Public Health Systems Call for Papers Organizing, Financing & Delivering Public Health Services: New Evidence for Improvement Chair: Glen Mays, University of Arkansas for Medical Services Sunday, June 25 • 10:30 am – 12:00 pm ●A Case Study Using Organizational Network Analysis to Model Public Health Agency Structure Jacqueline Merrill, RN, M.P.H., DNSc, Kathleen Carley, Ph.D., Suzanne Bakken, DNSc, Maxine Rockoff, Ph.D., Kristine Gebbie, DrPH, MIcheal Caldwell, M.D., M.P.H. Presented By: Jacqueline Merrill, RN, M.P.H., DNSc, Interim Research Director, Columbia University School of Nursing, Center for Health Policy, 630 West 168th Street GB 239, NYC, NY 10032; Tel: (212) 305 1794; Fax: (212) 305 0722; Email: jam119@columbia.edu Research Objective: Public health agency performance depends on specialized information that travels via communication networks among employees. Traditional organization charts and process maps fail to capture these complex interactions, with the result that important aspects of information exchange are unmanaged. Public health managers need to understand the link between information networks and performance to plan for and justify allocating resources to manage information needs. This study examined information flows in a local health department using organizational network analysis. Study Design: Organizational network analysis is an empirical, descriptive technique to model organizational structure. It is based on social network and graph theories, where the organization is conceived as a complex sociotechnical system. Data on the communication links among agency staff, and their links to agency resources were obtained via survey with a 90% response rate. These data were analyzed with Organizational Risk Analyzer—ORA—software developed at Carnegie Mellon University. The objectives were to: 1. Empirically describe the structure of the information network 2. Determine links between information flow and agency performance suggested by the network model 3. Assess utility of the method as a tool for public health managers Population Studied: They research was conducted in a public health department in a mixed urban-suburban county, with 156 employees that provide a range of public health services in 9 divisions and 19 program areas. Principal Findings: The results yielded graphical representations of network structure and statistical reports on the quality of the information network. Findings revealed problems in information flow, including likelihood that sub groups control knowledge and resources; overspecialization in knowledge; potential for significant knowledge loss through retirement; little back up for personnel turnover; and informational silos. These findings suggested that the department needs greater redundancy and better cross program coordination, but has strengths such as efficient communication paths and good social connectedness. The department’s leaders offered feedback on strategies they intend to use to address knowledge loss, increase shared situation awareness, and take advantage of network strengths. Conclusions: This study demonstrated that the method has potential for public health information management. Network insights helped the managers understand and direct information flows in the agency, and supplied evidence for planning to improve performance. Additional research is needed to refine network analysis methods, and establish baselines metrics, for the public health domain. Implications for Policy, Delivery, or Practice: The information network is a key aspect of public health agency structural capacity on which all practitioners depend. Network analysis targets information management as a means to better organizational performance. Performance measurement is difficult in public health due to wide structural variation in individual agencies. By examining a variety of these structures, organizational network analysis could prove a valuable resource for understanding factors that contribute to performance in public health. Longitudinal network studies across agencies could yield insights into how network structural elements affect performance and how structure and organizational capabilities co-evolve. Primary Funding Source: National Library of Medicine, National Institute of Nursing Research ●Financing Public Health System Improvement: Findings from the Turning Point Initiative—How did States Leverage Funds? Catharine Riley, M.P.H., Betty Bekemeier, RN, M.P.H., MSN, Bobbie Berkowitz, Ph.D., RN, CNAA, FAAN Presented By: Catharine Riley, M.P.H., Research Assistant, UW School of Public Health--Health Services, Turning Point National Program Office, 6 Nickerson Street, Suite 300, Seattle, WA 98109; Tel: (206)616-8410; Fax: (206)616-8466; Email: bettybek@u.washington.edu Research Objective: Examine and identify specific factors associated with the effective leveraging of resources toward financing public health systems improvement. Study Design: Turning Point states received funding from The Robert Wood Johnson Foundation between January 1998 and March 2005 in order to establish and implement strategic goals for achieving significant statewide public health system improvement through diverse, cross-sector partnerships. An exploratory descriptive study design was implemented to analyze approaches used by these states to leverage additional resources toward goals and objectives derived from their state public health improvement plans. Researchers from the Turning Point National Program Office used a semi-structured interview schedule to conduct key informant interviews with individual state Turning Point leaders. Key informant interview data were gathered for this study to supplement findings from a quantitative survey that enumerated the amounts and types of resources leveraged by Turning Point states to finance public health improvement efforts. Interview data were analyzed on an ongoing basis throughout the period of data collection using QSR N6 Qualitative Data Analysis software. Themes were developed that describe effective approaches to financing public health system improvement and influential factors in Turning Point state successes relative to leveraging resources. Population Studied: Sixteen state-level Turning Point partnerships established for public health systems change. Principal Findings: Former Turning Point state coordinators and key stakeholders in the Turning Point state partnerships were interviewed for this study. Interviews focused on eliciting perceived factors in successful leveraging as well as challenges encountered. Although each state’s goals, resources, strategies, and challenges were different, several common themes emerged regarding the effective leveraging of both hard dollars and soft funding (support given by an agency or partner, other than a cash award, that has value - donated personnel time, supplies, materials, meeting space, mailings, office equipment, advertising, product design, etc). Data analysis identified influential variables such as organizational structure, location of the Turning Point partnership in or out of state government, a comprehensive and inclusive planning process, decisions regarding which system priorities to focus on, breadth of partnerships, and the cultivation of influential “champions.” Conclusions: The public health community historically has assumed that activities supported by grants have secondary effects that are wider and more sustainable than the specific grant-funded objectives. These assumptions are rarely researched and the factors that facilitate this type of leveraging are largely unknown. Through key informant interviews we found that developing and fostering cross-sector partnerships was pivotal to successful leveraging. Successful leveraging of funds was also strongly linked to having a comprehensive, inclusive, systematic planning process that results in an improvement plan that can be relied upon as opportunities arise. Implications for Policy, Delivery, or Practice: Successful sustainability of public health systems change requires ongoing relationships with multiple partners and the deliberate cultivation of resources. Opportunities to leverage funding and support are important to the sustainability of any public health system improvement effort. Findings from this study provide strategic and systematic approaches that can used to leverage resources for the public health system. Primary Funding Source: RWJF ●Improving Service Delivery in a County Health Department WIC Clinic: An Application of Statistical Process Control Techniques William Riley, Ph.D., Debra Boe, BS, RN Presented By: William Riley, Ph.D., Associate Professor, School of Public Health, University of Minnesota, 420 Delaware Street, Minneapolis, MN 55455; Tel: 612-625-0615; Email: riley001@umn.edu Research Objective: The purpose of this research is to measure and improve the wait time experienced by clients in a WIC clinic of a county public health department in a major metropolitan area using a continuous quality improvement (CQI) methodology and statistical process control (SPC) techniques. While CQI and SPC techniques are commonly used in the healthcare industry, a literature review indicates there is very little application of these methods to improving service delivery and process performance in public health settings. Study Design: The baseline process performance was measured using a short survey distributed to all adult WIC participants of their adult guardians to identify perceptions about length of their wait to receive WIC services that’s day, and other service expectations. In addition, service wait times were measured by the researchers. A process improvement study was conducted based on the baseline performance. The process study was conducted by the staff of the WIC program and the researchers. The CQI team identified various improvement strategies and selected process changes which were felt to increase client service. These process changes were incorporated into the WIC clinic and follow-up measures taken to assess the impact of the improvement efforts on process performance Population Studied: The study population consists of clients in a WIC clinic of a county public health department in a major metropolitan area. The study was conducted with all clients receiving services during two separate time frames each consisting of three weeks. The total study size is N= 716 clients with less than 1% of the clients declining to participate in the study. Principal Findings: We established the process capability for 2 key quality characteristics (service wait time and client satisfaction) using an XMR Control Chart and then studied the process for common cause and special cause variation. Once the process capability was determined, process re-engineering was done to improve the process performance. The sources of process variation were identified and investigated. Process improvement changes are assessed using control charts. Control charts have two important purposes: to determine the initial process capability; and to determine if process deterioration occurs in the future. Conclusions: Process performance in county health departments can be analyzed and improved. While CQI and SPC techniques are commonly used in other sectors of health care, they are seldom applied in public health settings. It is possible to apply highly reliable CQI and SPC techniques in a public health department setting to improve service delivery performance. Implications for Policy, Delivery, or Practice: Local public health departments are chronically under funded and strapped with increasing caseload demands and reduced staff to service client needs. Client satisfaction and wait time for public health agencies is an important quality characteristic that affects compliance rates and attendance rates it is possible to establish service expectations that meet healthcare industry benchmarks and to achieve positive customer service satisfaction and a process that allows for consistent wait times. Primary Funding Source: Local Agency Funding ●Evaluating the Effects of Private-Public Partnerships in Public Health Sergey Sotnikov, Ph.D., Toby Merlin, M.D. Presented By: Sergey Sotnikov, Ph.D., Senior Service Fellow, Public Private Partnerships, CDC, 4770 Buford Hwy., NE Mail Stop K-39, Atlanta, GA 30341-3724; Tel: 770-488-2528; Fax: 770488-2553; Email: ann0@cdc.gov Research Objective: The recent report from Institute of Medicine (IOM), “The Future of the Public’s Health in the 21st Century,” promotes partnerships as a way to improve performance of public health systems through better resources mobilization. This study intends to provide quantitative evaluation of the effects of public-private partnerships on performance of local health departments (LHDs). What is the role of partnerships in explaining variations in LHD performance? How large are these effects? Are these effects endogenous? Are there effects uniform at different levels of performance? Study Design: We use four statistical models that relate measures of overall LHD performance to their partnerships with businesses at the community level. In Model 1 we perform ordinary least squares (OLS) regression of performance scores on a set of variables that is commonly used to explain variation in LHD performance (expenditures, number of employees, high speed internet access, director education) and the set of variables that characterize LHD partnerships (number of partners, partnership by type). Estimates from Model 1 are measures of statistical association that do not necessarily imply causation. Some LHDs may be more likely to engage in partnerships due to unobserved characteristics and thus estimated partnership effects may be biased. We deal with this endogeneity issue by estimating a Probit model (Model 2) of business partner’s choice and using predicted probability of having a business partner from that model as a partner variable to re-estimate Model 1 by OLS (Model 3). Also, to account for skewness in our outcome variable (LHD performance) distribution, we re-estimate Model 3 by quantile regression method (Model 4). Population Studied: An inventory of 147 LHDs (108 rural and 39 urban) in three states. Performance data were obtained from the National Public Health Performance Standards Program (NPHPSP). The main sources of data for independent variables included the 1996 NACCHO survey of public health infrastructure, Area Resource Files and the CDC Health Alert Network program. Principal Findings: Partnerships with businesses appear more likely to develop if LHD per capita spending is low compared to peers, LHD is located in a more urbanized county, the LHD director has training in public health, and the LHD is engaged in fewer partnerships (Model 2). The effects of partnerships with businesses on performance are 11 percentage points higher after correction for endogeneity (10 for Model 1 compared to 21 percentage points for Model 3). Partnerships with businesses appear to have effects in the middle quantiles of performance distribution and no effects at low and high end of the distribution. Conclusions: Our results suggest that partnerships with local businesses are associated with higher LHD performance scores. The effects of partnerships on performance are neither exogenous, nor linear. “Returns” to LHD partnerships with businesses appear to be a concave function of LHD performance on the reported performance measures Implications for Policy, Delivery, or Practice: Partnerships with private businesses have been beneficial for LHDs with average performance. LHDs with very low or very high performance scores in our sample may have not yet realized all potential returns from partnerships with private businesses. The basis for this variation in effect warrants further study. Primary Funding Source: CDC ●Public Health Workforce Recruitment, Retention and Promotion in the Civil Service System Patricia Sweeney, JD, M.P.H., RN Presented By: Patricia Sweeney, JD, M.P.H., RN, Research Assistant Professor, Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 3109 Forbes Ave. Suite 210, Pittsburgh, PA 15260; Tel: (412)383-2400; Email: psweeney@pitt.edu Research Objective: A strong public health workforce is a vital component of our nation’s public health infrastructure. Yet present conditions severely strain this system’s ability to maintain a workforce sufficient to meet the challenges of contemporary practice. To provide the essential public health services, today’s public health professionals must possess certain core and discipline specific competencies. Therefore it is essential to determine the extent to which the workforce possesses these competencies. The objective of this study was to analyze state health department personnel procedures to determine the extent to which public health core and discipline specific competencies are utilized by state public health agencies when recruiting and promoting personnel. Study Design: The study was conducted in two phases. During phase one every state and territorial public health department human resource director was mailed a survey asking them to identify and submit job descriptions for their agency’s most difficult position to recruit, the position most vital to performance of the ten essential public health services, and the epidemiologist position most difficult to recruit. Utilizing keyword coding, the survey responses were tabulated and position descriptions were analyzed. The two positions most difficult to recruit were identified. During phase two of the study each state human resource director was mailed a survey to identify the procedures and criteria used to hire and/or promote individuals in the two identified positions. Each human resource director was also asked to submit a copy of the materials used to assess candidates for each position. Utilizing MaxQDA and keyword coding, the assessment materials were analyzed to determine the extent to which they assessed the candidate's attainment of the core and discipline specific competencies in the initial assessment and promotion processes. Population Studied: Surveys were mailed to all US state and territorial public health departments. (n=54) Principal Findings: State health department job titles and responsibilities vary widely across the states. However, coding key responsibilities and discipline specific competencies enabled the job descriptions to be stratified for analysis. While the states reported a number of positions as difficult to recruit, across the seventeen state health departments responding to phase one of the study, the position identified most consistently as most vital to performing the essential services and the position most difficult to fill was entry level public health nurse (n=12). The epidemiology position identified as most difficult to fill was senior level epidemiology supervisor or senior epidemiology scientist (n=13). Phase two findings determined that there is significant variability