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Strong property tax growth and proactive policies - including beginning the recession with a substantial surplus of $5.3 billion (9 percent of revenues) - offset a severe contraction in income tax receipts, protecting the City's budget such that it never contracted in absolute terms during or immediately following the Great Recession. Policymakers increased property and sales tax rates, utilized fund balances, cut agency budgets repeatedly, and re-appropriated retiree health benefits in response to the fiscal challenges brought about by the Great Recession. Whether one attributes it to compliance with a strong, state-mandated, balanced budget rule or adept leadership, New York City certainly appears to be dealing effectively with the Great Recession's impact on its budget. However, City leaders have asked lower income residents to bear a substantial portion of the burden by favoring more regressive tax policies and by cutting the social service agency's budget substantially. With forecast budget gaps of $3 billion and $4 billion in FY 2012 and FY 2013, the long-term impact of the Great Recession on New York City's budget remains an open question.

Transportation planners, policymakers, urban designers, and activists have expended considerable effort over the past few decades promoting walking as one of several alternatives to driving.  More recently, the public health benefit of a physically active population, including a population that walks more often, has become another reason to encourage walking.  Amongst all of this excitement about walking, there has so far been little exploration of the role walking plays in people’s lives and cities’ welfare.  One little understood aspect of walking is its appeal beyond simple “derived demand” travel choice frameworks.  Though we might intuitively know that people walk for more than just to get from A to B, there’s been little to explain what people gain from walking beyond its potential health benefit.  An investigation of pedestrian behavior using the 2009 National Household Travel Survey suggests that the reasons that people choose to walk vary considerably across place and class, and that walking in urban areas may best be explained by a dual conceptualization of walking as the mode of last resort and a highly-prized urban amenity.  This seemingly self-contradictory dual role suggests that policies that want to encourage walking across a broad swath of the population will need to overcome barriers rooted in everyday lifestyles just as much as in the quality of the built environment.

There has been little research to date on the linkages between air pollution and infectious respiratory illness in children, and the resulting health care costs. In this study we used data on air pollutants and national hospitalizations to study the relationship between fine particulate air pollution and health care charges and costs for the treatment of bronchiolitis, an acute viral infection of the lungs. We found that as the average exposure to fine particulate matter over the lifetime of an infant increased, so did costs for the child's health care. If the United States were to reduce levels of fine particulate matter to 7 percent below the current annual standard, the nation could save $15 million annually in reduced health care costs from hospitalizations of children with bronchiolitis living in urban areas. These findings reinforce the need for ongoing efforts to reduce levels of air pollutants. They should trigger additional investigation to determine if the current standards for fine-particulate matter are sufficiently protective of children's health.

There has been little research to date on the linkages between air pollution and infectious respiratory illness in children, and the resulting health care costs. In this study we used data on air pollutants and national hospitalizations to study the relationship between fine particulate air pollution and health care charges and costs for the treatment of bronchiolitis, an acute viral infection of the lungs. We found that as the average exposure to fine particulate matter over the lifetime of an infant increased, so did costs for the child's health care. If the United States were to reduce levels of fine particulate matter to 7 percent below the current annual standard, the nation could save $15 million annually in reduced health care costs from hospitalizations of children with bronchiolitis living in urban areas. These findings reinforce the need for ongoing efforts to reduce levels of air pollutants. They should trigger additional investigation to determine if the current standards for fine-particulate matter are sufficiently protective of children's health.

Children and youth vary in their developmental health due to differences in family economic security and exposure to toxic stress. The economic downturn has increased the challenges facing low-income children. The ARRA and the President's first budget made significant down-payments on investments in protecting and promoting the well-being of these children. But some of those investments are temporary and must be built into baselines going forward. Many other promising avenues for policy change could be implemented through reauthorization of PRWORA and ESEA. Further, a new era of experimentation in innovative program and policies is recommended for when the economy recovers.

Substance use (SU) disorders adversely impact health status and contribute to inappropriate health services use. This qualitative study sought to determine SU-related factors contributing to repeated hospitalizations and to identify opportunities for preventive interventions. Fifty Medicaid-insured inpatients identified by a validated statistical algorithm as being at high-risk for frequent hospitalizations were interviewed at an urban public hospital. Patient drug/alcohol history, experiences with medical, psychiatric and addiction treatment, and social factors contributing to readmission were evaluated. Three themes related to SU and frequent hospitalizations emerged: (a) barriers during hospitalization to planning long-term treatment and follow-up, (b) use of the hospital as a temporary solution to housing/family problems, and (c) unsuccessful SU aftercare following discharge. These data indicate that homelessness, brief lengths of stay complicating discharge planning, patient ambivalence regarding long-term treatment, and inadequate detox-to-rehab transfer resources compromise substance-using patients' likelihood of avoiding repeat hospitalization. Intervention targets included supportive housing, detox-to-rehab transportation, and postdischarge patient support.

