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Clinic Staffing Patterns and the Pregnant Adolescent
research and studies Clinic Staffing Patterns and the Pregnant Adolescent MARILYN f.KIEFFER, CNM, MS, and F. ROSS WOOLLEY, PhD The special problems of meeting the needs of the pregnant adolescent were studied with 52patients in three clinics with different stajing patterns. Data were obtained from medical records and a patient knowledge and satisfaction questionnaire. Results indicate signijcant dzJerences among provider groups (clinics) in eliciting patient satisfaction, although no differences in quality of care or patient knowledge were detected. Of the 52 patients queried, those expressing the most satisfaction with care were from the clinic staffed by a multidisciplinary team and those expressing the least satisfaction with care were from the clinic staffedprimarily by residents. The other clinic was staffed primarily by nurse-midwives
Satisfying patients has sometimes been viewed as a desirable though nonessential by-product of the physician-patient relationship. Recent studies indicate that patient satisfaction and the relationship between the patient and provider may be essential factors in the overall management of illness. Direct linkages among patient-physician communication, compliance, outcomes of care, and patient satisfaction have been indicated.'-4 Positive correlations have been demonstrated between communications, patient exp e c t a t i o n s , c o n t i n u i t y of c a r e , outcomes of care, and patient satisfaction." Such findings indicate a need for more understanding of the basis and effects of patient satisfaction in health care management. Cause-and-effect relationships are hard to demonstrate due, in part, to halo effects among various phenomena. Patients may be influenced more by the personality of the provider than by any real differences in the care they receive. However, patients can discriminate among separate aspects of health care delivery such as cost, accessibility, quality of care, and professional competence," which suggests that clinically important factors in the care process influence the satisfaction of patients as opposed to the halo effect of the provider's personality. In short, good surroundings and a dashing bedside manner cannot be substituted for November/Decernber 1979JOCN Nurszng
OOW-03I 1/79/1 I13-0333$0100
competent, cost effective, easily accessible care. Clearly one of the elements important to the patient is knowledge of, and active participation in, the health care process. T h e health care consumer of today is more demanding than ever before and will seek alternative forms of care if personally identified needs are not met. In evaluating patient and provider satisfaction, there is evidence that they are highly related.7 Although there is little data indicating where dissatisfaction might begin (with the patient or provider), the importance of this factor should not be dismissed lightly. An unsatisfied provider can maintain neither quality care nor effective interpersonal relationships." As with all circular questions, starting points are hard to define. It is hard to know whether poor care leads to a bad outcome and a dissatisfied patient or vice versa. In this study both patient satisfaction and the process of care were examined to determine the effects of provider differences. T h e pregnant adolescent presents a complex mix of medical management a n d psychosocial problems which frequently may not be met by traditional provider mixes. Indeed, it has been suggested that no single provider can adequately meet both of the special needs, medical and psychosocial, of these patients.' Acknowledging these needs before-
h a n d , measures were developed which evaluated patient satisfaction as well as the patient's knowledge of pregnancy and the quality of care (both process and outcome) in three provider settings-a unique opportunity to evaluate the effects of different provider mixes on a nearly homogeneous patient population.