across the states as to the departments deemed responsible for assessing candidates for state health department employment. In addition, the study found that for each position, discipline specific competencies are widely utilized in the assessment tools for both the public health nurse and senior epidemiology positions, however the core public health competencies were not assessed in these personnel processes utilized to recruit and/or promote either of the study positions. Conclusions: This study demonstrates that current state-level personnel systems do no support the competency-based recruitment, hiring, and promotion of public health professionals Implications for Policy, Delivery, or Practice: Over the past decade, much attention and funding have been devoted to the definition of “competencies” necessary to carry out essential public health services and to training the existing workforce. However, serious deficits remain. Healthy People 2010 set an infrastructure objective for public health agencies to incorporate specific competencies in the essential public health services into personnel services. This research demonstrates that we are far from reaching that 2010 goal. Further analysis of the impact of state civil service laws upon the state health departments' ability to revise personnel processes to include these competencies is needed. Phase three of this study to be conducted during 2006 will conduct this analysis. Primary Funding Source: Pfizer Faculty Scholar in Public Health Award Call for Papers Shocks to the System: Katrina, Emergency Preparedness & the Public Health Response Chair: Hugh Tilson, University of North Carolina, Chapel Hill Tuesday, June 27 • 8:45 am – 10:15 am ●Leveraging Social Networks for Protecting Vulerable Communities’ Health During Disasterss David Eisenman, M.D., MSHS, Kristine Cordasco, M.D., M.P.H., Steven Asch, M.D., MSHS, Joya Golden, BA, Deborah Glik, Ph.D. Presented By: David Eisenman, M.D., MSHS, Assistant Professor in Residence, Division of General Internal Medicine/Health Services Research, Geffen School of Medicine at UCLA, 911 Broxton Plaza, LA, CA 90095; Tel: (310) 794-2452; Email: deisenman@mednet.ucla.edu Research Objective: Hurricane Katrina demonstrated that impoverished communities are less likely to evacuate and are more affected by disasters. While poverty, lack of transportation to or shelter in safe areas, and experiences riding out hurricanes safely were certainly factors in delaying evacuation, social networks (the web of relationships that surround individuals) may also have played a role. We interviewed evacuees from Hurricane Katrina to give voice to those issues influencing evacuation in impoverished, minority communities. Study Design: From September 9 (11 days post-hurricane) to September 12, 2005 we performed qualitative interviews with 58 adult evacuees randomly sampled from Houston’s three major evacuation centers. Interviews focused on factors influencing evacuation behavior prior to the hurricane’s landfall. We analyzed the transcribed interviews using grounded theory methodology. Three investigators independently coded and resolved disagreements by consensus. Population Studied: 58 adult evacuees randomly sampled from Houston’s three major evacuation centers. Participants were mainly African American, low income, and from New Orleans Parish. Principal Findings: We identified 1194 statements coded into the following domains: 1) Instrumental: the resources and practicalities related to evacuation; 2) Cognitive/Affective: the receipt, understanding, and processing of evacuation messages; 3) Social/Cultural: the influence of social networks and attitudes about hurricanes.Participants affirmed the importance of the widely reported instrumental and cognitive reasons for non-evacuation, including income, transportation, jobs/property, health, and risk perceptions. However, these factors were mediated by the influence of social networks (a Social/Cultural sub-domain) that facilitated or hindered evacuation decisions. For some the extended family was a resource: “My sister, she had called me. So I went to pick her and her children up, and grand children, and we just started driving….” For others, church members encouraged evacuation: “So our clinical manager called back. She says, ‘Stella, the Lord said get out of that house.’ I said, ‘We're on our way out now if you would hang up.’” Participants described networks outside of New Orleans that provided “an open invitation” as facilitating evacuation or noted the absence of networks outside of New Orleans as hindering evacuation: “Really truly, we had cars, but we didn't know anybody to go to.” Obligations to the elderly influenced evacuations: “…We had to come back home. My mother-inlaw had called for us to come back…. You know when they get a certain age they get confused.” Participants who sheltered extended family members in their homes were subsequently unable to evacuate: “I could have made it on my own, but it was just my aunt and my uncle. Every few steps he made…she forgot his walker…every few steps he made he was falling down.” Conclusions: Improving disaster plans for impoverished, minority communities requires more than remedying access to shelter and transportation. The influence of social networks demands better community-based disaster programs. Implications for Policy, Delivery, or Practice: Programs should address social units (households, extended families, neighborhoods) and risk communications must account for social networks if they are going to sway those whose norms, risk perceptions, and decision-making are highly influenced by their social networks. Public health and disaster planners should leverage these networks by teaming with indigenous helpers, civic, and community organizations when devising their communications and plans. Primary Funding Source: Natural Hazards Research and Applications Information Center ●Ready or Not? Perceptions about Preparedness in Nursing Homes Before and After Hurricane Katrina Sarah Laditka, Ph.D., M.B.A., James N. Laditka, D.A., Ph.D., Sudha Xirasagar, MBBS, Ph.D., Carol B. Cornman, RN, P.A., Courtney B. Davis, MHA, Jane V.E. Richter, Dr.PH., RN Presented By: Sarah Laditka, Ph.D., M.B.A., Associate Professor, Health Services Policy and Management, University of South Carolina, 800 Sumter Street, Health Sciences Building, Columbia, SC 29208; Tel: (803) 777-1496; Fax: (803) 777-1836; Email: sladitka@gwm.sc.edu Research Objective: Nursing homes care for people with increasingly complex medical needs, and are a vital part of the health care continuum. Prior studies and the aftermath of Hurricane Katrina provide evidence that many nursing homes are inadequately prepared for major disasters. We surveyed Medicare and/or Medicaid-certified nursing homes in South Carolina, to understand administrators' experiences with disasters, and views about preparedness. A baseline survey was completed just before Katrina. A post-Katrina survey, conducted two weeks after the storm, provided insight into how administrators’ views about preparedness were influenced by Katrina. Study Design: A mailed survey, designed after consulting public officials responsible for nursing home preparedness, facility administrators, and preparedness guidelines, collected information about facility characteristics, and administrators’ satisfaction with ability to: evacuate residents and/or shelter evacuees, transport employees and residents; communicate with employees, rescue workers, and others; and work successfully with local agencies after a disaster. We also asked about experiences with emergencies, and preparedness strengths and weaknesses. The post-Katrina survey asked if the storm influenced preparedness views, and if it changed planning. Quantitative responses were analyzed with standard descriptive statistics. Qualitative data were coded independently by three researchers. Population Studied: All 192 nursing homes certified by Medicare and/or Medicaid in South Carolina, 2005. Principal Findings: 112 surveys were completed (response rate=58.3%). 92 facilities completed a survey prior to Katrina; 30 of these also completed a post-Katrina survey. 20 additional facilities completed the survey following Katrina, and also the post-Katrina survey. 68% were satisfied with their own ability to shelter evacuees from other facilities; 82% reported they would rely on cell phones and/or computers if telephone service were disrupted; 59% were satisfied with transportation resources. About 55% reported an emergency in the past 3 years, such as power loss (40%). Common themes of how public agencies could help were providing/coordinating transportation and alternative shelters (40%) and training (30%). Key preparedness strengths were staff (53%) and community support (30%). Areas for improvement included training (12%) and transportation (12%). 54% in the post-Katrina survey said the storm had changed their thinking about preparedness; they were reviewing supplies, staffing, administrative responsibilities, and communication. 36% felt well prepared. Conclusions: There was substantial variation in confidence about preparedness before Katrina, and immediately following Katrina. Administrators reported strengths, primarily staffing and community support. They were less confident in their ability to shelter evacuees or arrange for transportation. Most said they would rely on cell phones and/or the internet in an emergency. Implications for Policy, Delivery, or Practice: The experience of Katrina suggests that nursing homes may be isolated after large disasters, unable to communicate, and unassisted by community resources that are directed elsewhere. Some administrators’ preparedness expectations are unrealistic: relying on the internet or cell phones may leave them unable to communicate outside their facilities. It may be useful for public health agencies to provide facilities with additional preparedness guidance, particularly for transportation and communication. Facilities may benefit from preparedness guidelines for different risk profiles, such as coastal areas or fire zones. Public health officials should promote greater integration of nursing homes into community preparedness plans. Primary Funding Source: CDC ●Reported Levels of preparedness Among Registered Nurses in the National Capitol Region Peggy Maddox Presented By: Peggy Maddox, Director, Office of Research, Center for Health Policy, Research & Ethics, George Mason University; Email: pmaddox@gmu.edu Research Objective: The purpose of the study was to determine registered nurses’ preparedness to respond in major disasters and emergencies in order to inform regional planning and capacity building for disaster response in the Washington DC Metropolitan Region. The objective of this study was to identify the learning needs, perceived competence and training experience of registered nurses (RNs) as early responders during large-scale, all hazards emergencies. With recent community disaster experiences and apparent system failures, the need to ensure that nurses and other healthcare professionals are prepared to function in community disasters and emergencies has become an important priority for public health leaders, health systems, professional schools, and policy makers alike. This study was designed to obtain information on RN learning needs and perceived competence; to identify the adequacy of institutional education/training in various sectors and settings and to identify persistent gaps in RN’s disaster response knowledge and skills. Study Design: Initial data collection was conducted in the fall of 2004 to obtain baseline information from registered nurses within the metropolitan Washington, DC region on RN perceptions of their learning needs relative to nationally recognized competencies related to emergency preparedness, response to mass casualties, bioterrorism and other disasters. Data collection occurred through use of an online survey, using a researcher developed instrument based on developing competencies for nurses in emergency preparedness as identified from a variety of nationally recognized sources. The tool forced choice questions on the importance of being prepared and levels of readiness for specific functions. Qualitative data collection occurred through a series of regional focus groups held in the fall of 2005. The purpose of focus groups was to better understand current training activities and levels of readiness of institutions within the metropolitan Washington, DC region employing registered nurses. Deductive qualitative coding methods were used to identify major themes. Findings from focus groups informed and clarified finding derived from the on-line survey. Population Studied: RNs in the DC Metropolitan area were studied using a structured, web-based survey and focus groups. Data were collected via an online survey of RNs and via seven focus groups. The survey sample included 230 of RNs licensed in Virginia, Maryland and DC. Seven focus groups recruited RNs from the region who worked in hospitals, long-term care, assisted living, school health, public health, home health, and community settings. Principal Findings: 1-Almost all disaster response competencies were reported by RNs participating in the study as important. 2- Less than half reported high levels of competence in specialized knowledge and skills: recognizing biological, chemical radiological agents, emergency handling/treatment, psychological management of massive victims of a disaster, using protective equipment, public health reporting, and knowledge of responders outside their organization. 3- With the exception of RNs having served in the military, few reported having any hands-on or interdisciplinary team drills. Conclusions: 1-Hospital based nurses reported knowing about the existence of a disaster plan that would be implemented by their employer, but few report any knowledge of inter-agency/organizational plan coordination or knowledge about disaster specific knowledge and skills. 2-Nurses who work more in community based settings (i.e. occupational health, school health) and within government agencies were more knowledgeable about specific aspects of their organization/agency’s response plan and were more likely to report having participated in role specific exercises. 3-Nurses from all health sectors and settings reported less confidence than their employer about the comprehensiveness, readiness and adequacy of institutional response plans. Implications for Policy, Delivery, or Practice: 1 Performance goals/competencies are needed (degree or level of mastery) that are specific to RN role and service setting. 2 - Just in time, realistic, scenario-based and interactive, hands-on training is urgently needed. 3 - Findings from this study have implications for curriculum planning for undergraduate, graduate and continuing education programs for nurses for individuals planning regional/community disaster. Primary Funding Source: No Funding ●Trust Influences Response to Public Health Messages During a Bioterrorist Event Lisa Meredith, Ph.D., David P. Eisenman, M.D., MSHS, Bonnie Green, Ph.D., Andrea Cassells, M.P.H., Jonathan N. Tobin, Ph.D. Presented By: Lisa Meredith, Ph.D., Senior Behavioral Scientist, Health, RAND Corporation, 1776 Main Street, Santa Monica, CA 90407-2138; Tel: (310)393-0411 x7365; Fax: (310)260-8152; Email: seidel@rand.org Research Objective: Trust is a critical component in the health care decision making process and may play a significant role in individuals’ responses to public health crises, including bioterrorism. Studies document that African Americans relative to other race/ethnic groups are less likely to trust that the public health system will respond fairly to their health needs if there is a bioterrorist attack. These studies leave open questions of what specific aspects of trust are key, how it varies during an evolving bioterrorist attack, and how public health officials can design effective communication programs for maintaining trust in communities living with the suspicion of inequitable treatment. We sought to understand the specific components of trust that influence community responses to a bioterrorist attack and its public health recommendations. Study Design: We used qualitative analysis of data from 8 focus groups stratified by socioeconomic status (up to vs. above 200% of federal poverty guidelines) and age (18-39 years old vs. 40-65 years old). Discussions elicited reactions to information presented in escalating stages of a bioterrorism scenario that mimicked the events and public health decisions that might occur. We used an inductive analysis strategy to investigate how trust influenced participants’ reactions to the evolving public health decisions. Population Studied: 75 African-American adults living in Los Angeles County. Principal Findings: We identified 6 components of trust: 1) fiduciary responsibility, 2) honesty, 3) competency, 4) consistency/reliability, 5) faith, and 6) other trust-related issues that did not fit clearly into the other five categories. Honesty and information consistency were the components most frequently identified as determining trust with 143 and 140 passages each respectively, compared with 115 for fiduciary responsibility, 59 for faith, 58 for competency, and 31 other trust issues. The relative importance of the 6 trust components varied as the scenario evolved; honesty was most important upon initially hearing of a public health crisis: “The people at the top are only giving the people at the bottom maybe 30 percent of the truth…because they don't want everybody panicking.” Fiduciary responsibility (“I remember what happened with the AIDS virus…and [at] Tuskegee with syphilis and [smallpox with] the Indians… Our government has a history of using bioterrorism as a method of population control, so why would I suddenly trust them to save my life?”) and consistency were important upon confirmation of a smallpox outbreak and the ensuing public health response. Personal doctors were frequently described as trusted sources of information. The only variation by age and SES of the focus groups was that younger/high SES groups discussed honesty more frequent than did the other groups. Conclusions: Consistent with the risk communication literature, findings suggest that honesty and information consistency across multiple sources are essential to delivering effective risk messages. The absence of differences between groups was inconsistent with the literature suggesting that uniform policies can be used to address groups varying in age and SES. Implications for Policy, Delivery, or Practice: Findings can help public health officials design communications that enhance trust during a bioterrorist event. Primary Funding Source: CDC, RAND ●The Integration of Health Centers into Community Emergency Preparedness Planning: An Assessment of Linkages Nicole Wineman, MA, M.P.H., M.B.A., Barbara I Braun, Ph.D., Nicole L Finn, MA, Joseph A Barbera, M.D., Jerod Loeb, Ph.D. Presented By: Nicole Wineman, MA, M.P.H., MBA, Senior Research Associate, Health Policy Research, JCAHO, 1 Renaissance Blvd, Oakbrook Terrace, IL 60181; Tel: 630-7925948; Fax: 630-792-4948; Email: nwineman@jcaho.org Research Objective: To conduct a national baseline assessment of the extent to which health centers are integrated with other hospitals, public health agencies and traditional first responders in relation to community emergency preparedness. Specifically, to assess the prevalence of health center participation in community-wide planning and test whether better linkages were associated with the perception of a high number of community threats/hazards, or with experience planning for a national event or responding to an actual event. Study Design: With input from an expert panel, a mailed questionnaire was utilized to conduct the cross-sectional assessment on linkage issues related to health center experience with emergencies or disasters, involvement in community planning and their role in community response, communication, surveillance and training and drills in February 2005. Population Studied: All 2003 HRSA Bureau of Primary Health Care supported health centers (n=890); 307 health centers responded (34%). Principal Findings: 70% of responding health centers reported involvement in community planning. Most (60%) reported having become involved in planning during or after 2001; only 10% had been involved prior to 2001. 