Carolyn A. Berry
Affiliated Faculty, NYU Wagner; Associate Professor, NYU Langone School of Medicine
Carolyn Anne Berry holds a PhD in Community Psychology from New York University. Her current research focuses on the health and health care of low-income children and families, and includes both investigator initiated research and program evaluation. She recently concluded a five year grant from the National Institute of Environmental Health Sciences (NIEHS) entitled Social Factors and the Environment in Pediatric Asthma that is investigating racial/ethnic disparities in childhood asthma. She conducting an outcome evaluation of the SchoolFood Plus Initiative, a program designed to enhance the nutrition of children in the NYC public school system. Dr. Berry and Dr. Dennis Smith are in the final stages of a process study of WeCARE, a recently implemented program designed to provide specialized assessments and services to that portion of the public assistance population that is unable to work immediately. That program and study are funded by the NYC Department of Social Services/Human Resources Administration. Dr. Berry is part of a Wagner team working on the national evaluation of "Expecting Success", a demonstration project funded by the Robert Wood Johnson Foundation to address disparities in cardiac health care at 10 hospitals with large volumes of racial and ethnic minorities.
Dr. Berry regularly teaches Program Analysis and Evaluation
This course serves as an introduction to those evaluation tools most commonly used to assess the performance of publicly funded programs, in both the public and private sector. Topics include developing and assessing program theory, implementation and process assessment, methods of impact evaluation, and efficiency analysis (cost-benefit and cost-effectiveness analysis). The focus is on critical analysis and understanding of both the underlying programs and their evaluations.
Many policy problems require governmental leaders to forge vast networks beyond their own hierarchical institutions. This essay explores the challenges of implementation in a networked institutional setting and incentives to induce coordination between agencies and promote quality implementation. It describes the national evaluation of the Assuring Better Child Health and Development program, a state-based program intended to increase and enhance the delivery of child development services for low-income children through the health care sector, using Medicaid as its primary vehicle. Using qualitative evaluation methods, the authors found that all states implemented programs that addressed their stated goals and made changes in Medicaid policies, regulations, or reimbursement mechanisms. The program catalyzed interagency cooperation and coordination. The authors conclude that even a modest level of external support and technical assistance can stimulate significant programmatic change and interorganizational linkages within public agencies to enhance provision of child development services.
We sought to determine whether low acculturation among Mexican American caregivers protects their children against asthma. Methods. Data were obtained from an observational study of urban pediatric asthma. Dependent variables were children's diagnosed asthma and total (diagnosed plus possible) asthma. Regression models were controlled for caregivers' level of acculturation, education, marital status, depression, life stress, and social support and children's insurance. Results. Caregivers' level of acculturation was associated with children's diagnosed asthma (P=.025) and total asthma (P=.078) in bivariate analyses. In multivariate models, protective effects of caregivers' level of acculturation were mediated by the other covariates. Independent predictors of increased diagnosed asthma included caregivers' life stress (odds ratio [OR]= 1.12, P=.005) and children's insurance, both public (OR=4.71, P=.009) and private (OR = 2.87, P=.071). Only caregiver's life stress predicted increased total asthma (OR = 1.21, P=.001). Conclusions. The protective effect of caregivers' level of acculturation on diagnosed and total asthma for Mexican American children was mediated by social factors, especially caregivers' life stress. Among acculturation measures, foreign birth was more predictive of disease status than was language use or years in country. Increased acculturation among immigrant groups does not appear to lead to greater asthma risk.
We examined racial and ethnic disparities in the total potential burden of asthma in low-income, racially/ethnically heterogeneous Chicago schools, Methods. We used the Brief Pediatric Asthma Screen Plus (BPAS ) and the Spanish BPAS , validated, caregiver-completed respiratory questionnaires, to identify asthma and possible asthma among students in 14 racially/ethnically diverse public elementary schools. Results. Among 11 490 children, we demonstrated a high lifetime prevalence (12.2%) as well as racial and ethnic disparities in diagnosed asthma, but no disparities in prevalences of possible undiagnosed asthma. Possible asthma cases boost the total potential burden of asthma to more than 1 in 3 non-Hispanic Black and Puerto Rican children. Conclusions. There are significant racial and ethnic disparities in diagnosed asthma among inner-city schoolchildren in Chicago. However, possible undiagnosed asthma appears to have similar prevalences across racial/ethnic groups and contributes to a high total potential asthma burden in each group studied. A better understanding of underdiagnosis is needed to address gaps in asthma care and intervention for low-income communities.
