Facing the Challenge of Evaluating a Complex, Multi-Site Initiative
The Evaluation Exchange, a quarterly publication of the Harvard Family Research Project, Fall, Vol 9, No. 3.
Weitzman, B.C. & Silver, D.S.
Beth Weitzman and Diana Silver from New York University's Center for Health and Public Service Research offer their experience integrating a comparison group design into a theory of change approach.
New York City
Encyclopedia of Homelessness. Berkshire Publishing,
Weitzman, B.C. & Fischer, S.N.
At any given moment, about 3 million American women, men, and children are homeless. And another 5 million Americans spend over 50% of their incomes on housing, meaning that one missed paycheck, one health crisis, or one unpaid utility bill can push them out the door into homelessness. Homelessness is one of the major social problems and personal and family tragedies of the contemporary world. No community, city, or nation is immune and the lack of affordable housing and a decline in secure, well-paying jobs means that the problem will only get worse. The Encyclopedia of Homelessness is the first systematic effort to organize and summarize what we know about this complex topic that impacts not only the homeless but all of society. The Encyclopedia focuses on the current situation in the United States with a comparative sampling of homelessness around the world.
The Politics of Obesity: A Current Assessment and Look Ahead
Context: The continuing rise in obesity rates across the United States has proved impervious to clinical treatment or public health exhortation, necessitating policy responses. Nearly a decade's worth of political debates may be hardening into an obesity issue regime, comprising established sets of cognitive frames, stakeholders, and policy options.
Methods: This article is a survey of reports on recently published studies.
Findings: Much of the political discussion regarding obesity is centered on two "frames," personal-responsibility and environmental, yielding very different sets of policy responses. While policy efforts at the federal level have resulted in little action to date, state and/or local solutions such as calorie menu labeling and the expansion of regulations to reduce unhealthy foods at school may have more impact.
Conclusions: Obesity politics is evolving toward a relatively stable state of equilibrium, which could make comprehensive reforms to limit rising obesity rates less feasible. Therefore, to achieve meaningful change, rapid-response research identifying a set of promising reforms, combined with concerted lobbying action, will be necessary.
Obesity burst onto the U.S. national policy agenda in 2000/2001, initially fuelled by a widely disseminated set of maps by the Centers for Disease Control and Prevention (CDC) depicting sharply rising obesity rates nationwide, followed by the surgeon general's warning that obesity had become a "new national epidemic" (Mokdad et al. 2003; Oliver 2006; Satcher 2001). A snapshot of responses since then would include alarmed reactions from medical, media, and policy actors alike. The health establishment has rushed to devise medical treatments, from surgical to pharmaceutical, for obesity and its manifold health effects. Surging media attention to obesity and overweight features reports ranging from dire health alarms ("the current generation may be the first to live shorter lives than their parents-and obesity is to blame"; Belluck 2005, p. A1; see also Daniels 2006; Olshansky et al. 2005) to economic warnings (over $120 billion lost annually to obesity-related illnesses; see e.g., Bhattacharya and Sood 2006) to "lifestyle" stories of coffins, airplane seats, and hospital beds all made larger to suit the "supersizing of America" (St. John 2003, p. A13). Public officials at all levels have decried the "epidemic," although statutory reforms have been concentrated in a few energetic local and state polities; the federal government has been noticeably slow to act. All the while obesity rates continue to rise, with thirty-seven states reporting significant year-to-year increases from 2007 to 2008, with none reporting a decrease (TFAH 2008).
This article explores obesity politics as it has evolved in recent years. First I discuss the sustained struggles over framing the topic now that public agendas have begun to solidify into an "issue regime" around obesity. Then I examine popular local and state policy options and review approaches that could have an impact on soaring obesity rates, along with an assessment of the likelihood of their widespread adoption. While promising policy approaches exist, the opportunity to take action may be closing fast. On most public health issues, policymaking features a bustle of activity followed by a period of quiescence as a regime coalesces-even when the underlying problems continue to mount. Antiobesity advocates who face declining interest from lawmakers will therefore need to devise creative ways to sustain a focus on this topic.
A Prospective Study of Syphilis and HIV Infection among Injection Drug Users Receiving Methadone in the Bronx, NY
American Journal of Public Health, Aug 96 Part 1 of 2, Vol. 86 Issue 8, p1112-1115, 4p.
Gourevich, M., Hartel, D., Schoenbaum, E.E., Selwyn, P.A., Davenny, K., Friedland, G.H. & Klein, R.S.
