Hazard A p p r a i s a l method f o r l i f e s t y l e m o d i f i c a t i o n i s d e s c r i b e d . F i r s t t h e l i t e r a t u r e p e r t a i n i n g t o l i f e s t y l e m o d i f i c a t i o n and the impact o f such m o d i f i c a t i o n on t h e h e a l t h o f t h e i n d i v i d u a l a r e r e v i e w e d . S e c o n d l y , I demonstrate t h e contemporary n a t u r e o f l i f e s t y l e m o d i f i c a t i o n and t h e r e a s o n why i t i s s u i t a b l e f o r i n c l u s i o n i n an o r g a n i z a -t i o n w hich s t r e s s e s t h e d e l i v e r y o f p r e v e n t i v e programs. T h i r d l y , I o u t l i n e t h e new br a n c h o f m e d i c i n e , p r o s p e c -t i v e m e d i c i n e , which uses l i f e s t y l e m o d i f i c a t i o n as an i n t e g r a l p a r t o f i t s p r e s e n t a t i o n . F i n a l l y , t h e - .3 -l i t e r a t u r e pertaining to the HHA method, an important t o o l i n the delivery of prospective medicine, i s pre-sented, p a r t i c u l a r l y i t s s c i e n t i f i c precepts and the method of delivery. In Chapter 5 I describe the setting of the study. The s t a f f composition of the Peace River Health Unit and the geographical and s o c i a l s e t t i n g i s detailed. Furthermore, i n t h i s chapter I explore the organiza-t i o n a l properties of the Ministry of Health i n B r i t i s h Columbia and the Peace River Health Unit and how the Health Unit i s related organizationally to Central Of f i c e i n V i c t o r i a . In Chapter 6 the observations perceived and recorded by myself, and the PRHU s t a f f , about HHA-PRHU and the results of the introduction of HHA-PRHU into the PRHU are presented. These observations are summarized and discussed. Chapter 7 contains the conclusions. F i r s t , the res u l t s of the study with respect to the overview of change presented i n Chapter 3 are reviewed. Secondly, ways of f a c i l i t a t i n g the introduction of change into public health units i n B r i t i s h Columbia are discussed. This - 4 -d i s c u s s i o n i n c l u d e s ways o f u s i n g t h e e x i s t i n g o r g a n i -z a t i o n a l d e s i g n as w e l l as t h e ways o f r e s t r u c t u r i n g t h e e x i s t i n g o r g a n i z a t i o n a l d e s i g n . - 5 -2.0 Study Design and Methodology 2.1 Introduction Theoretically a bureaucratic structure such as the Peace River,.Health. Unit, (PRHU)., being part of the corporate structure of the B r i t i s h Columbia Ministry of Health, i s not suited to adopting l o c a l innovation. In fact the PRHU i s designed i n such a way so as to preserve the e x i s t i n g delivery system at the expense of innova-t i o n (see Chapter 3). Si m i l a r l y , the individuals working i n the Unit are in c l i n e d to r e s i s t change, and tend to be more comfort-able with the routine and the f a m i l i a r (see Chapter 3). Fleshner and Drenk (12, Chapter 3) contend that the li k e l i h o o d of change being accepted into public health units i s increased by rendering an administrative change or restructuring. To study t h i s r e l a t i o n s h i p of organizational structure to innovation at the l o c a l l e v e l I chose to introduce a new program (HHA-PRHU) into the PRHU. I chose t h i s method of studying change because Aiken and Hage (13) contend that the only change which can be considered of s u f f i c i e n t magnitude to e l i c i t a measurable organizational response to innovation i s the introduction of a new program. Changing techniques, - 6 -rules or even goals alone does not necessarily r e s u l t i n s i g n i f i c a n t enough changes i n the organizational system to e l i c i t a measurable response. Introducing a new program, on the other hand, can necessitate changes i n techniques, rules and even goals. 2.2 The Method of Introducing HHA-PRHU into the PRHU Pr i o r to the introduction of the task assignment, HHA-PRHU, (see time l i n e i n Figure 1) I introduced the subject of the HHA method and i t s r e l a t i o n s h i p to l i f e -s t y l e at the Senior Staff meeting of the PRHU. (Senior Staff are those s t a f f with administrative duties i n Nursing, Public Health Inspection, Long term Care, C l e r i c a l , Audiology Divisions as well as the Medical O f f i c e r of Health). I did t h i s to acquaint the Senior Staff with these concepts and to c o l l e c t t h e i r opinions about the f e a s i b i l i t y of i n s t i t u t i n g HHA-PRHU into the PRHU. Also, p r i o r to the task assignment, I delivered an inservice lecture to the nursing s t a f f of the PRHU on the HHA method and l i f e s t y l e . F i n a l l y , p r i o r to the introduction of HHA-PRHU, I asked a l l s t a f f of the PRHU to complete a self-teaching ques-tionnaire (Appendix A) pg. 85) on HHA and l i f e s t y l e modification. - 7 -TIME LINE FOR OVERALL PLANNING January, 19 78 Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. January, 1979 Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. } > Planning at UBC with thesis committee Senior Staff approached about l i f e s t y l e programs Self Teaching Questionnaire to s t a f f and s t a f f HHA p a r t i c i p a t i o n Inservice education to nursing s t a f f about the HHA method Program Manager appointed and giver task assignment > I n s t a l l a t i o n of HHA-PRHU in the Peace River Health Unit V— Questionnaire to s t a f f Observations and J> progress notes by author Evaluation completed Figure 1 - 8 -A d d i t i o n a l l y , I offered a l l s t a f f an opportunity to par t i c i p a t e i n HHA with counselling being given by myself. I did thi s to f a m i l i a r i z e a l l the s t a f f with the HHA method and i t s r e l a t i o n to l i f e s t y l e and hope-f u l l y to engender in t e r e s t i n the s t a f f on the subject of l i f e s t y l e and i t s r e l a t i o n s h i p to health. I offered a l l t h i s information to the PRHU s t a f f to ensure the smooth entry of HHA-PRHU into the Health Unit at a future date. To introduce HHA-PRHU into the PRHU I issued a d i r e c t order, i n writing, to the Supervisor of Nurses of the PRHU in s t r u c t i n g her to be the Project Manager (PM) for a new task assignment i n the Health Unit. S p e c i f i c a l l y I appointed her PM for the design, imple-mentation, surveillance and evaluation of the ef f e c -tiveness of a system for d e l i v e r i n g a l i f e s t y l e modi-f i c a t i o n program to the PRHU catchment area. Delivery would be by the PRHU s t a f f using the HHA method. This program was c a l l e d HHA-PRHU. The PM was instructed to ensure that HHA-PRHU was i n e f f e c t for at least f i v e months and to integrate i t permanently into the PRHU delivery system i f possible. - 9 -To carry out thi s task the PM was given instructions to form any groupings necessary to d e l i v e r HHA-PRHU, including committees for decision making and informa-t i o n c o l l e c t i n g . The PM was to use e x i s t i n g s t a f f for the program. I was to be consulted for the re-source materials and advice regarding HHA. 2.3 The Method of Studying HHA-PRHU i n the PRHU 2.3.1 Introduction It was my aim to study whether or not HHA-PRHU was adopted by the Health Unit and how the organizational design of the PRHU influenced t h i s outcome. On the basis of t h i s information I intended to draw conclu-sions about the present organizational design of the PRHU and to o f f e r constructive suggestions for change i f necessary. However, the f i n a l outcome of HHA-PRHU i n the PRHU i s also dependent on the s u i t a b i l i t y of HHA-PRHU i n the PRHU, the nature of the s t a f f of the PRHU and the nature of the environment. The actual study of the impact of HHA-PRHU on the PRHU therefore includes an examination of these aspects i n an attempt to elimin-ate them as confounding variables. In t h i s way the concluding remarks can be more reasonably directed towards the organizational design of the PRHU. - 10 -2.3.2 Items for Examination The following l i s t was designed to f a c i l i t a t e the structure of the observer's notes and the s t a f f questionnaire, to ensure the reasonable elimination of the confounding variables and to d i r e c t attention towards the organizational design of the Health Unit. a) The Outcome of HHA-PRHU 1. The HHA-PRHU Plan 2. The Actualization of HHA-PRHU b) The Confounding Factors 1. The S u i t a b i l i t y of HHA-PRHU (i) the amount of disruption to the PRHU ( i i ) the ease of delivery ( i i i ) the ease of comprehension (iv) the goal congruence with respect to goals of the PRHU (v) the goal congruence with respect to the goals of the.staff (vi) the s u i t a b i l i t y with respect to job descriptions (vii) the s u i t a b i l i t y of the HHA method ( v i i i ) the $2.00 charge 2. The Experience and Attitudes of the Staff of the PRHU (i) length of service with the B r i t i s h Columbia Ministry of Health ( i i ) length of service with the PRHU ( i i i ) attitudes to l i f e s t y l e modification (iv) attitudes to HHA (v) willingness to change - 11 -(vi) effectiveness i n d e l i v e r i n g established programs (vi i ) a b i l i t y to design new programs 3. The Nature of the External Environment c) The Organizational_Characteristics 1. Leadership 2. The Intelligence System 3. The Decision Making Systems 4. Communication Systems 5. Motivation Techniques 6. Planning Techniques 7. C o n f l i c t and C o n f l i c t Resolving Techniques 8. Central Office Response To observe the items chosen for examination I used two methods. F i r s t I kept detailed progress notes of my perceptions of p a r t i c u l a r items. Secondly I surveyed the PRHU s t a f f perceptions of p a r t i c u l a r items by means of a questionnaire (Appendix B). (i) ( i i ) the need for l i f e s t y l e change the willingness of the s o c i a l struc-ture to change 2.3.3 Methods of Observation 2.3.3.1 The D i r e c t o r 1 s Observations My observations were charted d a i l y , weekly and monthly beginning at the i n i t i a l planning stages of the study - 12 -and f o l l o w i n g t h r o u g h t o . t h e p l a n n i n g o f HHA-PRHU, t h e d e l i v e r y o f HHA-PRHU and f o r s i x months f o l l o w i n g t h e f i v e month e f f e c t i v e d e l i v e r y o f HHA-PRHU. Data were o b t a i n e d by watching-and l i s t e n i n g . As w e l l , I meas-u r e d c o n f l i c t by r e c o r d i n g my own i n t u i t i v e awareness and e m o t i o n a l r e s p o n s e s o f c o n f l i c t n o t e d i n s t a f f -s t a f f r e l a t i o n s i p s and s t a f f - s u p e r i o r r e l a t i o n s h i p s . I n p a r t i c u l a r I r e c o r d e d d a t a on t h e f o l l o w i n g : 1. The method o f d e s i g n i n g t h e s t u d y 2. The method o f d e s i g n i n g HHA-PRHU 3. The w r i t t e n m a t e r i a l o u t l i n i n g t h e p l a n f o r d e s i g n , i m p l e m e n t a t i o n methods, s u r v e i l l a n c e and HHA-PRHU e f f e c t i v e n e s s e v a l u a t i o n methods 4. The d i s p l a c e m e n t o f m a t e r i a l s and o t h e r programs 5. The v o i c e d o p i n i o n s o f t h e s t a f f about t h e s u i t a b i l i t y o f HHA-PRHU w i t h r e s p e c t t o t h e g o a l s o f t h e s t a f f and t h e g o a l s o f t h e PRHU 6. The amount o f c o n f l i c t engendered by HHA-PRHU 7. The v o i c e d o p i n i o n s about the s u i t a b i l i t y o f HHA i n ch a n g i n g l i f e s t y l e 8. The per s o n s i n t h e H e a l t h U n i t who were r e g a r d e d by t h e s t a f f as b e i n g t h e l e a d e r s i n t he HHA-PRHU 9. The g r o u p i n g s o f t h e s t a f f formed f o r i n f o r m -a t i o n c o l l e c t i n g and d e c i s i o n making 10. The m o t i v a t i o n t e c h n i q u e s employed 11. The e x t e n t o f r e l i a n c e p l a c e d on me as a r e s o u r c e p e r s o n - 13 -2.3.3.2 The S t a f f Q u e s t i o n n a i r e (Appendix B, pg. 88) The s t a f f q u e s t i o n n a i r e i s made up o f t h r e e s e c t i o n s d e s i g n e d t o o b t a i n i n f o r m a t i o n about t h e s t a f f and t h e i r p e r c e p t i o n s o f t h e ite m s f o r e x a m i n a t i o n . The f i r s t s e c t i o n was completed by a l l s t a f f i n t h e PRHU. 1. Q u e s t i o n s 1-5 r e f e r t o p e r s o n a l s t a f f d a t a 2. Q u e s t i o n s 6-8 r e f e r t o comprehension o f HHA-PRHU 3. Q u e s t i o n s 9-12, 30-32 r e f e r t o g o a l congruence 4. Q u e s t i o n s 13-16 r e f e r t o c o n f l i c t 5. Q u e s t i o n s 17-20 r e f e r t o l e a d e r s h i p 6. Q u e s t i o n s 21-23 r e f e r t o the environment 7. Q u e s t i o n s 24-29 r e f e r t o H e a l t h U n i t d i s r u p t i o n 8. Q u e s t i o n s 32-34 a r e s t a f f change i n d i c a t o r s 9. Q u e s t i o n 35 i s t h e p e r c e p t i o n o f t h e need and s u i t a b i l i t y o f HHA-PRHU as a permanent program i n t h e PRHU 10. Q u e s t i o n s 36-39 r e f e r t o s t a f f p a r t i c i p a t i o n i n HHA and r e f l e c t s t a f f i n t e r e s t as w e l l as i n v o l v e m e n t The second s e c t i o n was completed by the n u r s i n g s t a f f , t h e u s e r s o f t h e HHA method. 1. Q u e s t i o n 1 r e f e r s t o a c t u a l i z a t i o n d a t a 2. Q u e s t i o n s 2-6 r e f e r t o t h e n a t u r e o f HHA-PRHU w i t h r e s p e c t t o ease o f d e l i v e r y 3. Q u e s t i o n 7 r e f e r s t o the e n v i r o n m e n t a l response 4. Q u e s t i o n s 4,5,6,8 and 10 r e f e r t o t h e n a t u r e o f t h e s t a f f 5. Q u e s t i o n s 7,11,12 r e f e r t o t h e s u i t a b i l i t y o f HHA-PRHU i n t h e PRHU - 14 -The t h i r d section was completed by the c l e r i c a l s t a f f . 1. Questions 1-3 rel a t e to the s u i t a b i l i t y of HHA-PRHU i n the PRHU 2. Question 4 asks for suggestions for improvement 2.4 Concluding Remarks The purpose of the study, the items for observation and the method of examination have been described. Besides t h i s material the following chapters could be considered as part of the method for examining the confounding variables; i n p a r t i c u l a r the s u i t a b i l i t y of the HHA method and the nature of the s t a f f and the environment are examined. Thus Chapter 4 describes the Health Hazard Appraisal Method and i t s r e l a t i o n to l i f e s t y l e modification; i n p a r t i c u l a r i t describes the relevance of l i f e s t y l e modification and i t s q u a l i t i e s which re l a t e to the needs of the s o c i a l environment. Furthermore Chapter 5 describes i n part the nature of the environment as well as the organizational setting including some of the components of the nature of the PRHU s t a f f . - 15 -3.0 Organizations and Innovation - An Overview 3.1 Introduction Innovation i s the act of innovating or the e f f e c t i n g of change i n the established order or the introducing of something new (4). The established order or system that has been chosen for study i s the Peace River Health Unit component of the B r i t i s h Columbia Ministry of Health. The change being introduced i s the new program, HHA-PRHU. In the overview presented i n th i s chapter the r e l a t i o n -ship of organizational change to organizational struc-ture and some of the i n d i v i d u a l obstacles to change are discussed. The overview also explores some of the plan-ning strategies necessary for successful innovation. As well, a c r i t i q u e of the health unit design i n r e l a -tionship to i t s a b i l i t y to innovate .is reviewed. References quoted i n the overview are from material I found p a r t i c u l a r l y h e l p f u l i n understanding the organizational topics of organizational design, innova-t i o n , planning, and health unit structure. - 16 -3.2 Organizational Structure There are two c l a s s i c a l types of organizational struc-tures. The f i r s t i s the mechanistic type and the second i s the organistic type. Weber (6) i s the h i s t o r i c a l proponent of the mechanistic organization. He describes bureaucratic organizations as being monocratic. He contends that t h i s type of administration i s capable of attaining the highest degree of e f f i c i e n c y and i s the most r a t i o n a l means of control over human beings. The mechanistic organ-i z a t i o n i s predictable and i s applicable to a l l kinds of administrative tasks. The mechanistic organization i s characterized by formal-ism, the l i n e of least resistance and the tendency for o f f i c i a l s to treat t h e i r o f f i c i a l function from a u t i l i -t a r i a n point of view i n the perceived i n t e r e s t of the welfare of those under t h e i r authority,. Weber continues that i n such organization there i s c e n t r a l i z a t i o n of authority, clear l i n e s of authority, clear l i n e of command, s p e c i a l i z a t i o n and expertise, marked d i v i s i o n of labour, rules and regulations and clear separations of l i n e and s t a f f . - 17 -According to McGregor (7) and L i k e r t (8) , organ!stic  organizations are characterized by pooling of s p e c i a l knowledge i n a contributive type of framework with attention being directed to the common task of concern. There i s continual r e - d e f i n i t i o n and adjustments of tasks through interactions with others. There i s spread of commitment beyond technical d e f i n i t i o n and a network structure of control, authority, and communication, with i n d i v i d u a l s . As well, i n the organistic organization there i s conduct derived from presumed community of i n t e r e s t with the re s t of the working organization. There i s a l a t e r a l rather than a v e r t i c a l d i r e c t i o n of communication and communication being one of information and advice rather than instructions and decisions. There i s a tendency to place commitment to tasks before l o y a l t y and obed-ience to authority. F i n a l l y there i s delegation of authority, employee autonomy, tr u s t and openness, con-cern with the "whole i n d i v i d u a l " , and interpersonal dynamics. Li k e r t says that to the mechanistic school the organistic school represents a system which i s disordered and i n -e f f i c i e n t . Chaos seems to them evident and the r e s u l t -ant i n e f f i c i e n c y does not o f f s e t the increased a b i l i t y . to innovate. - 18 -S c o t t (9) s t a t e s t h a t modern o r g a n i z a t i o n a l t h e o r y has d e v e l o p e d methods f o r t h e dynamic e x a m i n a t i o n o f t h e c l a s s i c a l o r g a n i z a t i o n a l t h e o r i e s a s w e l l as p r o v i d -i n g an o p p o r t u n i t y f o r u n i t i n g what i s v a l u a b l e i n c l a s s i -c a l o r g a n i z a t i o n a l t h e o r y w i t h what i s v a l u a b l e i n t h e o r g a n i s t i c o r g a n i z a t i o n a l t h e o r y i n t o a s y s t e m a t i c and i n t e g r a t e d c o n c e p t o f human o r g a n i z a t i o n . S c o t t c o n t i n u e s t h a t modern o r g a n i z a t i o n t h e o r y h as t h e d i s t i n c t i v e q u a l i t i e s o f a c o n c e p t u a l a n a l y t i c a l b a s e , a r e l i a n c e on r e s e a r c h d a t a , and, above a l l an i n t e g r a t i n g n a t u r e . T h e s e q u a l i t i e s a r e f r a m e d i n a p h i l o s o p h y w h i c h a c c e p t s t h e p r e m i s e t h a t t h e o n l y m e a n i n g f u l way t o s t u d y an o r g a n i z a t i o n i s t o s t u d y i t as a s y s t e m . A c c o r d i n g t o S c o t t , modern o r g a n i z a t i o n t h e o r y a d d r e s s e s a r a n g e o f i n t e r r e l a t e d q u e s t i o n s . What a r e t h e s t r a -t e g i c p a r t s o f t h e s y s t e m ? What l i n k s t h e p a r t s t o -g e t h e r and what a r e t h e g o a l s ? T h i s l e a d s t o s y s t e m s a n a l y s i s where component p a r t s o f t h e s y s t e m a r e c o n -s i d e r e d t o be t h e i n d i v i d u a l , t h e f o r m a l s t r u c t u r e , t h e i n f o r m a l o r g a n i z a t i o n , s t a t u s r o l e p a t t e r n s and t h e p h y s i c a l e n v i r o n m e n t o f work. The l i n k s between t h e s e p a r t s a r e c o m m u n i c a t i o n and d e c i s i o n m a k i n g . - 19 -F i n a l l y Scott says that modern organizational theory has tools of analysis and a conceptual framework uniquely i t s own, but i t must also allow for the incorporation of relevant contributions of many f i e l d s such as de c i -sion theory, information theory and cybernetics. 