54% reported being represented on the community planning group. Although 80% of health centers reported having an internal written emergency operations plan, only 43% had plans that were developed collaboratively with the county/local emergency management agency. 30% reported that the health center’s role in the event of an emergency was documented in the local or county emergency operations plan. 31% had participated in community-wide training and 19% in drills. Funding for preparedness activities was limited; only about one-third reported receiving support for these activities. Thirty percent had responded to an actual disaster or public health emergency and 11% to a potential/suspected emergency. 111 health centers reported having responded to 195 events; the most commonly reported responses included providing medical care (50%), closing (40%), reassigning staff (27%), offering education and information (23%) and/or serving as a communication link (21%). The most commonly reported barriers to building effective linkages were staff limitations and time constraints (70%), lack of funding for training and/or equipment (59%) and the health center’s potential role not being understood by planners (57%). An analysis of associations between linkage elements and demographic factors, perceived high number of community threats/hazards, experience in planning for a national event or responding to an actual event is underway. Conclusions: Though most respondents reported being involved in community planning, the extent of integration was not sufficient for adequate response since few had participated in community-wide exercises or had pre-defined roles. Not surprisingly, collaborative planning and community involvement rose sharply after 2001. These findings may overestimate health center involvement since non-respondents may have been less involved in community preparedness activities. Implications for Policy, Delivery, or Practice: The effectiveness of community response to any disaster, either natural or man-made, is greatly enhanced by collaborative planning with all community assets and stakeholders. The importance of including health centers in the planning process seems to be underestimated. During hurricane Katrina, reports indicated many health centers had a central role in providing essential care and services to many. Community planners should be encouraged to include such potentially valuable resources. Primary Funding Source: AHRQ Related Posters Public Health Systems Poster Session B Monday, June 26 • 5:30 pm – 7:00 pm ●Healthy Communities in an Era of Global Oil Depletion Melissa Ahern, M.B.A., Ph.D., Robert Scarfo, Michael Hendryx, Ph.D. Presented By: Melissa Ahern, M.B.A., Ph.D., Associate Professor, Health Policy & Administration, Washington State University Spokane, PO Box 1495, Spokane, WA 99210; Tel: (509) 358-7982; Email: ahernm@wsu.edu Research Objective: To investigate the consequences to the health care system of global oil depletion and substantially higher energy prices that will occur over the next 5 to 10 years. Study Design: A critical research synthesis of the literature and current data on global oil depletion and the literature on unsustainable elements of the current health care system. Population Studied: This investigation will focus on implications for community health care delivery systems. Principal Findings: Substantial evidence from a growing number of credible experts and sources indicates that global peak production of oil is likely to occur within the next decade, and possibly within the next five years. The growing gap between supply and demand of energy resources has nontrivial implications for all markets, including the health care markets. Prices of health care goods and services will rise substantially, federal and state reimbursements will shrink, and the number of unemployed and uninsured will grow substantially. A growing number of studies identify huge potential savings in health care by reducing perverse reimbursement incentives, reducing excess administrative costs, and reallocating resources to address the broad determinants of health and prevention. Conclusions: An understanding of the impact of global energy issues for the next decade indicates that reexamining ways to lower health care costs and improve health is a matter of growing urgency. Generally, local economies are going to become increasingly important, as the transportation component of goods and services increases substantially. Prices of health care goods and services and services will be substantially higher because they are inextricably linked to energy costs. Health care is likely to increasingly depend on local community systems, rather than national and state programs. Implications for Policy, Delivery, or Practice: It is critical that health care leaders focus on implementing strategies for building healthier communities. Approaches that limit health care costs and optimize health, and approaches that provide basic preventive care to all members of the community will be increasingly important. These approaches include such strategies as creation of walkable communities, neighborhood access to basic health care services, maximizing delivery of health care in low cost settings, and increasing energy efficiency in health care facilities. Research should focus on assisting communities in implementing strategies for sustainable health care that anticipate the enormous challenges posed by the coming era of fossil fuel depletion and rising energy prices. Primary Funding Source: No Funding ●Obesity and Health in Europeans Ages 50 and Above Tatiana Andreyeva, MA, MPhil, Pierre-Carl Michaud, Ph.D., Arthur van Soest, Ph.D. Presented By: Tatiana Andreyeva, MA, MPhil, Doctoral Fellow, Pardee RAND Graduate School, 1776 Main Street, Santa Monica, CA, CA 90407-2138; Tel: 310.393.0411 x6047; Fax: 310.260.8155; Email: tatiana@rand.org Research Objective: To document the prevalence of obesity and related health conditions for Europeans aged 50 and above, and estimate how the association between obesity and health outcomes varies across 10 European countries. Study Design: Data were from the 2004 Survey of Health, Ageing and Retirement in Europe, a cross-national survey of 22,777 Continental Europeans over the age of 50. The outcome measures included four weight classes (defined by body mass index (BMI) from self-reported weight and height), fair or poor self-reported health, depression, and doctordiagnosed chronic conditions, including diabetes, high blood cholesterol, hypertension, arthritis, and heart disease. Population Studied: Adults ages 50 and above from 10 European countries. Principal Findings: The prevalence of obesity (BMI>=30) ranged from 12.8% in Sweden to 20.2% in Spain for men and from 12.1% in Switzerland to 25.5% in Spain for women. Adjusting for compositional differences across countries changed little in the observed heterogeneity in obesity. Compared with normal weight individuals, men and women with greater BMI had a significantly higher odds ratio for all chronic conditions examined except for heart disease in overweight men. Depression was linked to obesity in women only. Conclusions: Cross-country differences in the prevalence of obesity in older Europeans are substantial and exceed sociodemographic differentials in obesity. Obesity is strongly associated with major health risk factors, yet cross-country differences exist in how obesity is related to depression, heart disease and high cholesterol levels. Implications for Policy, Delivery, or Practice: Large heterogeneity in obesity across European countries should be investigated further to identify areas for effective public policy. Primary Funding Source: NIA ●Financing Public Health System Improvement: Findings from the Turning Point Initiative— How much was leveraged? Betty Bekemeier, RN, M.P.H., MSN, Catharine Riley, M.P.H., Bobbie Berkowitz, Ph.D., RN, CNAA, FAAN Presented By: Betty Bekemeier, RN, M.P.H., MSN, Deputy Director, UW School of Public Health--Health Services, Turning Point National Program Office, 6 Nickerson Street, Suite 300, Seattle, WA 98109; Tel: (206)616-8410; Fax: (206)616-8466; Email: bettybek@u.washington.edu Research Objective: Enumerate the actual resources leveraged toward public health system improvement through the partnerships, planning, and implementation activities funded by the Robert Wood Johnson Foundation as a part of the Turning Point Initiative. Study Design: Turning Point states received funding from The Robert Wood Johnson Foundation between January 1998 and March 2005 in order to establish and implement strategic goals for achieving significant statewide public health system improvement through diverse, cross-sector partnerships. Researchers from the Turning Point National Program Office developed and pilot tested a survey to gather specific financial data to reflect various amounts and types of resources leveraged by these states in association with their public health improvement plans and their infrastructure priorities implemented through funding by the RWJF. State Turning Point leaders were surveyed to provide specifics regarding the amount of hard dollars and other resources leveraged. Survey participants utilized their own budget records and experience with their state partnerships to provide figures for several categories of funding. Categories related to types of resources garnered for system improvement efforts related to their Turning Point priorities and were leveraged by grantees themselves and by their partners. Population Studied: Sixteen state level Turning Point partnerships established for public health systems change. Principal Findings: Sixteen of the 21 Turning Point states participated in this survey research. Of the 16 states represented in these findings, a majority of them indicated having significantly improved their state’s public health financing toward system improvements through additional grants and financial support from other sources. Not all of these states leveraged significant additional funds for systematically improving their public health infrastructure. Turning Point states in total, however, leveraged 6 times the national investment made by RWJF to these grantees. These leveraged dollars, some newly designated or redistributed, were used for the primary system improvement priorities identified from their public health improvement plans. Turning Point state partners, who were not specific RWJF grantees themselves, similarly contributed to or leveraged investments garnered by state grantees, adding many times over the RWJF investment again. Conclusions: Currently “no systematic means” exists (Moulton et al., 2004) for public health leaders to study effective strategies or innovations in maximizing financial support for their public health systems. The examination of outcomes from the Turning Point Initiative contributes to the research and practice findings regarding public health financing and begins to fill gaps identified in the recommendations from the Institute of Medicine’s 2003 report The Future of the Public’s Health in the 21st Century— that “innovative financing mechanisms that add new resources” be identified and best practices articulated. The findings from this study show that, despite national challenges related to developing stable and secure financial resources for public health activities, significant funds can and have been leveraged by states to build new public health structures and capacity through innovation brought about by grant funding that supports planning and partnerships. Implications for Policy, Delivery, or Practice: The findings from this research show the extent to which states can significantly expand statewide investments dedicated to public health system improvement and thereby enhance the capacity of public health systems. Primary Funding Source: RWJF ●Time Is Money? -- The Impact of EMS Response and Transporting Time on Hospital Care Use and Expenditure of Car-Crash Injured Patients Li-Wu Chen, Ph.D., Liyan Xu, M.S., Catherine Leo Presented By: Li-Wu Chen, Ph.D., Associate Professor, Preventive and Societal Medicine, University of Nebraska Medical Center, 984350 Nebraska Medical Center, Omaha, NE 68198-4350; Tel: (402)559-5260; Fax: (402)559-7259; Email: liwuchen@unmc.edu Research Objective: With about 500,000 hospitalizations and 4 million emergency room visits resulting from car crash injuries annually, it is important to understand how Emergency Medical Services' (EMS) response and transporting time affects crash victim’s use of hospital care. However, little has been written in this area. This study intends to examine this research topic. Study Design: We use a logistic regression approach and an ordinary least squares (OLS) approach to examine the effect of EMS response (to the scene) and transporting (to hospital) time on car-crash victim’s likelihood of being hospitalized and hospital spending, respectively. Logarithm transformation is used to correct possible skewness of hospital expenditure data in the OLS model. Our models control for crash characteristics (e.g., type, speed limit, driver negligence, car/weather condition) as well as victim’s characteristics (e.g., demographic, injury severity, insurance type). Population Studied: This study uses a state-wide sample of car-crash victims who have received both EMS and hospital care afterwards. Data come from the 1996-1999 Nebraska Crash Outcome Data Evaluation System (CODES). Principal Findings: The car-crash victims who are sent to arrive at a hospital within 30 minutes from the time point of dispatching an EMS unit are 42% less likely to be hospitalized (p<0.01) and incur 18% less hospital expenditure (p<0.05), than their counterparts who have more than 30 minutes of the same interval (an average hospital expenditure of $1,079 and $1,318 is predicted for the former and latter group, respectively). In addition, the car-crash victims who are treated by an EMS unit within 5 minutes from the time point of dispatching an EMS unit are 26% less likely to be hospitalized than their counterparts who have more than 5 minutes of the EMS response (to the scene) time (p<0.1). Having a less than 5-minute EMS response time, however, does not significantly reduce a car-crash victim’s hospital spending. On the other hand, having a less than 20-minute transporting time between EMS’ arrival at the scene and at the hospital significantly reduces a car-crash victim’s hospital spending by 17% (p<0.01). Conclusions: A shorter EMS response time is critical in reducing the likelihood of being hospitalized for car-crash victims (through stabilizing patient’s condition sooner), while a shorter transporting time between EMS’ arrival at the scene and at the hospital plays a more significant role in reducing hospital spending (through having appropriate hospital care available sooner). In sum, a shorter time between dispatching an EMS unit and arrival at hospital helps reduce a car-crash victim’s likelihood of hospitalization and hospital spending. A saving of $239 in hospital spending is estimated for each patient who is sent to arrive at a hospital within 30 minutes from the time point of dispatching an EMS unit, instead of having an interval of longer than 30 minutes. Implications for Policy, Delivery, or Practice: The enhancement of the infrastructure (e.g., EMS workforce, coordination, communication, transportation vehicle) in the EMS delivery system will help improve patients’ outcomes as well as result in significant savings in hospital care. Such enhancement may be especially important to rural areas, as our data also suggest that a greater proportion of rural carcrash victims experience a longer time interval between EMS dispatch and hospital arrival than do their urban counterparts. The benefits from having a more efficient EMS response and transporting system may further manifest if a large-scale public health disaster occurs. Primary Funding Source: No Funding ●Challenges in Providing Outpatient Care in Almaty City, Kazakhstan: A Pilot Study of Ethnic Differences in Breast Cancer Prevention Askar Chukmaitov, M.D., Ph.D., Thomas T.H. Wan, Ph.D. Presented By: Askar Chukmaitov, M.D., Ph.D., Assistant Professor, Family Medicine and Rural Health, Division of Health Affairs, FSU College of Medicine, 1115 West Call Street, Suite 3200-C, Tallahassee, FL 32306-4300; Tel: (850) 6456897; Email: askar.chukmaitov@med.fsu.edu Research Objective: The primary care system in Kazakhstan is characterized by fragmentation, underfunding, and a lack of coordination of services with specialists. Cancer detection and prevention has suffered because there were no clear roles and responsibilities determined for primary care physicians and specialists. Health reform targets these issues and emphasizes primary care. However, important determinants of patients’ health seeking behavior, such as their ethnic background, beliefs in effectiveness of preventive care, knowledge and attitude toward prevention and primary care, have not been incorporated into the reform movement. This study assesses how patient ethnic background, beliefs, knowledge, and attitudes affect breast cancer prevention in Almaty City, Kazakhstan. Study Design: A cross-sectional survey design was used. Data on women’s demographics, knowledge about breast cancer, preventive health attitudes, beliefs in prevention, health functioning, health services use, and other