Increasing the representation of Spanish-speaking study participants requires development and dissemination of reliable and valid translated scales. In the current study the construct validity was assessed of the Spanish version of the Crisis in Family Systems-Revised, a measure of contemporary life stressors, with a convenience sample of 377 parents interviewed in a study of childhood asthma, although over half of the respondents did not have children with asthma. Most respondents were foreign-born women between 20 to 60 years old (M = 35, SD = 7). 52% had not completed high school or its equivalent, and 55% reported a household income of $15,000 or less. For a subsample of 25 respondents test-retest reliability was .86 over 2 wk. Reporting more life stressors was associated with greater depressive symptomatology, poorer physical and mental health function, and lower household income. These relationships support the construct validity of the test in Spanish. This study provided strong evidence that this version is a valid and reliable measure of life stressors for a Spanish-speaking population living in the United States.
Objective. Recent national survey data indicate an overall asthma prevalence of 12.2% for children who are younger than 18 years. Previous research in clinical samples of children with asthma suggests that their mothers are at greater risk for symptoms of depression. We describe the relationship between maternal symptoms of depression and having a child with asthma in a community-based sample.
Methods. After a school-based ascertainment of asthma and asthma symptoms in 15 low-income, racially/ethnically diverse public elementary schools, 1149 eligible mothers agreed to participate in a longitudinal study. Mothers either had a child with previously diagnosed asthma or a child with symptoms consistent with possible asthma or were in the randomly selected comparison group in which no child in the household had asthma. During the first interview, mothers responded to questions about their own life stressors, supports and mental health, and their children's health.
Results. In bivariate analyses of a community-based sample of children who share low-income neighborhoods, mothers of children with diagnosed or with possible undiagnosed asthma had more symptoms of depression than did mothers of children who have no asthma. Mothers of children with diagnosed or with possible undiagnosed asthma also experienced more life stressors than did mothers of children without asthma. Using nested linear regression, we estimated a model of maternal symptoms of depression. Most of the variation in Center for Epidemiologic Studies-Depression score was accounted for by life stressors and social support. There were no independent effects of either asthma status or asthma status-specific child health status on maternal symptoms of depression.
Conclusion. Children who are under care for chronic conditions such as asthma live and manage their illness outside the clinical setting. Their social context matters, and maternal mental health is related to their children's physical health. Although having a child with asthma may be "just" another stressor in the mother's social context, complex treatment plans must be followed despite the many other pressures of neighborhood and family lives.
Background: The health and health care needs of non-English-speaking Hispanic families with children are poorly understood, in part because they are often excluded from research owing to language barriers. Instruments that are valid in English and Spanish are necessary to accurately evaluate the magnitude of asthma prevalence and morbidity among Hispanics.
Objective: To establish the sensitivity and specificity of the English and Spanish versions of the asthma portion of the Brief Pediatric Asthma Screen Plus (BPAS ) in a low-income Hispanic population.
Methods: The validation sample consisted of 145 children whose parents completed the BPAS in Spanish and 78 whose parents completed it in English. Bilingual clinicians conducted the examinations on which the clinical assessments were based. We compared the BPAS results with the clinical assessment findings to determine the sensitivity and specificity of the BPAS among Hispanics in terms of identifying children who warrant further medical evaluation for asthma.
Results: The sensitivity and specificity of the asthma portion of the Spanish BPAS were 74% and 86%, respectively. The sensitivity and specificity of the asthma portion of the English BPAS were 61% and 83%, respectively.
