Poverty, Educational Attainment and Health Among America’s Children: Current and Future Effects of Population Diversification and Associated Socioeconomic Change

A complex of interrelated factors including minority status, poverty, education, health status, and other factors determine the general welfare of children in America, particularly in heavily diverse states such as Texas. Although racial/ethnic status is clearly only a concomitant factor in that determination it is a factor for which future projections are available and for which the relationships with the other factors in the complex can be assessed. After examining the nature of the interrelationships between these factors we utilize direct standardization techniques to examine how the future diversification of the United States and Texas will affect the number of children in poverty, the educational status of the householders in households in which children in poverty live and the health status of children in 2040 assuming that the current relationships between minority status and these socioeconomic factors continue into the future. In the results of the analyses, data are compared with the total population of the United States and Texas in 2040 assumed in the first simulation scenario, to have the race/ethnicity characteristics of 2008 and in the second those projected for 2040 by the U.S. Census Bureau for the nation and by the Texas State Data Center for Texas in 2040. The results show that the diversification of the population could increase the number of children in poverty in the United States by nearly 1.8 million more than would occur with the lower levels of diversification evident in 2008. In addition, poverty would become increasingly concentrated among minority children with minority children accounting for 76.2 percent of all children in poverty by 2040 and with Hispanic children accounting for nearly half of the children in poverty by 2040. Results for educational attainment show an increasing concentration of minority children in households with householders with very low levels of education such that by 2040, 85.2 percent of the increase in the number of children in poverty would be in households with a householder with less than a high school level of education. Finally, the results related to several health status factors show that children in poverty will have a higher prevalence of nearly all health conditions. For example, the number of children with untreated dental conditions could increase to more than 4 million in the United States and to nearly 500,000 in Texas. The results clearly show that improving the welfare of children in America will require concerted efforts to change the poverty, educational, and health status characteristics associated with minority status and particularly Hispanic status. Failing to do so will lead to a future in which America’s children are increasingly impoverished, more poorly educated, and less healthy and which, as a result, is an America with a more tentative future.

Comparison of clinical knowledge management capabilities of commercially-available and leading internally-developed electronic health records.

BACKGROUND: We have carried out an extensive qualitative research program focused on the barriers and facilitators to successful adoption and use of various features of advanced, state-of-the-art electronic health records (EHRs) within large, academic, teaching facilities with long-standing EHR research and development programs. We have recently begun investigating smaller, community hospitals and out-patient clinics that rely on commercially-available EHRs. We sought to assess whether the current generation of commercially-available EHRs are capable of providing the clinical knowledge management features, functions, tools, and techniques required to deliver and maintain the clinical decision support (CDS) interventions required to support the recently defined "meaningful use" criteria. METHODS: We developed and fielded a 17-question survey to representatives from nine commercially available EHR vendors and four leading internally developed EHRs. The first part of the survey asked basic questions about the vendor's EHR. The second part asked specifically about the CDS-related system tools and capabilities that each vendor provides. The final section asked about clinical content. RESULTS: All of the vendors and institutions have multiple modules capable of providing clinical decision support interventions to clinicians. The majority of the systems were capable of performing almost all of the key knowledge management functions we identified. CONCLUSION: If these well-designed commercially-available systems are coupled with the other key socio-technical concepts required for safe and effective EHR implementation and use, and organizations have access to implementable clinical knowledge, we expect that the transformation of the healthcare enterprise that so many have predicted, is achievable using commercially-available, state-of-the-art EHRs.

Adolescents’ Sexual Health Matters: Texas Should Get on Board

Texas has an appalling record on adolescent sexual health. The Markham, et al. analysis of three data sets comparing Texas with the United States suggests what can be done to remedy the state's negative trends: (1) acknowledge that teens are having sex; (2) provide earlier, medically-accurate sex education; and, (3) provide reproductive health services in school-based health centers.

Evaluating Family Preservation in Nevada: A University-State Agency Collaboration

In this paper, concepts from the emerging family-centered paradigm in child welfare and mental health are applied to evaluative research in family preservation: the ecological perspective, enhancement of competence, a consumer orientation, and collaborative relationships. The experience of family preservation research collaborators from the School of Social Work at the University of Nevada, Reno and the Nevada Division of Child and Family Services illustrate these concepts. The researchers apply the theory of isomorphism to the research endeavor to produce eight principles of effective research partnerships derived from family-centered concepts and their own experiences.