The purpose of this study was to assess the relationship between syphilis and human immunodeficiency virus (HIV) infection in injection drug users. Methods. A 6-year prospective study of 790 injection drug users receiving methadone maintenance treatment in the Bronx, NY, was conducted. Results. Sixteen percent (4/25) of HIV-seroconverting patients, 4.8% (16/335) of prevalent HIV-seropositive patients, and 3.5% (15/430) of persistently HIV-seronegative patients were diagnosed with syphilis. Incidence rates for early syphilis (cases per 1000 person-years) were 15.9 for HIV-seroconverting patients, 8.9 for prevalent HIV-seropositive patients, and 2.9 for persistently HIV-seronegative patients. Early syphilis incidence was higher among women than men (8.4 vs 3.2 cases per 1000 person-years). Independent risks for early syphilis included multiple sex partners, HIV seroconversion, paid sex, and young age. All HIV seroconverters with syphilis were female. Conclusions. Diagnosis of syphilis in drug-using women reflects high-risk sexual activity and is associated with acquiring HIV infection. Interventions to reduce the risk of sexually acquired infections are urgently needed among female drug users.
Analysis of a Population-Based Pneumocystis carinii Pneumonia Index as an Outcome Measure of Access and Quality of Care for the Treatment of HIV Disease
American Journal of Public Health, Mar, Vol. 92 Issue 3, p395-398, 4p.
Arno, P.S., Gourevitch, M.N., Drucker, E., Fang, J., Goldberg, C…& Schoenbaum, E.
A population-based Pneumocystis carinii pneumonia (PCP) Index was developed in New York City to identify geographic areas and subpopulations at increased risk for PCP. Methods. A zip code-level PCP Index was created from AIDS surveillance and hospital discharge records and defined as (number of PCP-related hospitalizations)/(number of persons living with AIDS). Results. In 1997, there were 2262 hospitalizations for PCP among 39 740 persons living with AIDS in New York City (PCP Index = .05691). PCP Index values varied widely across neighborhoods with high AIDS prevalence (West Village = .02532 vs Central Harlem = .08696). Some neighborhoods with moderate AIDS prevalence had strikingly high rates (Staten Island = .14035; northern Manhattan = .08756). Conclusions. The PCP Index highlights communities in particular need of public health interventions to improve HIV-related service delivery.
Economic Evaluation of an HIV Prevention Intervention for Seropositive Injection Drug Users
Journal of Public Health Management & Practice, Nov/Dec 2005, Vol. 11 Issue 6, p508-515, 8p.
Tuli, K. & Sansom, S., Purcell, D.W., Metsch, L.R., Latkin, C.A., Gourevitch, M.N. & Gomez, C.A.
To assess the cost-effectiveness of Intervention for HIV-Seropositive injection drug users-Research and Evaluation (INSPIRE), designed to reduce risky sexual and needle-sharing behaviors in research sites in four US cities (2001-2003). Methods: We collected data on program and participant costs. We used a mathematical model to estimate the number of sex partners of injection drug users expected to become infected with human immunodeficiency virus (HIV) (with and without intervention), cost of treatment for sex partners who became infected, and the effect of infection on partners' quality-adjusted life expectancy. We determined the minimum effect that INSPIRE must have on condom use among participants for the intervention to be cost-saving (intervention cost less than savings from averted HIV infections) or cost-effective (net cost per quality-adjusted life year saved less than $50,000). Results: The intervention cost was $870 per participant. It would be cost-saving if it led to 53 percent reduction in the proportion of participants who had any unprotected sex in 1 year and cost-effective with 17 percent reduction. If behavior change lasted 3 months, the cost-effectiveness threshold was 66 percent; if 3 years, the threshold was 6 percent. Conclusions: Although cost-saving thresholds may not be achievable by the intervention, we anticipate that cost-effectiveness thresholds will be attained.
Two Wrongs Do Not Make a Right
National Tax Journal, Sep 2006, Vol. 59 Issue 3, p491-508, 18p.
This paper analyzes proposals to remedy tax-induced distortions in health care by using new tax incentives and retaining all of the existing distortionary tax incentives. In the process of remedying some distortions, this approach magnifies others--most notably increasing the total tax preference for health care. The paper considers two examples--the Bush administration's FY 2007 budget proposal and a plan by Cogan, Hubbard and Kessler (2005)--and shows that both could result in higher health spending and reduced welfare. Finally, the paper discusses the circumstances in which tax incentives could be warranted to remedy market failures in health insurance.
The President's Proposed Standard Deduction for Health Insurance: Evaluation and Recommendations
National Tax Journal, Sep 2007, Vol. 60 Issue 3, p433-454, 22p.
Burman, L.E., Furman, J., Leiserson, G. & Williams Jr, R.C.