characteristics were collected in November 2001 in Almaty City, Kazakhstan. Structural equation modeling was used to determine how breast cancer knowledge, attitudes, beliefs, and other characteristics affect women’s preventive behavior. The same model was also separately performed for Kazakh, Korean, and Russian groups. Population Studied: The total sample size was 500 women, stratified by their ethnic background – 124 Kazakhs, 242 Koreans, and 124 Russians. Principal Findings: We found that breast cancer knowledge and beliefs in prevention are positively related to breast cancer preventive practice. Preventive attitude do not influence preventive behavior in Kazakhstani women. Interestingly, as a level of perceived health status increases, the preventive behavior decreases. Also, women who use herbal therapy are more likely to practice preventive behavior. In stratified ethnic samples, a better knowledge of breast cancer symptoms and prevention leads to higher level of preventive behavior in a Korean group. There were no findings for Kazakhs and Russians. Conclusions: Our findings suggest that breast cancer knowledge and belies in effectiveness of prevention are the major determinants of breast cancer preventive behavior in Kazakhstani women in Almaty City. We found that good health status may be a perceived barrier to seek prevention, which may occur due to women’s fatalistic approach towards their health and a lack of control over their future health status. However, women – users of alternative medicine are more likely to be “health minded” and involve in breast cancer prevention. Urbanization may have decreased ethnic differences in breast cancer preventive behavior in Kazakhstani women. Implications for Policy, Delivery, or Practice: Breast cancer prevention needs to be integrated into the primary care system. Clinicians have to educate and remind women of all ethnic backgrounds about breast cancer risks and prevention. Breast cancer education and awareness campaigns have to target women with a high level of perceived health status, which may provide an effective means in improving breast cancer prevention in Kazakhstan. Primary Funding Source: The Williamson Institute for Health Studies at Virginia Commonwealth University ●Public Health System Improvement: The Role of Trauma Care Julia Costich, J.D., Mary E. Fallat, M.D., Nancy Galvagni, Davis P.T. Potter, M.P.H. Presented By: Julia Costich, J.D., Chair, Dept. of Health Services Management, College of Public Health, 121 Washington Ave., Lexington, KY 40536-0003; Tel: 859-2576712; Fax: 859-257-3909; Email: julia.costich@uky.edu Research Objective: Traumatic injury is a serious public health problem, particularly among children and young adults, for whom it is the leading cause of death. Trauma care capacity is also a critical element of public health preparedness. Trauma care resources often appear to be available in inverse proportion to geographic distribution of the burden of trauma, and local jurisdictions in greatest need are most likely to lack a tax base adequate to support service requirements. A coalition of Kentucky stakeholders explored options for public health system improvement in the area of trauma care. Study Design: Two surveys were fielded. The first assessed understanding of and support for trauma system improvement, while the second gauged the readiness of hospitals to participate in a comprehensive system of care for trauma patients. The random-digit-dialed telephone survey yielded 800 complete responses, and the written survey of hospital emergency departments garnered a 94% response rate. Results were analyzed using descriptive statistics in SPSS. Population Studied: One instrument surveyed a random sample of Kentucky adults; the other assessed all Kentucky hospitals with emergency departments. Principal Findings: Several of the telephone survey findings indicated that respondents identified trauma care as an integral part of their community’s public health services. Emergency medical services (EMS) were highly valued by respondents, with 79.3% finding them as important as police and fire services. Large majorities of respondents supported better funding for trauma care (79.3%), government support for care not funded by third-party coverage (69.8%), and legislation to fund trauma care (83.2%). The most popular funding option was a 5% tax on the purchase of guns and ammunition (69.6%). A slight majority (55%) of those who had ever used a trauma center were able to identify such a center correctly, while majorities of other respondents identified non-certified facilities. The hospital survey also indicates broad support for public sector responsibility in trauma care. One-third indicated that they could not fund needed upgrades to emergency care on their own, and the single greatest deficiency identified statewide was in EMS capacity, another public health system issue. Payment sources for injury care were primarily in the public sector, with commercial health and auto insurance covering only a total of 38% of care. Conclusions: The findings of two statewide surveys indicate that trauma care needs cannot be met adequately unless they are more explicitly integrated with the public health system. Broad support for government funding of trauma care can be linked with clear indications of facility needs that are unmet by market forces alone to make a stronger case for public funding. Implications for Policy, Delivery, or Practice: Geographic and socioeconomic disparities in trauma-related death rates suggest that action should be taken at the state rather than local level. Policymakers must assure adequate funding of a comprehensive range of public health services and avoid diverting already meager resources from existing programs to trauma care. Primary Funding Source: HRSA ●Predicting the Economic Impact of an Avian Flu Epidemic Andrea DeVries, Ph.D., Patricia Gladowski, RN, MSN, Susan Berger, LPN Presented By: Andrea DeVries, Ph.D., Practice Manager, Medical Informatics Research and Analysis, Highmark BCBS, 120 Fifth Avenue, Suite P7205, Pittsburgh, PA 15222-3099; Tel: 412-544-0794; Fax: 412-544-0700; Email: andrea.devries@highmark.com Research Objective: To determine the economic impact of Avian flu (H5N1) should it become pandemic in the United States on the financial stability of Highmark, a large health insurer in Western Pennsylvania. Study Design: The purpose of the study was to determine the impact that an Avian flu epidemic could potentially have on the financial solvency of Highmark, a large health insurer with over 4 million members. Literature review, along with updated daily reports of the progression and virulence of Avian flu was used to build the assumptions used in the model. The initial steps involved pulling ICD9, CPT, HCPCS, DRG and NDC codes for the various diagnoses, procedures, and medications typically used to treat various stages of influenza, including mild upper respiratory symptoms to severe conditions resulting in pneumonia and requiring ventilator assisted breathing. The codes were then used to determine costs of care based on Episode Treatment Groups (ETGs). ETG methodology is used to measure episodes of care for medical treatment as an outpatient, inpatient, or both. This software system was developed by Symmetry Health Data System, Inc. The population was then divided into low, moderate and high-risk individuals. Risk ranking was determined by factors such as age, comorbid conditions, and whether the individuals worked as direct care providers in the health care industry. Literature review relying on expert opinion determined that the rate of infection could vary from 25 to 55 percent. Infection rate was then applied using a progressive model with the lowest rate applied to the low risk individuals and the highest risk applied to direct care providers due to their degree of exposure. Additional steps involved ranking the at-risk indivuals by their chance of developing minor, moderate or severe symptoms. Based on patterns of illness severity, along with CDC estimates, as high as 50% of those infected were developing server symptoms, often resulting in death. Population Studied: All health plan members where Highmark would incur some degree of financial liability, including self-insured groups that purchase excess risk insurance and those who purchased disability coverage through Highmark. Principal Findings: Using the model described, preliminary results revealed that Highmark would face significant financial liability in the range of several billion dollars should the Avian flu become a pandemic in the United States. The model was placed in an Excel spreadsheet application that could be adjusted by percentage risk and severity ranking based on updated information related to risk factor identification, rates of infection and severity ranges. Conclusions: Although the study relied on several assumptions based on literature review and patterns seen over time with Avian flu progression, it was determined that there would be a significant impact on financial and human resources should a pandemic reach our area. In this era of increasing numbers of natural and manmade disasters, it is essential that we be prepared both financially and through appropriate manpower to manage these issues. Implications for Policy, Delivery, or Practice: The model developed could be could be easily replicated to other insurers or providers to evaluate potential resources needed and to anticipate and plan for future needs. Primary Funding Source: No Funding ●Public Health Interventions and Years of Healthy Life Paula Diehr, Ph.D., Ann Derleth, Ph.D., Anne Newman, M.D., Liming Cai, Ph.D. Presented By: Paula Diehr, Ph.D., Professor, Biostatistics, University of Washington, Box 375232, Seattle, WA 98195-7232; Tel: 206-543-1044; Fax: 206-543-3286; Email: pdiehr@u.washington.edu Research Objective: Public health interventions can improve population health by improving health at baseline or by changing the probabilities of transition from one health state to another. Study Design: Based on transition probabilities estimated from three large datasets, we used multi-state life table methods to estimate the impact of eight types of interventions on longevity, years of healthy life, years of morbidity and lifetime medical expenditures. Population Studied: Results were calculated for a Birth cohort and for a cohort beginning at age 65 (called the Retiree cohort). Principal Findings: In the Retiree cohort, making everyone healthy at baseline would increase life expectancy by 0.23 years and increase years of healthy life by .54 years. An equal amount of improvement could be obtained with a 12% decrease in the probability of getting sick, a 16% increase in the probability that a sick person recovers, a 15% decrease in the probability that a sick person dies, or a 14% decrease in the probability that a healthy person dies. Interventions aimed at keeping people healthy increased longevity and years of healthy life, while decreasing morbidity and medical expenditures. Interventions focusing on lowering mortality would have a greater effect on longevity, but would increase morbidity and medical expenditures. Results were different in the two age cohorts. Conclusions: It is possible to improve survival without increasing morbidity, but not all interventions will achieve this compression of morbidity. The choice of intervention must depend on the health objectives,the population of interest, and the relative value of an additional year of sick life. Implications for Policy, Delivery, or Practice: Our findings suggest that providing a comprehensive health examination for older adults when they enter Medicare could increase survival and years of healthy life, and also decrease future medical expenditures. Primary Funding Source: NHLBI ●Healthy Business Building Program in Healthy City Development in Jing-An District of Shanghai Xiao-Cang Ding, M.M., Hui-Lian Cao, M.D. Presented By: Xiao-Cang Ding, M.M., Deputy Director, Bureau of Health, Jing-An District, Shanghai, 422 Jiang-Ning Road, Shanghai, China, Shanghai, 200041; Tel: 86-21-62717133; Fax: 86-21-62719375; Email: xcding@gmail.com Research Objective: To evaluate the Healthy Business Building Program in improving indoor environment and healthiness of office workers. Study Design: A systematic review was performed to compare a group of indicators before and after the implementation of the plan, including indoor air quality, drinking water and food safety, waste disposing, public space arrangement, sub-health, etc.. Only were some short-term measures examined and more measures will be assessed in the future. Population Studied: About 30,000 people working in business buildings in Jing-An District in 2005. Principal Findings: While Healthy City Program was applied in Jing-An District, Shanghai, China, business buildings used to be neglected and remained uncovered. However, as a Central Business District of 305,000 residents, there are up to 80,000 people working in more than 200 business buildings, where the concentrated people are too busy to pay attention to their daily health care. Thus, the government of Jing-An district has been working on a new program known as Healthy Business Building, in which 5 buildings were chosen in 2004 as first period trial, and 12 more buildings were added, in 2005, to perform an advanced trial. In the 17 buildings, a Health Promotion Committee consisting of CEOs, employees and security guards was established to have direct contact with the government, and works as an efficient feedback system. We started with the fundamental but critical improvements; improving air circulation is one of them. Reconstruction was conducted to provide more fresh air to the entire building. Central air conditioning systems were cleaned on a timely basis, and in 3 buildings the cleaning was even extended to the entire air ventilation system. Water tanks got professional clean-up twice a year. Lunch delivery service was standardized and 2 buildings were authorized to set up their own cooking canteen. Such changes have also been made to waste disposing, public space arrangement, indoor green space, etc. the office workers and white collars being at high risk of a state of sub-health, experts were sent to provide advice and lectures on self-care to improve their working experience. At the end of 2005 a survey was conducted to evaluate the program. An 8% increase of satisfaction rate and a remarkable 22% increase of rent-out rate were observed in 2 buildings, respectively, which shows a win-win situation between both the building owner and the clients. In the following year, the trial is broadened to 50 buildings, which is a 25% coverage of all the business buildings in Jing-An district. Updated with the new concept of priority health care service, we will try to meet the increasing multi-ply health care demand and higher expectations. Conclusions: Some short-term progress has been observed since 2004 in improving the indoor environments, sub-health state of office workers, as well as the economic outcome, of the business buildings involved. Implications for Policy, Delivery, or Practice: Using the Healthy Business Building progress to enhance indoor environments is important in Central Business District that has helped business buildings on economic development. Although some short-term improvement has been observed in Jing-An, more long term indicators are to be assessed to see whether the program is effective and sustainable in the longrun. Primary Funding Source: Jing-An District Bureau of Health, Shanghai, China ●Economic Impact in Rural Communities of National Health Service Corps Primary Care Providers. Martey Dodoo, Ph.D. Presented By: Martey Dodoo, Ph.D., Senior Economist, , The Robert Graham Center, 1350 Connecticut Av, N. W. Ste 201, Washington, DC 20036; Tel: 202-331-3360; Fax: 202-331-3374; Email: mdodoo@aafp.org Research Objective: To provide an assessment of the economic contribution of primary care providers in the NHSC to rural communities and show the extent to which State and regional economies would be affected if the NHSC were not funded. Study Design: A standard input-output social accounting framework was used to estimate the direct, indirect and induced economic impacts of NHSC personnel working in rural areas. First, the total number of direct health care jobs generated due to the presence of the NHSC providers was estimated, assuming that 4 support staff persons are needed per NHSC provider. Sensitivity of the model to changes in this assumption was tested. Second, the number of total staff and the total jobs generated by the NHSC presence was fed into the input-output model to derive the direct, indirect and induced impacts on economic output, value added and indirect business taxes, and the indirect and induced impacts on employment, in rural communities. Population Studied: NHSC personnel including physicians, dentists, physician assistants and nurse practitioners who provide health care services in rural communities throughout the US. Principal Findings: Most of the economic impacts of rural ambulatory health care services (84 percent) are from health care jobs (direct) or personal consumption by new workers (induced). Since the input-output model is linear, changes in the “Support Staff / Provider” ratio affect the impact results proportionately. There were 1,230 NHSC primary care providers in rural areas in 2005 and they generated additionally: (a) 3,920 health care support staff jobs. (b) 1,458 jobs related to providing medical materials and supplies; (c) 6,597 jobs to support the personal consumption of the above jobs. Nationwide, due to an output multiplier of 2.5, NHSC providers generated $1.4 billion worth of economic output and $49 million in indirect business taxes (tax multiplier = 12.4) in rural communities in 2005. Within these communities, each NHSC provider generated about $1.2 million per year as economic output and about $40,000 in business taxes. Conclusions: It is remarkable that in addition to the crucial health services NHSC providers contribute to the rural community, they also generate an extremely large economic output contributing immensely to the business and commercial life of these communities. Implications for Policy, Delivery, or Practice: This analysis shows that rural communities lose about $1.2 million of economic output and almost $40,000 of business taxes for each NHSC provider position that is not funded. This is also a measure of what communities that are not actively recruiting NHSC providers forgo. Primary Funding Source: No Funding ●Disparities in Hurricane Katrina Evacuation: Factors Impacting African Americans’ Evacuation Response Keith Elder, Ph.D., M.P.H., M.P.A., Sudha Xirasagar, MBBS, Ph.D., Whiejong Han, Ph.D., MA, Shelly Ann Bowen, DrPH(c), MS, Debeshi Maitra, M.H.A. Presented By: Keith Elder, Ph.D., M.P.H., M.P.A., Assistant Professor, Health Services