An educational and behavioral approach toward increasing patient activation in hypertension management

The shift in patterns of disease toward chronic illness necessitates greater patient participation in its management and in their own rehabilitation, and they require greater social support over longer peiods. Patient activation, or the enhancement of patient and support group involvement in personal health care through teaching management techniques and problem-solving skills, has emerged in health education in response to this need. This paper will examine combined educational and behavioral approaches to increasing social support and patient activation in hypertension management. Activation in this study involves increased feelings of personal control over the contingencies surrounding the management of medical regimens. Both family support intervention and small group sessions oriented to changing compliance behavior by changing expectancy frames were offered to a randomized sample of 200 inner city, black, hypertensive patients who were part of a larger study. Patients were examined within a pretest—posttest randomized factorial design on measures of locus of control, belief in seriousness, efficacy of treatment, medication compliance, and blood pressure control. This combined approach showed small differences on the attitude and behavioral measures but displayed a significant effect on the program outcome variableblood pressure control (62% in control among intervention groups versus 46% in nonintervention groups).Dr. Morisky is with the Johns Hopkins University Division of Health Education and Health Services Research and Development Center, 624 North Broadway, Baltimore, Maryland 21205; Dr. Bowler is with the George Mason University, Fairfax, Virginia; and Dr. Finlay is with the Agency for International Development, Washington, D.C..This work was supported by NHLBI grant numbers 1R25 HL 17016-10, and 1T32 HL 07180, Lawrence W. Green and David M. Levine, co-principal investigators, and Sigrid Deeds, project coordinator, and NHLBI HV 1-72986. The authors wish to acknowledge the help of Carol Johns, Patterson Russell, Joan Wolle, Judy Chwalow, Christine Lewis, Lorraine Midanick, Sam Shapiro, Lee Bone, and Marion Field Fass. Portions of this paper were presented at the 1979 National Conference on High Blood Pressure Control, Washington, D.C., April 4–6, 1979.     

New health professionals and older persons

Because the number of aged persons in the population is increasing and localized maldistributions of health care manpower persist, it has been suggested that new health professionals might provide health services for older persons who would otherwise face problems in obtaining health care. In this study, the authors tested the degree to which older persons know about and are accepting of care by new health professionals. They found that older persons know less about and accept less NHP care than do younger persons, although they are still mostly accepting of such care. In addition, older persons are more satisfied with their current care providers. Taken together, these findings indicate that older persons do not currently provide a source of expressed demand for NHP services.Dr. Fox is Senior Program Planning Analyst, Analytical Planning Unit. Kaiser Foundation Health Plan, Los Angeles, California 90027. Ms. Storms is Research Associate in the Department of International Health, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Maryland 21205. This research was funded by the Office of Health Manpower Studies, School of Health Services, The Johns Hopkins University, through a grant from the Robert Wood Johnson Foundation, Princeton, New Jersey. Responsibility for any errors lies solely with the authors.     

Reorganization of a Medical house staff (Firm System)

In 1975, the Johns Hopkins Medical house staff was reorganized into four Firms. Each Firm provides inpatient and outpatient care to a group of patients. Two of the goals of the reorganization were to improve accessibility and continuity of care. This study, based on a before and after research design utilizing routinely collected data, sought to determine whether these goals had been attained. Accessibility was assessed by observing changes in waiting time for appointments, broken appointments, and number of patients seen before their scheduled appointments. The results showed that mean waiting time for a Medical Clinic appointment fell from 15 days to 1 day (p<0.01); broken appointments for new patients fell from 54% to 34% (p<0.01); no significant changes occurred in broken appointments for old clinic patients (34% vs 32%); and patients seen before their scheduled appointments increased from 30% to 38% (p<0.001).Continuity was assessed by observing changes in use of emergency and walk-in clinic services, the proportion of Medical Clinic patients lost to follow-up care, the proportion of hospital readmissions returning to the same nursing unit, and the proportion of patients discharged from the hospital who returned to the Medical Clinic. The results showed that use of emergency and walk-in clinic services fell slightly, from 24% of all visits before to 22% of all visits after the Firm System (p<0.001); no change occurred in the proportion of patients lost to Medical Clinic follow-up (21% before and after the Firm System); the proportion of hospital readmissions returning to the same nursing unit increased from 35% to 73% (p<0.005); and the proportion of patients discharged from the hospital who returned to the Medical Clinic increased from 21% to 35% (p<0.001). These data suggest that implementing the Firm System led to improvement in several selected aspects of accessibility and continuity of care but that further improvements could be made.From the Johns Hopkins University, Baltimore, Maryland. Supported in part by the Robert Wood Johnson Foundation Clinical Scholars Program and the Health Services Research and Development Center (PHS Grant HSO 1964) and the Department of Medicine of the Johns Hopkins University. Dr. Horan is an instructor in the Department of Medicine; Dr. Steinwachs is Research Manager, Health Services Research and Development Center; Dr. Smith is Chief, Division of Internal Medicine; Mr. Shapiro is Director, Health Services Research and Development Center. The authors wish to express thanks to Dr. Victor A. McKusick, Dr. David M. Levine, Mr. John Stiney, Ms. Gail Otis, Ms. Sharon Mitchell, and to the Faculty of the Division of Health Care Organization, School of Hygiene and Public Health. Reprint requests should be sent to Dr. Horan, Johns Hopkins Hospital, Harvey 402, 600 N. Wolfe Street, Baltimore, Maryland, 21205.     