Conclusions: The asthma portion of the BPAS , a valid screen for identifying children who are in need of further evaluation for potentially undiagnosed asthma, is valid for low-income Hispanics in Spanish and English. As the Hispanic population continues to grow, it is imperative that researchers have English and Spanish instruments that are valid for this population.
The functional status and health-related quality of life (HRQOL) of children who survive liver transplantation (LT) have not been well documented. The purpose of this study was to determine the functional status and HRQOL in this population using a validated measure for children, the Child Health Questionnaire-Parent Form 50 (CHQ-PF50).
Methods: The CHQ-PF50 instrument was completed by the parents of 55 children who agreed to participate in a mailing survey. Subscale scores for the sample were compared with those of a published normal population (n = 391).
Results: Study sample characteristics were: 87% Caucasian, 54.5% female, mean age at survey was 9.6 years (range, 5-17 years). Responding caregivers were 95% biologic parents and 93% female. Compared with the normal population, LT recipients had lower subscale scores for general health perceptions (P < 0.0005), emotional impact on parents (<0.0005) and disruption of family activities (0.0005). The mean physical summary score of the LT recipients was lower than that of the normal population 48.1 /- 12.1 (P = 0.005), but the mean psychosocial summary score was similar 48.8 /- 11.9 (P = 0.156). Within the LT population, the original diagnosis (biliary atresia vs. other), type of LT (living donor vs. cadaveric), age at LT, z score for height, and hospital days did not significantly influence any of the subscale scores.
Conclusions: Children who have survived LT have functional outcomes in the physical domain that are lower than those of normal children. Self-esteem and mental health in this group appeared normal. The parents in this sample experienced more emotional stress and disruption of family activities than did parents in a normal population.
Background: Asthma is the most common disease of childhood, but the recognition and detection remain poor, especially among schoolchildren. There has been an increase in the number of instruments available to detect the risk of asthma earlier in children. We have previously validated a simple, self-reported screen, the Brief Pediatric Asthma Screen (BPAS).
Objective: To develop a new screen for asthma and allergies based on the BPAS (BPAS ) with the intent of keeping the screen brief and simple, while including allergy detection.
Methods: Questions from the BPAS were extensively revised, and questions regarding allergic rhinitis were added. A panel of parents of asthmatic children reviewed and critiqued the questions. The final BPAS was distributed in elementary schools, and a cohort of 129 participated in a validation against the gold standard of evaluation by an expert in asthma.
Results: For asthma the best items were wheeze, persistent cough, night cough, and response to change in air temperature. The simplest scoring, any 1 of the 4 items, yielded the best balance of specificity (73.6%) and sensitivity (73.3%). For allergy, using all six items, having any one or any two of the items had sensitivity of 71.4% and specificity of 77.3%.
Conclusions: The BPAS provides a rapid and valid method for the detection of potential allergy and asthma in schoolchildren. Sensitivity and specificity are acceptable for both asthma and allergies.
The purposes of this paper are to (1) review the 24-hour intake of a nationally representative sample of adolescents, (2) describe data from a 24-hour food intake record from a sample of adolescents with diabetes, and (3) discuss the implications of this nutritional information for diabetes health providers.
This paper describes the development and psychometric properties of the Diabetes Problem-Solving Measure for Adolescents (DPSMA).
The DPSMA is a structured, interview-based questionnaire that examines how adolescents with type 1 diabetes solve diabetes-related self-management problems. Seventeen diabetes-related self-management problem vignettes were derived from a survey of adolescents and their parents. The vignettes were reviewed and finalized by a multidisciplinary team of diabetes experts. A sample of 43 adolescents, 13 to 17 years old, with type 1 diabetes, was used to establish the psychometric properties of the instrument.
The scale demonstrated acceptable internal consistency and interrater reliability. Predicted relationships with scores on concurrently administered measures of adherence, diabetes quality of life, and metabolic control provided support for construct validity.