3.3 The Organization and Innovation According to Thompson (11) the responsiveness of an organization to change i s a function of a complex set of variables. Hasenfeld et a l . (10) contend that the dilemma between change and s t a b i l i t y i s ubiquitous i n formal organiz-ations. At a l l times organizations encounter contin-uous st i m u l i to change both from the external and the in t e r n a l environment. However, change always involves costs to the organization i n terms of i t s i n a b i l i t y to recover past investments made to at t a i n the ex i s t i n g modes of operations. The costs of innovation coupled with the costs of the poten t i a l loss of past invest-ments generally r e s u l t i n a notable resistance to change on the part of the organization. Hasenfeld et a l . continue to say that to e f f e c t change the organization must have an organizational - 20 -i n t e l l i g e n c e system which w i l l determine whether the need for change i s perceived by the members of the organization. Furthermore organizational goals and  ideologies also act as f i l t e r i n g devices for new ideas; and executive leadership can act as a change agent. Every s i g n i f i c a n t organizational innovation requires the a v a i l a b i l i t y of uncommitted organizational resources i n the form of money, personnel, time, s k i l l and t o l e r -ance for i n i t i a l f a i l u r e . The administrative structure i s a determinant i n organizational change. Rates of change i n organizations are negatively cor-related with the degree of organizational formalization and c e n t r a l i z a t i o n according to Thompson (11). He says that decentralization and a low degree of formalization are conducive to innovativeness i n the sense that they provide workers with a c e r t a i n amount of autonomy, thereby allowing such workers to.be innovative and creative. Flashner and Drenk (12) state that innova-t i o n i s also enhanced by freer communications, project organization, rotation of assignment, a greater r e l i -ance on group processes and a continual restructuring and modification of the incentive system. The need for innovation arises when adaptation to change i s outside the scope of e x i s t i n g programs for the purpose - 21 -of keeping the system i n balance, according to Scott (9). New programs have to evolve in. order for the system to maintain i n t e r n a l harmony. New programs are often, then, a tr i a l - a n d - e r r o r search for feasi b l e alterna-t i v e s to cope with a need for a given change. Scott summarizes by saying that the successful i n t r o -duction of innovation depends on the poten t i a l of the system to supply information, the range of available information i n the memory of the system, the operat-ing rules governing the analysis and flow of informa-ti o n within the system, and the a b i l i t y of the system to forget previously learned solutions to change. 3.4 The Individual and Innovation According to T o f f l e r (14), as a rule many individuals f e e l threatened and uncomfortable by change to the ex-tent that they w i l l usually t r y to avoid i t i f possible. At times t h i s resistance to change by such individuals borders on i r r a t i o n a l i t y . The corporate head who wants to reorganize a department, the educator who wants to introduce a new teaching method, the mayor who wants to achieve the peaceful integration of the races of his c i t y - a l l , at one time or another face t h i s b l i n d resistance. - 22 -Perrow (5) states that change involves c o n f l i c t . Decisions must be made to l e t go of the old and accept the new, and p r i o r i t i e s must be rearranged. There are l i m i t s on man and his a b i l i t y to handle t h i s c o n f l i c t . Because man i s generally li m i t e d i n i n t e l l i g e n c e , reasoning powers, information at his disposal, time available and means of ordering his preferences c l e a r l y he w i l l usually seize on the f i r s t acceptable alterna-t i v e when deciding rather than looking for the best ideas. Thus he i s i n c l i n e d to remain with routine, thus preventing innovation. Pondy (15) believes that c o n f l i c t and c o n f l i c t resolu-t i o n are es s e n t i a l to successful organizations. Scien-t i f i c management theory overflows with such terms as c o n f l i c t behaviour, goal congruence, c o n f l i c t r e l a t i o n -ships, c o n f l i c t episodes, c o n f l i c t t r a i t s , c o n f l i c t p o t e n t i a l and c o n f l i c t management, latent c o n f l i c t , perceived c o n f l i c t , f e l t c o n f l i c t , manifest c o n f l i c t and c o n f l i c t aftermath. The concepts embodied i n these are now discussed b r i e f l y . According to Freeman (16) c o n f l i c t i n indivi d u a l s can r e s u l t i n constructive or destructive behaviour. Furthermore c o n f l i c t i n i t s e l f i s not bad. In fac t i f there i s no c o n f l i c t i t i s l i k e l y that the organ-i z a t i o n has reached a dangerous degree of complacency. - 23 -A good manager does not try to eliminate c o n f l i c t , a l -though he t r i e s to keep i t from wasting the energies of the people involved. Galbraith (17) says that c o n f l i c t often arises when the goals of the organization d i f f e r from the goals  of the i n d i v i d u a l . This c o n f l i c t centres on d i f f e r e n t sets of values held by i n d i v i d u a l s which are incongru-ent with the objectives of the organization. T o f f l e r says that i f the c o n f l i c t i s beyond the i n d i ~ vidual's coping mechanism he/she may exhibit abnormal behaviour and become incapable of functioning. . This can be overtly recognized i n a number of forms. The i n d i v i d u a l may demonstrate an anxiety neurosis, host-i l i t y to authority, senseless violence, physical i l l -ness, depression, apathy, e r r a t i c behaviour with swings i n l i f e s t y l e , s o c i a l withdrawal and i n some cases psy-chotic paranoia. To handle c o n f l i c t , management has attempted a v a r i e t y  of solutions. Cooper (19) stated that the early approaches to changing organizations naively assumed that human behaviour was based on the l e g a l and moral obliga t i o n that people, having contracted to work, would then carry out the terms of t h e i r contractcand that - 24 -people, when informed of the organization's goals, would s t r i v e wholeheartedly to achieve these goals. Hasenfeld et a l . (10) are of the opinion that these early approaches were replaced by the human relations approach to organizations. Organizational change can be achieved mainly through changing the behaviour of the members of the organization. This, they continue, i s accomplished by power equalization whereby manage-ment shares i t s power with those who must implement the innovation. In addition, the lower l e v e l s t a f f are encouraged to p a r t i c i p a t e i n the decisions about the proposed change. Massie et a l . (18) say that c o n f l i c t may be resolved by the i n d i v i d u a l i n a number of ways. He/she may .. accommodate and suff e r , accommodate and gain, f i g h t and lose, f i g h t and win, create a support group, over-react or go outside for rewards. The selection of s t a f f can be important i n predispos-ing an organization towards the a b i l i t y to more read i l y accept innovative ideas. Corwin (1) states that s t a f f members are more l i k e l y to accept and p a r t i c i p a t e i n innovation i f they are l i b e r a l , creative and unconven-t i o n a l outsiders with fresh ideas and perspectives. - 25 -Furthermore, these s t a f f members should be young and f l e x i b l e and have positions that are secure and pro-tected from the status r i s k s involved i n change. 3.5 Planning and Innovation Before and during the process of e f f e c t i n g change some type of planning takes place. Planning i s defined by Friedman(20) as the guidance of change within the s o c i a l system. There i s no formula to guarantee successful innovation. The conceptual model for planning as shown i n Figure 1 depicts the ingredients which can be used i n the plan-ning process. Many combinations are possible. There are d i f f e r e n t methods of planning just as there are d i f f e r e n t methods of implementation. Implementa-ti o n i s dependent on e x i s t i n g technologies, resources and the i n t e r n a l and external environment. Friedman states that planning i s dependent on the philosophy and s k i l l s of the planner and the e x i s t i n g t r a d i t i o n , wisdom and i n t u i t i o n of the s o c i a l s e t t i n g . Friedman believes that thought can determine innova-t i v e outcomes. If the thought i s bounded and r a t i o n a l with respect to the s o c i a l setting innovation i s more - 26 -Tradi t ion Intuit ion Wisdom Ends g iven 5 General ends Ends var iab le S p e c i f i c ends Funct iona l ly Rational Thought Substant ia l l y Rat ional Thought Utop ian ond I d e o l o g i c a l Thought Mainta in ing System Balances Inducing System Trans format ion A l l o c a t i v e P lonning: C e n t r a l Guidonce C luster ' u Innovative Planning: Is lands of C h a n g e " S y s t e m P e r f o r m a n c e A C o n c e p t u a l Model f o r the A n a l y s i s o f P l a n n i n g B e h a v i o u r from Freidman (20,p. 228) F i g u r e 2 - 27 -l i k e l y to take place smoothly. I f the innovation i s a r e s u l t of unbounded or i d e o l o g i c a l thought great forces may be required to e f f e c t change. According to Friedman planning can have varied charac-t e r i s t i c s . F i r s t l y , planning can be developmenta1 with no account being taken of others external to the planning system when setting ends and means. Develop-mental planning i s dependent on p o l i t i c a l i n s t i t u t i o n s for resolution of c o n f l i c t . Secondly, planning can be adaptive i n which case deci-sions are heavily contingent on the actions of others external to the planning system. Adaptive planning tends to adapt to what i s , with reliance on p o l i t i c a l manipulation to achieve ends and means. Thirdly, planning can be innovative and tend to ignore the t o t a l value spectrum of society. Innovative planners have more in t e r e s t i n mobilizing resources than i n the optimal a l l o c a t i o n among competing uses. This type of planning i s disruptive to e x i s t i n g balances and i s uncoordinated and competitive. Fourthly, planning can be a l l o c a t i v e where account i s taken of competing resources and the need of t h e i r - 28 -d i s t r i b u t i o n on the basis of established p r i o r i t i e s . Over time, and as the pace of change slows down, a l l o -cative planning tends to replace innovative planning i n the management not only of the organization but also i n the s o c i a l system as a whole. Planning includes "actors" who w i l l be implementing change. They can be involved by command, inducement, negotiation, p a r t i c i p a t i o n or competition. Friedman summarizes the planning process: "If planning i s accepted as the attempted i n t e r -vention of reason i n history, then i t i s clear that such intervention cannot be immediate and d i r e c t , but must be f i l t e r e d through a series of complex structures and processes to be e f f e c t i v e . I t i s not the great mind that intervenes, but a multitude of i n d i v i d u a l actors, each playing his role i n a c o l l e c t i v e purpose that he does not f u l l y comprehend because he i s involved i n i t himself and lacks perspective. Reason, therefore, ... i s a ' c o l l e c t i v e representation' ... whose func-tioning i s contingent on structure and forces which are independent of i t s e l f . " (20,p.369) 3.6 Public Health Units and Innovation Flashner and Drenk (12) contend that the present trad-i t i o n a l organizational design and administrative proced-ures found i n many public health agencies are counter-productive to the successful accomplishment of rapidly changing tasks. - 29 -They continue by saying that the present organizational design tends to create s i g n i f i c a n t i n t e r n a l operating problems which hinder our e f f o r t s to de l i v e r services e f f i c i e n t l y . The main problem, they claim, i s a misunderstanding . and misuse of s p e c i a l i s t s and generalists. Professional and management roles have been blended without benefit to either people i n the professions, the program delivery or the organization. As a r e s u l t administration i s delivered by t e c h n i c a l l y trained personnel and there i s l i t t l e time for program development and the evaluation of goals. Consequently the working emphasis i n health units tends to be oriented towards a l l e v i a t i o n of c r i s e s and the enforcement of regulations. To solve these d i f f i c u l t i e s Flashner and Drenk suggest the creation of a dual system of organizational design. Administration should be delivered by generalists who are trained to be administrators and who are comfort-able and s a t i s f i e d with t h i s occupation. The adminis-trator would be referred to as a Management Program Co-ordinator ~ who would be responsible for the sel e c t i o n - 30 -of d i v i s i o n and program managers and the co-ordination of these managers i n order to provide better use of present programs. The design, delivery and surveillance of the programs on the other hand would be under the d i r e c t i o n of spec-i a l i s t s who would be u t i l i z e d for such professional tasks as, technical consultants, program advisors and monitors of the success i n reaching goals. A Medical Program Co-ordinator would be the head of the professional pool and would be responsible for the assignment of individuals to designated task teams as well as for the creation of the task teams responsible for s p e c i f i c programs. A l l these professionals and the Medical Program Co-ordinator are management personnel rather than l i n e s t a f f . In summary Flashner and Drenk contend that public health departments are bureaucratically structured i n such a fashion that innovation, goal setting and objectives are not an in t e g r a l part of program operations. They are of the opinion that i f programs i n health units were task oriented and administered by s p e c i a l i s t s , free - 31 -o f t h e a d m i n i s t r a t i v e d u t i e s o f the g e n e r a l i s t s , t h e o r g a n i z a t i o n a l s t r u c t u r e would be l e s s b u r e a u c r a t i c and more a d a p t i v e t o t h e c h a n g i n g needs o f the commun-i t y . As w e l l t h e y say t h a t h e a l t h u n i t s would have a b e t t e r q u a l i t y o f programs as a r e s u l t o f c o n t i n u a l m o n i t o r i n g and r e s t r u c t u r i n g o f the program c o n t e n t . - 32 -4.0 H e a l t h Hazard A p p r a i s a l , L i f e s t y l e M o d i f i c a t i o n  and P r o s p e c t i v e M e d i c i n e 4.1 L i f e s t y l e and D i s e a s e The e x t e n t o f p r e v e n t a b l e d i s e a s e today i s s i g n i f i c a n t (27,28,29). The r e l a t i o n s h i p o f d e a t h t o h e a l t h r i s k s i s p r e s e n t e d i n F i g u r e 3. A c c o r d i n g t o f i g u r e s a c q u i r e d by Lauzon ( 3 0 ) , d eaths due t o motor v e h i c l e a c c i d e n t s , i s c h a e m i c h e a r t d i s e a s e , o t h e r a c c i d e n t s , r e s p i r a t o r y d i s e a s e , l u n g c a n c e r and s u i c i d e a c c o u n t f o r 59.8 per c e n t o f t h e l o s s o f p r o d u c t i v e l i f e y e a r s i n Canada. I n a d d i t i o n , t h e s e d i s e a s e s and m e n t a l i l l n e s s a c c o u n t f o r t h e m a j o r i t y o f days spent i n a c u t e c a r e h o s p i t a l s (30). The c o s t s o f c e r t a i n i d e n t i f i a b l e consequences a s s o c i -a t e d w i t h c i g a r e t t e smoking were e s t i m a t e d t o be 5 3.9 m i l l i o n d o l l a r s i n 1971 (30) . S i m i l a r c o s t e s t i m a t e s have su g g e s t e d f i g u r e s o f 1.23 b i l l i o n d o l l a r s f o r a l -c o h o l r e l a t e d problems and i n e x c e s s o f one b i l l i o n d o l l a r s f o r deaths due t o motor v e h i c l e a c c i d e n t s ( 3 0 ) . A c c o r d i n g t o L a l o n d e ( 3 1 ) , s e l f - i m p o s e d r i s k s and t h e environment a r e t h e p r i n c i p a l o r i m p o r t a n t f a c t o r s i n each of t h e f i v e major causes o f d e a t h between age one and s e v e n t y . F o r example f o r t h e age 35 male t h e t o p t h r e e k i l l e r s a r e motor v e h i c l e a c c i d e n t s , o t h e r a c c i -d e n t s and s u i c i d e . The most r a t i o n a l s t r a t e g y t o - 33 -Causes of Death by Health Risks Cause of Death Motor vehicle accidents A r t e r i o s c l e r o t i c heart disease Cancer of the cervix Cancer of the lungs C i r r h o s i s of the l i v e r Emphysema Hypertensive heart disease Health Risks Alcohol habits Drugs and medication Mileage per year Seatbelt use Blood pressure Cholesterol l e v e l Exercise habits Smoking habits Weight Economic and s o c i a l status Marriage or onset of intercourse Smoking habits Alcohol habits Smoking habits Blood pressure Weight Adapted from Lauzon (30, p.2) Figure 3 - 34 -minimize the incidence of these disease states, says Lalonde, i s the discovery and modification of those precursors which seem i n practice to be modifiable. Such a strategy has conclusively implicated the i n d i -vidual's l i f e s t y l e among the most important factors contributing to the major causes of health and d i s -a b i l i t y . Despite t h i s knowledge, programs aimed at reducing disease by abatement of known contributing factors are generally weak or non-existent i n our society. Accord-ing to Milsum (32), there i s , unfortunately, an expecta-t i o n by the general public that health technology has the inherent c a p a b i l i t y to develop the appropriate "technological f i x " for any of the i l l n e s s e s that b e f a l l s the human body. Health technology has been the c o n t r o l -l i n g influence i n the development of the present pattern of health delivery i n the i n d u s t r i a l i z e d world. Because technology i s administered by i n s t i t u t i o n s i n order to make the technology more cost e f f e c t i v e t h i s system i s hospital rather than community-oriented. Canadians t r a d i t i o n a l l y now equate t h e i r l e v e l of health with the a v a i l a b i l i t y of physicians and hospitals. Future improvements i n the l e v e l of health of Canadians l i e mainly i n improving the environment, moderating s e l f -imposed r i s k s and adding to our knowledge of biology(31). - 35 -Health Hazard Appraisal i s an important component i n the delivery of those health services which are directed at reducing l i f e s t y l e r i s k s and subsequent l i f e s t y l e induced death and disease. Health services of t h i s nature are included i n the f i e l d of Prospective Medi-cine (33,34) . 4 . 