Some factors for refusal to participate in nutrition survey

content prior to taking the final examination. The years of 4-H membership and verbal SAT scores ranked second and third, respectively. (See Table 3.) Because of the ranking of the predictor variables for exemption group, hypotheses 1 and 2 were rejected. The pre-test ranked first as a predictor variable in both the large group, 1967, and the smaller homogeneous group, 1969. Hypotheses 3 and 4 were rejected on the evidence that the years of 4-H membership and verbal SAT scores were significantly related to t,he final examination raw scores (P ~. OI). The secondary predictors will not suffice as criteria for exemption but should be incorporated into the overall evaluation of the student's background. Conclusions Serendipity in research is to find that, criteria established by a prior study is current and may provide guidelines for the future. If a test mean of 80.67 is characteristic of the exempt group, then the probability of passing the final examination is greatly enhanced when a

mended procedure for helping the instructor to know the learner, re-evaluation of the instrument assures t,h at the inferences drawn about the learner are reliable and current. Exemption allows the learner to function at a level commensurat,e with his ability.

student scores 80 or better on the pretest. Further study of the accumulative data may find the pre-test, to be sufficient for exemption without taking the final examination. The other aspect of validating the predict.or variables-specifically, the pretest for the introductory food and nutrition course-is to consider the human factor in the learning-teaching situation. A grade reflects not only what a student, has learned of the course content but, moreover, the innate abilities and learning experiences that he possesses. Nutrition educators have a responsibility for learning about the learner. Food and how the body uses it is a constant of life; therefore, some degree of student success is essential for continued motivation, learning, and application of principles taught,. When students enroll in basic nutrition classes, do they come with adequate background to do the work, to go on to advanced study, or are they already predisposed to "achieve poorly?" Pre-testing of students is a recom-

REFERENCES 1. Bloom, B. S., Taxonomy of Educational Objectives. Handbook I; Cognitive Domain, Longmans, Green and Company, New York, 1956.

2. The Committee on Measurement and

Evaluation of the American Council on Education, College Testing. Washington, D.C., 1959. 3. Steelman, V. p " "Development of an Objective Written and Laboratory Pre-test Based on the Aims and Generalizations for a Beginning College Food Preparation Course," M. S. Thesis, Oklahoma State University, 1963. 4, Lee, V. T., "Placement of College Students in Elementary Foods Course," J. Home Econ. Assoc., 57:638-40, 1965.

5. Ebel, R. E . ."Procedures for the Analysis Classroom Tests," Educ. and Psych . Mea-

surem ent, 14: 352-64, 1954. 6. Li, J. C. R.,Statistical Inference, Edwards Brothers, Inc, Ann Arbor, 1964.

SOME FACTORS FOR REFUSAL TO PARTICIPATE IN NUTRITION SURVEY Patrick M. Morgan, Lorraine E. Demarest; Walter G. Unglaub* and Ruth S. Hubbard Many persons selected at random for a nutrition survey did not participate. Restructuring of procedure provided better results and recommendations for methods to make future surveys more effective.

Several states throughout the United States within the past two years have participated in a National Nutrition Survey at the request of the Department of Health, Education, and Welfare. The purpose of the survey is to determine the prevalence and type of nutritionalj health problems within low-income groups. The National Center for Health Statistics randomly s~lected certain census enumeration districts within each state THE AUTHORS are, respectively, Associate Professor of Public Health Nutrition and Coordinator, Nutrition Training Program; Instructor, Dept. of Health Services Administration; Professor of Public Health Nutrition and Director, Nutrition Section;* and Research Associate, Nutrition Sectioll, all at School of Public Health and Tropical Medicine, Tulalle University, New Orleans, La. 70112.

"Professor Unglaub is deceased. WINTER, 1971

from which the subjects would be drawn (1). Each district had a mean family income in the lowest quartile on a national basis. Each participat,ing district was carefully mapped, a number given to each housing unit within the district, and 20 households randomly selected from each of the dis,tricts. Effort was made to contact each household of the 20 selected, soliciting cooperat,ion in the survey and affording each family member t,he opportunity to be transported to the survey loca60n and returned home. At the survey site samples of urine and blood were collected. Participants were asked to bring a fecal specimen to the clinic. Anthropometric measurements were recorded, questions were asked concerning health and dietary intake, and dental and physical examinations were conducted on each individual.

It was evident from the beginning that many persons selected as part of the sample population in the state of Louisiana would not partici'pate. However, the response in the larger cities was poor beyond expectation. New Orleans, the largest city in the state, had t,h e smallest percentage of family participation. The overall participation Toate for this city was 19.6 percent in the first 13 of the 22 selected census enumeration districts for this area. The low part,icipation rate was a cause of concern, and a decision was made to postpone the survey in the remaining nine districts in the city until recommendations could be given to possible ways of improving participation. Since Louisiana was one of the first two statest,o conduct the nutritionaljhe~th survey, any problems encountered arid solved here would benefit other states

JOURNAL OF NUTRITION EDUCATION /

103

conducting identioal or similar surveys and possibly would increase participation in other urban areas of Louisiana. Recognition was given to the fact that personnel initially contacting the sample population in Louisiana were relatively untrained in professional interview techniques. A skilled interviewer with a background in sodal work and research (hereafter referred to as the researcher) was retained to det.ermine the following: 1. Specific reasons for failure of the selected individuals to take part in the study; 2. Whether an experienced interviewer could obtain greater participation from the selected group; and 3. Ways in which participation in an urban location could be increased.

Method The records of the 183 non-participating families in the orginaJ 13 New Orleans enumeration districts were made available to the researcher. These records indicated tha,t 34 (19 percent) of the 183 families had refused to talk with the interviewer, six (3 percent) had been interviewed and refused to participate, 96 (52 percent) had agreed to attend the survey clinics but did not, 38 (21 percent) were never found at home, four (2 percent) of the residences were vacant at the time of contact for the interview, and five (3 percent) did not. participate for undetermined reasons. The researcher proposed to contact as many of these non-participants as possible, determining reasons for the lack of participation in the initial survey clinic, and to encourage attendance at. a make-up . clinic to be held in the. near future. A period of six weeks was set aside as the time necessary to complete this portion of the project. Accompanying the researcher for the first four weeks was one of the four initial interviewers, each assisting the researcher for one full week. The reasons for this were two-fold. First, since the researcher was a female, it was felt she should not be alone in many of the areas involved. Second, this time could be utilized as a trainmg period for the inexperienced interviewer by observation of the researcher and discussion of ways in which certain problems might be handled. During the fifth week, the researcher and a city public health nurse contacted as many of the sample population as possible, urging their attendance at the survey clinic to be held during the sixth week. In visiting the 183 non-participating families, the researcher completed a 1
short questionnaire in which were recorded .the previous status of the household relative to clinic participation, reasons for non-participation in the original survey, and whether an appointment was accepted for a make-up clinic. If an appointment was accepted, a space was provided to indicate whether or not at least one member of the family attended. Each of the 183 residences was visited at least once but none more than three times. Seven of the remaining nine selected enumeration districts within New Orleans became the basis of comparison with the participation rate of the original 13 districts. Each of t'h e 140 residences within the seven district.s was visited by the researcher .accompanied by one af the inexperienced interviewers. Each person contacted was offered transportation to and from the clinic even if only a block away. A careful record of the resuits was compiled. A compilation was made to compare the survey partiCipation findings of the 13 enumeration districts, the contact made by the researcher with the nonparticipants in those same 13 districts, and the participation results in the seven new enumeration districts. A final analysis was then made of the entire 20 enumeration districts surveyed in New Orleans.

TABLE I Findings by the Researcher A breakdown of the reasons for non-participation in the original survey of the 183 families as found by the researcher follows: No. of Families

36 (19'7'0) 24(13%) 10

(6'7'0)

40 (22%)

8 (2.5'7'0)

8/4.5%}

41 (22%)

9 (5'10) 5 (3%)

2

(1%1

Reasons

Told researcher they had never been contacted. Not interested in participating. Told researcher transportation to clinic did not arrive. Did not understand survey and feared participation would interfere with eligibility for welfare payments or for free medical a nd hospital service. Claimed illness Or disability of some member of the family Told researcher they had been contacted but that no follow-up was made . Not contacted by researcher although three visits were made to residence at different times of the day. House vacant at time visited by re,earcher. Other reasons such as working during clinic hours, even though clinics continued into the evening hours. Undetermined.

It is interesting that of the 36 families who rold the researcher they had never been contacted, 14 (40 percent) had given detailed information to the previous interviewer with nine of these families agreeing to attend the survey clinic but failing to keep the appointment.

Of the 183 families, 49 percent accepted appointments from the researcher but only 18 percent kept the appointments. However, of the 89 families in this group who said they would participate, 37 percent attended the make-up clinic. Twenty-four percent declined to participate in the survey, and 27 percent were not contacted because of absence of the family from the home or the house being vacant. Those refusing appointments the second time were not necessarily the same families who refused the first, time. In the seven enumeration districts contacted for the first time, the survey showed a participation of 40 percent of the 140 families involved with members of 56 percent of the households not attending as they had said they would. Refusals and those not at home comprised only four percent. This portion of lhe survey represented the only instance in which partial households (one or more family members) participated more than did total households. Using the minimum discrimination information statistics (2), it was concluded that the professionally trained interviewer, i.e ., the researcher, showed a signifioantly higher proportion of reporting families 'and a significantly lower proport.ion of non-reporting families than did the less skilled interviewers. The two surveys (183 non-participating plus 140 new households) yielded 35 percent family participation as compared to 19.6 percent in the original 13 enumeration districts of New Orleans.

Discussion Non-participation can be divided into t.h reeoategories: patient-oriented, sur~ vey-oriented, and undetermined. The patient - oriented non-participation (13 percent) was the group which was not interested. The survey-oriented non-par~ ticipation (52 percent) included those areas in which the survey failed to follow through in some way-no contact, failure of bus to appear, lack of understanding by family, 'a nd no follow-up contact. The remaining 35 percent was undetermined. In attempting to eliminate some of tbe survey-oriented reasons for non-participation, efforts were made to correct some WINTER, 1971

of the reasons given for failure to attend the first survey.

searcher was accompanied by a public health nurse.

One in five act,ually was not contactd in the initial survey although three visits were made at different times of the day covering a 12-hour period. While it is to be expected that some persons will not be contacted, ~his number along with the number of vacant homes could have been minimized if the sample selection had been flexible enough to allow for these contingencies.

Recommendations Based on the empirical data as well as on personal observations in the field, the follQwing recommendations are made: 1. The sample should allow for 20 household acceptances for participation in each enumerat,iQn district rather than a total of 20 residences, some of which might be vacant or with which no contact can be made. 2. There should be someone at the local level involved in the survey whom the potential participants know and trust. 3. Lett,ers of recommendation by agencies with which .the potential participants have personal contact might be helpful. For instance, letters recommending participation and an eX'planation of the survey enolosed with the checks of welfare recipients. 4. There should be ·some concrete reward :fior participation. This should not be monetary but may be in the form of a report indicating the general healt,h status of the parti6pants as determined by their examinations and tests. 5. Initial contacts should be made by people well skilled in interviewing techniques. 6. As many family members should be ·contaoted as possible, and recruitment for the survey should be done by the interviewers instead of leaving this to be done by a few family members.

One in 10 individuals indicated they did not participate because the bus did not come as expected. This was alleviat,ed when all participants expecting a bus were given a number to call if this transportation did not arrive. In addition to the previously mentioned difference in families repQrting for the professionally t,rained interviewer and thQse less skilled, the researcher also experienced fewer verbal refusals to participate. The higher rate of refusals to the less ·skilled interviewers may have been due to their attitude. In many instances they were condescending to' t,he people contacted. It is possible that other actiQnssuch as using first names in talking to those contacted, refusing to enter homes, and carrying Qut routine procedures wuthout an explanat.ion (such as labeling fecal cups before their purpose was explained) would tend to elicit refusals from SQme potential participants. Since such actions were observed by the researcher, it might be suspected that such behavior was even more prevalent when the researcher was not present. The statements of those who said they were never contacted, yet records indicated the contrary, are questionable. It is suspected that either the participants did not remember, did not want to admit previous contact for some reaSQn, or another member of the family had been contacted without relaying the information to' anyone else. Became of the high participation (as much as 85 percent) in SQme rural areas, the researcher accompanied the survey team to one of then-ural surveys to see if she could understand the differences in attendance. Based on personal observations and conversations with the public health nurses who were very involved in this area, the researcher observed that the "personal touch" was much more apparent between the nurses and the selected group. ThQse requested by the nurse to participate usually did so. This observatiQn was reinforced by incidents in New Orleans during the week the reWINTER. 1971

Conclusions From this study a few conclusions may be reached: 1. People who say they will participate do not necessarily do so. 2. Persons will participate in surveys with litt,Ie or no understanding of the survey if they know or ·trust the person requesting their participation. 3. Professionally trained interviewers can elicit more information and acceptance in the homes than less skilled interviewers. 4. As much as possible,t,otal involvement of a family in an interview is desirable. Summary A study was done Ito determine the causes of poor participation in a nutrition/health survey in a large city in Louisiana and to determine whether a professionally trained interviewer could be more successful than a les.s skilled interviewer in increasing active participation. Results from rthe first survey were used in an attempt to improve the participation in the second survey and the attendance for both was compared. REFERENCES 1. National Center for Health Statistics, Cooperation in Health Examination Surveys, Superintendent of Documents, U. S. Gov. Ptg. Office, Washington, D.C., PHS Publication No. 1000, Series 2:9, July, 1965, p. 4. 2. Kullback, S., M. Kemperman and H. H. Ku, "Tests for Contingency Tables and Markov Chains," Technometrics, 4:573608, Nov., 1962.

ACKNOWLEDGEMENT The Society for Nutrition Education is pleased to acknowledge receipt since publication of the last issue of financial contributions for the development of the JOURNAL OF NUTRITION EDUCATION from Roche Chemical Division of Hoffman-La Roche, Inc.; Kraftco Corp., and Nutrition Foundation, Inc. Contributions in support of the Journal or the Society for Nutrition Education will be acknowledged in each issue of the Journal. Major financial support for the development of the Journal is provided by Research Grant No. LM00734-02 from the National Library of Medicine, National Institutes of Health, DHEW, to the Department of Nutritional Sciences, University of California, Berkeley. Since publication of the Journal began. contributions have been received from: American Heart Association; Green Giant Company;, Roche Chemical Division, Hoffman-La Roche, Inc.; Kraftco Corp.; Thomas J. Lipt~n"lnc.; Mead Johnson Research Center; Miles Laboratories, Inc.; Nutrition Foundation, Inc.; and The Quaker Oats Co. Anyone or any firm desiring information concerning fin~ncial contributions {which are tax deductible} to this Journal, is invited to write to the Executive Manager, Society for Nutrition Education. P. O. Box 931, Berkeley, CA 9470 I.

JOURNAL OF NUTRITION EDUCATION / 1'05