Abstract

Background: Pay-for-performance is an increasingly popular approach to improving health care quality, and the US government will soon implement pay-for-performance in hospitals nationwide. Yet hospital capacity to perform (and

improve performance) likely depends on local resources. In this study, we quantify the association between hospital performance and local economic and human resources, and describe possible implications of pay-for-performance for socioeconomic equity.

Methods and Findings: We applied county-level measures of local economic and workforce resources to a national sample of US hospitals (n = 2,705), during the period 2004–2007. We analyzed performance for two common cardiac conditions (acute myocardial infarction [AMI] and heart failure [HF]), using process-of-care measures from the Hospital Quality Alliance [HQA], and isolated temporal trends and the contributions of individual resource dimensions on performance, using multivariable mixed models. Performance scores were translated into net scores for hospitals using the Performance Assessment Model, which has been suggested as a basis for reimbursement under Medicare’s ‘‘Value-Based Purchasing’’ program. Our analyses showed that hospital performance is substantially associated with local economic and workforce resources. For example, for HF in 2004, hospitals located in counties with longstanding poverty had mean HQA composite scores of 73.0, compared with a mean of 84.1 for hospitals in counties without longstanding poverty (p,0.001). Hospitals located in counties in the lowest quartile with respect to college graduates in the workforce had mean HQA composite scores of 76.7, compared with a mean of 86.2 for hospitals in the highest quartile (p,0.001). Performance on AMI measures showed similar patterns. Performance improved generally over the study period. Nevertheless, by 2007—4 years after public reporting began—hospitals in locationally disadvantaged areas still lagged behind their locationally advantaged counterparts. This lag translated into substantially lower net scores under the Performance Assessment Model for hospital reimbursement.

Conclusions: Hospital performance on clinical process measures is associated with the quantity and quality of local economic and human resources. Medicare’s hospital pay-for-performance program may exacerbate inequalities across regions, if implemented as currently proposed. Policymakers in the US and beyond may need to take into consideration the balance between greater efficiency through pay-for-performance and socioeconomic equity.

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New York. London. Paris. Although these cities have similar sociodemographic characteristics, including income inequalities and ethic diversity, they have vastly different health systems and services. This book compares the three and considers lessons that can be applied to current and future debates about urban health care.

Highlighting the importance of a national policy for city health systems, the authors use well-established indicators and comparable data sources to shed light on urban health policy and practice. Their detailed comparison of the three city health systems and the national policy regimes in which they function provides information about access to health care in the developed world's largest cities.

The authors first review the current literature on comparative analysis of health systems and offer a brief overview of the public health infrastructure in each city. Later chapters illustrate how timely and appropriate disease prevention, primary care, and specialty health care services can help cities control such problems as premature mortality and heart disease.

In providing empirical comparisons of access to care in these three health systems, the authors refute inaccurate claims about health care outside of the United States.

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Purpose

This study investigates the degree to which the racial composition of the school environment may influence the body mass index (BMI) of children aged 10 to 18 years. This research may be viewed as extending prior work that has found that the prevalence of risk behaviors among nonwhite adolescents is influenced by exposure to white adolescents.

Methods

This research used data from the Survey of Adults and Youth, which was conducted as part of the evaluation of the Robert Wood Johnson Foundation's Urban Health Initiative. The study population for this analysis is comprised of parent and child respondents in the 2004 to 2005 survey wave who lived in one of the five program cities: Baltimore, Detroit, Oakland, Philadelphia, and Richmond. We constructed two-level school random effects models and added school and census tract-level variables that describe the racial composition of the residential community and the school attended.

Results

Black and Hispanic adolescent girls who attend schools with a mostly nonwhite student body have higher BMIs than do their white counterparts. However, black girls in predominately white schools do not have higher BMIs than white girls. Further, black and Hispanic girls whose schoolmates are predominately white have significantly lower BMIs than black and Hispanic girls in schools where fewer than half the students are white. These associations are not found among boys, and are net of a broad variety of individual, household, and group level characteristics.

Conclusions

Our findings suggest that the BMI of minority adolescent girls is influenced by the norms of the social environment.