Interview with Dr. Omar Khan, noted global health specialist

Dr. Khan has had a distinguished career in global health. He has served as a faculty member at the University of Vermont College of Medicine and Johns Hopkins University School of Public Health. He is currently a family medicine physician at Christiana Care Health System in Newark, Delaware, and is President of the Delaware Academy of Family Physicians. Dr. Khan has authored more than 55 peer-reviewed journal articles and book chapters and has conducted research and lead primary care and public health initiatives in numerous countries. Last year, Dr. Khan also coedited a book titled Megacities and Global Health sponsored by the American Public Health Association with Dr. Gregory Pappas, Deputy Health Commissioner for Washington, DC.     

An interpretation of implicit judgments in chart review

The effects of methods that are commonly employed to summarize implicit judgments about quality-of-care assessments, based on medical records, are examined. A sample of 250 medical records, from three outpatient clinics in a municipal hospital, was studied. Two, or three, reviewers judged the quality of both the process of care and the outcome of care, as reflected in each medical record; the reviewers were medical school faculty members. Thirty-seven combinations of the data were used to summarize the judgments made on each medical record. These combinations resulted in significant differences in interpretation within each clinic, but there were only insignificant differences in interpretation across the three clinics. Hence, the use of a single method to summarize data may distort the conclusions. These results demonstrate that data often should be summarized by several methods and that measures of association should be used to supplement tests of significance so as to develop a comprehensive understanding of a set of data.Dr. Horn is Assistant Professor, Department of Health Care Organization, School of Hygiene and Public Health, The Johns Hopkins University, 615 North Wolfe Street, Baltimore, Maryland 21205. Dr. Pozen is presently Assistant Professor, Department of Medicine, Boston University School of Medicine at Boston City Hospital, Thorndike Memorial Laboratories. This study was begun while he was at the Department of Medicine at Baltimore City Hospitals and the Department of Health Care Organization at The Johns Hopkins University. This work was supported by DHEW grant 5-R01-HS-01590 from the National Center for Health Services Research and Development.     

The Role of the Federal Government in Promoting Health Through the Schools: Report from the Office of Disease Prevention and Health Promotion

Statement of J. Michael McGinnis, MD, Deputy Assistant Secretary for Health, Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Dept. of Health and Human Services, before the Subcommittee on Oversight of Government Management, Committee on Governmental Affairs, U.S. Senate, November 14, 1991.     

National security and the health of people: human needs and the allocation of scarce resources

Gellhorn, a professor at the Harvard School of Public Health, delivered this paper as the opening address to the Eighth International Conference on the Social Sciences and Medicine, held in Scotland in August 1983. He discusses the impact of the international arms race on public health and economic development, particularly in Third World nations. His paper is followed by commentaries by Christine K. Cassel of the University of Oregon Department of Medicine; Margot Jefferys, emeritus professor of medical sociology at the University of London; F.M. Mburu of the University of Nairobi Department of Community Health; Peter J.M. McEwan, a professor of social sciences in Scotland; Vicente Navarro of the Johns Hopkins University School of Hygiene and Public Health; Harmon L. Smith of the Duke University Divinity School; and Philip Wood, of the University of Manchester ARC Epidemiology Research Unit.     