The results suggest that the DPSMA has acceptable internal consistency, interrater reliability, and construct validity. It may be a useful tool to help healthcare providers understand the diabetes-related problem-solving abilities of their adolescent patients.
The objectives of this study were to establish the validity of the Crisis in Family Systems-Revised, a recently developed measure of contemporary life stressors, using the same validation technique as in the original validation and to provide further evidence of construct validity by assessing its relationship to socioeconomic status and residential location. We conducted 124 in-person interviews with parents in three outpatient pediatric asthma clinics affiliated with an academic medical center. The design was cross-sectional and correlational. Total count of life stressors accounted for 19% of the variance in scores on the Center for Epidemiologic Studies-Depression. Respondents using Medicaid and living in the city experienced more objective stressors, but the proportions of stressors rated as negative or positive (Valence), and ongoing (Chronicity) were fairly constant across subsamples, as was the Difficulty rating. Psychologists and health and mental health services researchers are in need of constructs relevant to contemporary society and its issues and tools to measure these constructs. Life stressors appears to be such a construct and the Crisis in Family Systems-Revised a measure with considerable utility.
Objective: To examine the relationships among demographic characteristics, caregiver life stressors, and depressive symptoms of mothers and their children's asthma morbidity.
Setting: Three pediatric asthma subspecialty programs, 2 in the inner city and 1 in the suburbs.
Design: Cross-sectional census sample of caregivers of children with asthma: interviews mostly with mothers (N = 123) regarding their children's asthma symptoms and health care utilization. Information collected on demographics and caregivers' own recent life stressors and depressive symptoms.
Subjects: Caregivers of children ages 18 months to 12 years with asthma at their subspecialty visit.
Measures: Structured interviews: a survey instrument prepared for this study and standardized instruments for depression (Center for Epidemiologic Studies--Depression) and life stressors (Crisis in Family Systems).
Results: A total of 32% of respondents' children had high asthma morbidity, 28% intermediate, and 40% low. Caregiver life stressors and depression and the children's sex showed the strongest relationships to asthma morbidity in a model that also included race, residence, and Medicaid status. Children were more likely to have high morbidity if they had caregivers with more depressive symptoms and negative life stressors and if they were female.
Conclusions: Respondents experienced many life stressors and symptoms of depression while managing their children's illness. Caregivers' lives may affect their children's asthma morbidity, offering empirical evidence for the potential value of targeted case management for children in subspecialty care.
Objective: We explored the current state of developmental screens, child development services, mechanisms to fund screens and services, and incentives for adopting new services within managed care organizations serving Medicaid enrolees.
Design: National, cross-sectional mail survey. Survey of 388 Medicaid managed care organizations (MMCO) enrolling children in 1998–99.
Results: Most of the 155 plans that responded provided an array of developmental screenings and services, funded primarily through internal mechanisms or under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) programs. Plan contacts expressed interest in implementing new services, particularly if additional funding was available. The most important motivators included requiring services in the Medicaid contract, enhanced capitation rates, and demonstration that providing child development services would reduce other utilization costs.
Conclusions: If state Medicaid agencies want to enhance the child development services available through health plans, they could initiate steps such as requiring child development services in contracts with plans or providers; revising EPSDT language and engaging in more consistent enforcement; and enhancing capitation rates. More research on effectiveness and benefits of specific developmental screens and services is needed.
Objective. We sought to understand why certain Medicaid managed care organizations (MMCOs) implemented child development services or programs and how they had done so. We also sought to identify barriers and facilitators to successful initiation and implementation of child development programs.
Methods. We conducted 9 key informant interviews and 4 site visits, and performed qualitative analyses to identify major themes across responses.
Results. We identified a small number of MMCOs with child development services. High-level support was crucial for program initiation; physician buy-in, staff support, and strong working relationships with outside health professionals or agencies were principal factors in successful program implementation.
Conclusions. MMCOs that were committed to implementing child development services were successful in doing so, without external funding or regulatory mandate. The results provide valuable strategies for MMCOs interested in developing programs and for researchers and advocates interested in promoting child development services for low-income children. Key words: Medicaid managed care, child development services.