Patients with frequent hospitalizations generate a disproportionate share of hospital visits and costs. Accurate determination of patients who might benefit from interventions is challenging: most patients with frequent admissions in 1 year would not continue to have them in the next. Our objective was to employ a validated regression algorithm to case-find Medicaid patients at high-risk for hospitalization in the next 12 months and identify intervention-amenable characteristics to reduce hospitalization risk. We obtained encounter data for 36,457 Medicaid patients with any visit to an urban public hospital from 2001 to 2006 and generated an algorithm-based score for hospitalization risk in the subsequent 12 months for each patient (0 = lowest, 100 = highest). To determine medical and social contributors to the current admission, we conducted in-depth interviews with high-risk hospitalized patients (scores >50) and analyzed associated Medicaid claims data. An algorithm-based risk score >50 was attained in 2,618 (7.2%) patients. The algorithm’s positive predictive value was equal to 0.67. During the study period, 139 high-risk patients were admitted: 60 met inclusion criteria and 50 were interviewed. Fifty-six percent cited the Emergency Department as their usual source of care or had none. Sixty-eight percent had >1 chronic medical conditions, and 42% were admitted for conditions related to substance use. Sixty percent were homeless or precariously housed. Mean Medicaid expenditures for the interviewed patients were $39,188 and $84,040 per patient for the years immediately prior to and following study participation, respectively. Findings including high rates of substance use, homelessness, social isolation, and lack of a medical home will inform the design of interventions to improve community-based care and reduce hospitalizations and associated costs.

This article uses the evaluation of the Robert Wood Johnson Foundation’s (RWJF) Urban Health Initiative (UHI), a 10-year effort to improve health and safety outcomes in distressed cities, to demonstrate the strength of an evaluation design that integrates theory of change and quasiexperimental
approaches, including the use of comparison cities. This paper focuses on the later stages of implementation and, especially, our methods for estimating program impacts. While the theory of change was used to make preliminary identification of intended outcomes, we used the sites’ plans and early implementation to refine this list and revisit our strategy for estimating impacts. Using our integrated design, differences between program and comparison cities are considered impacts only if they were predicted by program theory, local plans for action, and early implementation. We find small, measurable changes in areas of greatest programmatic effort. We discuss the importance of the integrated design in identifying impacts.

Yellow-dust storms (YDSs) have attracted increasing attention worldwide in the past decade. They can extensively disrupt socioeconomic activities and pose hazards to ecosystems, as well as human health.  In recent years, China has invested multi-billions of dollars to mitigate the impact of YDSs.  However, the effectiveness of such YDS-control programs has rarely been evaluated. This research develops a causal model to quantify the environmental benefits of YDS-control programs in China, and further employs regional economic models to evaluate the ensuing economic impacts. The economic benefits generated from the YDS-control programs have remained stable across the years, primarily because of the multiplier effect of the investments, while the environmental benefits tend to decline over time.  Our results suggest that YDS-control programs should consider stimulating local economic activities in addition to environmental goals in order to be cost-effective and sustainable in the long term.

Developing community capacity to improve health is a cornerstone of community-based public health. The concept of community capacity reflects numerous facets and dimensions of community life and can have different meanings in different contexts. This paper explores how members of one community identify and interpret key aspects of their community's capacity to limit the availability and use of tobacco products. Particular attention is given to examining the interrelationship between various dimensions of community capacity in order to better understand the processes by which communities are able to mobilize for social change. The study is based on qualitative analysis of 19 in-depth interviews with key informants representing a variety of community sectors in Harlem, New York City. Findings indicate that the community is viewed as rich in human and social resources. A strong sense of community identity and connectedness underlies this reserve and serves as a catalyst for action.

The South Bronx, New York, has one of the highest asthma rates among school-age children in the United States. Since children spend significant parts of their day at school, an understanding of where schools are located in relation to environmental health hazards that can potentially affect asthma can provide important information for making
decisions related to urban land-use planning and environmental policy. GIS provides communities with an important tool for leveraging data for policymaking efforts and improving policy makers' understanding of how different land uses might affect public health.

A collection of writings by leading experts and newer researchers on the SARS outbreak and its relation to infectious disease management in progressively global and urban societies.

We find that estimates of the prevalence of teenage smoking and drinking in “urban,” “suburban,” and “rural” areas vary with different definitions of these types of geographic units. Given the salience of youth risk behavior to the public debate, we urge researchers to purposefully choose their definitions of geographic areas and to be explicit about those choices.