Conceptual Bases of the Planning Process in Family Preservation/Family Support State Plans

Congress and the Department of Health and Human Services (DHHS) intend for the Family Preservation and Support Act of 1993 (P.L. 103-66) to catalyze major reforms in state human services systems. DHHS and numerous other institutions developed conceptual and procedural guidance for the states' planning processes. Review of the planning dimensions of participation and expertise reveals that major emphases on stakeholder participation and technical planning processes obscure the need for expertise in family preservation and family support.

An empirical examination of relative profitability in the nursing facility industry between ownership form and regionality in the state of Texas

The purpose of this research is to examine the relative profitability of the firm within the nursing facility industry in Texas. An examination is made of the variables expected to affect profitability and of importance to the design and implementation of regulatory policy. To facilitate this inquiry, specific questions addressed are: (1) Do differences in ownership form affect profitability (defined as operating income before fixed costs)? (2) What impact does regional location have on profitability? (3) Do patient case-mix and access to care by Medicaid patients differ between proprietary and non-profit firms and facilities located in urban versus rural regions, and what association exists between these variables and profitability? (4) Are economies of scale present in the nursing home industry? (5) Do nursing facilities operate in a competitive output market characterized by the inability of a single firm to exhibit influence over market price?^ Prior studies have principally employed a cost function to assess efficiency differences between classifications of nursing facilities. The inherent weakness in this approach is that it only considers technical efficiency. Not both technical and price efficiency which are the two components of overall economic efficiency. One firm is more technically efficient compared to another if it is able to produce a given quantity of output at the least possible costs. Price efficiency means that scarce resources are being directed towards their most valued use. Assuming similar prices in both input and output markets, differences in overall economic efficiency between firm classes are assessed through profitability, hence a profit function.^ Using the framework of the profit function, data from 1990 Medicaid Costs Reports for Texas, and the analytic technique of Ordinary Least Squares Regression, the findings of the study indicated (1) similar profitability between nursing facilities organized as for-profit versus non-profit and located in urban versus rural regions, (2) an inverse association between both payor-mix and patient case-mix with profitability, (3) strong evidence for the presence of scale economies, and (4) existence of a competitive market structure. The paper concludes with implications regarding reimbursement methodology and construction moratorium policies in Texas. ^

A prospective cohort study evaluating the state of medical readiness in the United States Air Force and risk factors to improve the medical readiness posture

A cohort of 418 United States Air Force (USAF) personnel from over 15 different bases deployed to Morocco in 1994. This was the first study of its kind and was designed with two primary goals: to determine if the USAF was medically prepared to deploy with its changing mission in the new world order, and to evaluate factors that might improve or degrade USAF medical readiness. The mean length of deployment was 21 days. The cohort was 95% male, 86% enlisted, 65% married, and 78% white.^ This study shows major deficiencies indicating the USAF medical readiness posture has not fully responded to meet its new mission requirements. Lack of required logistical items (e.g., mosquito nets, rainboots, DEET insecticide cream, etc.) revealed a low state of preparedness. The most notable deficiency was that 82.5% (95% CI = 78.4, 85.9) did not have permethrin pretreated mosquito nets and 81.0% (95% CI = 76.8, 84.6) lacked mosquito net poles. Additionally, 18% were deficient on vaccinations and 36% had not received a tuberculin skin test. Excluding injections, the overall compliance for preventive medicine requirements had a mean frequency of only 50.6% (95% CI = 45.36, 55.90).^ Several factors had a positive impact on compliance with logistical requirements. The most prominent was "receiving a medical intelligence briefing" from the USAF Public Health. After adjustment for mobility and age, individuals who underwent a briefing were 17.2 (95% CI = 4.37, 67.99) times more likely to have received an immunoglobulin shot and 4.2 (95% CI = 1.84, 9.45) times more likely to start their antimalarial prophylaxsis at the proper time. "Personnel on mobility" had the second strongest positive effect on medical readiness. When mobility and briefing were included in models, "personnel on mobility" were 2.6 (95% CI = 1.19, 5.53) times as likely to have DEET insecticide and 2.2 (95% CI = 1.16, 4.16) times as likely to have had a TB skin test.^ Five recommendations to improve the medical readiness of the USAF were outlined: upgrade base level logistical support, improve medical intelligence messages, include medical requirements on travel orders, place more personnel on mobility or only deploy personnel on mobility, and conduct research dedicated to capitalize on the powerful effect from predeployment briefings.^ Since this is the first study of its kind, more studies should be performed in different geographic theaters to assess medical readiness and establish acceptable compliance levels for the USAF. ^

An examination of the rate of high school completion experienced by handicapped and nonhandicapped students in the state of Texas