To determine the effects of aspects of residency training on AIDS-related treatment practices. METHOD: The authors conducted a nationwide longitudinal panel study of 394 physicians who graduated in 1989 from six medical schools in New York State. Data were collected during the participants' fourth year of medical school, their third year of residency training, and six years after they had graduated from medical school. Questionnaires sought information about AIDS-related practice behaviors, including avoiding invasive procedures, minimizing contact, emphasizing AIDS prevention and education, and volume of people with AIDS treated. RESULTS: Aspects of residency training had a sustained impact on how the physicians cared for patients with AIDS but not on the numbers of patients they treated. Determinants of treatment practices included aspects of the residency environment (e.g., emphasis on problem solving, student orientation; p < .01), characteristics of the faculty (e.g., commitment to teaching, tolerance of varied viewpoints), cynicism about patient care (p < .001), social biases (homophobia and aversion to intravenous drug users; p < .001), and AIDS-related attitudes (p < .01). CONCLUSIONS: Fundamental changes to residency training, all of which are associated with learner-centered education, can improve physicians' treatment of their patients with HIV and AIDS.
To assess the extent of physical disability in juvenile rheumatoid arthritis (JRA), classified according to subtype, and whether synovitis or flexion contractures are present on examination.
This retrospective study included 88 JRA patients and 50 controls without musculoskeletal disease. The outcome measure was the disability index (DI) derived from the Childhood Health Assessment Questionnaire (CHAQ).
DI scores for JRA patients with synovitis (mean 0.49, range 0-1.88) and without synovitis (mean 0.37, range 0-1.75) were significantly higher (P < 0.001 for both groups) than for controls (mean 0.06, range 0-0.75, P < 0.001), but not significantly different from one another. Similarly, DI scores for JRA patients with and without any flexion contractures were higher than for controls, but not significantly different from one another. DI scores for JRA patients with both synovitis and flexion contractures were significantly higher than DI scores for JRA patients with neither, but were not distinguishable from JRA patients with synovitis only or flexion contractures only. Likewise, DI scores for JRA patients lacking synovitis and flexion contractures were not significantly different than those for JRA patients with one or the other. DI scores for systemic and polyarticular patients were higher than for pauciarticular patients, and DI scores for all 3 subtypes were higher than for controls.
Our findings suggest that many JRA patients, including those with pauciarticular JRA, have problems with physical function, even when synovitis and flexion contractures are not present. Further attention and research is needed to elucidate the causes or origins of disability in JRA patients with seemingly well-controlled disease. We recommend that health status instruments like the CHAQ be more widely used for JRA patients to complement other assessments, especially in planning occupational and physical therapy.
Study objectives: The purpose of this study was to confirm the validity of a brief screen for pediatric asthma in schools.
Background: Asthma is the most common chronic disease of childhood, yet the frequency with which this condition is recognized among school-aged children varies widely. Several methods are used to increase the accuracy of detection of asthma, but many are cumbersome and difficult to apply on a large scale.
Design: We elected to validate a five-question instrument, the Brief Pediatric Asthma Screen (BPAS), to screen for the presence of asthma among children attending school in Region 5 of the Chicago school district, where the schools report a 2.7% frequency of asthma. The questionnaire was distributed to the parents of grade-school children at the time of report-card pick-up.
Setting: A clinical assessment was performed on a selected group of children whose parents completed the questionnaire in a school and in a hospital outpatient clinic.
Participants: Of 4,147 questionnaires that we distributed, 1,796 (43%) were returned. We excluded 341 children (19% of the total sample) whose parents reported that they had been diagnosed with asthma. The remaining pool indicated that the children of 183 responders (10%) had symptoms suggestive of asthma, while 1,272 parents (71%) indicated that their children did not have symptoms of asthma.