Climate change and human health are intertwined.  The heat waves in Chicago, in 1995, and in Paris, in 2003, followed by Hurricane Katrina_s destruction of New Orleans, raised awareness of the risks faced by vulnerable older people. Many cities have responded by announcing emergency preparedness plans; some of these plans have already been tested. Last summer, from July 27 to August 5, New York City suffered a mild heat wave with temperatures reaching 100-F. Paris, as well, was hit by another heat wave from July 17 to July 29, with maximum temperatures reaching 104-F, which was considerably milder than in 2003 when they often exceeded 110-F. In New York, there were 100 "excess deaths," an increase of 8% over past trends. In Paris, the number of excess deaths in 2006 (42), also an increase of 8%, was considerably lower than the 1,294 deaths registered in 2003-an increase of 190% compared to the preceding three-year average. Given existing surveillance capacity, it is impossible to know whether the reduction in excess deaths in Paris was due, partly, to its enhanced preparedness or whether it reflects no more than the effects of a far milder heat wave. Nevertheless, the milder heat wave of 2006 does provide an opportunity to examine the actual implementation of the heat wave preparedness plan. In light of ongoing efforts to develop such plans in cities worldwide and completed studies on the effects of the 2003 heat wave in Paris, what may be learned to promote urban health and improve understanding of the factors that put vulnerable older people at greatest risk?

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.

Background: Access to timely and effective medical services can reduce rates of premature mortality attributed to certain conditions. We investigate rates of total and avoidable mortality (AM) and the percentage of avoidable deaths in France, England and Wales and the United States, three wealthy nations with different health systems, and in the urban cores of their world cities, Paris, Inner London and Manhattan. We examine the association between AM and an income-related variable among neighbourhoods of the three cities. Methods: We obtained mortality data from vital statistics sources for each geographic area. For two time-periods, 1988–90 and 1998–2000, we assess the correlation between area of residence and age- and gender-adjusted total and AM rates. In our comparison of world cities, regression models are employed to analyse the association of a neighbourhood income-related variable with AM. Results: France has the lowest mortality rates. The US exhibits higher total, but similar AM rates compared to England and Wales. Rates of AM are lowest in Paris and highest in London. Avoidable mortality rates are higher in poor neighbourhoods of all three cities; only in Manhattan is there a correlation between the percentage of deaths that are avoidable and an income related variable. Conclusions: Beyond the well-known association of income and mortality, persistent disparities in AM exist, particularly in Manhattan and Inner London. These disparities are disturbing and should receive greater attention from policy makers.

Released in partnership with the Human Rights Project of the Urban Justice Center, this shadow report highlights the persistent discrimination experienced by people of color and immigrants in NYC and brings attention to the failure of the City to meet its full obligations under CERD.

We find that estimates of the prevalence of teenage smoking and drinking in "urban," "suburban," and "rural" areas vary with different definitions of these types of geographic units. Given the salience of youth risk behavior to the public debate, we urge researchers to purposefully choose their definitions of geographic areas and to be explicit about those choices.

Abstract The U.S. faces rising rates of overweight and obesity. Active living-urban planning and design to promote physical activity?has emerged as a strategy to combat growing obesity. The active living movement initially targeted mostly middle-class, suburban communities. In this article, I argue that planning for active living must especially address low-income, Black, and Latino communities, where obesity and related health risks are greatest and resources least available. First I review the problem of obesity and related health conditions among low-income, Black, and Latino populations in the U.S., and identify the role of insufficient physical activity in this problem. I then examine physical environment and other factors that shape opportunities for physical activity in low-income communities and communities of color. Finally, I identify strategies that may help to promote active living in urban settings to better serve these communities. Abstract The U.S. faces rising rates of overweight and obesity. Active living-urban planning and design to promote physical activity?has emerged as a strategy to combat growing obesity. The active living movement initially targeted mostly middle-class, suburban communities. In this article, I argue that planning for active living must especially address low-income, Black, and Latino communities, where obesity and related health risks are greatest and resources least available. First I review the problem of obesity and related health conditions among low-income, Black, and Latino populations in the U.S., and identify the role of insufficient physical activity in this problem. I then examine physical environment and other factors that shape opportunities for physical activity in low-income communities and communities of color. Finally, I identify strategies that may help to promote active living in urban settings to better serve these communities.

Declining birthrates, increasing longevity and growing urbanization have created a new challenge for cities: how to respond to an aging population. The World Cities Project was designed to examine whether the four largest cities among the wealthiest nations of the world - New York, London, Paris and Tokyo - offer a model of what other cities will someday resemble as their populations grow older.