This research examines the graduation rate experienced by students receiving public education services in the state of Texas. Special attention is paid to that subgroup of Texas students who meet Texas Education Agency criteria for handicapped status. The study is guided by two research questions: What are the high school completion rates experienced by handicapped and nonhandicapped students attending Texas public schools? and What are the predictors of graduation for handicapped and nonhandicapped students?^ In addition, the following hypotheses are explored. Hypothesis 1: Handicapped students attending a Texas public school will experience a lower rate of high school completion than their nonhandicapped counterparts. Hypothesis 2: Handicapped and nonhandicapped students attending school in a Texas public school with a budget above the median budget for Texas public schools will experience a higher rate of high school completion than similar students in Texas public schools with a budget below the median budget. Hypothesis 3: Handicapped and nonhandicapped students attending school in large Texas urban areas will experience a lower rate of high school completion than similar students in Texas public schools in rural areas. Hypothesis 4: Handicapped and nonhandicapped students attending a Texas public school in a county which rates above the state median for food stamps and AFDC recipients will experience a lower rate of high school completion than students living in counties below the median.^ The study will employ extant data from the records of the Texas Education Agency for the 1988-1989 and the 1989-1990 school years, from the Texas Department of Health for the years of 1989 and 1990, and from the 1980 Census.^ The study reveals that nonhandicapped students are graduating with a two year average rate of.906, while handicapped students following an Individualized Educational Program (IEP) achieve a two year average rate of.532, and handicapped students following the regular academic program present a two year average graduation rate of only.371. The presence of other handicapped students, and the school district's average expense per student are found to contribute significantly to the completion rates of handicapped students. Size groupings are used to elucidate the various impacts of these variables on different school districts and different student groups.^ Conclusions and implications are offered regarding the need to reach national consensus on the definition and computation of high school completion for both handicapped and nonhandicapped students, and the need for improved statewide tracking of handicapped completion rates. ^

The prevalence of burnout among psychologists and psychological associates in the state of Texas

This study investigates the prevalence of burnout among a sample of Texas psychologists and psychological associates as well as differences between the three categories of practitioners within that group (Licensed Psychology Health Care Providers (LPHCP), Licensed Psychologists - Certified Psychologists (LP-CP), Psychological Associates (PA)).^ The Maslach Burnout Inventory and a questionnaire seeking demographic information was used in this cross-sectional survey. Sample size was 654. A stratified proportionate random sample of Texas Psychologists was drawn. The response rate based on usable returns was 55% (n = 359). General demographic characteristics were determined mainly by frequency distributions. For comparing means of samples, t and multiple range tests were used. A series of one-way and two-way analysis of variance procedures were used to compare subgroup differences in burnout.^ The universe was representative for the sample and for the three categories of psychologists. Urban subjects were more likely to respond, as were male PAs. Practitioners were as likely male as female, working in an urban area, in their present job eight years, and in the occupation for fifteen. The LPHCP group were older, had been in psychology and at their present job longer, and were more likely to belong to both state and local professional organizations than the other two groups. Males outnumbered females in this group and in LP-CPs. This gender trend was reversed for PAs. Of the total sample, 76% reported high job satisfaction and 77% had high levels of perceived job autonomy. There was no significant difference between the study sample and the mental health norms in emotional exhaustion (EE). Our sample had significantly less feelings of depersonalization (DP) and higher feelings of personal accomplishment (PA). Psychological Associates felt significantly less personal accomplishment than the other groups. Predictors for the total sample indicated younger practitioners and those with low job satisfaction had significantly higher burnout, as did males when compared to their female cohorts. Some types of jobs were more likely to contribute to burnout than others. Membership in their local area professional organization lessened the chances for burnout significantly. Predictors for categories of psychologists indicated that males in the LPHCP and LP-CP groups were at higher risk than females. Further, for LP-CPs low job satisfaction and job autonomy, as well as job sites, were significant. Those in this group who worked as school psychologists were at the highest risk for burnout. Job dissatisfaction was the major predictor of burnout for psychological associates. Practitioners working in state or government agencies, school systems and administrative jobs generally had higher burnout than those on a university faculty or in private practice. (Abstract shortened by UMI.) ^

Patterns of care and outcomes for pregnant inmates and their infants in Texas state prisons: Epidemiologic and ethnographic analyses