Measurements and results: We selected 90 of the respondents who did not indicate that their children had a diagnosis of asthma. Of this group, 81 completed the validation, in which their responses suggested symptoms of asthma (n = 34) or no asthma symptoms (n = 47). The children of these respondents were given a blinded clinical evaluation consisting of history, physical examination, and spirometry. The survey demonstrated a sensitivity of 75% and a specificity of 81.2% for the presence of asthma among those who were unaware of the diagnosis.
Conclusions: The BPAS is brief, can be filled out by parents, and appears accurate in detecting asthma.
To develop and validate a measure of contemporary life stressors. STUDY SETTING: Three interview studies: Study 1 (pilot), 32 caregivers receiving case management services for a child with chronic illness; Study 2 (validation), 311 caregivers of children receiving general pediatric care at a university clinic; Study 3 (reliability), 17 caregivers of children with a complex medical diagnosis. STUDY DESIGN: Study 1: item development via discussions with case managers; piloted with caregivers. Study 2 examined psychometric properties of the measure and correlated it with the CES-D, a measure of depressive symptomatology and the PRQ85-Part 2, a measure of perceived social support, to establish its convergent construct validity. Study 3 established the test-retest reliability of the measure over two weeks by correlating two administrations of the index. DATA COLLECTION: Face-to-face interviews in homes (Study 1) or in clinic waiting rooms (Studies 2 and 3) and by telephone (Study 3 retest). PRINCIPAL FINDINGS: The CRISYS is a flexible, multidimensional tool that demonstrates strong face, content, and construct validity, and excellent test-retest reliability. The format is easy to use and well accepted by respondents and is suitable for low-income populations. CONCLUSIONS: Researchers will find the CRISYS useful when evaluating the success of a clinical model or a healthcare system, and the effectiveness of an insurance plan or a government program. Clinicians may also find that the CRISYS is an effective screen for family needs.
The impact of training on physicians' commitment to professional values is examined, using a cohort design to assess the evolution of attitudes toward AIDS during residency training. Cohorts of surgeons training in the same six residency programs were followed at key junctures, and their outlooks on three AIDS-related attitudes were examined: willingness to treat people with AIDS (PWAs), concern about exposure to HIV, and perceived benefits of treating AIDS. The findings revealed a consistent, negative impact of training on all three attitudes. Cohort and period (historical) effects were limited: younger cohorts more often viewed treating PWAs as a clinically valuable experience, and greater concern about exposure was evidenced as training progressed. The findings yield new evidence of the importance of residency training to professional socialization. More knowledge of alterable aspects of residency training that play a role is key to assuring that physicians emerge with a dedication to fulfilling their social responsibilities.
Understanding the impact of training on the development of physicians' attitudes toward AIDS is important to furthering our knowledge of the mechanisms through which socialization affects professional outlook, as well as promoting an adequate supply of providers to treat people with AIDS (PWAs). This prospective panel study collected data on 383 physicians at two critical stages: as fourth year medical students and as third-year residents. Aspects of residency training (e.g., residents' morale and positive faculty role models) were the most powerful predictors of increase in willingness was primarily a product of negative social attitudes - homophobia and IVDU-phobia (aversion to intravenous drug users). Cynicism toward patient care acted as a trigger activating the negative effects of IVDU-phobia; having an acquaintance who is HIV positive mediated the negative impact of homophobia. Notably, cynicism was associated with basic aspects of training (specific characteristics of the faculty and of the educational milieu). The findings support a view of socialization as pervasive process implicating intrinsic aspects of training and having an impact on a broad spectrum of outlooks. Accordingly, interventions must address structural characteristics that transcend AIDS-specific concerns.
Few instruments exist for the assessment of adolescent mental health. In order to examine the appropriateness of the Mental Health Inventory (MHI) for use with adolescents, secondary analyses were conducted of the large subsample (n = 953) of adolescents who participated in the community-based Rand Health Insurance Study. The reliability and readability of the MHI were confirmed. Subscales reflecting Psychological Well-Being and Psychological Distress were derived. The MHI, with its adolescent norms, is recommended for the assessment of adolescent mental health, particularly in studies in which comparison to a nonpsychiatric, normative adolescent population is indicated.