Perhaps the four world cities examined here will always be regarded as special cases; however, they share in common a host of important characteristics. Within them live the largest number of older people in their countries and in some neighborhoods the percent of elders 65 or older far exceeds what the census demographers project for their nations in 2030. Thus, these great cities may serve as laboratories to inquire about the implications of demographic change for health and quality of life, living arrangements and housing, and the provision of long-term care to older adults when they eventually become frail.

Chronic diseases of environmental origin are a significant and increasing public health problem among the children of New York State, yet few resources exist to address this growing burden. To assess New York State pediatricians self-perceived competency in dealing with common environmental exposures and diseases of environmental origin in children, we assessed their attitudes and beliefs about the role of the environment in children's health. A four-page survey was sent to 1,500 randomly selected members of the New York State American Academy of Pediatrics in February 2004. We obtained a 20.3% response rate after one follow-up mailing; respondents and nonrespondents did not differ in years of licensure or county of residence. Respondents agreed that the role of environment in children's health is significant (mean 4.44 +/- 0.72 on 1-5 Likert scale). They voiced high self-efficacy in dealing with lead exposure (mean 4.16-4.24 +/- 0.90-1.05), but their confidence in their skills for addressing pesticides, mercury and mold was much lower (means 2.51-3.21 +/- 0.90-1.23; p < 0.001). About 93.8% would send patients to a clinic "where pediatricians could refer patients for clinical evaluation and treatment of their environmental health concerns." These findings indicate that New York pediatricians agree that children are suffering preventable illnesses of environmental origin but feel ill-equipped to educate families about common exposures. Significant demand exists for specialized centers of excellence that can evaluate environmental health concerns, and for educational opportunities.

This article describes the nature and utility of fiscal analysis in evaluating complex community interventions. Using New York University's evaluation of the Robert Wood Johnson Foundation's Urban Health Initiative as an example, the authors describe issues arising in defining and operationalizing constructs for fiscal analysis. The approach's utility is demonstrated in the use of interim findings to help redefine the program's goals for resource allocation, to modify its theory of change to include greater emphasis on state-level action, and to emphasize the importance of local public schools as resource centers and intervention targets. The fiscal analysis also provides new insights into the limitations of "preventive" versus "corrective" spending categories and helps make goals for such functional reallocation more realistic. The authors discuss limitations of fiscal analysis due to available data quality, the extent of cooperation needed from public officials to collect relevant data, and the level of expertise needed to interpret the data.

Health services research is, by nature, multidisciplinary, for it draws on the methods,concepts and theories of social sciences, which are relevant to the study of how the organization and financing of health services can improve the delivery of health care services (Gray, et al., 2003). While medicine and public health, too, are multidisciplinary enterprises drawing on such disciplines as molecular biology, physiology, anatomy, genetics, epidemiology and more, health services research departs from these disciplines in focusing not on the nature of disease and health but rather on the financing and organization of health systems.

So it is with urban health services research albeit that this field is more narrowly focused on health services in cities. The city focus has resulted in a large body of research on vulnerable groups, barriers to service access, public health clinics and community health centers. Likewise, it has led to important investigations of safetynet institutions, e.g. public hospitals and health centers, which serve a disproportionate share of uninsured and low-income patients. In addition, urban health services research has focused on a host of specific services associated with subpopulations suffering from TB, HIV/AIDS, drug addiction and other social pathologies that are typically associated with the "inner city."

Details the hospital experience of a health professional who underwent cardiac arterial bypass graft on the said urban medical center. Errors or potential errors that were cited in the way that ancillary staff, nurses and even some physicians failed in or neglected their responsibilities, both medical and humane; System failures observed, largely in the provision of nonclinical, so called hotel services; Possible cause of many of the problems identified.