METHODS In a prospective study data were obtained on 52 patients seen in three prenatal clinics (Clinics M, N, a n d R) in the Salt Lake City area. All patients delivered at the University of Utah Medical Center. T h e three clinics are all afiliated with the university but differ in their staffing patterns. Clinic M uses a multidisciplinary approach with a team which includes obstetricians, a nurse-midwife, a pediatrician, a pediatric nurse clinician, a dental hygienist, and a health aide. It is a fee-for-service clinic, but a sliding-scale schedule based on ability to pay is used. Patients are assisted in delivery by either an obstetrician or a nursemidwife from the clinic. Clinic N is staffed by certified nurse-midwives who are members of the University of Utah College of Nursing faculty. Patients are usually assisted in delivery by the resident on call at the medical center when the patient arrives for delivery. (On rare occasions, prior arrangements have been made for a nurse-midwife to assist in delivery; however, n o such delivery occurred during this study.) Clinic K is staffed by residents in obstetrics and gynecology from the medical center. Patients are usually assisted in delivery by the resident on call at the medical center when the patient arrives for delivery. Clinics N and R share facilities and provide free prenatal care to women of low income. However, all laboratory and hospitalization costs are the personal responsibility of each patient. The support staff for Clinics N and K is identical. The two clinics meet on different days of the week and patients select which clinic they will attend based on convenience of the day or their prefer333
ences for care by residents O r nursemidwives. Once the selection has been made, however, they are required to remain with that form of care. Patients who were selected for this study met four criteria: 1) had a yearly income of under $6,000; 2) were between 15 and 2 1 years of age; 3) were between 38 and 42 weeks’ gestation; and 4) had a minimum of four previous prenatal visits to their respective clinics. Of the patients contacted to participate in the study, none declined. However, two who completed the initial questionnaire did not deliver at the University of Utah Medical Center and were later dropped from the study. They are not included in the 52 patients cited above. Data were obtained by personal contact with the patients while they were waiting to be seen in their respective clinics and from two medical records reviews. The knowledge and satisfaction questionnaire was completed by the patient and then returned to the interviewer in the waiting room. It usually required between five and ten minutes to complete, and it consisted of 20 patient-satisfaction statements, 11 knowledge questions, and 10 demographic items. Seventeen of the satisfaction statements used a four-point modified Likert scale response technique. The responses ranged from “strongly agree” to “strongly disagree” on such items as “I felt the person taking care of me knew what he was doing;” “I now feel adequately prepared for my labor and delivery experience;” a n d “If I -had more money, I would have gone elsewhere for my care.” Two items rated care, using a five-point scale ranging from “much worse” to “much better,’’ to compare their current care with their previous care or that of friends or relatives. The last question related to location of previous prenatal care. The patient knowledge questions were divided into two parts. The first consisted of nine statements which measured the patient’s ability to discriminate between normal and abnormal occurrences during a pregnancy. The responses indicated what
334
Table 1. Demographic Variables Among 52 Pregnant Adolescents in Three Prenatal Clinics Clinic percentages
Marital status Married Separated Single Living with partner Yes No Manner of health care payment Welfare Insurance Cash Religious preference LDS (Mormon) Catholic None Not stated Age
Chi Square P<
M
R
N
15.4 5.8 21.2
26.9 1.9
23.1
-
-
-
5.8
.01
15.4 26.9
26.9 1.9
25.0 3.8
13.5 9.6 19.3
3.8 3.8 21.2
-
19.2 11.5 9.6 5.8 17.2
19.2 3.8
19.2
5.8
9.6 3.8 19.1
Demographic item
3.8 17.9
1.9 26.9
-
.001
.01
.05 .01*
Analysis of variance used to test age differences.
action should be taken for events such as “YOU are spotting small amounts of blood,” or “You have had a real bad headache for two days.” The responses were 1) don’t worry, it’s normal; 2) wait until your next appointment; 3) call the University Medical Center or clinic; 4) go to the University Medical Center to be checked. Two other statements related to the frequency and methods in taking iron supplements. T o evaluate the quality of the health care process, a 21-item list based on the 1974 American College of Obstetricians and Gynecologists Standards was developed. Data on these 21 items were obtained from a n audit of prenatal charts. The charts were reviewed to evaluate whether the specific procedure or measure was recorded during the course of prenatal care. Pelvic measurements, urinalyses, blood type, fundal height, edema, and fetal heart tones were included among the items. The outcome of care was determined by evaluating both the infant’s and the mother’s postpartum record. These data were length of hospital stay for both the mother and infant, Apgar score for the infant obtained at one and five minutes after birth, duration of labor. mother’s hematocrit on the second
postpartum day, and weight of the infant in grams.