The President's proposal to replace the current exclusion of employer-paid health insurance premiums with a standard deduction for qualifying health insurance would level the playing field for employment-based coverage and private plans but would risk the loss of insurance for many workers, threaten existing risk- sharing pools, and unfairly favor the wealthy. This paper evaluates the President's plan, suggests changes that would improve it, and assesses alternatives that would address the plan's shortcomings and improve its likelihood of expanding coverage to many families who now lack insurance.
Simplifying Children's Medicaid And SCHIP
Health Affairs; May/Jun2004, Vol. 23 Issue 3, p233-246, 14p.
Kronebusch, K. & Elbel, B.
The states have implemented the State Children's Health Insurance Program (SCHIP) in a variety of ways. We describe these choices and estimate the resulting enrollment impacts. Many widely adopted policies, including mail-in applications and twelve- month continuous eligibility, have had limited impacts. Other policies that increase enrollment, including presumptive eligibility and self-declaration of income, have not been widely adopted. SCHIP programs administered as Medicaid expansions have been more successful in enrolling children than either separate SCHIP plans or combination programs. Waiting periods, premiums, and welfare reform have had important negative impacts on children's program enrollment.
Enrolling Children in Public Insurance: SCHIP, Medicaid, and State Implementation
Journal of Health Politics, Policy & Law; Jun 2004, Vol. 29 Issue 3, p451-489, 39p.
Kronebusch, K. & Elbel, B.
The Balanced Budget Act of 1997 established federal grants to the states to create the State Children's Health Insurance Program (SCHIP). This presented the states with a number of implementation choices concerning administrative models for the new programs, as well as choices about eligibility standards, enrollment simplification, crowd-out, and cost sharing requirements. At the same time, the states were also implementing welfare reform. We describe the most important of these implementation choices, and using data from the Current Population Survey, we estimate the impacts of state policy on enrollment in this multiprogram environment. The results indicate that SCHIP programs that are administered as Medicaid expansions are more successful than either separate SCHIP plans or combination programs in enrolling children. States that remove asset tests and implement presumptive eligibility and self-declaration of income have higher enrollment levels. Continuous eligibility and adoption of mail-in applications have no effect on overall enrollment. Waiting periods and premiums reduce enrollment. Stringent welfare reform reduces children's enrollment, despite federal policy that was intended to protect children from the consequences of welfare reform. The negative impacts of a number of these policy reforms substantially reduce enrollment, potentially offsetting the more favorable impacts of other policy choices. We estimate that if all states adopted the policy options that facilitate program use, enrollment for children with family incomes less than 200 percent of the poverty line could be raised from the current rate of 42 percent to 58 percent.
Some Reflections On A Few Of The Pitfalls In The World Of Foundation Grant Making
Health Affairs, Nov/Dec 2007, Vol. 26 Issue 6, p1772-1775, 4p.
This paper offers some reflections on the grant-making process from a former foundation executive. Some of the opportunities, challenges, and pitfalls inherent in the foundation world are described, and one approach to grant making, the "call for proposals," is examined as an example of the need for greater attention to and investment in the science of grant making itself, to maximize the potential return from philanthropy.
Improving The Management Of Care For High- Cost Medicaid Patients
Health Affairs, Nov/Dec 2007, Vol. 26 Issue 6, p1643-1655, 13p.
Billings, J. & Mijanovich, T.
The article discusses the improvement of care management for high-cost Medicaid patients. It explores on Medicaid budgets which have prompted policymakers to redouble efforts to explore ways of boosting efficiency in care delivery, particularly for people with high-cost and chronic conditions. It also illustrates John Billings and Tod Mijanovich's article which examines the cost-effectiveness of care management for chronic disease patients treated in fee-for-service practice. The authors present an algorithm that identifies patients at high risk of future hospitalizations and offer a business-case analysis about the rate of reduction in future hospitalization and the cost of the intervention.
Reliability and Validity of the Spanish Versions of the Crisis in Family Systems - Revised
Psychological Reports, Feb 2006, Vol. 98 Issue 1, p123-132, 10p.
Berry, C., Quinn, K.A., Portillo, N. & Shalowitz, M.
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.
The Effects of Acculturation on Asthma Burden in a Community Sample of Mexican American Schoolchildren
American Journal of Public Health, Jul 2007, Vol. 97 Issue 7, p1290-1296, 7p.
Martin, M.A., Shalowitz, M.U., Mijanovich, T., Clark-Kauffman, E., Perez, E. & Berry, C.
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.
Jump-Starting Collaboration: The ABCD Initiative and the Provision of Child Development Services through Medicaid and Collaborators
Public Administration Review, May 2008, Vol. 68 Issue 3, p480-490, 11p.