Mass transit is a critical infrastructure of urban environments worldwide. The public uses it extensively, with roughly 9 billion mass transit trips occurring annually in the United States alone according to the U.S. Department of Transportation data. Its benefits per traveler include lower emissions of air pollutants and energy usage and high speeds and safety records relative to many other common modes of transportation that contribute to human health and safety. However, mass transit is vulnerable to intrusions that compromise its use and the realization of the important benefits it brings. These intrusions pertain to physical conditions, security, external environmental conditions, and equity. The state of the physical condition of transit facilities overall has been summarized in the low ratings the American Society of Civil Engineers gives to mass transit, and the large dollar estimates to maintain existing conditions as well as to bring on new improvements, which are, however, many times lower than investments estimated for roadways. Security has become a growing issue, and numerous incidents point to the potential for threats to security in the US. External environmental conditions, such as unexpected inundations of water and electric power outages also make transit vulnerable. Equity issues pose constraints on the use of transit by those who cannot access it. Transit has shown a remarkable ability to rebound after crises, most notably after the September 11, 2001 attacks on the World Trade Center, due to a combination of design and operational features of the system. These experiences provide important lessons that must be captured to provide proactive approaches to managing and reducing the consequences of external factors that impinge negatively on transit.

This report presents data on computer access, Internet use, and factors associated with health information seeking on the Internet among a sample of youths aged 15 to 30 years in New York City. Findings from street intercept surveys indicate substantial computer access at home (62%) and frequent (everyday or a few times a week) Internet use (66%). Fifty-five percent of the sample reported seeking health information on the Internet, which was associated with positive beliefs about getting a health checkup and frequent Internet use.

This paper examines public spending on children between 1997 and 2000 in five localities: Baltimore, Detroit, Oakland, Philadelphia, and Richmond. These cities participate in the Urban Health Initiative (UHI), a ten-year Robert Wood Johnson Foundation program aimed at improving health and safety for young people in these cities. The Center for Health and Public Service Research at New York University is evaluating the program. The evaluation seeks to determine whether collaborative efforts of interested organizations can develop and implement plans to change service delivery systems for children, and whether such changes result in better outcomes for children. A group of ten additional cities serves as a comparative benchmark.

The purpose was to examine attitudinal and contextual factors associated with the occurrence of sexual health assessments during adolescent primary care visits. A total of 313 primarily African-American youth aged 11-21 years from 16 community-based organizations in suburban Maryland and in New York City completed questionnaires focusing on sexually transmitted diseases (STD) and health care. The analysis examined the relationship of sexual activity, attitudes, and presence of the parent at the health care visit with discussion of three sexual health topics and testing for STD at the most recent health care visit. Data were analyzed using Chi-square tests and logistic regression. Overall, 74% of respondents reported that they had talked about at least one sexual health topic at their last health care visit but only 32% had discussed all three topics of sexual behavior, birth control, and STD. Females were more likely than males to discuss birth control although there were no gender differences in the overall likelihood of talking about a sexual health topic. Few adolescents initiated discussion of sexual issues. Positive attitudes toward discussing sexual issues with a provider and absence of a parent at the visit were independently associated with higher odds of discussing at least one sexuality topic and STD testing. Although relatively large numbers of adolescents in the sample received sexual health assessments, the proportion was below recommended guidelines. The opportunity to speak privately with a clinician and having positive attitudes about discussing sex with a doctor appear to be important influences on the receipt of sexual health assessments. Improving the quality of adolescent preventive care will require creating a health care environment that facilitates discussion of sexual health issues

Background: Gender disparities in the treatment of coronary artery disease (CAD) have been extensively documented in studies from the United States. However, they have been less well studied in other countries and, to our knowledge, have not been investigated at the more disaggregated spatial level of cities.

Objective: This study tests the hypothesis that there is a common international pattern of gender disparity in the treatment of CAD in persons aged ≥65 years by analyzing data from the United States, France, and England and from their largest cities-New York City and its outer boroughs, Paris and its First Ring, and Greater London.

Methods: This was an ecological study based on a retrospective analysis of comparable administrative
data from government health databases for the 9 spatial units of analysis: the 3 countries, their 3 largest
cities, and the urban cores of these 3 cities. A simple index was used to assess the relationship between
treatment rates and a measure of CAD prevalence by gender among age-adjusted cohorts of patients.
Differences in rates were examined by univariate analysis using the Student t test for statistical differences
in mean values.

Results: Despite differences in health system characteristics, including health insurance coverage, availability
of medical resources, and medical culture, we found consistent gender differences in rates of percutaneous
transluminal coronary angioplasty and coronary artery bypass grafting across the 9 spatial units.
The rate of interventional treatment in women with CAD was less than half that in men. This difference
persisted after adjustment for the prevalence of heart disease.

Conclusions: A consistent pattern of gender disparity in the interventional treatment of CAD was seen
across 3 national health systems with known differences in patterns of medical practice. This finding is
consistent with the results of clinical studies suggesting that gender disparities in the treatment of CAD
are due at least in part to the underdiagnosis of CAD in women.