Policy and Management, University of South Carolina Arnold School of Public Health, 800 Sumter Street, Health Sciences Building Room 116, Columbia, SC 29208; Tel: 803-777-5041; Fax: 803-777-1836; Email: kelder@gwm.sc.edu Research Objective: The United States' public health system is a key line of defense in emergencies such as infectious disease outbreaks and natural disasters. Public health's success critically depends on the public's willingness to cooperate and comply with mandates during emergencies. The public may be called upon to engage in difficult tasks such as evacuation and separation from family and friends until a crisis has subsided. "If a sizable group refuses to cooperate, that group could suffer greater mortality... and could jeopardize the success of the containment effort”.1 Disproportionately large numbers of those who refused to evacuate has been African American. This study aimed to identify the factors driving African Americans’ decision not to evacuate in the wake of government’s evacuation requests, using a theory-driven framework. Study Design: Six focus groups conducted within 2 months of Hurricane Katrina, to assess the psychosocial, financial, community network, civic, and communication factors in African Americans’ evacuation responses. Population Studied: Convenience sample of 50 African American evacuees from New Orleans who were relocated to Columbia, SC following Hurricane Katrina Principal Findings: Psychosocial functioning (riding out previous hurricanes, optimism of outcome, confidence, religious beliefs, and hurricane impact perceptions) were the most common themes among reasons for not evacuating. Financial factors (liquid resources/ready cash for travel), community network factors (racism in access to publicly provided transportation for evacuation, neighborhood crime/looting concerns) were also recurrent themes in the reasons for not evacuating. Implications of extended families (disabled and chronically ill older persons inhibiting evacuation, opinion of older adults) and historic governmentcitizen relationships (perceived racism, racial concordance of government officials and citizens, and communication skills) were also significant factors in not evacuating. Other community network factors (neighbors’ support, church leader support) were not predictors for not evacuating. Inadequate hazard information or public health warnings were not cited as reasons for not evacuating by any participant. There were no differences in responses by gender and age. Higher income participants and homeowners cited property related concerns for not evacuating, relative to low income and renter respondents. Conclusions: Participants’ decisions not to evacuate were driven mainly by their past experience in surviving hurricanes, inadequate resources to evacuate, historic and concurrent experience of racism, lack of communication of shelter information, evacuation planning by governmental officials, and religious beliefs (faith). Most participants were low income, low education, renters (rather than home-owners), and single older adults. Implications for Policy, Delivery, or Practice: Federal, state and local governments should emphasize in all disaster preparedness plans, the incorporation of culturally sensitive communication, resource allocation, and logistic planning for facilitating the evacuation of minority, low income, and underserved communities. Each state and local disaster preparedness plan should be based on findings from locally relevant, participatory research involving these groups. This is critical to prevent disproportionate mortality and impact among minority and disadvantaged Americans in future. Primary Funding Source: University of South Carolina Research Foundation ●Measuring the Quality of Life of Children Infected With HIV: Updated Results and Future Research Paul G. Farnham, Ph.D., Stephanie L. Sansom, Ph.D., M.P.P., M.P.H., Ken Dominguez, M.D., M.P.H., John Anderson, Ph.D., Mary Jo Earp, M.P.H. Presented By: Paul G. Farnham, Ph.D., Associate Professor, Economics, Georgia State University, 14 Marietta St., NW, Suite 531, Atlanta, GA 30303; Tel: (404) 651-2624; Fax: (404) 651-4985; Email: pfarnham@gsu.edu Research Objective: Analyses of the cost-effective use of health care resources require a comparison of the cost of preventing new cases of disease with the savings associated with dollars that would have been spent to treat the disease and the quality-adjusted life years (QALYs) gained from disease prevention. Both treatment costs and QALYS have changed significantly since the mid-1990s for all individuals infected with human immunodeficiency virus (HIV), given the availability of highly-active antiretroviral therapy (HAART). Although there has been much research on treatment costs and QALYs for adults, the literature on costs and QALYs for perinatally HIV-infected children is sparse. Moreover, measuring quality of life among children with any disease and assigning utility weights to life years involves a unique set of methodological problems. The goal of this research is to develop updated estimates of QALYs for HIV-infected children that better measure disease state and to outline the research questions that still need to be addressed to adequately measure quality of life for this population. Study Design: From surveys of several large electronic data bases, including AIDSLINE, Medline, and PsycINFO, we reviewed the medical and economic literature measuring QALYs for childhood diseases with a particular emphasis on HIV infection. Using data from the Pediatric Spectrum of Disease (PSD) study for 1,900 perinatally HIV-infected children in 2001, we stratified participants into 5 age groups and assessed the proportion of children with an HIV classification of N (no symptoms), A or B (symptomatic), C (severe symptoms) using two approaches—the traditional worst-ever lifetime clinical classification and a newer approach focusing on the worst clinical classification during the previous 12 months. Drawing on the published adult literature, we assigned a utility weight to each clinical classification and computed an overall utility weight for each age. We then determined expected QALYs under both disease state classifications using a 3% discount rate and an assumed life expectancy of 15 years. Finally, we compared this methodology with the standards existing for other childhood diseases. Population Studied: The PSD study, funded by the Centers for Disease Control and Prevention (CDC) from 1988 through 2004, collected longitudinal medical record data, from time of HIV exposure or diagnosis until death, on children and young adults who were infected with HIV prior to 13 years of age in 6 U.S. sites. PSD sites included the District of Columbia, Los Angeles County, Massachusetts, New York City, Puerto Rico, and Texas. Enrollment in 2001 included an estimated 21% of all living perinatally HIV-infected individuals in the U.S. Principal Findings: Under the newer approach to measuring disease state, the utility-adjusted weight for children in the PSD sample was 88.50 for the first year of life, compared with 88.25 under the traditional approach; it was 89.25 and 82.70 for years 1 through 4 under the newer and traditional approaches, respectively; 89.78 and 79.96, for years 5 – 9; 89.32 and 79.83 for years 10 – 15; and 88.36 and 78.57 for years 15 and older. Assuming a life expectancy of 15 years, QALYs under the newer approach totaled 10.99, 10% higher than the 9.98 generated by the traditional approach. The literature review indicated that studies using utility weights derived from adult surveys are unable to address issues specific to children, including how children of different ages perceive their health status and quality of life, children’s potential inability to consistently judge the future consequences of their actions and, thus, to understand or respond to valid utility assessment instruments, and the effect of children’s dependency on others, which may influence the scope of the analysis. Conclusions: Assessing utility in perinatally HIV-infected children associated with their most recent disease clinical classification increases their expected lifetime QALYs, holding years of survival constant, because this approach reflects advances in HIV treatment efficacy and the improved clinical status of those infected. This change in measuring disease state, which is most important in the post-HAART era, has been recommended by quality of life researchers who applied the Child Health Questionnaire (CHQ) to a sample of HIVinfected children. However, all current research on quality of life in HIV-infected children is limited by the use of adult utility weights. Implications for Policy, Delivery, or Practice: We can no longer assume that quality of life simply decreases over time for perinatally HIV-infected children in the post-HAART era. The approach used here of measuring disease state with the most recent disease clinical classification provides a more realistic estimate against which to assess the costs and benefits of perinatal HIV prevention and treatment. Much more research is needed, however, to adequately value the utilities associated with these different disease states. Primary Funding Source: CDC ●Developing an Action Plan to Improve the Quality and the Quantity of Data about Paralysis Michael H. Fox, Sc.D., Jennifer Rowland, Ph.D., M.P.H, P.T, Katherine Grobe, Ph.D., Dee Vernberg, Ph.D., Glen White, Ph.D. Presented By: Michael H. Fox, Sc.D., Associate Professor and Interim Chair, Health Policy & Management, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160; Tel: (913)588-2687; Fax: (913)588-3762; Email: mfox2@kumc.edu Research Objective: 1. Investigate ways in which paralysis are currently being measured in this country; 2. Examine the validity of prevalence and incidence estimates based on these approaches; and 3. Identify promising measurement reporting systems. Study Design: There were three major components to the investigative research: 1. Review existing national, state, and organization surveys to examine questions related to paralysis that could be used to estimate the number of persons with this condition; 2. Survey state and federal agencies and organizations representing persons with disabilities related to paralysis to assess their surveillance capacities; 3. Follow up survey findings with more in-depth discussions with, or site visits of, potential ‘best practice sites’ to determine more accurately the nature of elements in data systems or organizational structures that could lend themselves to collecting more reliable paralysis estimates. Population Studied: Our population studied were state and federal agencies in which paralysis data are being used, as well as private organizations and foundations whose work included persons with paralysis Principal Findings: Survey Results: Completed interviews were obtained from 56 state and federal agencies and 83 condition-specific organizations for two separate but similar survey instruments. Federal and State Results • 30/56 (54%) of state and federal agencies intervewed collect paralysis information. • 22/30 (73%) of federal and state agencies collecting paralysis information report collecting ICD clinical diagnosis codes, with others reporting External (E)-codes, research intake forms, state registry information, and special surveys. Organization Results • 14/83 (17%) of organizations interviewed collect some form of paralysis information. • 14/14 (100%) of organizations collecting paralysis information report collecting some form of state registry information, with some also collecting ICD codes, information from people seeking services, research intake forms, and special surveys. • 8/14 (57%) of organizations collecting paralysis information considered their primary mission to provide services or information to individuals seeking assistance; the remaining 6/14 (43%) considered themselves research institutions. • When asked to rate the importance of collecting information for their agency or organization: 43% (13/30) state and federal agencies and 64% (9/14) of organizations rated paralysis as important information to collect. Conclusions: Two primary types of data are being collected at the national and state levels regarding paralysis: (1) diagnostic and (2) functional limitation. Because data specific to paralysis are not currently available through existing surveillance, our recommendations focus on future ways to collect this information. A major target of the Healthy People 2010 initiative is to improve surveillance of people with disabilities. Our work supports this Healthy People 2010 initiative and addresses ways these data could be used to change polices and to improve services for people with disabilities who are affected by conditions associated with paralysis. Implications for Policy, Delivery, or Practice: Specific recommendations: 1.Develop a uniform definition of paralysis that captures the breadth of possible ways that paralysis can manifest itself. As part of initial efforts to explore this issue on the national level, researchers need to develop a definition of paralysis that includes all people who experience functional limitation and resulting decreased social participation. 2. Develop paralysis survey questions on ways that people with paralysis are limited functionally. This paradigm shift parallels recent changes by the World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF), adopted in 2001, to replace the International Classification of Impairment, Disability and Handicap (ICIDH) system that focused on diagnosis from a deficit perspective. Working among states, the validity and usefulness of these data for informing policy and enhancing existing services can also be tested. 3. Provide incentives to encourage organizations representing persons with conditions where paralysis exists, such as the MS Society and the ALS Foundation, to add items to an ongoing data collection system to collect more detailed information on severity or nature of the condition. 4. Improve future data collection efforts by working more closely with participating states that have data-driven public policy capacities in place (e.g., Minnesota, South Carolina, Ohio, Alaska, Colorado, etc.). The goal is to support the development of demonstration programs through grants or contracts to build capacity for ongoing state paralysis surveillance independent of state surveys or registries. 5. Further involve consumers in the process of data use to translate improved surveillance information into practice. A national advisory group comprised exclusively of persons with paralysis should be convened to help interpret improved surveillance information to ensure that these data are used to benefit people who have been diagnosed with conditions associated with paralysis. Primary Funding Source: The Christopher Reeve Foundation ●The Employment Effect of Antidepressant Use for Women living with HIV in the United States: Evidence from the Women's Interagency HIV Study (WIHS), 19952004 Omar Galarraga, Ph.D. Candidate, David Salkever, Ph.D., Stephen Gange, Ph.D., Judith Cook, Ph.D., Alvaro Munoz, Ph.D. Presented By: Omar Galarraga, Ph. D. Candidate, Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 326, Baltimore, MD 21205; Tel: 410-366-2759; Email: ogalarra@jhsph.edu Research Objective: Since the mid-1990s highly active antiretroviral treatment (HAART) has extended the lives, and the ability to work for individuals living with HIV in the United States. During the same period, antidepressants have become some of the most widely prescribed drugs. Employment of persons living with HIV depends on several factors including physical and mental health status, as well as local area labor market characteristics. This paper tries to measure the effect of antidepressant use on the employment probability of women living with HIV. Study Design: The methodological challenge is that more depressed persons are more likely to receive treatment, but they are also more likely to be unemployed. This paper uses the econometric method of instrumental variables to identify the treatment effect of antidepressants on employment. The main instrument is a measure of the generosity of the Medicaid program at the State level in terms of coverage of a particular class of antidepressants: selective serotonin reuptake inhibitors (SSRIs). The instrument helps to predict treatment choice independently of individual-level confounders, and thus reduce the bias in estimation. The paper hypothesizes two channels for depression treatment to affect the labor market outcomes of persons living with HIV. First, a direct channel by which antidepressants may reduce depression symptoms and thus may improve the likelihood of being employed. Second, an indirect channel by which antidepressants may improve adherence to HAART regime, improving physical health, and then lead to better employment outcomes. Population Studied: This paper investigates the effect of antidepressants on the employment probability, using data from the Women’s Interagency HIV Study (WIHS). Started in 1995, the WIHS is a prospective cohort of 3,768 participants to comprehensively study the effects of HIV on women. About 80 percent of the participants are from racial minority groups in Bronx and Brooklyn (New York), Chicago (Illinois), Los Angeles and San Francisco (California), and Washington, D.C. Principal Findings: The empirical results from linear, nonlinear, and auto-regressive models (under fixed and random effects assumptions) suggest that antidepressants may have a positive effect on the employment probability for the women’s sample. Conditional on receiving HAART, and controlling for individual and local area labor market characteristics, women who use antidepressants may have at least a sevenpercentage-point higher probability of being employed than women who do not use antidepressants. Conclusions: The temporal and geographical variation in the generosity of the State Medicaid reimbursements for mental health treatment can serve to help identify antidepression treatment in a population with high Medicaid coverage. Conditional on receiving HIV treatment, access and use of antidepression treatment in this population of low socioeconomic status minority women seems to improve the likelihood of employment. Implications for Policy, Delivery, or Practice: The findings suggest that increasing efforts to improve screening, diagnosis, and treatment of depression in specific high-risk groups may be warranted not only for the physical and mental health benefits, but also as an avenue to increase employment. Furthermore, since the majority of the HIV care is financed by public funds, sustained and continued access to depression treatment through the Medicaid and Ryan White CARE Act formularies may potentially improve labor market outcomes of persons living with HIV. Primary Funding Source: National Institute of Mental