Berry, C., Krutz, G.S., Langner, B. & Budetti, P.
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.
Behavior Changes After Notification of HIV Infection
American Journal of Public Health, Dec 1991, Vol. 81 Issue 12, p1586-1586, 5p.
Cleary, P.D., Van Devanter, N., Rogers, T.F., Singer, E., Shipton-Levy, R., Steilen, M., Stuart, A., Avorn, J. & Pindyck, J.
To learn more about how people who did not volunteer for testing react to information about HIV infection, we assessed short-term behavior changes in HIV-positive blood donors. Methods. Blood donors who were notified at the New York Blood Center that they were HTV positive were asked to participate in a study. A nurse elicited a medical history, performed a limited medical examination, and asked participants to complete a questionnaire that included questions about drug use, sexual behavior, and psychological characteristics. Participants were asked to return in 2 weeks to complete another questionnaire. Results. Many fewer men and women reported engaging in unsafe sexual behaviors in the 2 weeks preceding the follow-up visit than had reported such behaviors prior to notification. These changes were greater than those other investigators have reported, but about 40% of the participants still reported unsafe sexual activity at the follow-up interview. Conclusions. To make nonvolunteer screening programs for HIV infection more effective in reducing the spread of HTV infection, we need to learn more about how to help people change their high-risk behaviors.
Depressive Symptoms in Blood Donors Notified of HIV Infection
American Journal of Public Health April, Vol. 83 Issue 4, p534-539, 6p.
Cleary, P.D., Van Devanter, N., Rogers, T.F., Singer, E., Shipton-Levy, R., Steilen, M., Stuart, A., Avorn, J. & Pindyck, J.
Understanding more about the psychological state of persons notified of human immunodeficiency virus (HIV) infection is critical for designing notification and counseling programs that will have the most positive effect. Methods. The subjects were blood donors who had been notified of HIV infection by the New York Blood Center. A nurse elicited a medical history, performed a limited medical examination, and asked the subjects to complete a questionnaire that included questions about drug use, sexual behavior, and psychological characteristics. The subjects completed another questionnaire approximately 2 weeks later. Results. The average depressive symptom scores for both men and women were substantially higher than scores typically found in representative population samples. More than a quarter of the men and more than a third of the women reported seeking psychological or psychiatric services in the first few weeks following notification. Conclusions. Anticipating and meeting individuals' psychological needs may be necessary if HIV screening programs are to address effectively the needs of persons infected with HIV.
Recent Data Are Needed to Support Public Health Training and Workforce Initiatives
American Journal of Public Health, May 2000, Vol. 90 Issue 5, p809-809, 3/8p
Gerzoff, R.B. & Van Devanter, N.
A letter to the editor and a response to the letter by Nancy L. Van Devanter about the shortage of public health professionals and the need to support efforts to enhance public health training are presented.
Pneumoconiosis and Exposure of Dental Laboratory Technicians
American Journal of Public Health, Nov 1984, Vol. 74 Issue 11, p1252-1257, 6p
Rom, W.N. & Lockey, J.E., Lee, J.S., Kimball, C., Ki Moon, B., Leaman, H., …& Gibbons, H.L.
One hundred and seventy-eight denial laboratory technicians and 69 non-exposed controls participated in an epidemiological respiratory study. Eight technicians who had a mean of 28 years' grinding nonprecious metal alloys were diagnosed as having a simple pneumoconiosis by chest radiograph. Mean value for per cent predicted FVC and FEV[sub 1] were reduced among male nonsmoker technicians compared to male nonsmoker controls: after controlling for age. there was also a reduction in spirometry with increasing work years. An industrial hygiene survey was conducted in 13 laboratories randomly selected from 42 laboratories stratified by size and type of operation in the Sah Lake City, Utah metropolitan area. Personal exposures to beryllium and cobalt exceeded the Threshold Limit Values (TLVs) in one laboratory. Occupational exposures ia dental laboratories need to be controlled to prevent beryllium-related lung disorders as well as simple pneumoconiosis.
Negotiation, Jul 2006, p1-4, 4p.
The article presents information on the role of power in negotiation. Power could generate competition or conflict in negotiations, however, effective channelization of power helps in bringing the win-win situation to both the parties. Social psychologists have described power as lack of dependence on others. Individuals possessing power tend to have the approach related to the behavior that includes positive mood or searching for rewards in their environment. On the other hand, powerless individuals show a great deal of self-inhibition and fear towards potential threats. INSETS: WOMEN: INCREASE YOUR POWER AT THE TABLE;POWER ACROSS CULTURES.