2 Prospective Medicine Prospective medicine i s concerned with disease before i t reaches c l i n i c a l stages; precursors such as smoking and high blood pressure are i d e n t i f i e d . For example refe r to Figure 4. By examining disease states i n t h i s fashion precursors may be eliminated with the p o s s i b i l -i t y of preventing or at least delaying or minimizing the stages of c l i n i c a l d i s a b i l i t y or even death. Sec-ondarily, prospective medicine i s concerned with slow-ing the progress of disease and conserving maximal function (33) . Prospective medicine, i n contrast to preventive medi-cine, i s comprehensive and not fragmented by s p e c i a l -t i e s . The i n d i v i d u a l i s treated as a whole person, being i n a complex s o c i a l setting with concern being given to t o t a l r i s k , not just r i s k from one cause (26). Furthermore, prospective medicine i s concerned with (1) (2) (3) (4) (5) (6) NO RISK AT RISK: VULNERABLE TO PRECURSOR AGENT, PRECURSOR PRESENT SIGNS SYMPTOMS DISABILITY 4 —• -HEALTH HAZARD APPRAISAL • MULTIPHASIC TESTING « TRADITIONAL MEDICAL CARE EXAMPLE: HEART ATTACK (ARTERIOSCLEROTIC HEART DISEASE) HIGH BLOOD ABNORMAL HEART AGE PRESSURE ELECTRO- CHEST ATTACK ( E G . A B O V E HIGH CHOLESTEROL, CARDIOGRAM PAINS (MYOCARDIAL 45 Y E A R S ) CIGARETTE SMOKING (ECG) INFARCTION) HEALTH HAZARD APPRAISAL AND THE NATURAL HISTORY OF DISEASE Taken from Prince et a l (26 p.3) Figure 4 - 37 -the i d e n t i f i c a t i o n of the individual's changing r i s k s of disease and the recognition of his e a r l i e s t devia-tions from a state of health. By promoting health and preventing disease i t complements the art of medical care (25). 4.3 Health Hazard Appraisal Health Hazard Appraisal (HHA) i s a major tool of pros-pective medicine whose goal i s to enrich and extend the span of l i f e of individuals by reducing d i s a b i l i t y and death due to preventable r i s k (22,23). It shows the quantitative and i n t e r a c t i v e nature of risk-taking behaviour and the personal relevance and immediacy of threats to health. Through the HHA method individuals become aware of r i s k groups to which they belong for leading health problems. Subsequently pot e n t i a l bene-f i t s are shown to emerge i f cert a i n l i f e s t y l e improve-ments are made (24). HHA provides an e f f i c i e n t and highly e f f e c t i v e means for age-specific screening and i d e n t i f y i n g high r i s k i ndividuals requiring medical intervention. The means i s provided for reaching large groups of people for promoting l i f e s t y l e changes, and thus of approaching the e f f e c t i v e control of accidents and the major non-communicable diseases (25) . - 38 -The HHA method of l i f e s t y l e modification i s usually employed by health professionals or health para-professionals interested i n prospective medicine (Figure 5). Using the HHA questionnaire (Appendix C) as a vehicle for discussion, the health counsellor and the c l i e n t enter a prospective health education process. After completing the questionnaire and receiving the HHA computer printout (Appendix C) a counselling  session i s held, focusing on the individual's l i f e -s t y l e r i s k s , on the encouragement of continuing appro-priate behaviour and of modifying r i s k taking behaviour. A keystone of success i n compliance i s the recognition by the i n d i v i d u a l of his/her own r e s p o n s i b i l i t y for h i s / her health and acceptance that he/she has the power to e f f e c t and maintain changes. It i s h e l p f u l i f counsel-l o r s convey the b e l i e f that there i s a large volume of accessible knowledge about health and l i f e s t y l e and that there are f a c i l i t i e s to back up the c l i e n t ' s attempt to change (26). Milsum (37) states that the counselling between c l i e n t and professional i s i n many respects s i m i l a r to the student-teacher and child-parent r e l a t i o n s h i p s . In p a r t i c u l a r , c l i e n t s are t y p i c a l l y more motivated by what the counsellors do than what they say. - 39 -Client's Health Status Before ] After i Client's Risk Reduction (Lifestyle) Programs Questionnaire Input (Format, Technique) Other H H A Data Banks . J Health Professional Counselor (s) Educational Programs (Health Counselors) HHA Processing Program Data Bank (Cumulative Anonymous HHA Records) HHA Evaluation (Before: After Data, Cost: Effectiveness) Appraisal Output (Print-out format) Statistical and Epidemiological Analysis I Government . Policies A on HHA and , Health ^ Promotion ~1 Community Resources for Lifestyle change Educational Programs (Public) UBC HEALTH HAZARD APPRAISAL SYSTEM From M i l s u m (49,p.110) F i g u r e 5 - 40 -Indeed, Milsum continues, a l l c l i e n t s w i l l presumably assess t h e i r counsellors regarding whether they believe i n the concepts and information they are transmitting. With the counsellor having the knowledge of the import-ance of t h i s exemplar e f f e c t i n inducing change i n the c l i e n t , the onus would be on the counsellor to " l i v e as he/she preaches i f he/she desires to be e f f e c t i v e . " Therefore i f the counsellor changes his/her own l i f e -s t yle when involved i n the HHA method i t would indicate a desire to p a r t i c i p a t e a c t i v e l y i n the HHA method. That i s , a change i n the counsellor would indicate a desire to change the c l i e n t . This c l e a r l y has i m p l i -cations for the.particular HHA-PHRU program being stud-ied here. In summary, l i f e s t y l e modification i s an important approach i n reducing many of today's most prominent diseases. The re l a t i o n s h i p of l i f e s t y l e modification to disease i s the subject of a new branch of medicine termed prospective medicine. An e f f e c t i v e t o o l i n the practice of prospective medicine i s the HHA method. - 41 -5.0 The Organizational Setting and Administrative Design 5.1 The Peace River Health Unit The Peace River Health Unit (PRHU) i s a p r o v i n c i a l government body of health professionals and support s t a f f responsible for the provision of public health programs to the Peace River-Liard d i s t r i c t of B r i t i s h Columbia (Map 1). The PRHU s t a f f are located i n six o f f i c e s which are located i n Dawson Creek, Fort St. John, Chetwynd, Hudson's Hope, Fort Nelson, and Cassiar (Map 2). During t h i s study the Health Unit was staffed by a complement of forty-two persons, comprising a di r e c t o r , sixteen preventive health nurses, three home care nurses, two nurse's aides, three public health inspec-tors, four long term care nurses, ten c l e r i c a l workers, one audiologist, one audiometric aide and a speech path-o l o g i s t . The d i s t r i b u t i o n of s t a f f was concentrated i n Dawson Creek and Fort St. John which between them employed t h i r t y - f o u r persons. The remaining s t a f f members were divided between the other four o f f i c e s . \ - 42 -G r e a t e r Vancouver G r e a t e r V i c t o r i a E a s t Kootenay S e l k i r k West Kootenay N o r t h Okanagan South Okanagan South C e n t r a l Upper F r a s e r C e n t r a l F r a s e r Boundary Simon F r a s e r Coast G a r i b a l d i S a a n i c h & S.Van.Is. C e n t r a l Van. I s . Upper I s l a n d Car i boo Skeena Peace R i v e r I BRITISH COLUMBIA HEALTH UNITS I Map 1 co TERRITORIAL MAP WITH DISTANCES BETWEEN SUBUNITS Map 2 - 44 -5.2 The Geographical Setting and the Economy The Peace River-Liard D i s t r i c t covers 100,000 square miles. Most of t h i s i s unorganized t e r r i t o r y . The major centres are Dawson Creek and Fort St. John which have populations of 13,000 and 15,000 persons, respec-t i v e l y . Chetwynd and Fort Nelson each has 4,000 persons, Hudson's Hope and Cassiar each has about 2,000 persons (38). There are another 18,000 persons i n r u r a l areas and i n the small hamlets of Taylor, Pouce Coupe, Progress, Swan Lake, Rolla, Farmington, Buick Creek, Deas Lake, Good Hope Lake, Telegraph Creek and A t l i n , to name some of the small settlements. This t o t a l of 58,000 persons accounts for the o f f i c i a l population of the area. In addition, there are an estimated 20,000 persons i n the unorganized t e r r i t o r i e s engaged i n exploration and related work (38). The Peace River-Liard D i s t r i c t has a mixed economy. In the southern parts of the d i s t r i c t , farming and logging are major industries, whereas i n the north, mining and logging are important. The whole area i s r i c h i n energy resources as a r e s u l t of gas, o i l and coal deposits and fast flowing r i v e r s . Major corpora-tions such as B.C. Hydro, West Coast Transmission, and Canadian Forest Products and B.P. Gas provide employment - 45 -and a s t r o n g t a x base f o r some communities. P r e s e n t l y , e x t e n s i o n s t o t h e Peace R i v e r Dam e l e c t r i c p r o j e c t s and the development o f l a r g e c o a l and gas d e p o s i t s a r e under way. S i g n s o f r a p i d economic growth a r e e v i d e n t i n the r e c e n t appearance o f many new r e s t a u r a n t s and t h e i s s u i n g o f an i n c r e a s i n g number o f b u i l d i n g p e r m i t s . Support bus-i n e s s e s such as shopping m a l l s , t r u c k i n g f i r m s , m o t e l s , r e p a i r shops o f a l l t y p e s , hobby shops and t h e l i k e have commenced t r a d i n g i n t h e p a s t y e a r . D e s p i t e such economic growth t h e r e i s l i t t l e d i s p l a y o f w e a l t h . The fa r m e r s a r e dependent on c l i m a t i c con-d i t i o n s and th e y c l a i m t o be e a r n i n g m i n i m a l incomes. F u r t h e r , w h i l e l a r g e sums o f money a r e p r e s e n t l y b e i n g made by d e v e l o p e r s , many r e s i d e n t s a r e w i t h o u t phones and many c i t y and c o u n t r y r o a d s a r e not paved. As an i n t e r e s t i n g s i d e n o t e , t h e f u n d i n g b o d i e s o f t h e l o c a l c h u r c h es s t i l l c l a s s i f y t h e a r e a as a m i s s i o n a r y zone. 5.3 S o c i a l S e t t i n g and L i f e s t y l e The e t h n i c o r i g i n s o f t h e i n h a b i t a n t s a r e mixed. The major c e n t r e s have a l a r g e Anglo-Saxon component. I n the r u r a l a r e a s many European c o u n t r i e s a r e r e p r e s e n t e d w i t h l a r g e p o p u l a t i o n s o f Sudetans and H u t t e r i t e s i n t h e - 46 -s o u t h . I n d i a n s and M e t i s a r e s c a t t e r e d t h r o u g h o u t t h e d i s t r i c t . E l e m e n t a r y and secondary e d u c a t i o n a r e b o t h a v a i l a b l e t h r o u g h o u t t h e d i s t r i c t , b u t remote a r e a s use t h e f a c i l -i t i e s o f t h e l a r g e r c e n t r e s f o r h i g h e r e d u c a t i o n . There a r e community c o l l e g e s i n Dawson Creek, F o r t S t . John and Chetwynd p r o v i d i n g c o r e academic programs and a v a r i e t y o f community e d u c a t i o n c o u r s e s . S a t e l l i t e t e a c h -i n g i s a f e a t u r e o f t h e i r c u r r i c u l u m . A l a r g e number o f s t u d e n t s drop o u t o f s c h o o l i n grades seven, e i g h t and n i n e (39). The Peace R i v e r - L i a r d d i s t r i c t has a f u l l complement o f government and community r e s o u r c e s . A g e n c i e s such as t h e Government Agent, Human Re s o u r c e s , A g r i c u l t u r e , E nvironment, Highways, C h i l d Development C e n t r e s , A t t e n d -ance C e n t r e s and Woman's C e n t r e s a r e r e p r e s e n t e d . There i s e x c e l l e n t communication between a g e n c i e s . V a r i o u s h e a l t h programs a r e a v a i l a b l e i n a d d i t i o n t o H e a l t h U n i t a c t i v i t i e s . Though t h e r e a r e g e n e r a l - p h y s -i c i a n s and s p e c i a l i s t s , complex problems a r e f r e q u e n t l y r e f e r r e d t o major m e d i c a l c e n t r e s i n Edmonton and Van-c o u v e r . D e n t i s t s a r e a v a i l a b l e but th e y a r e n o t numer-ous and t h e r e i s o n l y one o r t h o d o n t i s t i n t h e a r e a . N u t r i t i o n a l p r a c t i c e s a r e i n need o f improvement as - 47 -evidenced by extensive dental caries (40) and low-birth-weight babies (41) . Self-breast examination c l i n i c s are conducted annually i n the major centres. Alcohol-related diseases are common i n t h i s area (42). At s o c i a l functions there are appreciable numbers of smokers. Seat belts are seldom used (43). Mortality figures (44) demonstrate an increase i n v i o l e n t deaths, including suicides, motor vehicle accidents and indus-t r i a l accidents over the past f i v e years.- In p a r t i c -u l a r , suicide rates are above those for the r e s t of the province (45) . Nevertheless there i s a p o s s i b i l i t y that some stress factors are lower i n t h i s area since people appear to move at a slower pace compared with the Vancouver area, and appear to be more relaxed and easygoing. Community s p i r i t appears to be p o s i t i v e and supportive throughout. Close friends and frequent s o c i a l gather-ings seem to be the rule rather than the exception. An appreciable number of the community engage i n outdoor a c t i v i t i e s such as hunting, f i s h i n g , snowmobiling, sk i i n g , g o l f i n g , hiking and motorcycling. The major centres have public swimming pools and skating and c u r l i n g r i n k s . There i s , however, l i t t l e evidence of jogging or c y c l i n g a c t i v i t y . - 48 -5.4 Organizational Design The B r i t i s h Columbia Ministry of Health i s a large corporate body responsible for the delivery of the public sector component of health services to the people of B r i t i s h Columbia. The organizational chart as i t existed at the time of the study i n 1979 i s depicted i n Figure 6. The Ministry i s a formalized structure of the bureaucratic type with central o f f i c e s i n V i c t o r i a , B.C. The branch of the Ministry of Health that delivers community health programs has a d i v e r s i f i e d and highly competent s t a f f i n the central o f f i c e responsible for administrative and consultative duties with respect to f i e l d a c t i v i t i e s (Figure 7). It operates i n the f i e l d by d i r e c t i n g seventeen health units spread through-out the province. The l i n e s of authority are v e r t i c a l s t a r t i n g with the Minister of Health and ending with the l i n e s t a f f i n the f i e l d . The span of control, that i s the number of s t a f f accountable to a superior o f f i c e r , increases down the l i n e and i s greatest i n the f i e l d . The i n t e l l i g e n c e system converges on the central o f f i c e . A l l information from the f i e l d i s compiled and entered into data banks including perceived needs, v i t a l s t a t -i s t i c s and program-performance data. Personnel records - 49 -MINISTER OF H E A L T H M I N I S T E a ' S O F F I C E E X E C U T I V E D I R E C T O R H E A L T H P R O M O T I O N & I N F O R M A T I O N O E P U T Y M I N I S T E R O E P U T Y MINISTER'S O F F I C E C H A I R M A N F O R E N S I C P S Y C H I A T R I C S E R V I C E S COMMISS ION C H A I R M A N A L C O H O L & D R U G COMMISSION E X E C U T I V E D I R E C T O R P L A N N I N G A N O D E V E L O P M E N T SENIOR A O M P R O F E S S I O N A L A N O I N S T I T U T I O N A L S E R V I C E S SENIOR A O M COMMUfJ I TY H E A L T H S E R V I C E S A O M SUPPOR T S E R V I C E S C H A I R M A N . M E D I C A L S E R V I C E S COMMISS ION A O M H O S P I T A L P R O G R A M S A O M C A R E S E R V I C E S AOM P R E V E N T I V E S E R V I C E S V A N C O U V E R 3 U R E A U E M E R G E N C Y H E A L T H S E R V I C E S MINISTRY OF HEALTH From 1979 Annual R e p o r t (47.p.VII) F i g u r e 6 C a r e S e t v i c e s U i r c c t o i r W d t 4 I I l e a l U t 0 1 1 f c t o i l . T C 1 H o m e C a t t O i i L - c t u i S | > e c i . i | C a i e S e r •> i c e s l i e * 11 It O i a t r i c t U l t e c t o i M e n i a l H e a l t h C d i U r e Dif e c i o r ( s ) A d m i r t l t W o iur L o n g T u r m C a t a C o o i d i n a i o r M u m a C a r d S C I I I O H hOH C o m « u n l t y l i e * 1 t h A D M P r e v e n t i v e S e r v i c e s S e n i o r o i i e c t o i P r e v e n t i v « S e t v i c e s D i r e c t o r M m s i no, O i i f c t o i f u b l i c l l t i l t h I n s p e c I. i o n D e n t J1 S e r v i c e ! O i c i c t o i S p e e c h I l i e A i 1 t i g O i 1 e c t o r £ | > l < i e f a i o l o 9 y A d m t n i s t i a t I v i C 0 0 1 d t n a t o r N u i »ing S u p e r v i s o r C o m m u n i t y H e a l t h N u n i i . u S t a f f ] f A d r n i n l i D i i l i v e O f f i c e r O M i c o S u p e r v i s o r Ctnr lca l S t a f f A O M V a n c o u v e r B u r e a u O i r c c t o r L a b o r a t o r i e s 01 l e c t o r T A C o n t r o l D i r e c t o r V O C o n t r o l Ad™ ( n i t e r a t - O f P e a r t o n l l u a p i t a O i t e c t o r C o m m o n i t y V o c a t 1 o n * I R e h a b t I i L a t i o S « r v i c e s C h i e f H e a l t h 1 o s p e c t o r I m p a c t i o n s ! S t a f f D e n t a l P r o g r a m S t a f f S p e e c h & H e a r i n g S l o l f O t h e r R e s o u r c e S t a f f E x e c u i 1 v * O l i e c i o i H i a 1 i h b i i . . c t i . i N ' t 1 11 . 1 o COMMUNITY HEALTH ORGANIZATION F i g u r e 7 - 51 -are also stored c e n t r a l l y . Program planning for the province i s one of the functions of central o f f i c e . Also the central o f f i c e writes the acts, p o l i c i e s and regulations used i n the d a i l y operations of the p e r i -pheral health units. Identical operative instructions are sent to a l l health units, which are thus operation-a l l y s i m i l a r . Each public health unit i n B r i t i s h Columbia i s struc-tured according to p o l i c y manuals received from the central o f f i c e (45) . The d i v i s i o n a l heads in each health unit are responsible for d e l i v e r i n g an ordered set of health programs. The l o c a l d i v i s i o n a l leaders are accountable to dual authority as they report to the health unit d i r e c t o r i n the f i e l d and to the d i v i s i o n a l head i n central o f f i c e . This type of organizational structure d i l u t e s the power of the health unit d i r e c t o r as well as that of the d i v i s i o n a l head. However the dual accountability ensures the adherence to established p o l i c y as i t minimizes "individualism" ..on the part of the d i r e c t o r . Line s t a f f , that i s those s t a f f d e l i v e r i n g primary care and supportive services such as the public health nurses and the secretaries, are expected to conduct a l l pro-grams of t h e i r d i v i s i o n as detailed i n the p o l i c y manu- .. a l s . There i s very l i t t l e r otation of assignments. - 52 -Only r a r e l y does any organizing of projects occur s t r i c -t l y at the l o c a l l e v e l and when i t does i t i s usually i n response to a request by the central o f f i c e . How-ever, there i s some encouragement of innovation i n p r i n c i p l e since the p o l i c y manuals mention that adapta-ti o n of programs to l o c a l conditions i s occasionally necessary (46). The group process i s encouraged by having d i v i s i o n a l and mixed d i v i s i o n a l meetings: both at the central and the l o c a l l e v e l . Regional meetings-are also held. These meetings-usually are intended to promote information exchange, face-to-face encounter, and the tablin g and discussion of problems a r i s i n g from the delivery of established programs. On rare occasions l o c a l , regional and central discussion can influence central p o l i c y through the promotion of resolutions which are presented to higher le v e l s of government. The Ministry of Health places emphasis on profession-a l i z a t i o n and education i n structuring authority l e v e l s and pay scales. The Ministry of Health i s of course highly centralized with attendant formalization and regulation. Time, money, material, and personnel are resources that are allocated primarily by the central o f f i c e with very - 53 -l i t t l e l o c a l control over and above the routine needs. Budgeting r e l i e s heavily on the evaluation of the needs of previous years. Any attempt to achieve some reassign-ments of resources requires the invocation of intensive lobbying and p o l i t i c a l pressure. Although p o l i t i c a l systems and processes are an i n t e g r a l part of the changes which take place i n the health delivery process even they have d i f f i c u l t y i n changing the routine pro-gram delivery as set down by established p o l i c y . F i n a l l y , the organizational design of the Ministry of Health i s seldom characterized by any d e f i n i t e incen-t i v e system for encouraging motivation to change or innovate. The primary reward systems are long term i n the form of pensions and salary increments. These l a t t e r are usually awarded by s e n i o r i t y and/or through r e c l a s s i f i c a t i o n obtained by winning competitions and by additional educational e f f o r t s . - 54 -6.0 Results 6.1 Introduction The progress notes made by myself during the study are lengthy and not reproduced here. The s t a f f question-naire with responses i s reproduced i n Appendix B. A l l forms and communications used i n the program design, implementation and evaluation of effectiveness are a v a i l -able on request; a sampling of these are reproduced i n Appendix D. The completed•questionnaires are not reproduced as they must be protected by con-f i d e n t i a l i t y considerations. The following observations are l a b e l l e d to coincide with the l a b e l l i n g used for 2.3 of the methodology section where the items for examination are l i s t e d . My personal observations, i n most cases, were c o i n c i -dental with the perceptions of the s t a f f as answered in the questionnaire. Thirty out of the t h i r t y - f i v e who were sent question-naires responded. This i s a response rate of 85.7%. The reason that forty-one questionnaires were not d i s -tributed i s that during the f i v e months HHA-PRHU was - 55 -i n e f f e c t there were s t a f f changes. Only those s t a f f reasonably active i n the HHA-PRHU were contacted. 