Health (NIMH) ●Network Structure and Attitudes Toward Collaboration in a Community Partnership for Diabetes Control in the Border Southwest Jennel Harvey, MHSA, Keith Provan, Ph.D., Jill Guernsey de Zapien, Ph.D. Presented By: Jennel Harvey, MHSA, Graduate Teaching Associate/Ph.D Candidate, Public Administration and Policy, University of Arizona, 1130 E Helen, McClelland Hall 405, Tucson, AZ 85721; Tel: 520-626-3290/ 615-9671; Fax: 520-6265549; Email: jharvey@email.arizona.edu Research Objective: This study provides an empirical examination of collaborative efforts among 15 diverse nonprofit and public entities directed to reducing chronic disease in one community along the US-Mexican border and thereby, demonstrates how network analysis methods may be used to help communities build capacity. Study Design: Network analysis methods were used to analyze data on network structure and to help explain how involvement of agencies in the network (embeddedness) related to the attitudes of network members regarding trust, reputation and the perceived benefit of belonging to and participating in the network. Population Studied: Nonprofit and public organizations Principal Findings: Findings revealed that network members’ perceptions of network activity were not commensurate with actual activity. Large discrepancies were found when comparing unconfirmed and confirmed reports of relationships among organizations. In addition, organizations with a large number of direct, indirect and multiple ties to other organizations within the network (embeddedness) were seen by other network members as being trustworthy, had strong reputations (as seen by other network members) and had high expectations of the perceived benefit of participation in the network. Network involvement was most strongly related to organizational reputation. Agencies with strong reputations had a large number of direct connections to other network members and were able to act as “intermediaries,” bridging connections for unconnected network members. Conclusions: Systematic analysis is useful for highlighting and resolving relationship discrepancies. Network building is slow despite active efforts to collaborate. Network development may best be facilitated by initiating collaborations with agencies that have strong reputations. Implications for Policy, Delivery, or Practice: Broad based coalitions of organizations are better able to address community-level problems such as public health. Understanding how to structure, measure and assess the outcomes of collaborative efforts is essential for community leaders wishing to build community capacity through collaboration. Primary Funding Source: CDC ●The Impact of Droughts on Food Consumption and the Mitigating Effects of a Conditional Cash Transfer Program – Evidence from Rural Mexico Xiaohui Hou, MS, M.H.P.A. Presented By: Xiaohui Hou, MS, M.H.P.A., Health Services and Policy Analysis, University of California, Berkeley, 5446 Newcastle Ave, Apt109, Encino, CA 91316; Tel: 818-881-8714; Email: xhou@berkeley.edu Research Objective: (1) To evaluate the impact of droughts on food consumption in rural Mexico. (2) To evaluate whether Progresa, a conditional cash transfer program in Mexico can mitigate the impact of droughts on food consumption. Study Design: The research design proposed for this study employs three main sources of variations for identification. First, exogenous variation introduced by the random assignment of households to treatment and control communities to identify the effect of the program on food consumption. Second, exogenous natural shocks (droughts) can be used to identify the effects of shocks on food consumption. Third, I developed potential amount of transfers households could receive as an instrument variable. I utilize the variation in the amount of potential transfers as an instrument for actual transfers to estimate the differential effects of varying amount of transfers on mitigating the effect of shocks on food consumption. Using panel data from the Progresa experience I implement the first difference model with and without community fixed effect to estimate the impact of shocks on food consumption and to what degree Progresa can mitigate such effects. Population Studied: Three rounds of household panel data were used. 3277 households are from the control groups and 5149 households are from the treatment group. Principal Findings: Self-reported droughts reduces the calorie availability from vegetables and fruits by 6%, reduced calorie availability from animal products by 5%, and reduce calories from other sources by 3%, but increase calories from grains by 9%. PROGRESA can completely mitigate the effects of droughts on calories from vegetables and fruits, animal products and other sources, but not on calories from grains. The analysis on purchased calories and calories from homeproduction shows that the increased consumption from grains are mainly from purchased sources rather than homeproduction, which suggests that gains are an inferior goods for rural Mexican population. The Engel curve analysis further provides evidence that grains are inferior goods in rural Mexico. Conclusions: Exploiting panel data of a randomized experiment from the Mexican PROGRESA program, I have shown that droughts have a significant impact on the composition of calories available to households. PROGRESA can mitigate the impact of droughts on calorie availability from vegetables and fruits, from animal products, and from other sources, but not from grains. Using potential transfers as an instrument for actual transfers to estimate the pure transfer effects shows the similar results. Implications for Policy, Delivery, or Practice: PROGRESA, as a conditional cash transfer program, should strengthen the educational components on the importance of a balanced diet and nutritional intake. Primary Funding Source: UC MEXUS Dissertation Grant ●Water Fluoridation: Survey Design and Information Effect on the Public's Attitudes Minah Kang Kim, Ph.D., Yong Jun, Choi, Ph.D., M.D., Young Jeon, Shin, Ph.D., M.D., Dool Soon, Kim, M.A. Presented By: Minah Kang Kim, Ph.D., Assistant professor, Public Administration, Ewha Womans University, Daehyun Dong, Seodaemun-Gu, Seoul; Tel: 8210-6261-4725; Fax: 8223277-4100; Email: minahkang@ewha.ac.kr Research Objective: In many countries and in Korea as well, there has been an ongoing debate on the safety of the water fluoridation and whether fluoridation should be an individual choice. In Korea, public opinion surveys in each community are required by law for a decision making on the implementation of the water fluoridation program. However, when the public do not have sufficient knowledge of, or are not much interested in the subject, their responses to the survey may not be valid due-to the ‘non-attitude’ problem. This study aimed to understand, 1) the public’ knowledge level of the subject and 2) the way of information provision in the survey and other various survey methods, affects the people’s attitudes toward the implementation of the water fluoridation program. Study Design: Both qualitative and quantitative methods were used in this study. As a qualitative methodology, we conducted 3 focus groups in 3 regions with 7~ 8 people per group to find out their knowledge level on the subject and how they form their attitudes in a group setting. As a quantitative methodology, we conducted an opinion survey with questions on their knowledge of the subject and their attitudes toward water fluoridation. In order to understand the impact of various survey designs, we conducted the survey in 6 different experimental groups, by the content and order of information provided on water fluoridation (negative vs. positive), survey methods (face-to-face vs. telephone) and residence setting (urban vs. rural). An age-stratified random sampling (telephone survey) and a systematic random sampling was used (face-to-face survey). Population Studied: For focus groups, there were a total of 22 residents from 3 regions, two from a large city and one from a rural area. One group was consisted of people between 20~30 years old with middle income, the second group with people between 40~50 years old with middleincome and the third group with people between 40~50 years old with low income. A total of 1,200 people responded to the survey. About 48% of the respondents were male. About 34% were college graduate or had graduate level education. Principal Findings: We found that about half of the respondents were not knowledgeable on the water fluoridation program (53.3%) and its purpose (57.2%). Overall, 49.4% of the respondents agreed on implementation of the program in their community. 32.2% disagreed and 18.8% said ‘don’t know.’ Safety issue on fluoride was the most important reason (61%) for the disagreement, while individual choice was not as much important (16.3%). Their attitudes toward the water fluoridation were significantly affected by the knowledge level as well as the order and content of the information provided in the survey processes. Also, respondents’ attitudes were different between the face-to-face survey and the phone survey methods. We also found the respondents’ attitudes varied by income and education. Their demand for accurate and balanced information on the safety and effectiveness of the program was strong. The respondents to our survey reported that they most preferred decisions made by public opinion survey or ballot. The focus group discussion produced similar results although it seems that the participants' attitudes seemed to be affected by dominant people in the group discussion. Conclusions: Overall, we found that the public had a strong desire to take an active role in the policy decision making process on water fluoridation programs. However, we also found that they had a low level of knowledge on the subject and the results could be influenced by the content and order of the information provided in the survey as well as interview methods. Implications for Policy, Delivery, or Practice: All together, these results emphasized the importance of a standardized public opinion survey tool for a community to use the results for the decision-making on water fluoridation program. In addition, these findings will be informative for a current discussion on the revision of legislature regarding the water fluoridation program. Also, findings of this study are useful to understand the role of the public in the decision making on various public health issues. Primary Funding Source: Korean Ministry of Health and Welfare ●2005 National Profile of Local Health Departments Carolyn Leep, M.S., M.P.H., Carol K. Brown, M.S., Elaine O'Keefe, M.S.P.H. Presented By: Carolyn Leep, M.S. M.P.H., Program Manager, NACCHO, 1100 - 17th St. NW; Second Floor, Washington, DC 20036; Tel: (202) 783-5550; Fax: (202) 783-1583; Email: cleep@naccho.org Research Objective: To describe local public health departments in the U.S. in terms of governance, financing, workforce, activities/programs, collaboration, and information technology. Study Design: The 2005 National Profile of Local Health Departments was administered as a web-based questionnaire to every local public health department in the U.S (n=2865). A core set of questions was included in each questionnaire. In addition, a random sample of health departments, stratified by population served, received one of three modules (n=550 for each module). Questionnaires were first distributed in June 2005; data collection closed in November 2005. Population Studied: The study included every local public health department in the U.S., defined as an administrative or service unit of local or state government concerned with health, and carrying some responsibility for the health of a jurisdiction smaller than the state. Principal Findings: The National Profile included questions on governance, financing, workforce, activities/programs, collaboration, and information technology. 2298 local health departments completed the Profile questionnaire (response rate = 80.2%). Highlights of the findings of the 2005 National Profile, including comparisons with prior National Profiles, will be presented. Conclusions: The National Profile is the only national, comprehensive source of data on all local health departments. The study offers insight into the degree and nature of variation among local health department structure and operations. Implications for Policy, Delivery, or Practice: Much has changed in public health practice since the last survey of all U.S. local health departments (conducted in 1996). An obvious example is the increased funding and activities of local health departments related to emergency preparedness for threats ranging from bioterrorism to pandemic flu. It is important to understand how these changes have affected the financing, workforce, and activities of local health departments. The 2005 National Profile data will provide an up-to-date picture of local health departments in the U.S. and will permit comparisons among various types of health departments (in terms of governance, population served, demographics, and state) to identify differences in capacity and services provided. This will support more informed policy-making to improve the nation’s public health system. Furthermore, the 2005 Profile data will be a critical data set for public health researchers exploring specific hypotheses related to these characteristics of local health departments. Primary Funding Source: CDC ●Assessing State Immunization Requirements for Healthcare Workers and Patients Megan Lindley, M.P.H., Abigail Shefer, M.D., Gail Horlick, M.S.W., J.D., Margaret Clemens, J.D., Frederic Shaw, M.D., J.D., Ray Strikas, M.D. Presented By: Megan Lindley, M.P.H., ORISE Research Fellow, National Immunization Program, Centers for Disease Control & Prevention, 1600 Clifton Road N.E., Mailstop E-52, Atlanta, GA 30333; Tel: 404-639-8717; Fax: 404-639-8614; Email: MLindley@cdc.gov Research Objective: To determine the status of laws, regulations, and other legal requirements relating to immunization for patients and healthcare workers (HCWs) in healthcare settings, and other specified settings in which healthcare is provided. Study Design: From September 2004 to June 2005, the Centers for Disease Control and Prevention (CDC) Public Health Law Program collected state-specific laws and regulations from all 50 states and Washington, D.C. (“states”) using Lexis-Nexis and public web-based databases of state statutes and regulations. Data were obtained on immunization requirements for hospitals, ambulatory care facilities, individual providers’ patients, correctional facilities and facilities for the developmentally disabled. We examined assessment requirements (assessment of immunization status or screening for disease), administration requirements (offering, providing or arranging for vaccination), and medical, religious and philosophical exemptions to such requirements. Legal counsel from each state were given the opportunity to comment on the accuracy, completeness, and interpretation of study findings. Population Studied: The United States including the District of Columbia, N=51. Principal Findings: Only 2 of 51 states have any assessment requirements pertaining to HCWs. Assessment requirements for patients are more common, with 25 states requiring assessment of individual providers’ patients; 20, of residents in facilities for the developmentally disabled; 15, of inmates or residents in correctional facilities; and 9, of patients in ambulatory care facilities. Most legal requirements for administration of vaccines to hospital staff concern hepatitis B vaccination (17 states); only 4 states have laws pertaining to influenza vaccination of hospital staff. Only 3 of 51 states have laws on influenza or pneumococcal vaccination of hospital inpatients. Twenty-four of 51 states have laws regarding vaccination of HCWs in ambulatory care facilities; 7 regarding patients in ambulatory care facilities; 19 regarding residents in correctional facilities; and 40 regarding residents in facilities for the developmentally disabled. The majority of “ensure” laws (vaccination required unless an exemption is specified or patient refuses) are for residents in correctional facilities and facilities for the developmentally disabled, while laws for HCWs and patients in healthcare facilities are largely “offer” laws (vaccination available, but not mandatory). Of the 44 states with “ensure” laws, 33 provide exemptions in at least one setting, with 30 providing medical exemptions, 20 providing religious exemptions, and 6 providing philosophical exemptions. Research challenges included varying definitions of facilities in different states, and interpretation of statutory language. Conclusions: Vaccination laws vary widely by state in terms of which diseases and individuals are addressed. Further research on the impact of state laws should focus on awareness and enforcement of existing vaccination laws. Implications for Policy, Delivery, or Practice: Laws requiring immunizations for school entry have been shown to improve vaccination coverage in elementary and middle schools and colleges. Research suggests that vaccination of HCWs and patients can improve patient outcomes. Our results provide an overview of immunization laws for selected healthcare settings in the United States, and highlight wide state-by-state variation. This may serve as a starting point for the development of model legislation to create uniform immunization requirements among states. Primary Funding Source: CDC ●The Role of School-Based Health Centers in Meeting Children's Needs Following Hurricane Katrina Paula Madrid, Psy.D., Roy Grant, MA, Gregory A. Thomas, MS, Maureen Daly, M.D., M.P.H., Lynn Seim, M.S.N., Irwin Redlener, M.D. Presented By: Paula Madrid, Psy.D., Director, The Resiliency Program, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032; Tel: 212-342-5161; Email: pam2109@columbia.edu Research Objective: School-based health centers (SBHCs) are an increasingly important health access point for medically underserved children, now serving 2 million children in 44 states. Nationally, 66% are sponsored by hospitals, health centers, and local departments of health, potentially integrating SBHCs into community public health infrastructures. The role SBHCs may play in emergencies – natural disasters or terrorist attacks – has not been well elucidated. Studies of school nurses found a need for more training and preparation for emergencies including bioterrorism. Louisiana has a large school-based health center network, with 56 sites and about 47,000 enrolled students. Following Hurricane Katrina, 372,000 school children from Louisiana and Mississippi were displaced. More than 700 schools were closed; many were destroyed. In this context, medical and mental health professionals from The Children’s Health Fund and National Center for Disaster Preparedness became involved in the