RESULTS Of the 52 patients in this study, 22 were from Clinic M and 15 each from Clinics N and R. Demographic characteristics of the clinics were compared to determine differences among samples. These evaluations showed no differences among the three clinic samples in parity, educational level, presence of a partner or support person, reasons for choosing the clinic, attendance of prenatal classes, or total income. As shown in Table 1, there were differences among the clinics in age, marital status, whether they were living with a partner, religious background, and source of health care payments. Clinic N patients were found to be older (19.1 years) than those in Clinics R or M, who had mean ages of 17.9 and 17.2 respectively. Clinic M was found to have higher incidence of single patients and to receive more third-party payments in the form of welfare or insurance than the other clinics. Although the majority of patients in all three clinics were Latter Day Saints (Mormon), Clinic M had significantly more Catholic patients than did the other two. The results of an analysis of variNovernber/December 1979JOCN Nuisin8
Table 2. Score Differences Determined By Analysis of Variance in Study of 52 Pregnant Adolescents in Three Prenatal Clinics Variable measured Process of care Knowledge Outcome Satisfaction
Maximum score possible
Clinic mean scores M
R
N
Significance
21.00 1 1 .oo 7.00 32.00
21.00 8.23 6.40 26.31
19.90 8.64 6.07 13.00
20.70 8.14 6.50 21.53
NS NS NS P< .001
ance on the summary scores obtained for patient satisfaction, patient knowledge, and both process and outcome quality of care measures are presented in Table 2. Only on satisfaction scores was a significant (P < .001) difference obtained. Applying a Newman-Keuls multiple range test to the satisfaction scores, significant differences were detected among the three clinics. Clinic M, delivering c a r e i n a multidisciplinary setting, produced significantly higher scores, with Clinic N, staffed by nurse-midwives, coming in second. As seen in Table 2, care rendered and outcome scores are very close to the maximum possible for all three clinics. Although no significant differences in patient knowledge were found among the three clinics, all of them were well below the maximum possible score. T o determine if age had played a significant role in altering the satisfaction scores, a Pearson productmoment correlation was calculated between the age and satisfaction scores. A nonsignificant (P > .05) correlation of .28 was found. It would appear that age may have contributed slightly but not significantly to the differences observed in sat isfact ion. The results of this study indicate that the provider mix available in the prenatal care of adolescents may make a significant difference in their satisfaction. Although no differences were detected among clinics on outcomes of care, patient knowledge, or the process quality of the care measures, a longitudinal study may produce different results. The impact of short-term care and the attitudes of patients as related to long-term care health-seeking behavior and health status have yet to be determined. T h e rise of home deliveries, some unNovember/December 1979JOGN Nursing
5.
6.
physicians’ awareness of patients’ concerns. HSMHA Health Reports 86:741, 1971a Woolley FR, Kane RL, Hughes CC, Wright DD: The effects of doctor-patient communication on satisfaction and outcome of care. SOCSci Med 12:123, 1978 Korsch BM, Gozzi EK, Francis V: Gaps in doctor-patient interaction and Datient satisfaction. Pediatrics 42:85’5, 1968 Kane RL, Leymaster C, Olsen DM, Woolley FR, Fisher DF: Manipulating the patient: A comparison of the effectiveness of physician and chiropractor care. Lancet 1333-1336, 1974 Donabedian A: Promoting quality through evaluating the process of patient care. Med Care 629, 1968 Fielding JE, Nelson SH: Health care for the economically disadvantaged adolescent. Pediatr Clin North Am 20:975, 1973
d e r questionable circumstances, 7. may, however, be due in part to the dissatisfaction with traditional provider settings. T h e trend towards untrained or poorly qualified people 8. attending deliveries outside of wellequipped hospitals makes the need for improved satisfaction and in- 9. creased trust between patient and practitioner even more critical than in the past. The results of this study tend to support earlier statements that no Address for correspondence: F. Ross single health care provider can meet Woolley, PhD, Dept. of Family and the complex needs of the pregnant Community Medicine, University of adolescent. Further, they suggest the Utah, 50 North Medical Drive, Salt possibility of the pregnant adoles- Lake City, U T 84132. cent being able to establish a more positive relationship with female as opposed to solely male providers. Female nurse-midwives attended patients in both Clinics M and N. In Clinic R, aside from the support Marilyn Kiefer is a staff, only male Ob/Gyn residents destafnurse-midwqe at Phoenix Memorial livered the care. Clearly, in all three Hospital, Phoenix, clinics, the quality of the care renArizona. She h a s dered was high. There is, however, worked as a staJ more to meeting the needs of the panurse in labor and detient t h a n providing medically liuely and as a public sound prenatal care and assuring a health nurse. M s . safe delivery. If patients are to conKiejer received her tinue to choose sound medical care, BSfrom Loyola Unitheir psychosocial needs must also be versity, Chicago, Illinois, and her M S degree met in that same milieu. from the University of Utah. She is a member
References Francis V, Korsch B M, Morris MJ: Gaps in doctor-patient communication. N Engl J Med 280535, 1969 Vouri H, Aaku T, Aine E, et al: Doctor-patient relationship in the light of patients’ experiences. SOCSci Med 6:723, 1972 Davis MS: Variations in patients’ compliance with doctor’s advice: An empirical analysis of patterns of communication. Am J Public Health 58:274, 1968 Hulka BS, Kupper LL, Cassel JC, Thompson SJ: Method for measuring
of N A A C O G , A C N M , A N A , and ICEA.