6.2 The Outcome of HHA-PRHU 6.2.1 The HHA-PRHU Plan The plan as presented to me by the Program Manager (PM) was set down as follows: "HHA w i l l be presented to the community i n a num-ber of ways. F i r s t HHA w i l l be shown to c l i e n t s i n the Health Unit by waiting room displays and ind i v i d u a l approaches by Health Unit s t a f f . Sec-ondly HHA w i l l be presented to community groups such as TOPS, college groups and a t h l e t i c groups. Thirdly there w i l l be mall displays i n shopping centres with presentations by Health Unit per-sonnel. F i n a l l y there w i l l be newspaper, radio and t e l e v i s i o n advertising of HHA with encourage-ment to come to the Health Unit and pa r t i c i p a t e i n HHA. Completed HHA forms w i l l be placed i n HHA receiv-ing boxes. These boxes w i l l be placed i n s t r a -tegic locations such as the Health Unit waiting rooms, shopping mall, medical c l i n i c s and physi-cians' waiting rooms, and wherever else i t appears opportune. Health Unit personnel w i l l empty the boxes p e r i o d i c a l l y and send HHA forms i n batches to the Division of Health Systems, UBC for pro-cessing . Returned printouts w i l l be summarized by Health Unit personnel, i n writing, and mailed to c l i e n t s . With the summary a resource l i s t w i l l be included d i r e c t i n g c l i e n t s to resources capable of meeting the needs indicated by the printout. In addition, the c l i e n t w i l l be encouraged to seek personal counselling by the Public Health Nurses at the Health Unit, either i n d i v i d u a l l y or i n groups. The s t a f f of the Health Unit w i l l be given i n -service t r a i n i n g about the HHA method i n the form of HHA l i t e r a t u r e handouts. A resource person - 56 -from the Di v i s i o n of Health Systems, UBC, Van-couver w i l l be i n v i t e d to de l i v e r an in-service lecture on the HHA method. HHA-PRHU w i l l be delivered for one month, on a p i l o t project basis, i n Dawson Creek, After that i t w i l l be extended to a l l Health Unit o f f i c e s for a further four months. If HHA-PRHU enters the present delivery system smoothly i t w i l l re-main as a Health Unit program. Evaluation of the effectiveness of the HHA method in changing l i f e s t y l e , as delivered by the PRHU, w i l l be carr i e d out by h i r i n g a summer student to interview participants i n the HHA method. The evaluation method w i l l be modeled a f t e r that of Prince et a l . at UBC (26). To a s s i s t i n t h i s evaluation there w i l l be a form attached to a l l HHA forms requesting data necessary to ensure further contact. The public health nurses w i l l be the prime users of HHA although a l l s t a f f w i l l be encouraged to deli v e r HHA. Support s t a f f such as the clerks w i l l be used to d i s t r i b u t e information and ques-tionnaires and to promote p a r t i c i p a t i o n i n HHA. There w i l l be a form for recording data about the number of HHA's performed as well as the number of l i f e s t y l e changes recommended. The objective of the HHA-PRHU w i l l be to perform 1000 HHA's i n the f i v e month i n t e r v a l . " Note that the plan proposed by the PM did not include methods for surveillance of the delivery system with respect to ease of delivery, methods of delivery, ob-stacles to delivery, community compliance and so for t h . Nor did the plan include methods to be used for decision making with respect to a l t e r i n g plans to adjust to imper-fections i n the delivery system. That i s , there were no feedback or governing mechanisms i n the plan, allowing for in-course modifications. - 57 -6.2.2 The Actualization of HHA-PRHU Actual implementation of the HHA-PRHU program was d i f f e r e n t from the plan presented i n the previous section. Waiting room displays were present i n a l l the Health Unit o f f i c e s . There were no mall displays. There was no radio or T.V. advertising but there were two newspaper a r t i c l e s on HHA-PRHU i n Dawson Creek and two i n Cassiar. However, there was very l i t t l e i n d i v i -dual contact about HHA i n the larger centres. In the smaller centres, however, the HHA method was discussed between the c l i e n t s and professionals quite frequently. HHA was presented to the leaders of TOPS, the Smoking Cessation Program, Alcohol and Drug Services, the Ski Club, the Bowling A l l e y and the Speed Skating Club at a lecture i n the Dawson Creek o f f i c e one evening. This was not done i n any other communities. The HHA receiving boxes were placed i n Dawson Creek and Fort St. John i n the waiting rooms. They were not placed i n the other centres or i n c l i n i c or physicians' waiting rooms, or i n any shopping malls. The receiving boxes i n Dawson Creek and Fort St. John were not used. The f i r s t set of computer printouts for Dawson Creek and Fort St. John were summarized by Health Unit nurses and mailed to the c l i e n t s . However, t h i s was soon - 58 -stopped as the s t a f f f e l t i t was too expensive and lacked personal c l i e n t contact. The smaller centres never t r i e d the mailing method. There was some per-sonal counselling i n Dawson Creek and Fort St. John; in the smaller o f f i c e s there was considerable personal counselling. There were no group sessions held i n any o f f i c e s . The in-service education took place as planned. HHA l i t e r a t u r e was c i r c u l a t e d to the s t a f f . Dr. John Milsum, Director, D i v i s i o n of Health Systems, UBC came to the PRHU and delivered a lecture on the HHA method to the nursing s t a f f . The t o t a l number of HHA forms processed i n the fi v e month period was 108, broken down as follows: Dawson Creek, 8; Fort St. John, 9; Chetwynd, 11; Fort Nelson, 27; and Cassiar, 53. Personal counselling was performed on a few c l i e n t s i n Dawson Creek and Fort St. John. Personal counselling was performed on a l l c l i e n t s i n Chetwynd, Fort Nelson and Cassiar. The data sheet for recording the number of HHA's done and the number of l i f e s t y l e changes suggested was not used. An evaluation of the effectiveness of the HHA method in inducing change i n l i f e s t y l e was performed by the - 59 -nurses three months a f t e r the cessation of the d e l i v -ery of HHA-PRHU. At no time were there any s p e c i f i c task groups or com-mittees formed to monitor the delivery or help i n the decision making. The already established senior s t a f f meeting and the regular weekly nurses' meetings were used as vehicles for communication. 6.3 The Confounding Factors 6.3.1 The S u i t a b i l i t y of HHA-PRHU (i) I did not see signs of disruption of health unit routine as a d i r e c t r e s u l t of the delivery of HHA-PRHU. The s t a f f , in question 24 to 29 of section 1 of the questionnaire, also indicate that there was no disruption. Only 7/30 per-ceived more time spent with other s t a f f members. 2 3/30 perceived no time l o s t from other programs. Only one person perceived a disruption i n the normal routine of the o f f i c e and 5 indicated they worked harder and longer as a re s u l t of HHA-PRHU. Some of the c l e r i c a l s t a f f (questions 1-3, part 3) perceived an increase in time spent t a l k i n g with c l i e n t s but most of them noted no increase i n typing, answering the - 60 -telephone or i n photocopying. None of the s t a f f perceived an increase i n patient waiting time or the displacement of other duties. ( i i ) In questions 2-5, part 3 of the questionnaire, the nurses indicate that there was only l i t t l e d i f f i c u l t y i n d e l i v e r i n g HHA-PRHU. 3/11 had d i f f i c u l t y p r i o r i z i n g HHA with respect to other programs. Only 1/11 of the nurses found HHA 1 d i f f i c u l t to use. None of the nurses f e l t un-comfortable opening the subject of HHA to c l i -ents. However, 5/11 of the nurses forgot to mention HHA to c l i e n t s because they were con-centrating on other tasks. In addition, 5/11 of the nurses f e l t they would l i k e more t r a i n i n g i n the use of HHA perhaps i n d i c a t i n g they were not as comfortable with the use of HHA as they apparently believed by th e i r response to ques-tion 3, part 2 (10/11 did not have any d i f f i c u l t y using HHA). ( i i i ) The answers to questions 6-8, part 1 (30/30, 30/30 and 29/30) state that the s t a f f members perceived that they were aware of the new pro-gram and comprehended the HHA method and the method of delivery. -61 -(iv) In question 9, part 1, a l i t t l e l ess than half of the respondents f e l t that HHA-PRHU met the goals of the PRHU. However, questions 10 to 12 indicate that the s t a f f were quite clear about the objectives of the HHA-PRHU i n the PRHU. 25/30 stated that the objectives of HHA-PRHU were c l e a r l y defined, while 22/30 f e l t the ob-jectives of the PRHU were c l e a r l y defined. Also 19/30 r e a l i z e d that one of the objectives of HHA-PRHU was to do as many HHA's as possible. (v&vi) In response to question 30, part 1, more than half of the s t a f f (17/30) perceived HHA-PRHU as compatible with t h e i r job descriptions. Of the rest, 5 were undecided and only 8 f e l t HHA-PRHU was incompatible. In question 31, part 1, some of the s t a f f (7/30) f e l t that HHA-PRHU had actu-a l l y made th e i r job more enjoyable. Question 32 shows that 2 3/30 found they were more aware of the re l a t i o n s h i p of l i f e s t y l e to health. It i s in t e r e s t i n g to note that 7/30 counselled, which would be more than half of the public health nurses, while 10 out of 30 processed forms and 13 handed out forms. So although the program was compatible with job descriptions the majority of the personnel of the Health Unit - 62 -was not involved i n the delivery of the program. Question 36, part 1 shows that only one s t a f f member counselled more than f i f t e e n c l i e n t s . (vii) The s u i t a b i l i t y of the HHA method as a method for inducing l i f e s t y l e change and as a " f i t " for the Public Health Unit i s reviewed i n chap-ter 4. ( v i i i ) The s t a f f f e l t that the $2.00 charge for pro-cessing the HHA form was a deterrent to the successful implementation of HHA. See question 7, part 2 and comments by the nurses and by the clerks. 6.3.2 The Experience and Attitudes of Staff of the PRHU (i) The average length of stay with the B r i t i s h Columbia Ministry of Health was 5.6 years. However, the l i n e s t a f f , e s p e c i a l l y the nurses, on the average had between one and two years' experience. ( i i ) The average length of service with the PRHU was 4.8 years. - 63 -( i i i ) Questions 33 to 39 of part 1 would indicate an int e r e s t i n l i f e s t y l e modification by the s t a f f . 20 out of 30 talked about HHA to c l i e n t s . About half of the s t a f f talked about HHA at s o c i a l functions and offered HHA to friends and family. The f a c t that 24/30 of the s t a f f made l i f e s t y l e changes themselves indicated an int e r e s t i n l i f e -s t y l e modification. (iv) The attitudes about HHA-PRHU I would consider excellent as far as the philosophy of the pro-gram i s concerned. 24/30 indicated they would l i k e to see the HHA-PRHU stay i n the Health Unit (see question 35, part 1 ) . 6 were undecided and no one wanted i t dropped. I observed good a t t i -tudes about HHA i t s e l f . Many of the s t a f f ex-pressed i n t e r e s t i n knowing about themselves with respect to HHA. However, at lea s t four senior s t a f f asked me for proof that HHA was e f f e c t i v e i n inducing l i f e s t y l e change. (v) The s t a f f appeared w i l l i n g to change as i n d i c a -ted by the fac t that question 33 shows that there were 48 l i f e s t y l e changes reported i n a s t a f f of 30 during the operation of HHA-PRHU. As well, at the beginning of HHA-PRHU the majority of the - 64 -st a f f expressed a desire to pa r t i c i p a t e i n HHA-PRHU. The s t a f f who seemed the most r e l u c -tant to pa r t i c i p a t e i n HHA-PRHU were the sen-i o r s t a f f e s p e c i a l l y the PM. (vi) The PRHU s t a f f as a whole are quite e f f e c t i v e i n d e l i v e r i n g programs as indicated by th e i r excellent performance i n th e i r mandatory pro-grams. The l e v e l of education of the s t a f f i n i t s e l f would predict e f f e c t i v e performance. (vii) The s t a f f has had l i t t l e t r a i n i n g i n designing new programs. Except for the di r e c t o r , none of the s t a f f had been trained i n planning, de-sign, or methods of evaluating the effectiveness of programs. 6.3.3 The Nature of the External Environment (i) The need for a l i f e s t y l e modification technique for the community i s evidenced i n the material discussed i n chapters 4 and 5 of th i s study. ( i i ) The s t a f f (question 22, part 1) indicate that 8/30 perceived the program being accepted by the c l i e n t s and community, 12 were undecided and 10 perceived i t as not being accepted. Although - 65 -th i s indicates a reluctance on the part of the community to change, i t does indicate at least some in t e r e s t i n the topic of l i f e s t y l e change. Question 23 indicated that HHA was offered by other organizations i n the PRHU catchment area during the operation of HHA-PRHU. Investigation showed that indeed Action B.C. was o f f e r i n g HHA as part of the i r program for a short time i n a few northern communities. Staff also indicated that community i n t e r e s t was lagging because there was not enough advertising about HHA-PRHU (see question 21, part 1, and the comments of the clerks and nurses i n parts 2 and 3). 6.4 The Organizational C h a r a c t e r i s t i c s 6.4.1 Leadership It was my observation that leadership was not c l e a r l y defined i n the HHA-PRHU. The s t a f f , although t o l d the PM was i n charge, were at times confused and looked to myself for guidance and d i r e c t i o n . I t r i e d to discour-age any reliance on my p a r t i c i p a t i o n except for consult-ative services. Nineteen of the 30 respondents to ques-tion 20 of the questionnaire indicate that leadership was c l e a r , 6 were undecided and 5 perceived leadership as not being c l e a r . Although question 17 indicates that - 66 -29 o f 30 tho u g h t ( c o r r e c t l y ) , t h a t 1/ i n t r o d u c e d HHA-PRHU, o n l y 21 o r 66% knew t h a t t h e PM was i n charge o f i m p l e -m enting the program and o n l y 12 o r 32% knew t h a t t h e PM was i n charge o f s u p e r v i s i n g t h e program (see ques-t i o n s 18, 19, p a r t 1 ) . 6.4.2 The I n t e l l i g e n c e System I d i d n o t ob s e r v e any system f o r g a t h e r i n g o r s t o r i n g d a t a . There was communication o f r e s u l t s between s t a f f v e r b a l l y b u t I o b s e r v e d t h i s i n f r e q u e n t l y . No r e c o r d s were k e p t and no feedback from t h e community was c o l -l e c t e d . P r o b a b l y t h e l a r g e s t amount o f r e c o r d i n g was done by m y s e l f i n t h e form o f p r o g r e s s n o t e s . However, I d i d not show t h e s e t o t h e s t a f f . 6.4.3 The D e c i s i o n Making Systems There were no f o r m a l new groups e s t a b l i s h e d o r t e c h n i -c a l a p p a r a t u s used f o r d e c i s i o n making. D e c i s i o n s were o f an i n c r e m e n t a l c h a r a c t e r and u s u a l l y made e i t h e r by th e PM h e r s e l f o r by t h e PM i n o c c a s i o n a l c o n s u l t a t i o n w i t h the a l r e a d y e s t a b l i s h e d committees o f t h e s e n i o r s t a f f o r t h e n u r s e s ' m e e t i n g s , o r w i t h m y s e l f . - 67 -6.4.4 The Communication Systems There were no formal structures for communicating ex-cept verbal, either by d i r e c t conversation or telephone. There were no information exchange meetings except the established ones, i . e . senior s t a f f and nurses' weekly meetings. There were no motivation techniques used to encourage the p a r t i c i p a t i o n i n HHA-PRHU except the nebulous one of pleasing the direct o r and the PM. If anything, the pa r t i c i p a t i o n i n HHA-PRHU was actually discouraged by senior s t a f f and central o f f i c e with d i r e c t i o n being given to put emphasis on the established programs. The planning was done mainly by the PM i n consultation with myself, the nurses and the senior s t a f f occasion-a l l y . Planning was incremental, innovative, develop-mental and not involving p o l i t i c a l or t r a d i t i o n a l struc-tures. Planning was a r e s u l t of unbounded r a t i o n a l i t y of thought despite the demonstrated need for change. The community did not indicate a desire to change at th i s time. 6.4.5 Motivation Techniques 6.5.6 Planning Techniques - 68 -6.4.7 C o n f l i c t and C o n f l i c t Resolution I observed a considerable amount of c o n f l i c t p a r t i c u -l a r l y i n the d i f f e r i n g opinions as to whether or not HHA-PRHU should be i n the Health Unit at t h i s p a r t i c -u l a r time. C o n f l i c t situations arose both within s t a f f members as ind i v i d u a l s , between s t a f f and the PM, and between the health unit d i r e c t o r and the PM. There was also c o n f l i c t between the health unit and central o f f i c e . Although there was agreement that programing should r e f l e c t l o c a l issues the opponents to the pro-gram were i n s i s t e n t that e x i s t i n g programs must be pre-served before tr y i n g new ones. Many s t a f f members t o l d me that there was not enough time to f i t HHA-PRHU into t h e i r busy schedules. They f e l t th'at the established programs would suffer i f they spent a l o t of time on HHA-PRHU. In question 13, p a r t i , 13 of 30 of the s t a f f perceived c o n f l i c t within themselves when HHA-PRHU was introduced into the PRHU. In question 15, 14/30 perceived c o n f l i c t within the r e s t of the PRHU s t a f f . There were not any established groups for reporting t h i s c o n f l i c t s p e c i f i -c a l l y . If i t was done at the nurses' meetings or senior s t a f f i t was not when I was there. Questions 14 and 16 were answered in d i c a t i n g that the s t a f f perceived - 69 -a resolution of t h i s c o n f l i c t through informal meet-ings i n most cases, although some perceived the pass-age of time, discussion with senior personnel and bet-ter understanding of the program as being of help. One in d i v i d u a l sought outside counselling. I f e l t that a l l the c o n f l i c t was not resolved u n t i l a l l p a r t i c i p a t i o n i n HHA-PRHU had been stopped. HHA-PRHU continued to be a controversial issue throughout and never completely accepted by the s t a f f . C o n f l i c t disappeared with time es p e c i a l l y after the abandonment of the program. 