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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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214 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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216 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.