F. Ross Woolley is assistant professor in the Department of Family and Community Medicine, Universi4 of Utah College of Medicine, Salt Lake C i t y . He received his P h D Porn Brigham Young University, Proua, Utah.
335
Satisfying patients has sometimes been viewed as a desirable though nonessential by-product of the physician-patient relationship. Recent studies indicate that patient satisfaction and the relationship between the patient and provider may be essential factors in the overall management of illness. Direct linkages among patient-physician communication, compliance, outcomes of care, and patient satisfaction have been indicated.'-4 Positive correlations have been demonstrated between communications, patient exp e c t a t i o n s , c o n t i n u i t y of c a r e , outcomes of care, and patient satisfaction." Such findings indicate a need for more understanding of the basis and effects of patient satisfaction in health care management. Cause-and-effect relationships are hard to demonstrate due, in part, to halo effects among various phenomena. Patients may be influenced more by the personality of the provider than by any real differences in the care they receive. However, patients can discriminate among separate aspects of health care delivery such as cost, accessibility, quality of care, and professional competence," which suggests that clinically important factors in the care process influence the satisfaction of patients as opposed to the halo effect of the provider's personality. In short, good surroundings and a dashing bedside manner cannot be substituted for November/Decernber 1979JOCN Nurszng
OOW-03I 1/79/1 I13-0333$0100
competent, cost effective, easily accessible care. Clearly one of the elements important to the patient is knowledge of, and active participation in, the health care process. T h e health care consumer of today is more demanding than ever before and will seek alternative forms of care if personally identified needs are not met. In evaluating patient and provider satisfaction, there is evidence that they are highly related.7 Although there is little data indicating where dissatisfaction might begin (with the patient or provider), the importance of this factor should not be dismissed lightly. An unsatisfied provider can maintain neither quality care nor effective interpersonal relationships." As with all circular questions, starting points are hard to define. It is hard to know whether poor care leads to a bad outcome and a dissatisfied patient or vice versa. In this study both patient satisfaction and the process of care were examined to determine the effects of provider differences. T h e pregnant adolescent presents a complex mix of medical management a n d psychosocial problems which frequently may not be met by traditional provider mixes. Indeed, it has been suggested that no single provider can adequately meet both of the special needs, medical and psychosocial, of these patients.' Acknowledging these needs before-
h a n d , measures were developed which evaluated patient satisfaction as well as the patient's knowledge of pregnancy and the quality of care (both process and outcome) in three provider settings-a unique opportunity to evaluate the effects of different provider mixes on a nearly homogeneous patient population.
METHODS In a prospective study data were obtained on 52 patients seen in three prenatal clinics (Clinics M, N, a n d R) in the Salt Lake City area. All patients delivered at the University of Utah Medical Center. T h e three clinics are all afiliated with the university but differ in their staffing patterns. Clinic M uses a multidisciplinary approach with a team which includes obstetricians, a nurse-midwife, a pediatrician, a pediatric nurse clinician, a dental hygienist, and a health aide. It is a fee-for-service clinic, but a sliding-scale schedule based on ability to pay is used. Patients are assisted in delivery by either an obstetrician or a nursemidwife from the clinic. Clinic N is staffed by certified nurse-midwives who are members of the University of Utah College of Nursing faculty. Patients are usually assisted in delivery by the resident on call at the medical center when the patient arrives for delivery. (On rare occasions, prior arrangements have been made for a nurse-midwife to assist in delivery; however, n o such delivery occurred during this study.) Clinic K is staffed by residents in obstetrics and gynecology from the medical center. Patients are usually assisted in delivery by the resident on call at the medical center when the patient arrives for delivery. Clinics N and R share facilities and provide free prenatal care to women of low income. However, all laboratory and hospitalization costs are the personal responsibility of each patient. The support staff for Clinics N and K is identical. The two clinics meet on different days of the week and patients select which clinic they will attend based on convenience of the day or their prefer333
