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