6.4.8 The Central Office Response Central o f f i c e response was e l i c i t e d early i n the pro-gram by the s t a f f . We did not receive any written advice or comments about the program i n response to written requests for guidance. However, I had two phone c a l l s from my d i r e c t superior asking me what I was doing and why. Although my superior agreed that l i f e s t y l e modification was important and that there should be l o c a l i n i t i a t i v e to adapt to regional condi-tions, he f e l t that e x i s t i n g programs and harmony should have p r i o r i t y i n program considerations. At no time, however, was I advised to d i r e c t the PM to stop d e l i -very of HHA-PRHU. - 70 -6.5 Discussion The Peace River Health Unit f a i l e d to accept the innovative task assigned to i t . Although the i n i -t i a l response of the s t a f f was enthusiastic, there ' were reservations regarding the use of HHA-PRHU i n the health unit. There was considerable c o n f l i c t and the actual output of 108 HHA forms was far below the objective of.1000 forms. The health unit formulated a plan of action, not sophisticated, but i n d i c a t i v e of a response as assessed by the displays and the newspaper a r t i c l e s and the formulated plan, i n writing, as well as the interdepartmental memorandums and the 10 8 completed HHA forms. The i n i t i a l response of the health unit was short-l i v e d , however, and as enthusiasm waned and as pres-sures mounted, both from senior s t a f f to maintain e x i s t i n g programs and from the d a i l y operative prob-lems, the program p r i o r i t y dropped u n t i l f i n a l l y i t was abandoned. - 71 -The question I am attempting to answer i s : Of the following factors, which contributed most:, to the innovative f a i l u r e ? 1. The s u i t a b i l i t y of HHA-PRHU 2. The experience and attitudes of the s t a f f of the PRHU 3. The nature of the external environment 4. The organizational c h a r a c t e r i s t i c s 6.5.1 The S u i t a b i l i t y of HHA-PRHU My observations, the s t a f f perceptions and the l i t e r a -ture overview i n chapter 4 a l l agree that HHA-PRHU i s suitable for use i n the PRHU. It was not a disruptive program, i t had goal congruence with the PRHU and the s t a f f , i t i s easy to understand and de l i v e r , and i s suitable with respect to job descriptions. Most of the s t a f f perceived i t as being a program that merited permanent incl u s i o n i n the PRHU delivery system. One major objection was the $2.00 charge for processing the form. However, Kane (48) has observed that even at zero cost, many health services are not consumed. Another strong objection i s that HHA-PRHU did not i n -clude a strong enough advertising campaign. However in Chetwynd and Fort Nelson there was no advertising but a s i g n i f i c a n t number of HHA's performed. This - 72 -would indicate that word of mouth and professional-c l i e n t advertising are e f f e c t i v e tools, i n the promo-ti o n of HHA. 6.5.2 The Experience and Attitudes of Staff of the PRHU The s t a f f were adequately educated to d e l i v e r HHA and the senior s t a f f were experienced. However, the l i n e s t a f f did not have a working knowledge of a l l e x i s t -ing programs to the extent that they were able to eas-i l y p r i o r i z e the HHA-PRHU program. This could have been overcome with senior s t a f f guidance and d i r e c t i o n and encouragement coupled with a few "think tanks" on HHA. The most inexperienced and the least educated l i n e s t a f f nurse was the nurse i n Cassiar, where the most HHA's were performed. This i s compatible with Corwin 1s statements (1), that s t a f f members are more l i k e l y to be innovative i f they are l i b e r a l , creative and uncon-ventional outsiders with fresh ideas and perspectives. However, i t became apparent at a l a t e r date that the delivery of e x i s t i n g programs i n Cassiar suffered con-siderably during the time HHA-PRHU was i n e f f e c t ; to the extent that the p a r t i c u l a r s t a f f member was eventu-a l l y replaced by a more experienced and more highly trained nurse. - 73 -The attitudes of the s t a f f favoured the HHA-PRHU. There was a d e f i n i t e i n t e r e s t i n l i f e s t y l e modifica-t i o n as evidenced by the l i f e s t y l e changes of the s t a f f . This could also indicate a willingness to change and pa r t i c i p a t e i n the delivery of HHA-PRHU as i t could mean the s t a f f were using the exemplar technique i n counselling c l i e n t s . 6.5.3 The Nature of the External Environment The external environment demonstrated a need for change (see chapters 4 & 5 ) . However the s t a f f did not per-ceive a willingness on the part of the c l i e n t s of the PRHU to change (see comments part 2 of questionnaire by the nurses). In addition they f e l t the c l i e n t s were a f r a i d of the res u l t s and did not want to change t h e i r l i f e s t y l e . They thought there was low motivation on the part of the c l i e n t s . I f i n d t h i s a d i f f i c u l t item to resolve. In p a r t i c u -l a r I have d i f f i c u l t y assessing the willingness of a community to change e s p e c i a l l y where there i s no moti-vation such as pain or discomfort a f f e c t i n g the members of that community. Many c l i e n t s probably have the " i t can't happen to me" attitude; some c l i e n t s can be l a b e l -led as the "worried well", which i s a motivating factor. - 74 -I b e l i e v e , however, t h a t t h e onus i s on a new program t o r e a c h o u t t o t h e community and a l t h o u g h , on o c c a s i o n , a program f a i l u r e can be a t t r i b u t e d t o a d i s i n t e r e s t e d c l i e n t e l e , I t h i n k i t i s more a p p r o p r i a t e t o examine t h e program i t s e l f w i t h r e s p e c t t o i t s e f f e c t i v e n e s s i n r e a c h i n g t h e community. 6.5.4 The O r g a n i z a t i o n a l C h a r a c t e r i s t i c s I b e l i e v e t h e f a i l u r e o f t h e PRHU t o adopt HHA-PRHU i n t o t h e PRHU was a r e s u l t o f f a i l u r e o f t h e o r g a n i z a -t i o n a l d e s i g n and the p l a n n i n g methods. E i t h e r t h e e x i s t i n g o r g a n i z a t i o n a l d e s i g n was n o t used p r o p e r l y o r the p r e s e n t o r g a n i z a t i o n a l d e s i g n i s not c o n d u c i v e t o i n n o v a t i o n . S i g n i f i c a n t - d e f i c i e n c i e s n o t e d i n t h e o r g a n i z a t i o n a l d e s i g n were: ( i ) The l e a d e r s h i p was poor because o f t h e l a c k o f t e c h n i c a l s t a f f f r e e o f a d m i n i s t r a t i v e d u t i e s . ( i i ) There were no i n t e l l i g e n c e o r d e c i s i o n making systems a t t h e l o c a l l e v e l . ( i i i ) The communication between s t a f f was i n a d e q u a t e . ( i v ) There were no m o t i v a t i n g t e c h n i q u e s . - 75 -(v) There were no methods f o r r e s o l v i n g c o n f l i c t . ( v i ) There were no t a s k o r i e n t a t e d groups f o r moni-t o r i n g and r e d i r e c t i n g program d i r e c t i o n t h r o u g h adequate r e p l a n n i n g . ( v i i ) A l t h o u g h we a r e d e a l i n g w i t h a m e c h a n i s t i c o r -g a n i z a t i o n t h e power o f t h e d i r e c t o r i s -usurped by the f a c t t h a t s e n i o r s t a f f can r e p o r t d i r e c t l y t o s e n i o r p e r s o n n e l i n c e n t r a l o f f i c e and bypass the d i r e c t o r . / ( v i i i ) P l a n n i n g was a d a p t i v e , i n n o v a t i v e and a r e s u l t o f unbounded, a l b e i t r a t i o n a l , t h o u g h t . To be p r o p e r l y i n s t i t u t e d t h e program needed, t h e r e ^ f o r e , t h e s u p p o r t o f p o l i t i c a l f o r c e s and t h e s u p p o r t o f c e n t r a l o f f i c e t o overcome t h e t u r b u -l e n c e c r e a t e d by t h i s d i s r u p t i v e t y p e o f p l a n -n i n g (see c h a p t e r 3 ) . 6.5.5 The R o l e o f the D i r e c t o r The f a c t t h a t t h e D i r e c t o r and M e d i c a l H e a l t h O f f i c e r f o r t h e Peace R i v e r H e a l t h U n i t was, as w e l l , t h e e v a l u a t o r o f t h e e v e n t u a l outcome o f HHA-PRHU s h o u l d n o t have i n f l u e n c e d t h i s i n n o v a t i v e a t t e m p t u n f a v o u r -a b l y . The d i r e c t o r i n a h e a l t h u n i t c o - o r d i n a t e s , and a c t s as a r e s o u r c e f o r , t h e v a r i o u s programs. As such he/she - 76 -does not become a leader i n s p e c i f i c programs except i n unusual circumstances. The s t a f f are aware of my int e r e s t i n l i f e s t y l e modi-f i c a t i o n programs as well as my concern that these programs are not a c t i v e l y pursued i n the public health units, despite the urgent need. Therefore, although I maintained a passive role i n the leadership and de-l i v e r y of HHA-PRHU, there were few s t a f f members who did not know that I was anxious to have HHA-PRHU be-come a permanent part of the PRHU health care delivery system. - 77 -7.0 Conclusions 7.1 Introduction This study has demonstrated that a new program, HHA-PRHU, when introduced into the Peace River Health Unit, was not accepted into the ex i s t i n g delivery system of health care services offered by the Health Unit. HHA-PRHU was shown to be a program which i s a suitable " f i t " into the Peace River Health Unit. As well, HHA-PRHU i s a program designed to meet an urgent need in the community. F i n a l l y the s t a f f of the PRHU were shown to have the s k i l l s necessary to adequately d e l i v e r the active component of the delivery system of HHA-PRHU; that i s , the HHA method. The HHA-PRHU was not accepted because of the nature of the organizational design of the PRHU and the nature of the planning methods used i n the context of t h i s e x i s t i n g organizational design. 7.2 Organizational Design of the PRHU-Deficiencies 7.2.1 The PRHU i s a part of the B r i t i s h Columbia Ministry of Health which has been shown to be a mechanistic organization. However, innovation requires such - 78 -o r g a n i z a t i o n a l a s p e c t s a s d e c e n t r a l i z a t i o n , a low d e -g r e e o f f o r m a l i z a t i o n , f r e e c o m m u n i c a t i o n , p r o j e c t o r g a n i z a t i o n , r o t a t i o n o f a s s i g n m e n t , a g r e a t e r r e l i -a n c e on g r o u p p r o c e s s e s and a c o n t i n u a l r e s t r u c t u r i n g o f t h e i n c e n t i v e s y s t e m (11, 12). T h e s e a s p e c t s a r e t h e c h a r a c t e r i s t i c s o f o r g a n i s t i c , n o t m e c h a n i s t i c , o r g a n i z a t i o n s . 7.2.2 T h e r e a r e few o f t h e c h a r a c t e r i s t i c s o f modern o r g a n -i z a t i o n a l d e s i g n p r e s e n t a t t h e l o c a l l e v e l t o enhance i n n o v a t i v e a t t e m p t s . T h e r e a r e no e s t a b l i s h e d i n t e l -l i g e n c e , d a t a c o l l e c t i n g o r s o p h i s t i c a t e d d e c i s i o n mak-i n g s y s t e m s . As w e l l , t h e s t r a t e g i c components o f t h e h e a l t h u n i t ( t h e d i v i s i o n s ) a r e o n l y l o o s e l y i n t e g r a t e d by i l l - d e f i n e d c o m m i t t e e s . 7.2.3 T h e r e i s no method f o r t h e a l l o c a t i o n o f r e s o u r c e s a t t h e l o c a l l e v e l . B u d g e t s , p e r s o n n e l , ' b u i l d i n g and v e -h i c l e a l l o t m e n t a r e done a t a c e n t r a l l e v e l . 7.2.4 T h e r e a r e no i n c e n t i v e s a t t h e l o c a l l e v e l . The g o a l s and i d e o l o g i e s o f t h e M i n i s t r y o f H e a l t h o u t l i n e a n e e d t o a d a p t t o c h a n g i n g c o n d i t i o n s i n t h e e x t e r n a l e n v i r o n -ment. However, t h e r u l e s and r e g u l a t i o n s and p o l i c y m a n u a l s d i c t a t e t h a t t h e s t a f f a d h e r e t o e x i s t i n g p r o -grams. T h i s e n c o u r a g e s t h e s t a f f t o f o l l o w t h e i r - 79 -inherent tendency to avoid innovation. Instead of proceeding with innovation the s t a f f t r y to protect the present delivery system to avoid the loss of past investments. The s t a f f , with no incentive system, no access to re-sources, no available information with respect to the s k i l l s necessary to adapt to change, no operating rules governing the analysis and flow of information within the system and f i n a l l y , an emphasis to remember rather than forget previously learned solutions, i s very re-sis t a n t to change. 7.2.5 There are few methods formally established at the l o c a l l e v e l to handle the c o n f l i c t which arises i n the case of l o c a l i n i t i a t i v e . As well, the methods that are available, mainly through senior s t a f f and d i v i s i o n a l meetings, and access to l o c a l supervisors are not prop-e r l y used i n the Peace River Health Unit for c o n f l i c t r esolution. C o n f l i c t situations are usually avoided at these meetings. The present methods used to resolve c o n f l i c t are to appeal to central o f f i c e and p o l i t i c a l bodies for d i r e c t i o n , and for regulations and orders which w i l l hopefully resolve t h i s c o n f l i c t . These orders and directions do not arrive quickly. As a re-s u l t c o n f l i c t i s often not resolved. - 80 -7.2.6 F i n a l l y , planning at the l o c a l l e v e l i s not feasi b l e because the PRHU i s part of a larger system. The B r i t i s h Columbia Ministry of Health i s a functioning unit and for the health unit to disregard the other parts of the larger system i s to court disaster, i . e . l o c a l plans w i l l not be implemented. As well, a gov-ernmental structure such as the PRHU i s c l o s e l y a l l i e d to the p o l i t i c a l systems involved i n the s o c i a l and economic structure of the province of B r i t i s h Columbia and thus the PRHU should involve p o l i t i c a l bodies i n the plans for change. P a r t i c u l a r l y i s t h i s true i f the introducing of change i s done i n an innovative and developmental fashion such as was the case with HHA-PRHU. As well, the fact that many health programs may meet the needs of the s o c i a l structure but not neces-s a r i l y the wants of the community, warrants a need for p o l i t i c a l involvement i n the decision making processes when planning for change. 7.3 Organization Design - How to Innovate i n the PRHU 7.3.1 Using the Present Organizational Design 7.3.1.1 The leadership of the program should be established so that the PM i s recognized by a l l s t a f f as being i n charge of planning, implementation, evaluation, of the effectiveness of and the surveillance of the HHA-PRHU. - 81 -As well, the desire of the PM to accept the new program and the degree of motivation on the part of the PM must be favourable towards HHA-PRHU. The selection of the PM must be done af t e r considerable r e f l e c t i o n . 7.3.1.2 There should be established i n t e l l i g e n c e , decision mak-ing, and communication systems. This, I would suggest be based i n a task force committee defined as to member-ship, structure and p e r i o d i c i t y of meetings. This task force would generate decision making methods, data c o l -l e c t i n g methods and forms, and established l i n e s of communication, and feedback mechanisms. 7.3.1.3 There would be motivation techniques to induce change. The task force could e s t a b l i s h these incentives i n the forms of awards for indiv i d u a l s and o f f i c e s generating the most l i f e s t y l e changes i n a community i n a given period of time. 7.3.1.4 Planning should be adaptive and a l l o c a t i v e . Planning should involve the co-operation and consultation of central o f f i c e for decision making, resource a l l o c a -t i o n and data c o l l e c t i n g . P o l i t i c a l bodies such as the Local and Union Boards of Health would be involved i n the planning. This p o l i t i c a l involvement could be ex-tended to a l e g i s l a t i v e l e v e l by involving higher l e v e l - 82 -committees such as the Health O f f i c e r s ' Council, a coun-c i l of a l l the p r o v i n c i a l health unit d i r e c t o r s . This council can present resolutions to the Minister of Health of B r i t i s h Columbia. These resolutions can ultimately become p o l i c y with enforcing regulations i f the reso-lutions are p o l i t i c a l l y acceptable. 7.3.1.5 There should be established methods of c o n f l i c t reso-l u t i o n . Involving the l i n e s t a f f , central o f f i c e and p o l i t i c a l bodies i n the planning process would reduce the amount of i n i t i a l c o n f l i c t . The task force should outline ways of reducing c o n f l i c t as i t appears during program operation. For example, the task force could hold extra-ordinary meetings of groups i n which the c o n f l i c t appears. The s p e c i f i c purpose of these meet-ings would be to table and discuss the c o n f l i c t and arri v e at a method of resolving the c o n f l i c t . 7.3.2 Restructuring the Organizational Design 7.3.2.1 Decentralization i s necessary to allow l o c a l health units more control of resource a l l o c a t i o n and to give the d i r e c t o r more power. This would mean that central o f f i c e would have to give health units a global budget. The health unit would be accountable to the Union Board of Health. - 83 -7.3.2.2 Apart from core programs designated by p r o v i n c i a l l e g i s l a t i o n there would need to be directions to s t a f f to ensure that occasional assignment of new tasks was "legitimate" and part of the job description of a l l s t a f f . 7.3.2.3 Technical s t a f f such as the medical dir e c t o r and d i v i -s ional heads should be r e l i e v e d of a considerable amount of administrative duties. This would mean an increase of s t a f f who were trained i n administrative duties and who were prepared and s p e c i f i c a l l y hired to perform administration. 7.3.2.4 As well as technical t r a i n i n g i n medical f i e l d s , senior s t a f f i n charge of program design and delivery, plan-ning and surveillance, should be suitably trained to perform these tasks. 7.3.2.5 The health unit should have a dual organizational struc-ture. The f i r s t structure should be administrative, and responsible for budgeting, resource a l l o c a t i o n , employee appraisal and public r e l a t i o n s and so f o r t h . The second structure should be responsible for the technical nature of the programs; t h i s structure would assess the needs of the external environment and re-structure program delivery accordingly. - 84 -7.4 Conclusions This study evaluated an attempt to induce change i n a p r o v i n c i a l health u n i t . The l i t e r a t u r e indicates that to e f f e c t change within such a system i s a com-plex task. The r e s u l t s of t h i s study demonstrate that: (i) the organizational design of public health units i n the B r i t i s h Columbia Ministry of Health appears to be counterproductive to the successful accomplishment of l o c a l l y i n i t i a t e d innovation ( i i ) the entire system, e s p e c i a l l y the Central O f f i c e , must be included i n the planning and delivery system for new programs i n B r i t i s h Columbia public health units ( i i i ) innovation would seem to be enhanced by having administrators as well as medical co-ordinators i n B r i t i s h Columbia health units In closing I would propose that perhaps innovation would be enhanced by decentralization of the present B r i t i s h Columbia Ministry of Health organizational design. APPENDIX A INTRODUCTORY STAFF QUESTIONNAIRE - 86 -S e l f -Teach ingoQue s t i o n n a i r e : LIFE-STYLE MODIFICATION PROGRAMS Name: O c c u p a t i o n : E d u c a t i o n : PLEASE ANSWER QUESTIONS AS BEST YOU CAN 1) What i s a L i f e - S t y l e M o d i f i c a t i o n Program? 2) What i s t h e H e a l t h Hazard A p p r a i s a l Form? 3) Do you t h i n k l i f e - s t y l e a f f e c t s h e a l t h ? 4) Do you t h i n k l i f e - s t y l e p a t t e r n s i n f l u e n c e q u a l i t y o f l i f e ? 5) Do you t h i n k l i f e - s t y l e p a t t e r n s i n f l u e n c e l e n g t h o f l i f e ? 6) Would you be i n t e r e s t e d i n a L i f e - S t y l e Program f o r e v a l u a t i o n o f y o u r s e l f ? 7) Would you p a r t i c i p a t e i n a L i f e - S t y l e Program w h i c h i n c l u d e d e v a l u a t i o n o f c l i e n t s you meet i n t h e c o u r s e o f your work? 8) I f you w i s h t o p a r t i c i p a t e i n d i c a t e t o what degree you ar e w i l l i n g t o be i n v o l v e d (A) P r e s e n t forms (B) P r e s e n t forms w i t h i n s t r u c t i o n s (C) P r e s e n t forms w i t h i n s t r u c t i o n and f o l l o w up c o u n s e l l i n g - 87 -9) I f you p a r t i c i p a t e i n the program do you'think the added r e s p o n s i b i l i t y w i l l a f f e c t your job (check one) (A) A l i t t l e (B) Some (C) A g r e a t d e a l (D) Do not know 10) I f you do not p a r t i c i p a t e i n the program do you t h i n k having the program i n the u n i t w i l l a f f e c t your job? (Check one) (A) A l i t t l e (B) Some (C) A g r e a t d e a l (D) Do not know 11) I f you do not wish t o p a r t i c i p a t e p l e a s e i n d i c a t e the reason. (Check one) (A) Not i n t e r e s t e d (B) Do not f e e l t h i s i s an area f o r which I am r e s p o n s i b l e (C) Do not have the time 12) Do you t h i n k the community would accept a L i f e - S t y l e M o d i f i c a t i o n Program?' Yes No - 88 -APPENDIX B FINAL STAFF QUESTIONNAIRE - 89 -POST-IMPLEMENTATION QUESTIONNAIRE SECTION I (General) Respondents = 30 1 4 5, 6, 3. Demographic dat a . Length o f s e r v i c e w i t h B.C. M i n i s t r y o f H e a l t h : Average=5.6 y e a r s Length o f s e r v i c e w i t h PRHU: Average = 4.8 y e a r s Are you aware t h a t a new programme i n L i f e S t y l e M o d i f i c a t i o n has been i n t r o d u c e d i n t o the Peace R i v e r H e a l t h U n i t ? Yes [30 No 0 Do you u n d e r s t a n d t h e HHA form? Yes 30 No Do you u n d e r s t a n d t h e method o f d e l i v e r y and f o l l o w t h r o u g h o f the HHA programme t o t h e p u b l i c ? Yes 29 No Which o f the f o l l o w i n g g o a l s o f t h e Peace R i v e r H e a l t h U n i t were s a t i s f i e d by t h e HHA programme? C i r c l e one o r more. a) Good h e a l t h o f t h e community b) Good h e a l t h o f t h e PRHU s t a f f c) Good r e l a t i o n s h i p s w i t h t h e community d) Good r e l a t i o n s h i p s w i t h i n t h e h e a l t h u n i t e) Other ( p l e a s e s p e c i f y _ _ 13 11 15 10. 11, 12. The o b j e c t i v e s o f t h e HHA programme were c l e a r l y d e f i n e d : No | 0 | Yes 25 Undecided [ 5 | The o b j e c t i v e s o f t h e PRHU a r e c l e a r l y d e f i n e d : Undecided [ 6 1 Yes 22 No One o f t h e g o a l s o f the HHA programme was to do as many HHA forms as p o s s i b l e : Yes LL9 No El Undecided 13. When i t was announced t h a t t h e HHA programme was t o be t r i e d i n t h e H e a l t h U n i t d i d you f e e l c o n f l i c t ? i . e . a ngry, imposed upon, o r u n s e t t l e d . Yes 0.3 No ED Undecided 0 - 90 -14 15 16. 17; 18, How was t h i s c o n f l i c t resolved, looking back over the time the programme was i n operation? Please c i r c l e one or more of the following. a) Outside help, i . e . s e l f help groups, counselling, etc. b) Passage of time c) Talking informally with others i n the Health Unit d) Formal group meetings e) Discussion with senior personnel f) Disregard of the programme g) Not resolved When i t was announced that the HHA programme was to be t r i e d i n the Health Unit did you see evidence of c o n f l i c t within the Health Unit? i . e . persons or groups angry or upset or an unsettled atmosphere overall? Yes 14 No 0.4 Undecided How was t h i s c o n f l i c t resolved looking back over the time the programme was i n operation? Please c i r c l e one or more of the following. Passage of time Formal meetings i n groups Informal meetings within the Health Unit Informal meetings outside the Health Unit A r b i t r a t i o n by senior personnel Better understanding of the programme Disregard of the programme Not resolved Who introduced t h i s programme into the Health Unit? Choose one of the following. MHO 29 Nursing Supervisor [ 0 | Office Supervisor \ 0 Senior Staff [ 1 [ Nurses | 0 | Other | 0 | Who was i n charge of the setting up of the implementation of the HHA programme? Choose one of the following. MHO | 7 | Nursing Supervisor |21 Senior Staff m Nurses 0 Office Supervisor | 0 | Other 1 1 1 1_ _3_ 110_ _4_ 9_ _1_ 0 _5_ _5_ 9_ 0_ _0_ _9_ _0_ 0 Who was supervising the program during the f i v e months i t was i n effect? Choose one of the following MHO 11 Nursing Supervisor 12 Office Supervisor Was the leadership clear i n t h i s new program? a Yes 19 No Undecided 6 Was HHA well advertised i n the community? Yes | 9 | No | 5 | Undecided | 6 [ Did c l i e n t s and the community r e a d i l y accept t h i s new programme Undecided Yes 8 No 10 12 Are you aware of any other organizations that offered the HHA programme i n the PRHU from January to May of t h i s year? Yes No 27 Undecided | 0 1 HHA resulted i n more time spent with other s t a f f members. Yes | 5 1 No 23 Undecided a HHA took time away from my other programmes. Undecided | 1 | Yes No 23 HHA disrupted the normal routine of the o f f i c e . Yes | 1 1 No _27_ Undecided | 2 | HHA and displays displaced other displays and equipment. a Yes No 23 Undecided [ 2 | HHA resulted i n me working more hours, i . e . overtime No Yes 1 3 | 27 HHA resulted i n more labour intensive work during hours worked, i . e . I worked harder. Yes a No 22 Undecided a HHA was i n keeping with my job description. No | 8 [ Undecided [ 5 | Yes 17 The HHA programme made my job more enjoyable | 7 1 No | 9 1 Undecided Yes 14 - 92 -32 33, 35. 36 37, 38, 39 The HHA program resulted i n my becoming more aware of the rel a t i o n s h i p of l i f e s t y l e to health. Yes 23 No Undecided My personal habits changed i n the following areas while the HHA programme was i n the Health Unit, i . e . i n the months of January to May, 19 79 Improved Deteriorated Unchanged a) Diet 9 21 b) Smoking 3 27 c) Alcohol 3 27 d) Seat b e l t usage 10 20 e) Exercise pattern t 15 15 f) Breast care (women) 8 18 Comments: 1) There were 4 8 changes made i n a l l . 2) There were twenty-four of the t h i r t y s t a f f who made changes 34. If you completed an HHA form: How many months ago did you do so? Average = 10. 8 months How many changes were recommended? Average = 2.3 changes How many changes have you made? Average = 1.6 changes I would l i k e to see HHA stay i n the Health Unit, Undecided | 6 | Yes 24 No 1 0 | I a c t i v e l y p a r t i c i p a t e d i n the following number of HHA forms/ 0 1 - 5 5 - 1 0 10 - 15 More Handing out forms: 13 7 3 1 6 Processing forms: 20 6 1 0 3 Counselling: 23 4 2 0 1 I talked about HHA to c l i e n t s : Yes 20 No 10 I talked about HHA at s o c i a l functions. Yes 12 No 18 I gave HHA forms to friends and family, Yes Il4 I No (l6 - 93 -SECTION I I (Nurses) Respondents = 1 1 1. I used HHA i n : Yes No a) P r e n a t a l c l a s s e s 1 10 b) Schools 6 5 c) On house c a l l s 5 6 d) With l o c a l groups 3 8 e) In home care 0 1 1 f) C r i s i s i n t e r v e n t i o n 0 1 1 g) H o s p i t a l l i a i s o n 1 1 0 h) Maternal c h i l d conferences 3 8 i ) On i n d i v i d u a l c l i e n t s 9 2 j) During t r a v e l l i n g c l i n i c s 0 1 1 k) During s p e c i a l community • 5 6 events Please comment b r i e f l y where HHA was used most e a s i l y and e f f e c t i v e l y and comment on problems i n u s i n g i n other areas. (see the l i s t a t the end of S e c t i o n II) 2. 3. 4. 5. HHA was d i f f i c u l t to rank i n terms of p r i o r i t i e s with r e l a t i o n to oth e r programmes. Yes 8 No 3 HHA was d i f f i c u l t to use i n most s i t u a t i o n s . No Yes ru 10 Because of c o n c e n t r a t i o n on oth e r job s k i l l s I f o r g o t about HHA. Yes CD No 6 I f e l t uncomfortable about opening the s u b j e c t o f l i f e s t y l e w ith c l i e n t s . Yes CD No ru Undecided ru - 94 -Nurses (Continued) 6. I would l i k e more t r a i n i n g i n the use of HHA. Yes | 5 [ No 1 6 \ 7. The $2.00 fee was a deterrent to c l i e n t s using the HHA. No [ 7 ] Yes 8 Do you f e e l you have an adequate knowledge of community resources i n counselling with the HHA? Yes 11 No 1 0 1 Undecided [ 0 | 9. Was the programme presented to c l i e n t s and the public s a t i s f a c t o r i l y ? Yes [ j T No j 1 | Undecided | 2 | 10. I would l i k e to see more planning and elaboration on the presentation and use of the HHA programme. Yes | 4 | No 1 4 1 Undecided [ 3 | 11. Were the displays s a t i s f a c t o r y ? 1 1 | Undecided | 2 [ Yes No 12. Was the box idea a good one? Yes | 8 | No 1 3 1 Undecided | 0 [ Comments by Nurses Would have l i k e d more advertising. Many people were a f r a i d of the r e s u l t s and did not want to change t h e i r l i f e s t y l e . Over 30 population with middle class incomes were the most interested. Most appropriate i n s p e c i a l events and l o c a l groups. HHA i s best advertised by word of mouth. Participants were hesitant to pay the $2.00 c l i e n t fee Tended to forget about i t . Motivation low i n t h i s area. Health unit too hectic to get c l i e n t ' s attention, e.g. Mother i s interested i n children not HHA. Needs personal contact to get r e s u l t s . - 95 -SECTION III ( C l e r i c a l Staff) Respondents = 9 1. HHA programme resulted i n an increased work load i n the the following areas. a) Typing b) Copying c) Answering the telephone d) Talking to c l i e n t s Yes No 2 7 3 6 1 8 4 5 2. The HHA programme increased patient waiting time, Yes [ 0 | No 1 9 | 3. The HHA programme displaced other duties. Yes 1 0 | No | 9 1 4. Please comment on ways i n which the HHA programme could be more e f f e c t i v e l y presented to the public. More advertising needed.  Medical C l i n i c s should pass out forms. $2.00 fee i s a deterrent. • Strong promotion i n the community needed. ' More exposure on b u l l e t i n boards and newspapers needed. More intense and continuous p u b l i c i t y needed. Much more p u b l i c i t y needed. APPENDIX C HEALTH HAZARD APPRAISAL FORM AND COMPUTER PRINTOUT H E A L T H H A Z A R D A P P R A I S A L Processed By: Div is ion of Hea l th Systems Heal th Sc iences Cent re Univers i ty of Brit ish Co lumbia Vancouver, B.C. V6T 1W5, ' Phone:(61 3) 228-2258 ENTER A L L N U M B E R S C O R R E S P O N D I N G T O C O R R E C T R E S P O N S E S IN T H E S E C O L U M N S 1. Have you ever completed a HEALTH HAZARD APPRAISAL qLrest ionna i re? I 1 I ves LU " O 2. L A N G U A G E | 1 [ english | 2 I french 3. SEX j 1 | male | 2 | female 4. A G E • 5 - . MARITAL S T A T U S I 1 I single ) 4 I widowed I 2 I married | 5 ( divorced I 3 j separated | 6 | other 6. HEIGHT- N (without shoes) feet and inches OR centimeters 7. WEIGHT (naked! f pounds OR kilograms a) | 1 | smoker |_2 | ex-smoker (stopped) | 3 | non-smoker (never smoked) b) Enter average amount smoked per day in the last five years OR in the last five years before quirting Average number of cigarettes per day Average number of pipes / cigars inhaled per day Average number of pipes / cigars not inhaled per day \ c ) Enter number of years stopped smoking (Note: enter 1 for less than one year) 9 " A L C O H O L a) | 1 [ does drink I 2 | ex-drinker (stopped) | 3 [ non-drinker (never drank) D) If you drink alcohol, enter the average number of drinks per week bottles of beer (12oz) glasses of wine <4oz) shots of soirits (1-1 Vi oz) DISABLING DEPRESSION • LiJ< | 2 | seldom or never-^ - DISTANCE per year as driver of a motor vehicle and / or passenger of an automobile • miles OR kilometers 12- SEAT BELT USE (% of time used) J S U R N A M E I ! ! ! ! I I M I N I ! GIVEN N A M E 'I I I I I I I I I I INIT. I I I I SOCIAL INSURANCE NUMBER I I I I I I I II OCCUPATION ( I I I I I I I COUNSELLOR I I I I I I I I ORGANIZATION " STREET CITY PROVINCE P O S T A L CODE TELEPHONE ^ J u I 1 I I I L_ i ,a o; o NHW 676 110-781 HEALTH HAZARD APPRAISAL.FORM - 98 -ENTER A L L N U M B E R S C O R R E S P O N D I N G TO C O R R E C T R E S P O N S E S IN T H E S E C O L U M N S 13. Have you taken the C A N A D I A N H O M E F I T N E S S T E S T ? 1 1 I yes I 2 I no If YES, indicate level ach ieved If NO, indicate activity level ^ i 1 1 undesirable personal f itness level i \ I little or no physica l activity [ 2 | m in imum personal f i tness level I ?, J occas iona l physica l activity 1 3 1 r e commended personal f i tness level ( I 3 J regular physical activity at least 3 t imes per week N O T E : Phys ica l Act iv i ty inc ludes work and leisure act iv it ies that are susta ined physical exert ion such as wa lk ing briskly, running, lifting and carry ing. 14. Did your parents die of a H E A R T A T T A C K before the age of 60? I 1 1 v e s ' 1 2 1 v e s * 1 1 I [ - L - 1 both of them ^ one of them L i J n 0 15. Do you have a family history of SU IC IDE? (mother, father, sister, brother) [_LJyes LlJno 16. Do you have a family history of D I A B E T E S ? r (mother, father, sister, brother, chi ld) 1 1 [ yes | 2 | no 17. Do you have D I A B E T E S ? L-Llnot contro l led LLl contro l led L l J n 0 18. Do you have a history of R E C T A L D I S O R D E R S ? (other than hemorrhoids) b r ow tn Bleeding I 1 | yes I „?„! no I 1 I yes [_2j no 19. Has your physic ian ever said you have C H R O N I C B R O N C H I T I S and / or E M P H Y S E M A ? | 1 | yes | 2 j n o 20. S L O O D P R E S S U R E to be measured - otherwise leave blank S Y S T O L I C m m mercury D I A S T O L I C m m mercury 21. F A S T I N G C H O L E S T E R O L L E V E L to be measured • otherwise leave blank C H O L E S T E R O L mg / dl F E M A L E S ONLY C E R V I C A L C A N C E R RISK If you have had a hysterectomy (cervix removed), please leave blank P A P S M E A R | 1 j Have never had a pap smear | "2 | Have had 1 pap smear - more than 1 year ago - but less than five years ago • negat ive l 3 | Have had 1 pap smear w i th in the past year - negative I 4 | Have had 3 or more pap smears wi th in the past 5 years - all negat ive 2 3 ' R E G U L A R S E X U A L I N T E R C O U R S E began I 1 I .inc^.en I 2 I at age L i - i 20-25 1 ^  i a t a 9 8 26+ ' 'or never B R E A S T C A N C E R RISK 24. Did your mother or sister have B R E A S T C A N C E R ? | 1 | y e s [ _ 2 j n o ^ M O N T H L Y B R E A S T S E L F E X A M I N A T I O N | j j V e s i i 1 [ Z j n o HEALTH HAZARD APPRAISAL FORM (Continued) SEUENTRY HEM. TH S Y S 1 . U I V I S I L h LF FCHLIH SYSTEMS - UNI VI 11V OF B'RTTTSH" CuL UMB I A » > HEALTH HA/ARC APPRAISAL <<< >>> APPRAISAL TABLE <<< PAGE T .F F E B 2 4 , 1979 1 K H A L E S OF AGE 50 k l l A G H P R A I S F D | ABLE 1 CONDITION APPKAISEO PART TGTAL A C H I E V A B L E PAR T TOTAL i I 1 HEART ATTACK <.<.!>6 l d < i l 9 1)229 4 . 1 3 l . a s , 1 HEIGHT ISO PUUNCS 0 . 9 8 160 POUNOS 0 . 8 8 1 ' 1 SMOKING 30 C I G A R E T T E S / DAV l . * 5 STOPPED SMOKING 0 . 7 5 | _ 1 S Y S T O L I C BP 160 MH MERCURY 1 .30 R E C H E C K - S E E YOUR OR. 1 . 3 0 1 1 D I A S T O L I C BP 96 HM MERCURY l . * 5 R E C H E C K - S E E YOUR O R . l - * 5 1 1 1 CHOLESTEROL 2 80 M G / O L 1. 50 280 MG/DL 1 .50 1 1 1 P H Y S . ALTVTV L I T T L E UR NONE 2 . 2 5 REGULAR - 3 « PER MEEK 0 . 6 0 i 1 1 FH HEART Y E S - C N E PARENT <60 1 .20 YES - O N E PARENT <60 1 .20 J 1 O I A B E T E S NO 1. 00 NO 1 . 0 0 H THE TUP T o U V t A CAUSES lif E IAI I . IN N CANADA I 197 I I TIM 2 LUNG CANCER 3 STROKE • C I R R H O S I S UF LIVER 5 I N T E S T I N A L CANCER INCLUDING RECTUM 6 MOTOR V E H I C L E ACC IDE M S 8 CHRONIC L'KC KC H T IS ANl> EM PHY SI ri A 9 STUMALH CAI.LCK L H A N L E S UF 0 V I N 3 PER tOO.JOO I . I I M N TEN VCAPS A w- I A P - | OCHIEV-905 U 9 5 1116 535 1311 1204 362 855 "TTT TfiT ~TTt~ ITCTAL AND P A R T I A L R I S K S FCR EACH CAUSE OF Ct AT H DUE TU YOUR CONDI t ION/1 IFE STYLE ' R E L A T E D IU THCSb OF AN AVERAGE CANADIAN OF YOUR SEX ANO AGE 11 .001 1.231 SMOKING 30 C I C A R E I T E S / DAY 1.54 STOPPEO SMOKING 1 . 2 3 2 . 2 5 SUCKING S Y S T O L I C BP D I A S T O L I C BP 30 C I G A R E T T E S / DAY 1.20 160 MN MERCURY 1 .30 S 6 M M MERCURY l . * 5 CHOLESTEROL O I A B E T E S 280 M G / D L 1 .50 NO 1.00 STOPPEO SMOKING 1 . 0 0 R E C H E C K - S E E YOUR O R . 1 . 3 0 R E C H E C K - S E E YOUR O R . 1 . 4 5 280 M G / D L 1 . 5 0 N O 1 . 0 0 2 . 9 2 1 . 0 0 A L C O H O L 16 DRINKS PER WEEK 2 . 9 2 3 - 6 D R I N K S P E R W E E K 1 . 0 0 2 . 5 0 1 1 "RECTI OISORD RECTL OISORD R F C T A L GROWTH ~T.$0~ NO RECTAL B L E E D I N G ~ 1 . 0 0 T T E C T A l GROWTH J . 5 0 NO R E C T A L B L E E O I N G 1 . 0 0 TTTol ALCUHCL 16 0R1NKS PER WEEK 2 . 0 9 DRIVE / Y E A R 1 3 . 0 0 0 M I L E S 1 .30" SEAT B U T BUCKLED 1 7 » U F TIME 1 .03 3 - 6 OR INKS PER WEEK 1 . 0 0 1 3 , 0 0 0 M I L E S 1 . 3 0 BUCKLEO 1001 O F TINE 0 . 8 0 l.tt OF PRE SS ILN FH S U I t IDE SELDCP OR NEVER 1 .00 NO 1 .00 S E L D O M O R N E V E R 1 . 0 0 N O i.oo 1.0811 30 C I G A R E T T E S / DAY 1 . 5 * STOPPEO SMOKING 1 .08 1 . L O L D COMPUTER PRINTOUT S K I U T K V H E A L T H S Y S T . u 1^1 ill..I UF ME«MH SYSIEMS >>> HEAL TH HAZARD »> APPRMSAl ~IVT s r m n n i i s H COLUMBIA APPRAISAL <<< TAHLL <<< PACE OF— FEB 26, 1979 H THE TCP T K L L V C I CHUNCtS CF Oi INC -PEN CAUSES U P DfcAlH IN I I O O I J C O wll.MN 1EN YE AH S N C AN AO A i l t l l ) mn K HALES 01 «G[ 50 A/- | AP- I ACMIEV-ER4GHP«AISll)l ABLE 10 C A N C E R OF PANCREAS I L 11 D I S E A S E S U F A H T E K I A L I S Y S T E P .1 . I 1? TUMOUR-LYMPH, BLUUD I EXCEPT IEUKEPIA I 167 16 r 167 ALL OTHER CAUSES I J021 ALL CAUSES OF OEAIH| U2t)l I 2B57J 16722 TL1AL ANO PARIIAL RISKS fOR EACH CAUSE UF OEATH UUE TC YOUR CONOI IION/LI FESt VLE | RELAUD TL THOSE Cf AN AVERAGE CAN AC I AN OF YOUR SEX AND AGE 11.001 CCNOITION APPRA 1SED PART IOTAL A C H I E V A B L E PART TOTAL) I.CO I . l i t SICKING SYSTOLIC BP CIASTOL IC BP 30 C I G A R E T T E S / D A Y 1.20 160 P M M E R C U R Y 1.30 96 MM M E R C U R Y l.<ii STOPPED SMOKING 1.00 RECHECK-SEE YOUR OR. 1.30 RECHECK-SEE YOUR OR. CHOLESTEROL DI ABE IE S 2B0 MC/CL KO 1.50 I .00 280 MG/OL NO 1. SO 1.00 1.00 1.001 I . 001 ACTUAL AGE 50 IPPRMSEC AGE 62 ACHI EV ABLE_ AGE »> PRESCRIPTION TABLE <<< 5 ! YUUH ACHIEVABLE AGE IS BASEO UN THE FOLLOW ING POOIF1CAIIGNS OF YOUR CONOITICN/LIFESTYLE: AlCCHCl SYSTOLIC BP Dl AS TOL IC BP SEAT BELT FRCP 16 CR INKS PER WEEK TO "FRCP 160 MM MERCURY 10 FROM It MM MERCURY TO FRCP BUCKLED 17t OF TIME TO SMOKING FROM 30 CIGARETTES/ DAY TO WEIGHT FROM 180 POUNDS TO ACIVIY FRCP LITTLE CR NONE TU 3-6 DRINKS PER WEE K_ RECHECK-SEE YOUR OR. RECHECK-SEE YCUR OR. BUCKLEO 1001 OF TIME STOPPED SMCKING 160 POUNDS REGULAR -3X PER WEEK r—1 O O COMPUTER PRINTOUT (Continued) St J E M K Y H E A L I H S r S I . u i v i s i u U F ' H U H T S Y S T E M S - U N ' r s T T r o r n n r i I I S H C O I L M H I A >>> H E A L T H HAZARD . . I ' P R A I S A L « < >)> P R E S C R I P T I O N LA.ILC <<< A C T U A L AGE bO APPR A IS ED A GC ' 62 A C H I E V A B L E AGE 5 5 > S YOUR A C H 1 E V A H L E AGE I S H A S E C UN THE F O L L C W I N G MODIFICATIONS OF YOLR CONDI 11 O N / L I F E S T Y L E 1 CCKOI U U N / L I F E S T Y L E P R E S E N T R E C O M M E N D A T I C N P H Y S I C A L A C I I V I T Y l l I T L E OR NOSE f GRADUALLY ANC P R O G R E S S I V E L Y INCREASE REGULAR PHYSICAL A C I I V I T Y SMOKING ~ '~ 3 0 C I G A R E T T E S / DAY STCP - BEST TO QUIT - TRY TO CUT DOWN ANO SNITCH TO LCNER TAR ALCOHOL 16 DRINKS PER WEEK MODERATE - REDUCE TO 3 - 6 DK INKS PER KEEK S E A f B E L T USE . .„ W E I G H ! _ . BUCKLEC 171 OF TIME 1B0 POUNDS B I C K I F UP ALKAYS - 1 0 0 X OF TINE REOUCE TO APPROXIMATELY 1 6 0 POUNDS BLOOD PRESSURE 1 6 0 / 1 6 R E C H E C K - IF S T I L L E L E V A T E O CONSULT YOUR P H Y S I C I A N — -~ -' O COMPUTER PRINTOUT (Continued) N 5EDENUV— H E A L T H S T S I . THE N U M B E R OF HUMS S H U . . S TOUR R I S K R E L A T I V E I U I HE I) I VI M M HI- H I H I H S Y S T E M S - VK . P S TTT~T)T~FtR T TI SH C U L L H B l A >>> H E A L T H H A Z A R D A P P R A I S A L « < >>> A P P R A I S A L C H A R T <<< -pTGT ~~OT ~~ F E B 2 6 , 1 9 7 9 THE rttlAI C A N A J I AN I V t MAGNI A V E R A G E I l U U E CF I I . THE THE A V E R A G E C A N A D I A N R I S K FOR E A C H C A U S E OF C E A T H . T H E L E N G T H O F E A C H R O W S H O W S R E O U C I B L E P A R T UF TUUR R I S K I S I N D I C A T E D BY L E T T E R S I L E G E N O AT B O T T O M R I G H T I. I H E A R T A T T A C K L U N G C A N C E R ) S T R O K E * C I R R H O S I S OF L I V E R 5 I N T E S T I N A L C A N C E R I N C L U D I N G K t C I J M 6 MOTOR V E H I C L E A C C I O E N I S 7 S U I C I D E B C H R O N I C B R O N C H I I I S A N D E M P H Y S E M A V S T O M A C H C A N t I K 1 0 C A N C E R UF P A U L H E A S 11 D I S E A S E S CT A R T E R I A L S Y S T E M 12 T U N O I I R - l Y f F H , I ILCCO E X C L P T L E U K E M I A " " U k S S S S S S S S S S S S S V Y V V Y Y Y Y Y V Y Y V V V V Y Y V V V Y Y Y V V Y V V V V " " W w S S S S S S S S S S S S S Y Y Y V V Y Y Y Y Y Y V Y Y V V Y Y V Y V V V V V V Y Y Y Y V " • " W H S S S S S S S S S S S S S V V Y Y V Y Y V Y V V Y V Y V V V Y Y V V Y Y Y Y V Y Y Y V V " " h w S S S S S S S S S S S S S V Y Y Y Y V Y Y V V Y Y Y YYV Y V V Y V Y V V V Y Y Y Y T Y • t i W S S S S S S S S S S S S S Y V V Y V Y Y Y V V V Y Y V Y V V V V Y Y Y V V V Y V V V Y Y • W N S S S S S S S S S S S S S V V V V V Y Y V Y V Y V Y Y V Y Y V V V Y V V Y V V V V Y Y V " W M S S S S r f j S ^ S j S S S V Y V V V Y Y Y Y V Y Y Y Y Y Y V Y V V V Y V V Y Y V V V V V _ • W W S S S S S S S S S S S S S Y V V V Y Y Y V V Y Y V V Y V Y V Y V V Y Y Y Y V V V Y V V Y " - W h S S S S S S S S S S S S S Y Y V Y Y V V Y Y Y Y Y Y Y Y V Y Y Y Y Y Y Y Y Y Y Y Y Y V V - K H S S S S S S S S S S S S S V Y Y V V Y Y V Y V Y Y V Y Y T Y Y V Y Y V T Y Y T V Y Y V r • k k S S S S S S S S S S S S S V V V Y V Y Y Y Y Y Y Y Y V Y Y V V Y V V Y Y Y Y Y Y Y Y V V • W W S S S S S S S S S S S S S Y V Y V V Y Y Y Y V Y V V Y Y V Y Y Y T Y Y Y Y V V V Y V V r = l . W S S S S S S S S S S S S S Y Y Y Y V V Y Y V Y Y Y V Y Y V Y V V Y V Y Y Y V Y V V Y Y Y _ - h W S S S S S S S S S S S S S Y Y Y Y V V V Y Y V Y Y Y V V Y Y V Y V Y V V V Y Y Y V V Y V • l « W S S 5 S S S S S S S S S S Y Y Y Y Y Y V V V V V Y V V V Y V V V V V Y V V V Y V Y V V y • W W S S S S S S S S S S S S S Y V Y Y V Y Y Y Y V Y Y Y V Y V Y Y Y Y Y Y Y Y Y V V Y Y V T - W W S S S S S S S S S S S S S Y V V Y V V V Y V V Y V Y V Y Y Y V V V Y Y Y V Y Y Y Y V Y Y . - W W S S S S S S S S S S S S S V V V V Y Y Y V V V V Y Y V V Y V V V V V V Y Y Y V Y Y V Y Y » W H S S S S S S 5 S S S S S S Y V Y V Y Y Y Y Y Y V V V V V V V Y Y Y Y V V V Y V Y V V r V _ • W W S S S S S S S S S S 5 S S V V Y Y V V Y Y V V V V V Y V V V V Y Y V V V V Y V Y Y V V V • W W S S S S S S S S S S S S S V Y Y V Y Y V V V V Y Y Y V Y Y Y Y Y Y V Y Y V Y Y V V V Y V • S S S S S S • S S S S S S • S S S S S S • S S S S S S =ssss - ssss * A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A I A A A • A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A • A A A A A A A A A > A A A A A A A A A A A A C C C C c A A A A A A A A A A A A A A A A A A A A A A C C C C " " S S S S S S S S S I " • • • • A C H I E V A B L E R I S N * A L C O H O L ! " " S S S S S Y S T O L I C . . . . D I A S T O L I C Bf S E A T B E L T SMOKING WEIGHT . . . . P H Y S . AC T VT) O COMPUTER PRINTOUT (Continued) - 103 -APPENDIX D FORMS, COMMUNICATIONS AND ILLUSTRATIONS - 104 -DAWSON CREEK OFFICE FORT ST. JOHN OFFICE I l l u s t r a t i o n 1 FORT NELSON OFFICE ( P r o v i n c i a l B u i l d i n g ) I l l u s t r a t i o n 2 - 106 -CASSIAR OFFICE (Government B u i l d i n g ) I l l u s t r a t i o n 3 - 107 -Province of Ministry of British Columbia Health P E A C E R IVER H E A L T H UNIT YOUR FILE OUR FILE Nov. 27/78 Re: P i l o t Project - L i f e Style Modif icat ion January - May/79 Peace River Health Unit From January 1979 to May 1979 I would l i k e you to be Program Manager for the planning, implementation and surve i l lance of a p i l o t project in L i f e Sty le Modi f icat ion. This w i l l be a major project in the del ivery of preventive health to the Peace River Health Unit area. The program should make use of the Health Hazard Appraisal form. I w i l l be glad to act as a resource person in th i s area, not only in the use of HHA but also in the general p r inc ip le of l i f e s ty le modif icat ion as a tool in the reduction of morbidity and morta l i ty of the general pub l i c . As Health Hazard can be offered to groups as well as ind iv idua l s , I would suggest that the nurses be the major ind iv idua ls in the del ivery of the program. Although any one in the Unit could probably of fer the HHA forms to the pub l i c , the counsel l ing and fol low through should probably be carr ied out by the nurses; th is means they w i l l need instruct ions in th i s area as well as l i s t s of resources in the community such as groups that of fer se l f help with smoking, drinking and eating problems. It i s my hope that each nurse can counsel 2 to 3 persons per week for the f i ve month period resu l t ing in about 50 appraisals and counsel l ing per nurse with hopefully a unit load of between 750 and 1000 persons being handled in the f i ve month period. This may sound l i k e a large number and i t i s , and w i l l require a l l our energies to carry out. I would l i k e to stress that the morbidity and morta l i ty re lated to l i f e s ty le malpatterns has reached epidemic proportions and we are obl igated to get heavi ly i n -volved in th is area. Please keep s t a t i s t i c s as to the numbers counselled and the time spent by the Unit in carrying out th is new programme. I mentioned to you in conversation that we w i l l form any committees in or outside the Unit as necessary to carry out th is programme. The health gain of such a program i s very pos i t i ve to the publ ic health and I hope th is type of preventive program w i l l become part of the Health Unit routine and th is depends great ly on the success of the p i l o t project . My main job w i l l be to assess the impact of the program on the Unit . Good luck. JGL/at bcgeu Dr. James Lugsdin Director. SSmbia EST" MEMORANDUM To: Date: January 3, 1979 Senior Director Publ ic Health Programs Re: L i f e s t y l e Modif icat ion Program The Peace River Health Unit is implementing a p i l o t project in l i f e s t y l e modif icat ion from January to May of 1979 using the Health Hazard Appraisal form and pr intout offered by the Div is ion of Health Systems at UBC. The program has been designed by the Project Manager of the Peace River Health Unit . She w i l l be responsible for the ongoing use of the program in the Unit . I have enclosed a copy of my or ig ina l correspondence to her and the response she has out l ined. The Project Manager (PM) would l i k e to have an in-serv ice session in Dawson Creek towards the end of January with Dr. Milsum, the Director of the D i v i -sion of Health Systems at UBC. With th i s in mind I would l i k e to request d i rect ion in the acqu is i t ion of the funds to help in the project . S tat ion-ery, postage and presentation materials w i l l cost in the neighbourhood of $200. The cost of Dr. Milsum's v i s i t would be about $250. Allowing $150 for unexpected expenses th i s would make a request of $600 for the p i l o t project . In the north, as in other areas in Canada and the world, there i s an epidemic of l i f e s t y l e re lated diseases, in par t i cu la r cardiovascular, resp i ra tory , hepatic and MVA diseases. In our Health Unit there i s no spec i f i c program directed towards the a l l e v i a t i on of these diseases. I f th is p i l o t project enters the Unit without excessive disrupt ion of other programs i t i s hoped that we could keep HHA as a part of the preventative armamentarium of the Health Unit. There are two offshoots of th is p i l o t project . F i r s t l y I w i l l be studying the a b i l i t y of the Health Unit to absorb a new program such as th i s and presenting the resu l ts of my studies to a UBC thesis committee in order to complete my Master's Degree and thus meet the standards of my present pos i t ion . Secondly, the PM i s planning to study the effect iveness of HHA in the Health Unit in regard to changing the behaviour pattern of those pa r t i c i pa t ing . She plans to do th is by doing a follow-up study on par t i c ipants , probably by using a summer student. By the time you receive th is memo the project w i l l be well underway. Could you please give me construct ive comments and help me with the expense? Please l e t me know i f you require more information, I w i l l keep you posted of progress on a monthly basis and more frequently i f necessary. JGL/at James G. Lugsdin, M.D,, D/Peace River Health Unit #17 MS*ML* MEMORANDUM To: A l l S ta f f Date: Jan. 9/79 Re: L i f e Sty le Modif icat ion Program The current epidemic of l i f e s ty le re lated diseases, s pe c i f i c a l l y chest, heart, l i v e r and motor vehic le accident diseases, is s t a r t l i n g . I feel that i f any area of health care de l ivery should be involved in reducing ; the morta l i ty and morbidity of these diseases i t should be Publ ic Health Programs. We are cont inua l ly boasting to the publ ic about our be l i e f in prevention and most of the above mentioned diseases are preventable. To date we have had no involvement in L i f e Sty le Modi f i cat ion. To r e c t i f y th i s I would l i k e to see i f we can i n s t i t u t e a L i fe Sty le Modif icat ion Program as part of the "preventative medicine" offered to the Peace River Health Unit population. Presently a p i l o t project in L i fe Sty le Modif icat ion has begun in the Dawson Creek o f f i ce and th is w i l l spread to a l l other o f f i ces in the next month or two. The project uses the Health Hazard Appraisal form as a motivating tool to encourage ind iv iduals to adopt hea l th ier l i f e s ty les , The project is intended to stimulate the publ ic to take some respons ib i l i t y for the i r own health. , the Peace River Health Unit Nursing Supervisor, i s in charge of the project and is responsible for the successful implementation of the present Dawson Creek program. Although c l e r i c a l and nursing s ta f f are presently the main users of the HHA form and follow-up counse l l ing, I feel we w i l l a l l be touched by th is program in one way or another. Would you please co-operate with " and her delegates on th i s project and give her a l l the support you can. Probably the decision of keeping th is program w i l l depend on how eas i l y the Units can adopt th i s program using the present s t a f f . I would expect in the short term i t might be burdensome but hope in the long run i t would be a small but important part of our armamentarium in the f igh t against disease, thus the p i l o t project . The saving of a ch i l d ' s l i f e through the use of a seat bel t is but one example of the possible benefits of th is program. Other examples are re-duction in emphysema and c i r r hos i s . Women w i l l be encouraged to examine the i r breasts resu l t ing in e a r l i e r detection of breast cancer. The l i s t is extensive as you w i l l probably learn as the program progresses. F ina l l y I would l i k e to mention that any group entering the area of l i f e s ty le modif icat ion i s considered a pioneer. There are many unanswered questions and unexplored areas. Please keep the questions and ideas flowing and we can a l l learn together. Thank you in advance for your co-operation. JGL/at bcgeu James G. Lugsdin, M.D,, D/Peace River Health Unit . - ±xu -Province of British Columbia PEACE RIVER HEALTH UNIT Ministry of Health February 8, 1979 YOUR FILE OUR FILE Dear Doctor Re: Health Hazard Appraisal The Peace River Health Unit has introduced a new program in L i f e s t y l e Modif icat ion which is ava i lab le to the general publ ic at the local Health Unit o f f i c e . Essent ia l l y the program demonstrates the re la t ionsh ip between health and l i f e s t y l e r i sks such as smoking behaviour, alcohol usage, seat belt usage, exercise pattern, breast care (women), body weight and blood pressure. The hope i s that increased awareness of th is re la t ionsh ip w i l l lead to further attempts at moderation and a l te ra t ion of l i f e s t y l e r i s k s . In turn there would be a decrease in l i f e s t y l e re lated diseases such as accidents and v io lence, heart attacks and certa in chest condit ions such as bronch i t i s . Attached to th is l e t t e r i s a sample of the Health Hazard Appraisal (HHA) form avai lab le at the local Health Unit o f f i c e . Af ter an indiv idual completes th is form i t is sent to Vancouver for processing by a computer which returns a pr intout giving body age as calculated by l i f e s t y l e r i s k . Also on the pr intout i s a prescr ipt ion age which can be attained i f the ind iv idual fol lows the changes in l i f e s t y l e prescr ibed. The Health Unit s ta f f w i l l guide the indiv idual to helpful resources and of fer counsel l ing i f desired. The Health Unit s ta f f w i l l g ladly try to answer any questions that ar i se with respect to th is new program and w i l l keep you informed of the progress made. Yours t r u l y , James G. Lugsdin, M.D., Director. JGL/at Encl . - 113 -DAWSON CREEK HHA WAITING ROOM DISPLAY I l l u s t r a t i o n 4 - 114 -FORT ST. JOHN HHA WAITING ROOM DISPLAY I l l u s t r a t i o n 5 - 115 -CHETWYND HHA WAITING ROOM DISPLAY I l l u s t r a t i o n 6 - 116 -CASSIAR HHA COMMUNITY HALL DISPLAY I l l u s t r a t i o n 7 DAWSON CREEK FITNESS WEEK ACTIVITIES I l l u s t r a t i o n 8 - 1±B -Province of British Columbia P E A C E RIVER H E A L T H UNIT Ministry of Health YOUR FILE OUR FILE A METHOD OF FINDING OUT ABOUT YOUR HEALTH Hi t h e r e ! Attached to t h i s l e t t e r i s a H e a l t h Hazard A p p r a i s a l Ques-t i o n n a i r e . I f you wish to p a r t i c i p a t e then f i l l i n the form as best you can; i f there are q u e s t i o n s you cannot answer then leave those blank and proceed to the next q u e s t i o n . In our p r e s e n t age t h e r e i s an epidemic of h e a r t d i s e a s e , lung d i s e a s e and motor v e h i c l e a c c i d e n t d i s e a s e s . I f t h i s epi-: demic was i n the form of a p o l i o epidemic everybody would see i t and would be demanding t h a t something be done. The h e a r t , lung and a c c i d e n t epidemic i s not as easy to see, but i f you c o u l d study the s t a t i s t i c s we have i n the h e a l t h department you c o u l d see t h i s epidemic as e a s i l y as we do. T h i s q u e s t i o n n a i r e i s designed to h e l p you l e a r n c e r t a i n t h i n g s about y o u r s e l f which might encourage you to improve your h e a l t h i n c e r t a i n areas. You supply r e l e v a n t i n f o r m a t i o n about your l i f e s t y l e , e x e r c i s e h a b i t s and f a m i l y h e a l t h h i s t o r y . The computer responds with a "Health Risk P r o f i l e " r e l a t i n g to the p o s s i b i l i t y of f u t u r e h e a l t h problems. A f t e r you f i l l t h i s form out put i t i n the H.H.A. box w i t h $2.00 to cover the computer c o s t . You can p i c k up the computer p r i n t o u t with the i n t e r p r e t e d r e s u l t s , i n two weeks here a t the Health U n i t . At t h a t time you can a l s o make arrangements to see the P u b l i c Health Nurse i f you d e s i r e f u r t h e r h e l p i n e i t h e r understanding the r e s u l t s or i n d e c i d i n g how to f o l l o w the com-puter p r e s c r i p t i o n . The P u b l i c H e a l t h Nurse i n the H e a l t h U n i t w i l l be a v a i l -able f o r t a k i n g blood pressure from 3:30 to 4:30 from Monday to F r i d a y . We would l i k e you to h e l p us to f i n d out i f t h i s program i s worth c o n t i n u i n g i n the Health U n i t . To do t h i s p l e a s e f i l l out the y e l l o w form and you w i l l be c o n t a c t e d i n a few months time by one of the Health U n i t s t a f f . - i±y -Province of British Columbia Ministry of Health PEACE RIVER HEALTH UNIT YOUR FILE OUR FILE Name: These are the Tabulated resul ts of your Health Hazard Appraisal Attached are the f indings of your Health Hazard Appra isa l . This helps you to know ways in which you can improve your health. The Health Hazard Appraisal compares you to others your age and gives the l i ke l ihood of death in the next 10 years with your present l i f e s t y l e . It also gives you the age you could be i f you fol low certa in recommendations which are pointed out below. Your Present age i s : Your age based on your l i f e s ty le i s : (See page 2 of the pr intout) (Appraisal age) Your age could be: (See page 2 of the printout)(Compliance age) To improve your age the fol lowing are suggested recommendations: Alcohol Usage: Seatbelt Usage: Exercise Pattern: Breast Care:(Women): Blood Pressure: Smoking Behaviour: Your Body Weight: Province of British Columbia Ministry of Health To: Al l Offices Date : January 9, 1979 Tentative Agenda Thursday 9:30 a.m. PHN Staff Meeting January 25 and 26 in DAWSON CREEK Health Hazard Appraisal and Life Style Modification Guest: Dr. John Milsum If possible please bring your own HHA for your own use at this meeting. 1:30 p.m. Follow up of Problem Oriented Recording Please bring two records in this with your comments. 2:30 Bits and Pieces 3:30 p.m. Union Business Friday 8:00 a.m. 12:00 noon held at "Family Therapy" by Art Chapel!, Psychiatric Social Worker with Kelowna Mental Health Centre Assembly Hall Dawson Creek and Distr ic t Hospital 1:30 - 3:30 p.m. Preview Prenatal Films/slides Interview By E.T. Best THE NEWS, Dawson Greek,' B.C.'; Wednesday, February 28, 1979 13 SECOND FRONT PAGE are your - 123 -Penny Tuthill is seen receiving a copy of the Health Hazard Appraisal form from Iris Scholz, secretary at Peace River Health Unit. - 124 -PUBLIC HEALTH NEWS W Page Hi! Have you ever wondered how you would be doing physically in.twenty or thirty years from now? Would you be interested in seeing how you • can improve your chances for a longer and Lhealthier life? . • This is^ how possible through a program called ' Health Hazard Appraisal (HHA), offered by the University' of. B.C., through the Peace River Health Unit. The HHA consists of a short ques-tionaire which interested participants fill out. The form covers age, sex, weight, physical fit-ness, smoking . habits, alcohol consumption, " driving habits and family health history. The computer responds with a "Health Risk Profile" relating to the possibility of future. : health problems. You learn at what age you are functioning now and you receive a computer : "prescription" on what areas you need to im-prove in and how to go^about doing this.. It.takes about three weeks to receive the com-puter printout with the interpreted results from the Health Unit. At that time arrangements can be made to see the Health Nurse if you require further help in either understanding the results or in deciding how to follow the computer pre-scription. . Interested? Watch for an upcoming display in the Recreation Centre or drop by the M^ eace River.Health-Unit located.in Bunkhouse 81 for further information. Planning a trip to Tahiti? That's great, but a recent news release from the Health Minister, Bob; McClelland, has warned that travellers should be aware to take precau-tions against a mosquito-borne virus called 'dengue'. (Pronounced den-gi) Dengue is usually accompanied by high fever, headache, joint and.muscle pain and occasion-ally a rash. The virus is usually mild, however, recovery may be prolonged for a week or more. If you are planning a trip to Tahiti, take along a reputable insect repellent and wear protective clothing. A vaccine is not currently available for protection against dengue. Anyone having an illness with)a fever, within two or three weeks of leaving^Tahiti 'is advised., to contact'their physician. Ref- Dr. A. A, 'Lar;sen,. Dir. of.Epidemiology .*,... Ii:!!: .-1 !i.'C'\' 'Vtopri&rand XQU'Mij v.'' Centre for Disease Control "" Atlanta,.Georgia , ********* YELLOW FEVER VACCINATIONS . Prince George and Vernon have now become new centres for Yellow Fever vaccination. Prior to this, Vancouver and Victoria were the only centres in B.C. , • . The vaccine is supplied in a five dose vial which, when reconstituted, must be given within one hour. As the vaccine is quite costly, to avoid waste, appointments must be scheduled so that five people can be vaccinated within the hour. Travellers to parts of Africa and South America are advised to call the local health unit at for information on Yellow Fever Centres. Remember! Yellow Fever immunization only becomes valid ten days after it has been given. Please contact the Health Unit well before de-parture date.-Ref- A. F. Ross, M.B., Ch. B., M.Sc, F.R.C.P., Medical Health Officer and Director ******** LOVE IS NOT ENOUGH' IMMUNIZE YOUR FAMILY NOW! Child Health Conferences coming up are as follows: Thursday, February 22 Thursday, March 8 Thursday, March 22 Thursday, April 5 -Thursday, April 19? Please try to call ahead to make an appointment. Health Unit No. is See you there! - 125 -THE NEWS. Dawson Creek, B.C., Wednesday, February 14, 1979 25 New program at the Health Unit The Peace. River Health certain chest conditions such Unit has introduced a new as bronchitis. program in Liyestyle Modi- The program centres fication which is available to around the Health Hazard the general. public at the Appraisal form which is local Health Unit office. available at the local Health Essentially: the. progrm Unit Offic. After an individ-demonstrates the relation- ual completes this form it is ship between health and sent to Vancouver for pro-lifestyle risks such as smok- cessing by a computer which ing behaviour, alcohol returns a printout giving usage, seat belt usage, body age as calculated by. exercise pattern, breast care Lifestyle risk. Iso on , the (women), body weight and printout is a prescription age blood pressure. The hope is which can be attained if the that increased awareness of individual follows the this relationship will lead to changes in lifestyle pre-further attempts at modera- scribed. The Health Unit , tion and alteration of life- staff will guide the individual style risks. In turn there to helpful resources and would be a decrease in offer counselling if desired, lifestyle related diseases _ , such as accidents and The program is meant to ; violence, heart attacks and compliment our e^rng pro-grams and will not alter the present Health Unit schedul-1 ing with respect to Public Health Nursing services, Public Health Inspection and Long Term Care. For example, immunization and • child and maternal health care will carry on as usual. - 126 -Fun for the whole family >, TW NEWS, D O W , ™ c r^k , B . C „ ; Fitness Festival set to go this Sunday Friday, May 25, 1979 Dawson Creek's first annual "Fitness Festival" is all set for Sunday with fun and games for the whole family. Opening ceremonies will be held in Kin Park at 9:30 a.m., followed by the Fun Run at the Kin Park Band-shell, beginning at 10:00 o'clock Fun Run refresh-' ments will be available and prizes will be awarded. : The bicycle safety and registration clinic will be held at the Kin Park Band-shell at 11:00 a.m., so bring your bike and get it in-spected and registered. Free reflector stickers will be available. All other events will be held: in the Arena, Cen-'.. tennial Pool, Soccer field < behind the arena or at the Central Soccer Field. Free T-shirts and buttons I will be given to all par-I ticipants. 12:00 noon - Soccer Fun -will take place at the soccer field behind the Arena. Don't worry about your ability, just come out and have some fun. Health Hazard Appraisal & Fitness Testing - will be • held behind the Centennial • Pool. If you haven't filled in ] the computer form or if you : haven't been tested for your \ fitness level, it's time you' \ did. Results may surprise iyou. ; 12:00 Noon - Jazzercise - in j the arena to music. Yes, , exercise can be fun, come and participate. Disco Dancing will be demonstrated by children, teens and adults, and lessons on the "L.A. Hustle" will be given. Ballet will also be demonstrated by young children and all are welcome to join in the fun. 12:00 Noon - New Games -will be played behind the pool. These are total par-ticipation, non-competitive games such as earth ball, parachute, tug-o-war and also the famous "lap-sit." Come out and see what they're all about At 1:30 Tae Kwon Ddwill be demonstrated in the arena, and at 2:00 Ladies Fitness will also be demonstrated in the arena. A tug-o-war challenge is set for 3:00 between mem-bers of City Council and the D.C.A.A. This will conclude the events for the Fitness Festival in and around the arena. The Centennial Swimming Pool staff is offering exciting and. free events, so take advantage, of this op-portunity and don't forget to bring your bathing suit. • From 7:00 a.m. until noon, the Dawson Creek Seals Interclub Swim Meet will be held and all are welcome to watch. Demonstrations by the Seals Fun Races will go from 1:00 to 2:00, and from 2:00 until 4:00 a free swim will be held for all participants. A free family swim will go-from 4:30 to 6:30, so come and have a good time. . The Fitness Festival promises to be fun: for the whole family, so come and enjoy yourself Sunday. - 127 -assiar the Voice of Cassiar Country . . 10 cents March-April 1979 i Page 6 Cassiar Courier 6 months DPT 1 2 months Red Measles 13 months German Measles 18 months ........ .DPT Polio ' School entry (4-6 years) ::.DPT Polio' Red Measles (Children not previously im-.: munized) Grade 5 German Measles (girls ..not previously immunized) Grade 10. DT Polio The above schedule is now being used by the Peace River Health Unit. Parents of grade five students can set their children at ease. No more immunizations until grade 10! Health Hazard Appraisal Don't forget to have your Health Hazard Ap-praisals done. There has been a really good res-ponse from Cassiarites so far. Generally, most participants have benefited for their computer-ized results. Forms are available from the.Health Unit and Recreation Center. For further information contact the Health Nurse. -• . at - 128 -From P r o j e c t Manager t o D i r e c t o r - - J a n u a r y 20, 1979. IN VIEW OF THE PILOT PROJECT - LIFE STYLE MODIFICATION WHAT ARE THE PUBLIC HEALTH NURSING PROGRAM PRIORITIES?  WHERE DOES THE HEALTH HAZARD APPRAISAL FIT IN? 1. Communicable D i s e a s e . C o n t r o l ( R e g u l a t o r y s e r v i c e ) a) A d u l t c l i n i c b) CHC (90% o f p r e s c h o o l c o m p l e t e d , i m m u n i z a t i o n i s low a t p r e s e n t . c) V.D. e) I m m u n i z a t i o n o f s c h o o l s . f ) Home v i s i t s - p a r t i c u l a r l y f o r I.H. and S k i n D i s e a s e s . 2. Home Care N u r s i n g i f no Home Care N u r s e s . 3. M a t e r n a l - C h i l d H e a l t h ( E a r l y p r e v e n t i o n and d e t e c t i o n ) . P r e - n a t a l c l a s s e s . E a r l y c l a s s , s e r i e s o f f o u r . Newborn v i s i t s . Average 2 / f a m i l y . C a s e l o a d a n a l y s i s i n d i c a t e s number o f b i r t h s above avera g e . Denver s c r e e n i n g on "At R i s k " C h i l d r e n . Home v i s i t s on c h i l d r e n w i t h D e v e l o p m e n t a l d e l a y s . C h i l d Community Care f a c i l i t i e s 4. S c h o o l H e a l t h Program I m m u n i z a t i o n V i s i o n and H e a r i n g S c r e e n i n g M e d i c A l e r t s I n t e r v i e w i n g s t u d e n t s r e : h e a l t h c o n c e r n s Home v i s i t s on h e a l t h c o n c e r n s Resource on H e a l t h E d u c a t i o n to t e a c h e r s T e a c h i n g H e a l t h E d u c a t i o n 5. C h r o n i c D i s e a s e s Rheumatic F e v e r Program V i s i t s t o c h r o n i c d i s e a s e s e.g. C y s t i c F i b r o s i s , B l i n d Deaf, C P . , H e a r t , e t c . H.V. A c c i d e n t a l P o i s o n i n g from h o s p i t a l : i ) C h i l d r e n - C h i l d s a f e t y i i ) Overdoses - 129 -6. C r i s i s I n t e r v e n t i o n - H o m e v i s i t s 7. H o s p i t a l L i a s o n D o c t o r L i a s o n A d u l t Community Care F a c i l i t i e s R o t a r y Manor The P l a c e Peace L u t h e r a n L i a s o n w i t h o t h e r a g e n c i e s and o r g a n i z a t i o n s . 8. Time s t u d y done two y e a r s ago i n d i c a t e s t h a t 40% o f n u r s e s time s p e n t i n t r a v e l . 9. H e a l t h H a z a r d A p p r a i s a l ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? March, 1978 Case Load a n a l y s i s i n d i c a t e s : We have more b i r t h s and l e s s p r e n a t a l c l a s s e s / y e a r than the p r o v i n c i a l a verage. We a l s o have more i n f a n t s and p r e s c h o o l a t the CHC p e r month th a n the p r o v i n c i a l a v e r a g e . T b - h i g h e r than the p r o v i n c i a l a v e r a g e . P o p u l a t i o n i n F o r t S t . John, and F o r t N e l s o n above the p r o v i n c i a l "average. S c h o o l p o p u l a t i o n i n F o r t S t . John and F o r t N e l s o n above the p r o v i n c i a l average. Province of British Columbia Ministry of Health MEMORANDUM To: Dr. Lugsdin Date: January 22, 1979 Director PRHU S/PHN/PRHU Re: Health Hazard Appraisal and L i fe Style Modif icat ion P i l o t Project January 1979  A further update on previous memo dated December 22/78. Observations noted in the 3 weeks HHA has been operating in the Dawson Creek o f f i c e : -1. The procedure out l ined for dispensing the forms and giv ing resu l ts appears to be sa t i s fac to ry . 2. I t appears that those adults attending Chi ld Health Conference are centered on the i r ch i l d ' s health and the Dawson Creek nurses have f e l t th is i s not an optimum time to suggest HHA though i t should be ava i l ab le . They are presently using the pre-Denver questionnaire at CHC so feel two forms for the parents to deal with are too much 3. The Dawson Creek nurses w i l l now keep a few HHA on hand in a l l home v i s i t s and of fer i t where appropriate. 4. The Dawson Creek nurses see the greatest need i s for pub l i c i t y re: th is program and suggest Radio, TV, and newspaper with the po s s i b i l i t y of a Mall d isp lay. 5. The nurses are anxious to see groups approached but question how much time they have to do t h i s . They l i ked our idea of approaching a l l groups named in our Dawson Creek Resources l i s t to see i f we could work through them in both presenting the HHA to them and possibly having the groups present i t to the publ ic with a back-up consultat ive committee. 6. The nurses feel the $2 fee i s a deterrent. 7. The s ta f f also feel only doing B.P. at Adult C l i n i c i s also a deterrent. - 131 -REFERENCES Corwin, Ronald G. Strategies for Organizational Innovation. Reprinted i n Human Service Organizations, edited by Hasenfeld, Y. and English, Richard. Ann Arbor, the University of Michigan Press, 1974. Andrews and Greenfield; i n Lynton, Rolf P. "Linking an ' Innovative Subsystem into the System." Administrative Science Quarterly, 1969, v o l . 14, pp. 398-416. Department of National Health and Welfare, Health Services and Promotion Branch, Health Services Directorate. Guidelines for Accreditation of Public Health Units, Ottawa, 19 80. Webster's New Twentieth Century Dictionary; The World Publishing Company, United States, 1966. Perrow, Charles. "The Short and Glorious History of Organizational Theory," Organizational Dynamics, summer, 1973, by ANCOM, a d i v i s i o n of American Management Associations. Weber, Max. The Theory of Social and Economic Organizations The Free Press, copyright Talcott and Parsons, 194 7. McGregor, Douglas. The Human Side of Enterprise: McGraw-Hill, New York, 1960^ Lik e r t , R. New Patterns of Management: McGraw-HlTT, New York, lWJT. Scott, William G. "Organization Theory: An Overview and an Appraisal," Academy of Management Journal, 1961, v o l . 4, pp. 7-26. Hasenfeld, Y. and English, Richard. Human Service  Organizations: University of Michigan Press, Ann Arbor, 19 74. Thompson, Vic t o r A. "Bureaucracy and Innovation," Administrative Science Quarterly, 196 5, v o l . 10, pp. 1-20. - 132 -12. Flashner, Bruce A. and Drenk, Douglas. "A Functionally Structured Organization Model for Health Departments." Canadian Journal of Public  Health, 1972, v o l . 63, pp. 207-214. 13. Hage, Gerald and Aiken, Michael. "Program Change and Organizational Properties, American Journal of  Sociology, 196 7, v o l . 74, pp. 503-518. 14. T o f f l e r , A l v i n . Future Shock: Random House, New York, 1970. 15. Pondy, Louis R. "Organizational C o n f l i c t : Concepts and Models," Administrative' Science Quarterly, 1967, v o l . 12, pp. 296-320. 16. Freeman, Ruth B. Constructive Use of C o n f l i c t , Lecture i n a Workshop on Management given to Public Health Employees at Vancouver, B.C., 1966. 17. Galbraith, J.K. The New Industrial State: Haughton M i f f l i n , Boston, 1972. 18. Massie, Joseph L. and Douglas, John. Managing, A Contemporary Introduction: Prentice-Hall, Inc., Englewood C l i f f s , New Jersey, 1977. 19. Cooper, W.W.., Leavitt, H.J. and Shelly, M.W. New Perspectives i n Organizational Research: John Wiley and Sons, 1964. 20. Friedman, John. "A Conceptual Model for the Analysis of Planning Behaviour," Administrative Science  Quarterly, 1967, v o l . 12,pp. 225-252. 21. Townsend, Robert. Up the Organ!zation, How to Stop the Corporations from S t i f l i n g People and  Strangling Profits:~Fawcett Crest Books, Conn., 1970. 22. Colburn, H.N. and Baker, P.M. "The Use of Mortality Data i n Setting P r i o r i t i e s for Disease Prevention, CMA Journal, 1977, vol 110, pp. 679-681. / - 133 -23. Robins, Lewis C. and H a l l , Jack H. How to Practice Prospective Medicine; Gene Slaymaker, Methodist Hospital of Indiana, Indianopolis, Indiana. 24. Travis, John W., User's Guide to PHS computerized HHA i n Health Hazard Appraisal and Systems Technology by Milsum, John H. Divi s i o n of Health Systems, Health Sciences Centre, UBC, 19 74. 25. H a l l , Jack H. and Zwemer, Jack D. Prospective Medicine; Methodist Hospital of Indiana, Indianopolis") Indiana, 1979. 26. Prince, Peter;. Milsum, John H.; Laszlo, Charles A.; and Wilson, Robert G. A P i l o t Project with Health  Hazard Appraisal i n a Community Health Centre  Environment. Health Sciences Centre, University of B r i t i s h Columbia, 1975. 27. Belloc, Nedra B. and Breslow, Lester. "Relationship of Physical Health Status and Health Practices," Preventive Medicine, 1972, vol.1, pp. 409 - 421. 28. Fuchs, V i c t o r R. Who Shall Live; Basic Books, Inc., New York, 1974. 29. Milsum, John H. A Report on the Preventive Medicine Course Given by John~McAmy at Esalen I n s t i t u t e , Big Sur, C a l i f o r n i a : UBC Co^ordinator's O f f i c e , Health Sciences Centre, UBC. 30. Lauzon, Richard R.J. A Randomized Controlled T r i a l on the A b i l i t y of Health Hazard Appraisal  to Stimulate Appropriate Risk Reduction Behaviour• A Dissertation Presented to the University of Oregon for the Degree of Doctor of Philosophy, 1977, Unpublished. 31. Lalonde, Marc. A New Perspective On the Health of Canadians: Tri-graphic P r i n t i n g , Ottawa, Information Canada, Ottawa, 1975. 32. Milsum, John H. and Laszlo, Charles A. Cybernetics and Health Care. Chapter for Cybernetics; A Source-book, Editor Robert Trapple, Hemisphere Publishing Corporation, 1977. - 134 -33. Cheraskin, E. and Ringsdorf, W.M. Predictive Medicine: P a c i f i c Press Publishing Association, Mountainview, C a l i f o r n i a , 1973. 34. Milsum, John H. and Laszlo, Charles A. A Proposal for P r o v i n c i a l Funding: UBC Co-ordinator^s O f f i c e , D i v i s i o n of Health Systems, Health Sciences Centre, University of B r i t i s h Columbia. 35. HSU, H.S. and Milsum, John, H. Implementation of Health Hazard Appraisal and Its Impediment's." Divis i o n of Health Systems, Health Sciences Centre, University of B r i t i s h Columbia. 36. Colburn, H.N. and Baker P.M. "Health Hazard Appraisal A Possible Tool i n Health Protection and Promotion." Canadian Journal of Public Health, 1973, v o l . 64, pp. 490-492"; 37. Milsum, John H. "Health, Risk Factor Reduction and L i f e - S t y l e Change," Family and Community Health, 1980, v o l . 3, pp. 1-13. 38. B.C. Hydro Population Study, 1980. Source: Peace River Regional D i s t r i c t F i l e s . 39. School D i s t r i c t #59 records. 40. Personal Communication: Dental Hygienist, PRHU. 41. V i t a l S t a t i s t i c s , Province of B r i t i s h Columbia. 42. Dawson Creek Medical C l i n i c , Personal Communication. 43. Dawson Creek Chief of Police and Hudson's Hope Chief of Police, Personal Communication. 44. S t a t i s t i c s , Peace River Health Unit Annual Report, 1978. 45. Peace River Health Unit Mental Health Centre, Personal CommunicatiorH - 135 -46. B r i t i s h Columbia Ministry of Health, Policy Manuals: Province of B.C. Press, V i c t o r i a . 47. B r i t i s h Columbia Ministry of Health, 19 79 Annual Report of the Ministry of Health, Province of B.C. Press, V i c t o r i a , 1979. 48. Kane, Robert L., The Challenges of Community Medicine: Springer Publishing Company, New York, 1~9~74. 49. Milsum, John, H., "Health Hazard Appraisal and the Health Care System," Strategies for Public Health: Promoting Health and Preventing Disease, edited by Ng, Lorenz K.Y~ and Davis, Devra Lee. New York, Van Nostrand Reinhold Company, 1981. - 136 -Typed by L u c i l l e Kucher Reproduced at Northern Lights College ' Dawson Creek, B r i t i s h Columbia i 

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