delivery of medical and mental health services, and public health assessment and planning in Louisiana and Mississippi. To put our resources to best use, we met with local health, mental health and education officials to determine their priorities for direct service and training/technical assistance. Study Design: Within two weeks of the hurricane, we held a focus group in Lafayette Louisiana which was co-led by a physician, a psychologist, and a school safety specialist who had assisted in the evacuation of NYC schools on 9/11/01. Responses to our open-ended questions were recorded in writing and subsequently analyzed for trends. Population Studied: The focus group was comprised of 32 representatives including health providers and administrators from 24 of Louisiana’s SBHCs. Most were from sites distant from the hurricane-impacted area and were caring for evacuees from Louisiana, Mississippi, and Alabama. Principal Findings: The most powerful theme was the need to “help the helpers” – supporting professionals and volunteers caring for families affected by a disaster. Also emphasized was the need for training in identification and intervention for psychological trauma. Participants voiced concern about protecting confidentiality and arranging consent for services when providing care to children separated from their parents. There was discussion about how school health personnel can most effectively help teachers. Access to specialty care when serious health care needs were identified was highlighted as a pre-existing problem. The affected communities had been inadequately served for health care before Hurricane Katrina, which complicated absorbing new service needs. One city grew in population from 21,000 to 24,000 in under a week; one school enrolled 143 new students in 4 days. Participants were especially concerned about the problems that would arise if necessary service expansions that took place following Katrina are not sustained over time. They requested training in fund raising and advocacy. Conclusions: School-based health centers can be an important element of public health preparedness following a disaster. Staffs require sufficient resources and support. Training is needed on trauma and grief counseling, and emergency preparedness. Implications for Policy, Delivery, or Practice: An adequate baseline public health and mental health infrastructure is an essential component of disaster preparedness. Planning for post-disaster interventions should include the means to sustain new services as medical and psychological needs following a traumatic event emerge over time. Primary Funding Source: United Health Foundation, Others ●Effect of Training on Self-efficacy and Performance Post Hurricane Katrina Lisa McCormick, M.P.H., Maziar Abdolrasulnia, M.P.H., M.B.A., Lisle Hites, Andrew Rucks, Ph.D., Peter M. Ginter, Ph.D. Presented By: Lisa McCormick, M.P.H., Program Director, South Central Center for Public Health Preparedeness, University of Alabama at Birmingham, 1665 University Blvd. Room 330N, Birmingham, AL 35294-0022; Tel: 205-975-8971; Fax: 205-934-3347; Email: lmccormick@ms.soph.uab.edu Research Objective: As a result of Hurricanes Katrina and Rita, there is a unique opportunity to explore the relationship between public health professionals’ training and their disaster response roles. Reports from the affected states suggest that public health professionals are often expected to fill response roles unrelated to their job duties. Accordingly, this study has three major objectives. The first objective is to examine the effects of preparedness training on the public health workforce’s perceptions regarding the effectiveness of their response to the recent hurricanes. The second objective is to examine differences between an individual’s job role and response role and to further examine any complications that arise from these differences. Finally, the study seeks to identify training needs, barriers and gaps related to preparing for and responding to such events. Study Design: The South Central Center for Public Health Preparedness developed a survey consisting of 33 questions targeting perceived self-efficacy and performance for the public health response to Hurricane Katrina. This survey collects data that includes personal and organizational response roles, confidence in performing response tasks, level of training in preparedness and response to natural and human initiated disasters, barriers to effective response, and additionally collects demographic information from the respondents. Based on past research into the relationship between self-efficacy and performance, there is theoretical support to expect that public health responders who participate in a wide breadth of preparedness training will have increased self-efficacy for responding to disasters. Heightened self-efficacy should result in a corresponding increase in perceived abilities to perform. Although past studies have looked at these relationships in business environments, the current study seeks to establish this relationship for public health emergency responders operating during a catastrophic event. Prior to statewide distribution, the survey was pilot tested with state and local public health officials and reviewed by an expert panel of researchers from the University of Alabama at Birmingham, Tulane University, and the South Central Center for Public Health Preparedness for validity and reliability. For statewide distribution, the survey was sent to the state health departments in Mississippi and Alabama and subsequently administered electronically to the public health workforce in these states. Population Studied: The survey was distributed to state and local public health professionals in Alabama and Mississippi using the internal online distribution systems of the states. Approximately 2,000 individuals were contacted to voluntarily complete the 15-20 minute survey. Principal Findings: Data collection is ongoing and expected to be complete by March, 2006. Conclusions: We expect to find a strong, positive relationship between those who have participated in preparedness training and perceived levels of self-efficacy and performance in responding to the recent disasters. Implications for Policy, Delivery, or Practice: The data gathered will be used by the state governments of Mississippi and Alabama as well as by the CDC and the South Central Center for Public Health Preparedness to better understand the types of training necessary to equip public health professionals with skills needed to fulfill disaster response roles that might arise as a result of natural disaster. Primary Funding Source: CDC ●A Method for Assessing Changes in State Public Health Laws: What has been the impact of the Model State Public Health Act? Benjamin Meier, JD, LLM, Kristine Gebbie, DrPH, RN Presented By: Benjamin Meier, JD, LLM, Study Coordinator, School of Nursing, Columbia University, Center for Health Policy, 617 W. 168th Street, New York, NY 10032; Tel: (212) 305-0047; Fax: (212) 305-3659; Email: bmm2102@columbia.edu Research Objective: This study pilots a method to document the reform of state public health laws and programs pursuant to the Turning Point Model State Public Health Act. Study Design: The Turning Point Act, published in September 2003, provides a comprehensive template for states interested in public health law reform and modernization. This project focuses on documenting short-term reform of state law subsequent to the Turning Point Act by examining the effect of these legal amendments on public health regulations and programs. The methodology consists of semi-structured key informant interviews to explore 1. the role of the informant in the legal/regulatory changes; 2. the public health problems addressed by the changes; 3. the obstacles to changes in state law and the strategies used to overcome these obstacles; 4. subsequent changes in public health regulation, organization or programs; and 5. the expected changes in health outcomes. Population Studied: Case studies will be undertaken in up to six states that have reformed their public health laws subsequent to the Turning Point Act, including three of the five states--AK, CO, NE, OR, and WI--that participated in the Turning Point Public Health Statute Modernization Collaborative that produced the Turning Point Act. Key informants in each state will be identified from among public health officials, legislators or legislative staff, executive policy staff, and representatives of health-related advocacy or lobbying groups. They will be identified based upon their documented participation in the reform process. Principal Findings: This project will examine the specific content of the legal revisions accepted or rejected, the bases on which bills or resolutions adopt or deviate from Turning Point Act provisions, and the subsequent programmatic and regulatory changes in state laws. Findings are expected to include an identification of key policy participants, areas of policy contention, and processes through which obstacles to reform were overcome. Findings will serve as a companion in tracking legislative and regulatory changes in public health law and making such information available to the public health community, policy-makers and scholars on an ongoing basis. Conclusions: Conclusions based upon these in-depth informant interviews will produce key information on the impacts of legal reforms on improvements to public health preparedness and other communal goals, creating a framework for future, more complex and longer range studies and providing a model for ongoing data collection and analysis of the relationship between legal changes and health outcomes. Implications for Policy, Delivery, or Practice: This project will serve to inform policy-makers and public health officials of the ways in which the Turning Point Act can be used to frame reform of state, local, territorial, or tribal public health laws. The project is specifically designed to address a major information gap regarding public health laws, their reform, and subsequent changes in public health regulations, organizations, or programs. These gaps have significantly limited the amount and quality of public health systems research that could be conducted, and thus inform public health law and practice. This project should provide public health practitioners, policy-makers, and scholars improved resources to support their efforts. Primary Funding Source: RWJF ●A Balance Between Smaller and Larger Clinical Safety Databases Prior to Regulatory Approval Shelby Reed, Ph.D., Kevin J. Anstrom, Ph.D., Damon Seils, MA, Robert M. Califf, M.D., Kevin A. Schulman, M.D. Presented By: Shelby Reed, Ph.D., Assistant Research Professor, Center for Clinical and Genetic Economics, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715; Tel: (919) 668-8991; Fax: (919) 668-7124; Email: shelby.reed@duke.edu Research Objective: We sought to determine the expected incremental number of adverse drug events that could be prevented in a postapproval patient population resulting from a hypothetical regulatory mandate that would require larger versus smaller clinical safety databases for regulatory approval of new drugs. Study Design: Using a Microsoft Excel-based model, we calculated expected incremental gains from requiring larger safety databases compared to smaller databases in terms of the incremental number of adverse drug events (ADEs) that could be prevented in a drug’s target population. Although the model was hypothetical, assumptions about sample size, the background incidence of the event and the magnitude of the increased risk of the adverse event were based on cardiovascular and cerebrovascular events observed in trials of cyclooxygenase-2 inhibitors. In the base-case analysis, we assumed that data on 2000 and 4000 patients per treatment group would be available for the smaller and larger safety databases, respectively. The background annual incidence of the adverse event was 0.5% and the drug was assumed to increase the odds of the event by 2.5. We also evaluated the potential cost-effectiveness of requiring data on larger versus smaller numbers of patients in pre-approval safety databases. For this analysis, we assumed a case-fatality rate of 15% and an estimate of $10 000 per patient for additional clinical testing. Population Studied: Hypothetical cohorts of patients enrolled in pre-approval clinical trials and hypothetical target patient populations. Principal Findings: Assuming that 10 million patients would receive treatment with the drug, if approved, approximately 75 000 adverse drug events would be expected to occur in the target population. If detection of the adverse events would have prevented regulatory approval, 72 000 adverse events would have been prevented with the larger database, on average, compared to 57 000 with the smaller database, a gain of approximately 15 000 adverse events prevented. Sensitivity analyses showed that gains in ADEs prevented with larger safety databases reached a maximum point of efficiency. When holding constant the background annual risk of the event and the odds ratio, there were decreasing returns to scale from requiring additional patients in preapproval safety databases. When holding constant the number of patients and the background risk, as the odds ratio increased, the total number of expected ADEs increased in the postapproval population. However, the incremental gain in averted ADEs with the larger database peaked and then converged to the point at which there was little gain with the larger database. Similar findings were revealed when the background risk of the event was varied. Results of the cost-effectiveness analysis showed that the incremental cost-effectiveness ratio was approximately $17 800 per life saved in the postapproval patient population when the sample size of safety databases increased from 2000 to 4000 patients per treatment. Conclusions: Requiring larger databases can offer a costeffective means of preventing serious ADEs in a drug’s target patient population, under certain circumstances. Implications for Policy, Delivery, or Practice: Drug safety needs to be carefully considered from an epidemiologic perspective at a public policy level. Our framework would be a useful means to contribute to this assessment. Primary Funding Source: No Funding ●Resources for Public Health Systems Research Douglas Scutchfield, M.D., Michelyn Wilson Bhandari, DrPH, M.P.H., Allison Amrhein, M.P.H. Presented By: Douglas Scutchfield, M.D., Peter P Bosomworth Professor of Health Services Research and Policy, College of Public Health, University of Kentucky, 121 Washington Ave., Lexington, KY 45036; Tel: (859) 257-5678; Email: scutch@uky.edu Research Objective: Public health systems research (PHSR) has been hampered by the lack of a systematic resource that responds to the information needs of researchers in this developing field. Therefore, it would seem useful to apply the lessons learned from Health Services Research (HSR) to PHSR. One of those lessons is making available to PHS researchers data similar to that which exists in HSR. The objectives of this project are to disseminate information about a new PHSR database to the research community and to announce a forthcoming mini-grant program to encourage new Ph.D. junior faculty and/or post-doctoral level researchers to conduct small research projects which use a dataset or instrument contained in the PHSR database. Study Design: In partnership with the National Library of Medicine, the first phase of this research included a comprehensive review of the existing web listings on Health Services/Sciences Research Resources (HSRR) and the Health Services Research Projects in Progress (HSRProj) to identify "low hanging" data sets and collection instruments that have utility for PHSR. The second phase will involve more detailed and thorough searches for potential sources of information to be included on the HSRR site. These will be gathered from a number of sources including, but not limited to, professional organizations likely to have data sets useful to PHSR researchers. The third phase will involve an attempt to identify potential PHSR researchers with data sets which are public and would be available to new researchers. Only those data sets and instruments which are readily accessible to researchers will be recommended for inclusion in the PHSR database. Data sets which are proprietary will be included in the data base with contact information regarding purchase. Population Studied: This project involves a review of existing research databases. An expert panel of PHSR researchers was convened, was provided with the information obtained about existing databases, and were asked to identify and prioritize new data sets or instruments that they felt were essential to the field. Principal Findings: Approximately 20 to 40 datasets and 10 data collection instruments will be identified and descriptive records that would be useful in facilitating research in the public health system will be created. Conclusions: Most of the existing databases currently used by PHSR researchers will have been identified. Based on this knowledge, areas where new databases and instruments are vital to the continued growth and development of the discipline will be identified. Implications for Policy, Delivery, or Practice: This research provides an important agenda for those interested in providing support for continued development of PHSR. Grants will be given to support small research projects which use a dataset or instrument contained in the PHSR database. These grants could be awarded to institutions with major capacity in PHSR and with senior faculty to mentor post doctoral students using the databases. Grant recipients would obviously have the opportunity to present their research results at conferences and submit papers for publication in peer-reviewed journals, thus further assisting awareness of the PHSR database, developing new researchers and further enhancing the data which is necessary to further develop the discipline. Primary Funding Source: RWJF ●"Evaluation of Pandemic Influenza Plans Within the United States" Jennifer Sinibaldi, M.P.H., Dr. Peter Rumm, M.D., M.P.H., Dr. Curtis Cummings, M.D., M.P.H., Dr. Irini Daskalaki, MD, Ali Rizvi, B.S. (M.P.H. in progress) Presented By: Jennifer Sinibaldi, M.P.H., Research Coordinator, EOH- Center for Public Health Readiness and Communication, Drexel University School of Public Health, 1505 Race Street Bellet Building 11th floor, Philadelphia, PA 19102; Tel: 215-762-7345; Fax: 215-762-4088; Email: jls85@drexel.edu Research Objective: To evaluate various Pandemic Flu Plans throughout the United States and compare and contrast with the New Health and Human Services Pandemic Influenza Plan released in November of 2005. Study Design: State Pandemic Flu plans were selected by several individuals within the CPHRC and then reviewed and