ences for care by residents O r nursemidwives. Once the selection has been made, however, they are required to remain with that form of care. Patients who were selected for this study met four criteria: 1) had a yearly income of under $6,000; 2) were between 15 and 2 1 years of age; 3) were between 38 and 42 weeks’ gestation; and 4) had a minimum of four previous prenatal visits to their respective clinics. Of the patients contacted to participate in the study, none declined. However, two who completed the initial questionnaire did not deliver at the University of Utah Medical Center and were later dropped from the study. They are not included in the 52 patients cited above. Data were obtained by personal contact with the patients while they were waiting to be seen in their respective clinics and from two medical records reviews. The knowledge and satisfaction questionnaire was completed by the patient and then returned to the interviewer in the waiting room. It usually required between five and ten minutes to complete, and it consisted of 20 patient-satisfaction statements, 11 knowledge questions, and 10 demographic items. Seventeen of the satisfaction statements used a four-point modified Likert scale response technique. The responses ranged from “strongly agree” to “strongly disagree” on such items as “I felt the person taking care of me knew what he was doing;” “I now feel adequately prepared for my labor and delivery experience;” a n d “If I -had more money, I would have gone elsewhere for my care.” Two items rated care, using a five-point scale ranging from “much worse” to “much better,’’ to compare their current care with their previous care or that of friends or relatives. The last question related to location of previous prenatal care. The patient knowledge questions were divided into two parts. The first consisted of nine statements which measured the patient’s ability to discriminate between normal and abnormal occurrences during a pregnancy. The responses indicated what
334
Table 1. Demographic Variables Among 52 Pregnant Adolescents in Three Prenatal Clinics Clinic percentages
Marital status Married Separated Single Living with partner Yes No Manner of health care payment Welfare Insurance Cash Religious preference LDS (Mormon) Catholic None Not stated Age
Chi Square P<
M
R
N
15.4 5.8 21.2
26.9 1.9
23.1
-
-
-
5.8
.01
15.4 26.9
26.9 1.9
25.0 3.8
13.5 9.6 19.3
3.8 3.8 21.2
-
19.2 11.5 9.6 5.8 17.2
19.2 3.8
19.2
5.8
9.6 3.8 19.1
Demographic item
3.8 17.9
1.9 26.9
-
.001
.01
.05 .01*
Analysis of variance used to test age differences.
action should be taken for events such as “YOU are spotting small amounts of blood,” or “You have had a real bad headache for two days.” The responses were 1) don’t worry, it’s normal; 2) wait until your next appointment; 3) call the University Medical Center or clinic; 4) go to the University Medical Center to be checked. Two other statements related to the frequency and methods in taking iron supplements. T o evaluate the quality of the health care process, a 21-item list based on the 1974 American College of Obstetricians and Gynecologists Standards was developed. Data on these 21 items were obtained from a n audit of prenatal charts. The charts were reviewed to evaluate whether the specific procedure or measure was recorded during the course of prenatal care. Pelvic measurements, urinalyses, blood type, fundal height, edema, and fetal heart tones were included among the items. The outcome of care was determined by evaluating both the infant’s and the mother’s postpartum record. These data were length of hospital stay for both the mother and infant, Apgar score for the infant obtained at one and five minutes after birth, duration of labor. mother’s hematocrit on the second
postpartum day, and weight of the infant in grams.
RESULTS Of the 52 patients in this study, 22 were from Clinic M and 15 each from Clinics N and R. Demographic characteristics of the clinics were compared to determine differences among samples. These evaluations showed no differences among the three clinic samples in parity, educational level, presence of a partner or support person, reasons for choosing the clinic, attendance of prenatal classes, or total income. As shown in Table 1, there were differences among the clinics in age, marital status, whether they were living with a partner, religious background, and source of health care payments. Clinic N patients were found to be older (19.1 years) than those in Clinics R or M, who had mean ages of 17.9 and 17.2 respectively. Clinic M was found to have higher incidence of single patients and to receive more third-party payments in the form of welfare or insurance than the other clinics. Although the majority of patients in all three clinics were Latter Day Saints (Mormon), Clinic M had significantly more Catholic patients than did the other two. The results of an analysis of variNovernber/December 1979JOCN Nuisin8
Table 2. Score Differences Determined By Analysis of Variance in Study of 52 Pregnant Adolescents in Three Prenatal Clinics Variable measured Process of care Knowledge Outcome Satisfaction