A conversation with Elizabeth A. Stuart

Elizabeth A. Stuart is a Professor in the Departments of Mental Health, Biostatistics, and Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, and Associate Dean for Education at the school. She is a renowned expert in the area of causal inference, including propensity score methods for observational data and the generalizability of randomized trial results, and is also a Fellow of the American Statistical Association. Prior to her appointment to the faculty at Johns Hopkins, Professor Stuart received her Ph.D. in statistics from Harvard University and a bachelor’s degree in mathematics from Smith College. In 2015, Professor Stuart was recognized at the International Conference on Health Policy Statistics with the Mid-Career Award from the Health Policy Statistics Section of the American Statistical Association.     

Some influences on public participation in a genetic screening program

To identify the psychosocial factors associated with voluntary cooperation in mass genetic testing, stratified random samples of 500 participants and 500 nonparticipants were drawn from an identified at-risk population for Tay-Sachs disease. Participants were relatively younger and better educated, reported higher levels of perceived susceptibility to being a carrier, and also stated more often that the impact of learning of being a carrier would be low. Participants were also more likely to indicate they would not alter plans for future progeny. Recommendations are made for enhancing participation in future genetic screening programs of this type.Dr. Becker is Associate Professor, Departments of Pediatrics (School of Medicine) and Behavioral Sciences (School of Hygiene and Public Health), The Johns Hopkins University, Edwards A. Park Building, Room B172, The Johns Hopkins Hospital, 601 North Broadway, Baltimore, Maryland 21205. Dr. Kaback is Associate Professor, Departments of Pediatrics and Medicine, and Associate Chief, Division of Medical Genetics, School of Medicine, University of California at Los Angeles. Dr. Rosenstock is Professor and Chairman, Department of Health Behavior, School of Public Health, University of Michigan. Ms. Ruth is Chairman, Department of Community Health Nursing, School of Nursing, University of Maryland.     

Study of seniors identifies attitudes, barriers to promoting their health

What information and skills do older persons need in order to enhance their health? What obstacles stand in the way of promoting their health? One way to find out is simply to ask them, as the Office of Disease Prevention and Health Promotion (ODPHP), U.S. Department of Health and Human Services, did in a study undertaken as part of the Health Promotion and Aging Initiative sponsored by th Public Health Service nd Administration on Aging. Following are excerpts from an executive summary of "Aging and Health Promotion: Market Research for Public Education," a report of a research study that involved 15 focus groups of persons aged 58 and over, as well as a review of data on the media habits and the demographic characteristics of older Americans. The study, which was undertaken to serve as the basis for recommendations for national action, also offers insights that should be useful to program planners interested in meeting the needs and capturing the interest of older persons.     

QMHC interview: Robert M. Heyssel, M.D.. Interview by Marie E. Sinioris

In 1991, US News and World Report rated The Johns Hopkins Hospital as the best hospital in the country. Its survey of physicians revealed that Hopkins is perceived to be at or near the top in 13 of the 15 specialties studied. For the past three years, The Johns Hopkins Health System has been taking a hard look at the nonclinical aspects of health care delivery. Surveys of patients, physicians, nurses, and employees have revealed a litany of frustrations that can interfere with the delivery of excellent care. To focus on these issues, Hopkins launched a systemwide total quality management (TQM) process in 1989. Dr Robert M. Heyssel and other senior executives provided leadership that has been essential to the initiation and maintenance of the TQM process at The Johns Hopkins Health System. TQM has been associated with impressive results in several areas. In addition, more than 500 people have received intensive training in the use of statistical tools and teamwork. An additional 900 people are scheduled to attend this program in the future.     