Study objective: The study tests the extent to which primary care physician supply (office based primary care physicians per 10 000 population) moderates the association between social inequalities and infant mortality and low birth weight throughout the 50 states of the USA.

Design: Pooled cross sectional, time series analysis of secondary data. Analyses controlled for state level education, unemployment, racial/ethnic composition, income inequality, and urban/rural differences. Contemporaneous and time lagged covariates were modelled.

Setting: Eleven years (1985-95) of data from 50 US states (final n = 549 because of one missing data point).

Main results: Primary care was negatively associated with infant mortality and low birth weight in all multivariate models (p<0.0001). The association was consistent in contemporaneous and time lagged models. Although income inequality was positively associated with low birth weight and infant mortality (p<0.0001), the association with infant mortality disappeared with the addition of sociodemographic covariates.

Conclusions: In US states, an increased supply of primary care practitioners-especially in areas with high levels of social disparities-is negatively associated with infant mortality and low birth weight.

Awareness of youth violence has increased in recent years, resulting in more interest in programs that can prevent violent and aggressive behavior. Although overall rates of violence among young people have declined since the mid-1990s, rates of some forms of youth aggression, violence, and crime remain high. National data reveal that, each year, about 15 percent of high school students are involved in a physical fight at school and 8 percent are threatened or injured with a weapon. 1 Urban youth are at particular risk for exposure to violence and victimization.

This report describes one of the largest and longest running school-based violence prevention programs in the country-the Resolving Conflict Creatively Program (RCCP)-and discusses the results of a rigorous evaluation conducted by the National Center for Children in Poverty (NCCP) at Columbia University's Mailman School of Public Health. The evaluation provides concrete evidence that early, school-based prevention initiatives such as the RCCP can work and should be included in communities' efforts to prevent violence among children and youth.

BACKGROUND AND PURPOSE: The goal of this study was to test whether primary care reduces the impact of income inequality on stroke mortality. METHODS: This study used pooled time-series cross-sectional analysis of 11 years of state-level data (n=549). Analyses controlled for education levels, unemployment, racial/ethnic composition, and percent urban. Contemporaneous and time-lagged covariates were modeled. RESULTS: Primary care was negatively associated with stroke mortality in models including all covariates (P<0.0001). The impact of income inequality on stroke mortality was reduced in the presence of primary care (P<0.0001) but disappeared with the addition of covariates (P>0.05). CONCLUSIONS: In the absence of social policy that addresses sociodemographic determinants of health, primary care promotion may serve as a palliative strategy for combating stroke mortality and reducing the adverse impact of income inequality on health.

Studies over the last decade have demonstrated the effectiveness of public health interventions based on social and behavioral science theory for many health problems. Little is known about the extent to which health departments are currently utilizing these theories. This study assesses the application of social and behavioral science to programs in the New York City Department of Health (NYCDOH). Structured open-ended interviews were conducted with executive and program management staff of the health department. Respondents were asked about the application of social and behavioral sciences within their programs, and about the benefits and barriers to increasing the use of such approaches. Themes related to the aims of the study were identified, a detailed coding manual developed, narrative data were coded independently by two investigators (kappa.85), and data analyzed. Interviews were conducted with 61 eligible individuals (response rate 88%). The most common applications of social and behavioral science were individual-level behavior change to prevent HIV transmission and community-level interventions utilizing community organizing models and/or media interventions for health promotion and disease prevention. There are generally positive attitudes about the benefits of utilizing these sciences; however, there are also reservations about expanded use because of resource constraints. While NYCDOH has successfully applied social and behavioral sciences in some areas of practice, many areas use them minimally or not at all. Increasing use will require additional resources. Partnerships with academic institutions can bring additional social and behavioral science resources to health departments and benefit researchers understanding of the health department environment.

This paper explores the relationship between racial segregation and racial disparities in the prevalence of low birth weight. The paper has two parallel motivations. First, the disparities between black and white mothers in birth outcomes are large and persistent. In 1996, 13 percent of infants born in the United States to black mothers weighed less than 2,500 grams (5.5 pounds, or low birth weight), compared with just 6.3 percent of all infants born to white mothers. And the consequences may be grave. Low birth weight is a major cause of infant mortality and is associated with greater childhood illness and such developmental disorders as cerebral palsy, deafness, blindness, epilepsy, chronic lung disease, learning disabilities, and attention deficit disorder. 1 Given the strong connection between race and residence in this country, it seems plausible that residential location may shape these differentials.