evaluated by 3 individuals. Data was then entered into SPSS to compare state ratings. Each variable constituted one characteristic per section and there were a total of 11 overall sections. Those sections include the following: Surveillance, Laboratory Diagnostics, Healthcare Planning, Infection Control, Clinical Guidance, Vaccine Distribution, Antiviral Distribution, Community Disease Control and Prevention, Management of Travel-Related Risk of Disease Transmission, Public Health Communications, and Psychosocial Workforce Support Services. Within each category there was a maximum of 10 points to be earned. Population Studied: No particular population is being studied. It is more reflective of a Literature Review of the Pandemic Flu Plans for states within the United States. These states are representative of the U.S. Department of Health and Human Services 10 regions. Principal Findings: Many states have capabilities representative of the New HHS Pandemic Flu plan and there are many capabilities that need to be enhanced to meet the needs of the new guidelines for states and local governments. First, states need to work with local governments to accurately disseminate timely information to their communities; this requires cooperation from all three parties involved. Secondly, there needs to be consideration of psychosocial workforce support services for those responding to the pandemic and is not addressed fully in many of the state plans. Finally, pandemic plans need to take into account real time and should be exercised as appropriate. Conclusions: With continuing education and trainings for preparedness, states and local governments will be able to meet the capabilities requested of the U.S. Department of Health and Human Services. Adequate planning for a pandemic requires the involvement of every level of our nation. It will compel federal, state, and local governments, communities, corporations, families and individuals to learn about, prepare for, and collaborate in efforts to slow, respond to, mitigate, and recover from a potential pandemic. Implications for Policy, Delivery, or Practice: There is potential for states to which the CPHRC will be working with closely for another project to adopt some suggestions addressed within this review within their own plans to enhance their own capabilities. Primary Funding Source: Pennsylvania Department of Health and the U.S. Department of Health and Human Services (Region III) ●Identifying Subpopulations at High Risk for Tuberculosis in the United States: A Low-Cost Approach Using CensusBased Indicators John Stewart, MS, M.P.H., Ana Lopez De Fede, Ph.D. Presented By: John Stewart, MS, M.P.H., GIS Manager, Institute for Families in Society, University of South Carolina, 1600 Hampton St, Columbia, SC 29208; Tel: (803) 777-5516; Fax: (803) 777-1120; Email: jstewart@gwm.sc.edu Research Objective: Public health efforts to treat and prevent tuberculosis in the United States must effectively target highrisk subpopulations. Residents of resource-poor neighborhoods may be at increased risk for tuberculosis infection. To evaluate the association between tuberculosis and local socioeconomic disadvantage, this geographic information system (GIS)-based analysis compares incidence rates of tuberculosis in low- versus high-socioeconomic status (SES) neighborhoods in three different U.S. locations— Chicago, Illinois; Fulton County, Georgia; and the state of South Carolina. Study Design: For each site, tuberculosis cases recorded by local public health agencies during a multiple-year reporting period were geocoded at the ZIP Code Tabulation Area (ZCTA) level. Socioeconomic status was defined at the ZCTA level using two separate census-based indicators of neighborhood disadvantage: percent of the population below the poverty level and the Townsend Index, a composite measure of social deprivation representing the relative degree of local crowding, unemployment, and car and home ownership. Based separately on the distributions of poverty and Townsend Index social deprivation scores, ZCTAs were grouped into quartiles reflecting relative socioeconomic wellbeing. To evaluate tuberculosis incidence in low- versus highSES neighborhoods, average annual tuberculosis incidence rates were calculated for the highest and lowest ZCTA quartiles. Race-specific incidence rates were calculated in the same manner to assess the relationship between tuberculosis and neighborhood disadvantage for African Americans and whites, the two predominant racial categories in the three sites examined. Population Studied: All tuberculosis cases reported in Chicago, Illinois, 1999-2001 (n = 1,238); Fulton County, Georgia, 1997-2001 (n = 783); and the state of South Carolina, 1997-2001 (n = 1,432). Principal Findings: In all three study sites, tuberculosis incidence rates per 100,000 were higher in high poverty ZCTAs relative to low poverty ZCTAs (22.2 vs. 4.7 in Chicago; 42.7 vs. 1.8 in Fulton County, Georgia; and 12.9 vs. 2.9 in South Carolina). Similarly, in all three sites, tuberculosis incidence rates per 100,000 were higher in high social deprivation ZCTAs relative to low social deprivation ZCTAs (22.4 vs. 5.6 in Chicago; 41.1 vs. 1.3 in Fulton County, Georgia; and 11.9 vs. 2.8 in South Carolina). In all sites, race-specific tuberculosis incidence rates were higher among African American and white residents of low SES ZCTAs relative to their counterparts in high SES areas. Conclusions: Residents of disadvantaged neighborhoods may be at higher risk for tuberculosis. Although our results do not demonstrate causality, they do suggest the need for additional research to clarify the association between tuberculosis and such socioeconomic factors as poverty, unemployment, educational attainment, living arrangement, and neighborhood social capital. The association between SES and tuberculosis infection is complex and multidimensional, multilevel modeling methods are needed to adequately evaluate individual-level and contextual variables of interest. Implications for Policy, Delivery, or Practice: The findings are applicable for practitioner seeking to maximize reduced federal and state funding while maintaining the balance between prevention and treatment activities. Health policy makers and practitioners can use readily available, low-cost census data to identify socioeconomically disadvantaged neighborhoods for targeted tuberculosis treatment and prevention interventions. Primary Funding Source: CDC, SC DHEC ●The Knowledge, Adttitude and Practices Associated with Smoking and its Impact on Health Promotion Efforts in Singapore Matthias Paul Han Sim Toh, MBBS, MMed(Public Health), Bee-Hoon Heng, MBBS, MSc, Lai-Yin Wong, BA(Economics and Statistics), Audrey Siok-Ling Tan, MBBS, MSc, Jason Cheah, MBBS, MMed(Public Health), MSc Presented By: Matthias Paul Han Sim Toh, MBBS, MMed(Public Health), Registrar, Health Services and Outcomes Research, National Healthcare Group, 6 Commonwealth Lane #06-01 GMTI Building, Singapore, 149547; Tel: (65) 6471-8971; Fax: (65) 6471-1767; Email: matthias_toh@nhg.com.sg Research Objective: To study the knowledge, attitude and practice (KAP) of smoking and intra-household influence on smoking among Singapore residents and identify the segment of the population for more intense health promotion and smoking cessation efforts. Study Design: A population-based survey was conducted from December 2004 to October 2005. Households in Singapore were randomly chosen. Trained Health Survey Officers conducted face-to-face interviews using a questionnaire and gathered information on demographic characteristics, smoking status, lifestyle behaviour and practices, and whether there was any smoker living in the same household. Smokers’ KAP were compared with nonsmokers using SPSSv13. Significance testing of proportions was carried out using Fisher’s exact test, where a probability (p) of <0.05 was considered statistically significant. Population Studied: Singapore residents aged 15-69 years were randomly selected and invited to participate. Principal Findings: Altogether 2,632 respondents participated in the survey; their demographic characteristics were similar to and representative of the general Singapore population. There were 372(14.1%) current smokers. Prevalence rate of smoking was significantly higher among males than females (27.5% vs 3.2%; p<0.001). The smoking prevalence among younger females below 45 years of age was 1.5 times higher than females aged 45 years and older (3.8% vs 2.6%). Smoking prevalence rate was also significantly higher among the Malay population (18.9%) compared to the Chinese (13.3%) and Indian (12.4%), and those with up to Secondary/ITE education (16.7% vis-à-vis 7.9% with Pre-U/JC and university education, p<0.001). Among the current smokers, 99.5% were ever told that smoking was harmful and 96.2% also believed that smoking could harm one’s health. Similarly among the nonsmokers, the knowledge and belief of the harmful effects of smoking were equally high (99.2% and 99.6% respectively). Compared to non-smokers, smokers were more likely to be engaged in regular drinking (8.6% vs 1.7%, p<0.001). Compared to non-smokers, smokers had slightly higher chance of having another smoker in the household (24.7% vs 23.1%). Conclusions: There were gender and ethnic differences in the smoking prevalence among Singaporeans. People who received less formal education tended to smoke more than those with higher education. Although the overall smoking prevalence among female remained much lower than their male counterparts, the current trend suggested that prevalence among young female smokers might increase over time. Most respondents were aware that smoking was harmful to health. However, this did not translate into adoption of a ‘smoke-free’ lifestyle and was associated with significantly higher rates of regular drinking. Smoking prevalence was also associated with experience of intrahousehold smoking. Implications for Policy, Delivery, or Practice: Annual national smoking awareness campaigns have achieved its primary goal of creating a high level of awareness of smoking ills among the general public. Future health promotion campaigns and research should focus on reasons why smokers do not stop smoking despite having the knowledge and knowing that they should, especially so amongst younger females, the Malay subpopulation and those with secondary education and below. Primary Funding Source: National Healthcare Group ●Barriers and Conflicts to Public Health System Change Post 9/11 Joan Valas, Ph.D.(c) Presented By: Joan Valas, Ph.D.(c), Graduate Student, Applied Anthropology, Columbia UniversityTC/GSAS, 525 W. 120th St., New York,, NY 10027; Tel: 212-305-2809; Email: jv16@columbia.edu Research Objective: Purpose: In light of the World Trade Center and Anthrax attacks, the stability and health of million of people are dependent on the policies and practices of public health. This anthropological study describes the barriers and conflicts raised by professionals and policymakers of local boards of health in a densely populated county in the state of New Jersey having close proximity to New York City and the problems in effecting public health system change post 9/11. Study Design: This multi-site, ethnographic study used unstructured interviews, participant observation and archive review to develop a description of the conflicts and barriers to public health change. The data were collected using nonprobability purposive sampling of members of local boards of health, and selected public health practitioners and officials. Other data were collected using a convenience sample of municipal and state government workers. There was a simultaneous analysis of the texts created from interviews, field notes and records of the deliberations of local board of health members and public health practitioners to look for patterns of political behavior. Population Studied: Local public health policy makers and pracitioners Principal Findings: Archival data from public records, participant observation and interviews with public health professionals and policy makers revealed that much of the political activity took place within the social organization of the system centering on the health officers. There was very little direct attention paid to the social structure. For example: • Regulations for public health practice that were proposed pre 9/11 were passed post 9/11 with changes that supported the organizational development of emergency preparedness services. Despite the flurry of political activity among health officers, they began to work together towards those ends. • Boards of health members were generally not involved and most unaware of state-wide changes in the regulations governing the practice of public health services. • Despite the terrorist attacks of 9/11, board of health members were not directly involved in emergency preparedness activities but rather focused on local community public health services like food safety and sanitation. But these activities also did not present a barrier to public health system change. • There was a systematic avoidance to directly address the laws governing the structure of the public health system both pre and post 9/11. Conclusions: The study documents the problems encountered in effecting planned change in the face of emergencies and disasters. It describes the barriers raised by professional and political groups in an attempt to control and shape the public health system. As a result of the events of 9/11 organizational changes have been encapsulated and socially integrated. However, without addressing structural changes the status quo continues to serve as a barrier. Implications for Policy, Delivery, or Practice: Health professionals find themselves at different levels of involvement where policy is both constructed and applied. Many find themselves in positions with policy making authority. Understanding the barriers to change is necessary to both the development and implementation of policy. Primary Funding Source: No Funding ●Factors Associated with Population-based Public Health Nursing Practice: Two State Comparison Using SEM Susan Zahner, Dr.P.H., M.P.H., RN Presented By: Susan Zahner, DrPH, M.P.H., RN, Assistant Professor, Nursing, University of Wisconsin-Madison, H6/246 CSC; 600 Highland Avenue, Madison, WI 53792-2455; Tel: 608-263-5282; Fax: 608-263-5332; Email: sjzahner@wisc.edu Research Objective: Research on the extent to which public health nursing (PHN) practice has become more populationbased and the factors associated with such change in practice is limited. This study assessed recent practice change experienced by PHN in two states and explored factors associated with practice change. Study Design: A conceptual model adapted from the work of Carol Kelly (1998) was used in this study. Data were collected using cross-sectional written, mail-back surveys (63% overall response rate). Structural equation modeling (SEM) was used to test for relationships between measures of community, public health system, professional, health care system, and organizational factors and change toward more populationbased practice. The mediating effects of organizational factors were assessed. Population Studied: Data were collected from public health nurses with five or more years of experience working at the local level in two states with differing public health systems (n=408). Principal Findings: PHN has become more population-based in both states though more so in the state characterized by a decentralized public health system and a more highly educated PHN workforce. Public health system, health care system, professional, and organizational factors were found to have direct effects on outcome measures while community factors were not. One organizational factor was observed to mediate the effect of a public health system factor on the outcome. Conclusions: The conceptual framework and analytic methods offer a quantitative approach to the study of the influence of contextual factors on PHN practice change. Implications for Policy, Delivery, or Practice: Successful incorporation of population-based PHN practice recommendations will be enhanced by the adoption of population-based practice strategies at organizational and public health system levels and as well as by supporting resources for PHN practice. Primary Funding Source: University of Wisconsin-Madison ●Sector Wide Approach (SWAp) Dynamic and Health: Comparative Study from Benin, Mali and Senegal Véronique Zinnen, M.D., M.P.H., Elisabeth Paul, Bruno Dujardin, M.D., Ph.D., Denis Porignon, M.D., Ph.D., Daniel Grodos, M.D., Ph.D. Presented By: Véronique Zinnen, M.D., M.P.H., Researcher, Email: veronique.zinnen@epid.ucl.ac.be Research Objective: During the last decade, different aid evaluations pointed a multitude of problems and lack of effectiveness of the development cooperation, especially in the health sector. In reaction, the roles of the donors and the recipient countries have been redefined and the SWAp was developed and accepted by many multilateral and bilateral cooperation agencies. While SWAp process implementation is well documented for Eastern and Austral African countries, there is still limited research on it in the Western French speaking African part. This study would like to evaluate, analyse and compare the process of change in aid modalities in three West African countries. Study Design: A theoretical model with European Commission criteria was used to compare and evaluate the implementation of SWAp in each country. Official documents were also consulted. Then, 79 interviews were conducted and 35 questionnaires were distributed to reach a large panel of representative from government, aid agencies and civil society. Finally, 7 meetings, concerning the subject, were attended for observations. Principal Findings: The study showed that, for the three countries, the SWAp has started as a dynamic process, without having all recommended conditions in place. The national leadership was weak in the three countries but they all experienced macroeconomic stability. There was, mostly for Benin and Mali, a real and palpable willing to get things moving in that kind of partnership. Also, despite obstacles and slowness of the process some of its benefits were already well perceived and positive changes were in place. The SWAp is expected to enable to better manage additional resources devoted to the sector (like following the HIPC Initiative and possibly the Global Fund). Many points need more actions or improvements and another evaluation will be necessary later to follow the advance and the possible impact in health of the process. Conclusions: Sector wide approach needs to be strengthen in Western African countries. Measures have already been undertaken to improve efficiency of huge external fundings which are expected to come, especially for HIV/AIDS, malaria and tuberculosis control. Primary Funding Source: Belgian Co-operation