The influence of training level and practice setting on patterns of primary care provided by nursing personnel

The influence that the level of training and practice setting have on the patterns of primary care provided by nurses at the Frontier Nursing Service (FNS) is assessed. The Frontier Nursing Service is the only available source the residents of Leslie County, Kentucky have for primary care; it utilizes nurses for the management of approximately 80% of its primary care patients.Patterns of care given by family nurse practitioners and registered nurses at FNS during 1974 were analyzed according to two tracer conditions, otitis media and urinary tract infection. Data were obtained from the encounter forms that are filled out for all primary care visits to FNS. Computerized routines were developed to group the relevant encounters into episodes of care for the two tracer conditions.Results indicate that the practice setting, rather than the level of training, has the strongest effect on the patterns of primary care rendered by nurses in a rural environment such as FNS.Dr. Moscovice is Assistant Professor of the Center for Health Services Research, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, Washington 98195. Support for this research was provided by a traineeship of the National Center for Health Services Research, HS 0090-05, while the author was a trainee for the Center for the Study of Health Services at Yale University. Additional support was provided by grant SOC 75-1602 from the National Science Foundation.     

The Sociobiologic Integrative Model (SBIM): Enhancing the Integration of Sociobehavioral, Environmental, and Biomolecular Knowledge in Urban Health and Disparities Research

Disentangling the myriad determinants of disease, within the context of urban health or health disparities, requires a transdisciplinary approach. Transdisciplinary approaches draw on concepts from multiple scientific disciplines to develop a novel, integrated perspective from which to conduct scientific investigation. Most historic and contemporary conceptual models of health were derived either from the sociobehavioral sciences or the biomolecular sciences. Those models deriving from the sociobehavioral sciences generally lack detail on involved biological mechanisms whereas those derived from the biomolecular sciences largely do not consider socioenvironmental determinants. As such, advances in transdisciplinary characterizations of health in complex systems like the urban environment or health disparities may be impeded. This paper suggests a sociobiologic organizing model that encourages a multilevel, integrative perspective in the study of urban health and health disparities. Gibbons and Fox are with the Johns Hopkins Urban Health Institute, Baltimore, MD, USA; Brock, Baylin, and Levine are with the Johns Hopkins School of Medicine, Baltimore, MD, USA; Gibbons, Alberg, LaVeist, Levine, and Fox are with the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Brock, Alberg, and Baylin are with the Johns Hopkins Oncology Center, Baltimore, MD, USA; Gibbons and LaVeist are with the Johns Hopkins Center for Health Disparities Studies, Baltimore, MD, USA; Glass is with the Johns Hopkins Bloomberg School of Public Health Center on Aging and Health, Baltimore, MD, USA.     

The Effect of a Case Management Intervention on Drug Treatment Entry Among Treatment-Seeking Injection Drug Users With and Without Comorbid Antisocial Personality Disorder

We examined the effect of a case management intervention on drug treatment entry among injection drug users (IDUs) with and without comorbid antisocial personality disorder (ASPD). Injection drug users attending the Baltimore Needle Exchange Program who sought and were granted referrals to opioid agonist treatment were randomized to receive a strengths-based case management intervention or passive referral. Of 162 IDUs, 22.8% met the DSM-IV criteria for ASPD. Compared to those without ASPD, IDUs with comorbid ASPD who spent 25 or more minutes with their case manager prior to their treatment entry date were 3.51 times more likely to enter treatment than those receiving less than 5 min, adjusting for intervention status, race, and treatment site (95% confidence interval 1.04–11.89). Providing case management services to IDUs with comorbid ASPD may facilitate treatment entry and reduce the negative consequences of drug abuse. Havens is with the Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, USA; Cornelius is with the School of Social Work, University of Maryland, Baltimore, MD, USA; Ricketts, Huettner, and Strathdee are with the Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Latkin is with the Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Bishai is with the Department of Population and Family Health Sciences, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Lloyd is with the School of Social Administration, Temple University, Philadelphia, PA, USA; Strathdee is with the Division of International Health and Cross-cultural Medicine, Department of Family Health Sciences, University of California San Diego School of Medicine, San Diego, CA, USA.     