Second, while there is a growing literature on the costs of racial segregation, it has largely focused on economic outcomes such as education and employment. This paper aims to develop a fuller understanding of the costs of racial segregation by considering birth outcomes as well as such behaviors as tobacco and alcohol use among pregnant mothers. As Glaeser emphasizes (in his paper in this volume), information, ideas, and values are often transmitted through face-to-face interaction, and thus their transmission may be blocked by segregation. This includes information related to job openings and may include information and norms related to behavior and care during pregnancy.

Adopting in large part the methodology of David Cutler and Edward L. Glaeser, the paper thus examines how levels of racial segregation affect the birth outcomes of black mothers. 2 It examines influences on both black and nonblack mothers in an attempt to identify the differential effect of segregation on black mothers.

Improvements in health care and declining birth rates have combined to create rapidly aging populations throughout the industrialized world. By 2020, for example, nearly seventeen percent of the US population is expected to be over the age of sixty-five. In Japan that mark has already been passed, with more than one-quarter of the population expected to be over sixty-five by 2020. At the same time, the world's population is increasingly concentrated in urban areas: the United Nations estimates that by 2025, sixty-one percent of the world's population will live in cities. As both urbanization and population aging increase, we will need models of how to accommodate this population shift and examples to emulate in dealing with these phenomena.

Water pollution from agricultural pesticides continues to be a public concern. Given that the use of such pesticides on the farm is largely governed by voluntary behavior, it is important to understand what drives farmer behavior. Health belief models in public health and social psychology argue that persons who have adverse health experiences are likely to undertake preventive behavior. An analogous hypothesis set was tested here: farmers who believe they have had adverse health experiences from pesticides are likely to have heightened concerns about pesticides and are more likely to take greater precautions in dealing with pesticides. This work is based on an original survey of a population of 2700 corn and soybean growers in Maryland, New York, and Pennsylvania using the U.S. Department of Agriculture data base. It was designed as a mail survey with telephone follow-up, and resulted in a 60 percent response rate. Farm operators report experiencing adverse health problems they believe are associated with pesticides that is equivalent to an incidence rate that is higher than the reported incidence of occupational pesticide poisonings, but similar to the reported incidence of all pesticide poisonings. Farmers who report experiencing such problems have more heightened concerns about water pollution from fertilizers and pesticides, and illness and injury from mixing, loading, and applying pesticides than farmers who have not experienced such problems. Farmers who report experiencing such problems also are more likely to report using alternative pest management practices than farmers who do not report having such problems. This implies that farmers who have had such experiences do care about the effects of application and do engage in alternative means of pest management, which at least involve the reduction in pesticide use.

The effectiveness of current groundwater protection policies depends largely on farmers' voluntary compliance with leaching reduction measures, an important component of which is their willingness to adopt costlier production practices in order to prevent leaching of chemicals. Data from an original survey of 1611 corn and soybean growers in the mid-Atlantic region were used to estimate farmers' willingness to pay to prevent leaching of pesticides into groundwater. The results indicate that farmers are willing to pay more for leaching prevention than nonfarm groundwater consumers, both absolutely and relative to total income. The primary motivation appears to be concern for overall environmental quality rather than protection of drinking water or the health and safety of themselves and their families. Hobby farmers are willing to pay more than farmers with commercial activity. Certified pesticide applicators are willing to pay less than farmers without certification.

Examines a demonstration program to develop skills and experience for middle managers ar a mid-sized urban hospital in the United States. Background information on the management development program at the New York Downtown Hospital; Participation by middle and senior management; Program curriculum; Program weaknesses, opportunities, threats; Recommendations for replication.

The use of meta-analysis in environmental epidemiology can enhance the value of epidemiologic data in debates about environmental health risks. Meta-analysis may be particularly useful to formally examine sources of heterogeneity, to clarify the relationship between environmental exposures and health effects, and to generate information beyond that provided by individual studies or a narrative review. However, meta-analysis may not be useful when the relationship between exposure and disease is obvious, when there are only a few studies of the key health outcomes, or when there is substantial confounding or other biases which cannot be adjusted for in the analysis. Recent increases in the use of meta-analysis in environmental epidemiology have highlighted the need for guidelines for the application of the technique. Guidelines, in the form of desirable and undesirable attributes, are presented in this paper for various components of a metaanalysis including study identification and selection; data extraction and analysis; and interpretation, presentation, and communication of results, Also discussed are the appropriateness of the use of meta-analysis in environmental health studies and when metaanalysis should or should not be used.