Female inmates make up the fastest growing segment in our criminal justice system today. The rapidly increasing trend for female prisoners calls for enhanced efforts to strategically plan the correctional facilities that address the needs of this growing population, and to work with communities to prevent crime in women. The incarcerated women in the U.S. have an estimated 145,000 minor children who are predisposed to unique psychosocial problems as a result of parental incarceration.^ This study examined the patterns of care and outcomes for pregnant inmates and their infants in Texas state prisons between 1994 and 1996. The study population consists of 202 pregnant inmates who delivered in a 2-year period, and a randomly sampled comparison cohort of 804 women from general Texas population, matched on race and educational levels. Both quantitative and qualitative data were used to elucidate the inmates' risk-factor profile, delivery/birth outcomes, and the patterns of care during pregnancy. The continuity-of-care issues for this population were also explored.^ Epidemiologic data were derived from multiple record systems to establish the comparison between two cohorts. A significantly great proportion of the inmates have prior lifestyle risk-factors (smoking, alcohol, and illicit drug abuse), poorer health status, and worse medical history. However, most of these existing risk-factors seem to show little manifestation in their current pregnancy. On the basis of maternal labor/delivery outcome and a number of neonatal indicators, this study found some evidence of a better pregnancy outcome for the inmate cohort when compared to the comparison group. Some possible explanations of this paradox were discussed. Seventeen percent of inmates gave birth to infants with suspected congenital syphilis. The placement patterns for the infants' care immediately after birth were elucidated.^ In addition to the quantitative data, an ethnographic approach was used to collect qualitative data from a subset of the inmate cohort (n = 20) and 12 care providers. The qualitative data were analyzed for their contents and themes, giving rise to a detailed description of the inmates' pregnancy experience. Eleven themes emerged from the study's thematic analysis, which provides the context for interpreting the epidemiologic data.^ Meaningful findings in this study were presented in a three-dimensional matrix to shed light on the apparent relationship between outcome indicators and their potential determinants. The suspected "linkages" between the outcome and their determinants can be used to generate hypotheses for future studies. ^

Evaluating the relative status of health and safety programs for minority academic and research institutions

A variety of occupational hazards are indigenous to academic and research institutions, ranging from traditional life safety concerns, such as fire safety and fall protection, to specialized occupational hygiene issues such as exposure to carcinogenic chemicals, radiation sources, and infectious microorganisms. Institutional health and safety programs are constantly challenged to establish and maintain adequate protective measures for this wide array of hazards. A unique subset of academic and research institutions are classified as historically Black universities which provide educational opportunities primarily to minority populations. State funded minority schools receive less resources than their non-minority counterparts, resulting in a reduced ability to provide certain programs and services. Comprehensive health and safety services for these institutions may be one of the services compromised, resulting in uncontrolled exposures to various workplace hazards. Such a result would also be contrary to the national health status objectives to improve preventive health care measures for minority populations.^ To determine if differences exist, a cross-sectional survey was performed to evaluate the relative status of health and safety programs present within minority and non-minority state-funded academic and research institutions. Data were obtained from direct mail questionnaires, supplemented by data from publicly available sources. Parameters for comparison included reported numbers of full and part-time health and safety staff, reported OSHA 200 log (or equivalent) values, and reported workers compensation experience modifiers. The relative impact of institutional minority status, institution size, and OSHA regulatory environment, was also assessed. Additional health and safety program descriptors were solicited in an attempt to develop a preliminary profile of the hazards present in this unique work setting.^ Survey forms were distributed to 24 minority and 51 non-minority institutions. A total of 72% of the questionnaires were returned, with 58% of the minority and 78% of the non-minority institutions participating. The mean number of reported full-time health and safety staff for the responding minority institutions was determined to be 1.14, compared to 3.12 for the responding non-minority institutions. Data distribution variances were stabilized using log-normal transformations, and although subsequent analysis indicated statistically significant differences, the differences were found to be predicted by institution size only, and not by minority status or OSHA regulatory environment. Similar results were noted for estimated full-time equivalent health and safety staffing levels. Significant differences were not noted between reported OSHA 200 log (or equivalent) data, and a lack of information provided on workers compensation experience modifiers prevented comparisons on insurance premium expenditures. Other health and safety program descriptive information obtained served to validate the study's presupposition that the inclusion criteria would encompass those organizations with occupational risks from all four major hazard categories. Worker medical surveillance programs appeared to exist at most institutions, but the specific tests completed were not readily identifiable.^ The results of this study serve as a preliminary description of the health and safety programs for a unique set of workplaces have not been previously investigated. Numerous opportunities for further research are noted, including efforts to quantify the relative amount of each hazard present, the further definition of the programs reported to be in place, determination of other means to measure health outcomes on campuses, and comparisons among other culturally diverse workplaces. ^

The transformation of a health care system: An ecology perspective

Beginning in the early 1980s, the health care system experienced momentous realignments. