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APPENDIX
D
Site Visits:
Site Selection and Methodology
OBJECTIVES FOR THE SITE VISITS
Site visits to six states were included in the study plan in order to augment
the information available to the committee about the current state of public
health activities in the United States. The site visits were intended to elicit
directly the perceptions of key actors who shape public health activities
either through direct participation in those activities or through influence in
the establishment of public health policies. The visits were conceived as an
opportunity to learn more about the actual functioning of public health in
addressing health problems-eliciting information that goes beyond formal
organizational statements to probe more deeply into decision processes.
This information would add to the committee's understanding of how poli-
cies are established and implemented and what problems are encountered
that inhibit effective actions.
SITE SELECTION
The selection criteria aimed at a purposive sample that would maximize
the opportunities for the committee to learn from visits to only six states a
constraint imposed by time and resources. A purposive sample was viewed
by the committee as much more useful and valid than any attempt at
randomization with such small numbers. The site visit information would
augment other data available to the committee about all states (e.g., the data
from the Public Health Foundation), statements at the four regional meet
2Z3
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APPENDIX D
ings, and the extensive knowledge and experience of the committee, includ-
ing detailed knowledge among the committee of 13 additional states.
The selection process sought variety across the following dimensions:
· proportion of urban and rural population
· strength of economy, principal economic activities, and tax base
· intensity of public health activities (absolute and per capita expendi-
tures)
· range of public health activities
· structure of government for public health (e.g., inclusion of public
health in "superagency" versus independent public health agency)
· relative roles of state and local government in public health
· continuity of public health leadership
The intention was to visit localities within each state selected as well as the
state capital. Therefore, additional opportunity was provided in the selec-
tion to represent diversity over these dimensions.
Data and other information on all the states were compiled by staff for
consideration by the committee. In addition to the above dimensions, the
intent was to choose states to the extent possible where the committee
members were not currently active in administration of public health activ-
ities.
The final choices were made by the committee. The sites selected included
the capitals and several local areas in each of the following states: West
Virginia, New Jersey, California, Mississippi, South Dakota, and Washing-
ton.
METHODOLOGY
The design of the site visits drew on the recent literature concerned with
policy implementation research. (Pressman and Wildavskey, 1973; Na-
kamura and Smallwood, 1980; Sabatier and Nasmanian, 1980; Tooner, 1985;
Williams, 1980) The emphasis of this research is on the transformation,
within an administrative system, of inputs (laws, funds, personnel, tech-
niques) into outputs (people served, regulatory activities performed, trans-
fer payments made), and outcomes (lower infant mortality rate, control of
infectious disease outbreaks, etc.~. The effort is directed toward understand-
ing what is actually going on at the day-to-day operational level of public
problem-processing.
The site visits lasted 4 or 5 days. An advance visit was made by staff to
arrange the visits. Committee and staff participated in each visit. Descrip-
tive data on each state and locality were distributed to site visitors in
advance. Interviewees were selected through interaction with informed
persons in each state and locality visited. Interviewees included:--
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APPENDIX D
215
· public health officials (state and local and various levels within each
organization)
· officials of related agencies (welfare, environment, Medicaid, etc.)
· elected officials (state and local)
· staff at general purpose government levels (budget officials)
· practicing physicians and nurses
· other health leaders in the private sector (hospital associations, nursing
associations, social worker associations)
· consumer leaders
· media representatives
The interview process was semistructured. An interview guide was pro-
vided to each interviewer outlining objectives, emphasizing the need to elicit
the perceptions of those being interviewed without prejudgment from the
interviewer, giving examples of interview techniques to help achieve this
purpose and sample questions. The questions were aimed at eliciting not
only description and evaluation but also hopes and aspirations for public
health. Many of the questions were open-ended rather than highly struc-
tured in order to assure that the interviewees' perceptions were guiding the
. .
c .lscusslon.
A document describing the study and the purpose of the site visits was sent
in advance to interviewees. That document outlined a series of nine specific
health problems agreed to in advance by the committee in order to provide
some initial focus for the interviews. Those problems were:
AIDS
Tobacco Use and Addiction
Unintended Injuries
Hazardous Waste Disposal
Exposure to Asbestos
Pertussis Vaccine
Alzheimer's Disease
Medical Indigence
Teen-Age Pregnancy
The problem list was used as a starUng point. She interviews did not
attempt to confine the dimensions to those problems. (Indeed, some inter-
viewees were quite forceful in adding other problems to the discussion.)
Each interviewer wrote up the interviews immediately following the inter-
views. A summary report on each visit was prepared by staff for the use of
the full committee. As confidentiality was promised to interviewees, those
reports will not be published. Information from all interviewees was classi-
fied by topic and entered into a computer system for later retrieval and
analysis.
A shorter visit was made to the health department in Toronto, Canada.
This 1-day visit did not follow the process described above, but was in-
tended to provide some additional perspective on public health issues as
seen from another political, social, and cultural context. Substantial infor
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APPENDIX D
mation on public health activities in Toronto and Ontario was provided to the
committee.
REFERENCES
Nakamura, Robert T., and F. Smallwood. 1980. The Politics of Policy Implementation. St.
Martin's Press, New York.
Pressman, Jeffrey L., and A. Wildavskey. 1973. Implementation. University of California Press,
Berkeley.
Sabatier, Paul, and R. Nasmanian, eds. 1980. Special Issue on Implementation. Policy Studies
Journal, vol. 19.
Tooner, Theo A. J. 1985. Implementation Research and Institutional Design: The Quest for
Structure. Martinus Nijhoff, The Netherlands.
Williams, Walter. 1980. The Implementation Perspective. University of California Press,
Berkeley.
Representative terms from entire chapter:
six states
