Instant Health Info: The Telephone Connection

The further people are from an urban base of health information services the less they'll use such services.¹ Yet, most rural areas with a lack of health resources need these services. The University of Arizona, Cooperative Extension Service, with the endorsement of the Arizona Medical Association, found an answer to this problem. Extension established a cost-effective statewide toll-free telephone service called "Instant Health Info (IHI)." The user dials the toll-free number and gives the operator a tape number, title, or subject of interest. The county of residence of the caller is requested before the tape is played. The system operates 12 hours a weekday and 5 hours each on Saturday and Sunday.

Over 350 short (3-5 minute) tapes are available, including 31 in Spanish. The system averages 3,000 calls per month, with 65% coming from the rural areas in which only 25% of the state's population lives. Women call three times more often than men. Requests for the Spanish tapes are only one percent of the total, despite considerable promotion in Spanish. The most frequent requests are for tapes on weight loss, sex education, depression, drugs, herpes, chicken pox, and Valley Fever, a disease indigenous to the Southwest.

Surveying Impact

The goals of Instant Health Info were to have users be more knowledgeable, be better able to discuss problems with health providers, reduce health and safety hazards, recognize early warning signs of illness, and be more self-sufficient in home care.

To measure the degree to which these objectives were met, a randomized telephone survey of users and non-users (gleaned from Extension mailing lists and telephone directories) was conducted.

Procedure

Two weeks before the survey, an introductory letter describing the purpose of the evaluation was sent to potential respondents. Trained interviewers tried to contact each of the 1,253 individuals in the sample to first identify the purpose of the survey and then try to complete the survey. If the respondent wasn't familiar with IHI or hadn't called to hear a tape, the interviewer collected only demographic data. Of the sample pool, 541 (43.2%) weren't reached by phone.

Of the 712 who were contacted, 618 (86.8%) respondents agreed to participate in the survey. Of these, 45% had used the service. Respondents were asked how they first found out about the program, why and how many times they called, what tapes were requested, the degree to which the tapes were or weren't helpful, and if they "did anything differently" after hearing a tape. Travel time to their doctor and hospital, and length of time since last medical visit were also asked. Demographic questions were of age, sex, education, income, and residence. Finally, comments were solicited.

Findings

Significantly more users were younger in age and came from lower-income families than non-users. The majority of the sample of respondents were female. Only small differences existed between users and non-users in reported accessibility to and use of medical services. Forty-four percent of the respondents lived in the state's 2 urban centers and 56% lived in rural areas or small cities and towns. Only three interviews needed to be conducted in Spanish. Thirty percent of all respondents first heard about IHI by seeing a brochure/directory. Newspaper articles (9%) were the second most mentioned source. Eighty-four percent of the respondents who were aware of the program said they had a brochure. Almost all who didn't have a brochure requested one. In this way, the survey also became a tool to inform unaware residents about the program.

Overall, more people obtained their brochures through the mail (31.8%) than from any other source. The Extension office sites were second most popular (20%) and third (17%) was a medical facility (hospital, clinic, or doctor's office). The other 31.2% got their brochures at banks, libraries, community centers, etc. A total of 276 respondents said they called IHI at least once. Of these, 154 (56%) reported using IHI 3 or more times. Almost without exception, users were able to name the specific tapes or subject areas they'd called to hear.

The majority of respondents (75%) reported using the service in connection with a personal or friend's health concern. Another 25°/a were simply curious. Overall, 89% of the users were satisfied with the informational content of the tapes. As would be expected, satisfaction was greater for those who used the service frequently. Of those who were dissatisfied, the predominant opinion was that the tapes didn't contain enough information.

There was overwhelming agreement (98%) that the taped information was either very or moderately helpful. Those who had used the service most frequently were the most positive in their rating.

Respondents were almost evenly divided in reporting whether they did anything differently after hearing an IHI tape. Differences were a function of the number of times respondents reported using the service. Respondents who had used IHI three or more times were most likely to report changing their behavior. Of those who reported no changed behavior, the largest percent had called only once.

Among respondents who reported changing their behavior, most frequently mentioned was that they took some preventive action (see Table 1). The most frequently cited changes concerned aspects of child care and lifestyle changes such as: increased exercise; lowered salt, cholesterol, sugar, and/or caloric intake; quit or cut down smoking; and used sun screen lotions. Other actions were as diverse as "bought a smoke alarm," "had a lung capacity test," and "got rid of our cat."

Even where no changes were specified, respondents frequently commented that the information eased their mind or confirmed their present actions as correct. Voluntary comments were almost all highly positive, but weren't analyzed.

Implications for Extension

The fact that twice as many users of IHI as non-users were under age 20 is significant for Extension agents who serve or wish to serve the younger client. Many of the tapes, including 18 for young children, were placed in the library in hopes of attracting teenagers seeking information about rape, drugs, stress, and depression.

And, many have been used creatively. For example, after a schoolmate had reported being molested, a 4-H Club spent an entire meeting listening to the series of tapes on rape prevention, after which a frank discussion was held. In another situation, a senior citizen aide arranged to have clients who attended a remote clinic select tapes they wanted to hear. These were then played through a telephone amplifier so all in the room could hear. Then the aide led the group in a discussion related to the tape content.

The significant predominance of female to male callers in IHI is consistent with the experience of other telephone information services.² This phenomenon may be because women use all health care systems more than men and also because women see themselves, and are perceived by family members, to be the key caregivers and nurturers in the households.

To test the most effective methods for reaching rural populations, different promotional techniques were tried at various times in discrete rural areas. Note: these efforts were made after the survey was completed. By far, the most effective technique tried was to insert single-fold copies of the brochure/ directory into small local newspapers. Repeatedly, the weekly number of calls from a county would increase by a magnitude of several thousand percent after such a promotional effort. The calls gradually decreased in subsequent weeks, but the effect was noticeable for as long as one to two months.

Even more cost-effective, but somewhat less successful as to response, was printing the list of tapes in small rural newspapers. The pages were sponsored mostly by medical clinics or health care providers recruited by the newspaper. When the pages were printed in the paper's advertising supplement, the response was greater than when they were printed in the main body of the paper. It can be assumed that women were more likely than men to read those pages and take advantage of the opportunity described.

When small ads were placed in newspapers, the effect couldn't be measured. Bilingual radio public service announcements, as well as most other promotional efforts, were too diffuse and disparate to accurately correlate with usage. The experience of reported changes in behavior being positively correlated with increased usage of the system was also found by Tel-Med evaluators.³ It's reasonable to assume that those whose motivation encouraged them to call IHI repeatedly were also motivated to change their health behavior.

Despite significant data, caution is advised in taking reported behavior changes as hard evidence. Intent to change sometimes may be misreported as actual change.

Summary

The evaluation showed that all program objectives were met. The data confirmed that rural residents will use their telephones to access health and safety information if it's made available to them on the same basis (that is, toll-free) that urban residents have long enjoyed. The cost-effectiveness goal was also met. Including start-up costs of expanding and upgrading a former local Extension program, the out-of-pocket cost per call was about $1.63, although with the recent increased cost of WATS lines, this figure has since risen to about $2.00 per call.

The program supports the major societal shift towards appropriate self-sufficiency, the essential basis of which is accurate information. It also reinforces the notion well-known to Extension agents: Promotion is the key to success.

Footnotes

1. G. S. Wilkinson and others, "A Dial Access Cancer Education Service," International Journal of Health Education, XX (July/August/September, 1977), 158-63.

2. G. S. Wilkinson and others, "Utilization of a Cancer Telephone Information Facility: Comparison of Callers and Non-Caller Controls,"American Journal of Public Health, LXVII (December, 1978), 1211-13.

3. R. A. Disker, R. Michielutte, and V. Morrison, "Use and Reported Effectiveness of Tel-Med: A Telephone Health Information System," American Journal of Public Health, LX (March, 1980), 229-34.