Curing and caring—A proposed method for self-assessment in primary care organizations

Key research in the area of quality assessment is reviewed and a method for periodic assessment in primary care organizations is proposed. The suggested approach is designed for administrative, rather than research, purposes. Therefore, it focuses on indicators that are both practical and realistic for use in periodic monitoring.The proposed method is two-staged and includes both technical performance (curing) and satisfaction (caring). At the first level of evaluation, general areas of performance are examined; these are key performance indicators in prevention, diagnosis, and management of illness, and questionnaires dealing with the accessibility and acceptability of care, coupled with objective measures of satisfaction. Those areas of performance that are not up to management standards are then examined in greater detail at the second level of evaluation. Using this approach, organizations can build a longitudinal picture of performance and chart their progress annually.Ms. Howell, formerly an instructor in the Department of Community Medicine and International Health, Georgetown University School of Medicine, is now attending the John F. Kennedy School of Government, Harvard University. Dr. Osterweis is Assistant Professor, Department of Community Medicine and International Health, Georgetown University School of Medicine, Washington, D.C. 20007. Dr. Huntley is Professor and Chairman of that department. Reprint requests should be addressed to Dr. Osterweis. This work was supported in part by grant R18-HS-01040 from the National Center for Health Services Research.     

Injury-producing events among children in low-income communities: The role of community characteristics

Study Purpose Injury remains the leading cause of death in children aged 1 to 4 years. Past studies of determinants of injuries among young children have most often focused on the microlevel, examining characteristics of the child, parent, family, and home environments. We sought to determine whether and how selected neighborhood economic and physical characteristics within these low-income communities are related to differences in risk of events with injury-producing potential among infants and young children. Methods Our study used both individual-level data and information on the characteristics of the neighborhood of residence to describe the prevalence of events with injury-producing potential among infants and young children in three low-income communities in Baltimore City, Maryland. Our sample was 288 respondents who participated in a random household survey. Information on respondent (age, employment, and length of residence in the neighborhood) and neighborhood characteristics (average per capita income, rate of housing violations, and crime rate) were available. Methods of multilevel Poisson regression analysis were employed to identify which of these characteristics were associated with increased risk of experiencing an event with injury-producing potential in the month prior to the interview. Results Although all three communities were considered low income, considerable variation in neighborhood characteristics and 1-month prevalence rates of events with injury-producing potential were observed. Younger age of respondent and higher rates of housing violations were associated significantly with increased risk of a child under 5 years old in the household experiencing an event with injury-producing potential. Conclusions Information on community characteristics was important to understanding the risks for injuries and could be used to develop community-based prevention interventions. Dr. O'Campo is from the Departments of Maternal and Child Health and Epidemiology and Dr. Gielen is from the Department of Health Policy and Management, School of Hygiene and Public Health, Johns Hopkins University Dr. Wilson is from the Department of Pediatrics, School of Medicine, Johns Hopkins University.     

A baseline evaluation of family support programs

This paper presents a baseline evaluation of four demonstration family support programs located in communities identified as having a disproportionate number of families at risk for malfunctioning. In this baseline evaluation, a one year cohort of 422 family support participants were assessed along key dimensions of parenting known to contribute to child well-being and potentially to the incidence of child abuse or child neglect. These dimensions include parents' attitudes toward child rearing, knowledge of child development, level of perceived social support, and level of depression.Black participants and teenage parents had more punitive attitudes toward child rearing, less knowledge of child development, and less perceived social support than white or older parents. Overall, attitudes, knowledge, level of perceived social support and depression are inter-related in accordance with previous clinical observations and developmental theory, e.g., depressed parents are less knowledgeable, more punitive and have less support than nondepressed parents. The results of the baseline evaluation suggest that the demonstration projects are successful in reaching some subgroups of families at risk for parenting problems.Janet Reis, Ph.D. is Assistant Professor, Center for Health Services and Policy Research, 629 Noyes Street, Northwestern University, Evanston, Illinois 60201. Linda Barbera-Stein, Ph.D. is Assistant Research Professor, Center for Health Services and Policy Research, Northwestern University. Elicia Herz, Ph.D. is Assistant Research Professor, Center for Health Services and Policy Research, Northwestern University. John Orme, Ph.D. is Assistant Professor, School of Social Work, Louisiana State University. Susan Bennett, M.A. is Research Associate, Center for Urban Affairs and Policy Research, Northwestern University.This work was supported in part by a contract from the Illinois Department of Children and Family Services and the Pittway Charitable Fund to the Center for Health Services and Policy Research, Northwestern University. Special thanks are given to Dr. Edward Zigler for his early guidance on this project. An earlier version of this work was presented at the American Public Health Association, Washington, D.C., November 1985.     