Maximum score possible
Clinic mean scores M
R
N
Significance
21.00 1 1 .oo 7.00 32.00
21.00 8.23 6.40 26.31
19.90 8.64 6.07 13.00
20.70 8.14 6.50 21.53
NS NS NS P< .001
ance on the summary scores obtained for patient satisfaction, patient knowledge, and both process and outcome quality of care measures are presented in Table 2. Only on satisfaction scores was a significant (P < .001) difference obtained. Applying a Newman-Keuls multiple range test to the satisfaction scores, significant differences were detected among the three clinics. Clinic M, delivering c a r e i n a multidisciplinary setting, produced significantly higher scores, with Clinic N, staffed by nurse-midwives, coming in second. As seen in Table 2, care rendered and outcome scores are very close to the maximum possible for all three clinics. Although no significant differences in patient knowledge were found among the three clinics, all of them were well below the maximum possible score. T o determine if age had played a significant role in altering the satisfaction scores, a Pearson productmoment correlation was calculated between the age and satisfaction scores. A nonsignificant (P > .05) correlation of .28 was found. It would appear that age may have contributed slightly but not significantly to the differences observed in sat isfact ion. The results of this study indicate that the provider mix available in the prenatal care of adolescents may make a significant difference in their satisfaction. Although no differences were detected among clinics on outcomes of care, patient knowledge, or the process quality of the care measures, a longitudinal study may produce different results. The impact of short-term care and the attitudes of patients as related to long-term care health-seeking behavior and health status have yet to be determined. T h e rise of home deliveries, some unNovember/December 1979JOGN Nursing
5.
6.
physicians’ awareness of patients’ concerns. HSMHA Health Reports 86:741, 1971a Woolley FR, Kane RL, Hughes CC, Wright DD: The effects of doctor-patient communication on satisfaction and outcome of care. SOCSci Med 12:123, 1978 Korsch BM, Gozzi EK, Francis V: Gaps in doctor-patient interaction and Datient satisfaction. Pediatrics 42:85’5, 1968 Kane RL, Leymaster C, Olsen DM, Woolley FR, Fisher DF: Manipulating the patient: A comparison of the effectiveness of physician and chiropractor care. Lancet 1333-1336, 1974 Donabedian A: Promoting quality through evaluating the process of patient care. Med Care 629, 1968 Fielding JE, Nelson SH: Health care for the economically disadvantaged adolescent. Pediatr Clin North Am 20:975, 1973
d e r questionable circumstances, 7. may, however, be due in part to the dissatisfaction with traditional provider settings. T h e trend towards untrained or poorly qualified people 8. attending deliveries outside of wellequipped hospitals makes the need for improved satisfaction and in- 9. creased trust between patient and practitioner even more critical than in the past. The results of this study tend to support earlier statements that no Address for correspondence: F. Ross single health care provider can meet Woolley, PhD, Dept. of Family and the complex needs of the pregnant Community Medicine, University of adolescent. Further, they suggest the Utah, 50 North Medical Drive, Salt possibility of the pregnant adoles- Lake City, U T 84132. cent being able to establish a more positive relationship with female as opposed to solely male providers. Female nurse-midwives attended patients in both Clinics M and N. In Clinic R, aside from the support Marilyn Kiefer is a staff, only male Ob/Gyn residents destafnurse-midwqe at Phoenix Memorial livered the care. Clearly, in all three Hospital, Phoenix, clinics, the quality of the care renArizona. She h a s dered was high. There is, however, worked as a staJ more to meeting the needs of the panurse in labor and detient t h a n providing medically liuely and as a public sound prenatal care and assuring a health nurse. M s . safe delivery. If patients are to conKiejer received her tinue to choose sound medical care, BSfrom Loyola Unitheir psychosocial needs must also be versity, Chicago, Illinois, and her M S degree met in that same milieu. from the University of Utah. She is a member
References Francis V, Korsch B M, Morris MJ: Gaps in doctor-patient communication. N Engl J Med 280535, 1969 Vouri H, Aaku T, Aine E, et al: Doctor-patient relationship in the light of patients’ experiences. SOCSci Med 6:723, 1972 Davis MS: Variations in patients’ compliance with doctor’s advice: An empirical analysis of patterns of communication. Am J Public Health 58:274, 1968 Hulka BS, Kupper LL, Cassel JC, Thompson SJ: Method for measuring
of N A A C O G , A C N M , A N A , and ICEA.
F. Ross Woolley is assistant professor in the Department of Family and Community Medicine, Universi4 of Utah College of Medicine, Salt Lake C i t y . He received his P h D Porn Brigham Young University, Proua, Utah.
335