Emergency room management of patients with sore throats in a teaching hospital: Influence of non-physician factors

The care of 169 patients with sore throats was evaluated retrospectively to determine if the quality of medical care received in a teaching hospital's emergency room is associated with the degree of control managing physicians have over the medical care process. Diagnostic evaluation (temperature, throat and cervical node examination, and throat culture) was controlled by physicians and was judged adequate in 78% to 98% of the patients. Therapy, defined as appropriate antibiotics prescribed only for patients with positive throat cultures for group A beta-hemolytic streptococcus, was dependent on hospital support services, and the patients, as well, and was judged adequate for 62% of the patients; however, in only one of the 67 patients treated with antibiotics was the culture result known before treatment. The bacteriology laboratory processed the cultures slowly; no administrative mechanism existed to follow up patients. Thus, when medical care involved factors outside physicians' direct control, lower quality care was given.From the Department of Medical Care and Hospitals, the Johns Hopkins University School of Hygiene and Public Health and the Department of Medicine, Baltimore City Hospitals. Address reprint requests to Dr. Fletcher, Department of Medicine, McGill University Clinic, Royal Victoria Hospital, Montreal, Quebec, H3A 1A1, Canada. This work was supported in part by grants from the Carnegie Corporation, the Commonwealth Fund of New York City, and the Robert Wood Johnson Foundation, and by grants 5 H01 HS 00110 and 5 T01 HS 00012 from the National Center for Health Services Research and Development and 5 D04 AH 00076 from the National Institutes of Health, Department of Health, Education and Welfare. Dr. Fletcher was a Carnegie Commonwealth Clinical Scholar.     

Exploring “Wine Shops” as a Venue for HIV Prevention Interventions in Urban India

Addressing male heterosexual risk is a high priority for HIV prevention efforts in India. Particularly in urban India, which draws men for employment opportunities, these efforts are gaining momentum with a focus on understanding possible risk facilitators such as alcohol use. However, little is known about venues where such efforts might be targeted. In this paper, we explore community-based alcohol outlets or “wine shops” in Chennai, India, as potential venues. We conducted ethnographic research with wine shop staff and clients to understand alcohol use and sexual behaviors. We then surveyed 118 wine shop patrons to quantify these risk behaviors and plan an appropriate intervention. Our results show that wine shops are a venue where social and sexual networks converge. Reports and observations of regular and heavy drinking were frequent. Over 50% of patrons surveyed reported three or more sexual partners in the past 3 months, and 71% of all patrons reported a history of exchanging sex for money. Condom use history was low overall but, in the adjusted analyses, was significantly higher (OR = 20.1) among those who reported that their most recent partner was a sex worker and lower (OR = 0.28) among those who reported they drank to feel disinhibited. The data suggest that wine shops may be an appropriate location to target men for HIV prevention interventions. We discuss how these findings helped design such an intervention in Chennai. Sivaram, Go, and Celentano are with the Infectious Diseases Program, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Johnson, Srikrishnan, and Solomon are with the YRG Center for AIDS Research and Education, Voluntary Health Services, Taramani, Chennai, 600113, India; Bentley is with the Global Health School of Public Health, University of North Carolina, Chapel Hill, NC, USA; Latkin is with the Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.     

Primary care and local health departments: The initiation of a state-sponsored grant program

This study examines factors that differentiate health service organizations that were successful applicants for a grant program to initiate primary-care services from a matched sample of organizations that did not apply for the program. Factors that were different between the two sets of organizations include the attitudes and behaviors of physicians in the local community, previous success of the organization in obtaining grant support, and employee perceptions of selected organizational and grant program characteristics. These findings suggest that factors both internal and external to the organization are influential in decisions to initiate activities sponsored through grant programs. Implications of these findings for the design of state block grant programs are discussed.Dr. Hernandez is with the School of Community and Allied Health, University of Alabama in Birmingham, Birmingham, Alabama 35294.Dr. Kaluzny is with the School of Public Health, University of North Carolina, Chapel Hill, North Carolina 27514.This project was supported in part by Grant No. HS 01971 to the Health Services Research Center at the University of North Carolina at Chapel Hill from the National Center for Health Services Research, Department of Health and Human Services, and funds from the Division of Health Services, North Carolina Department of Human Services.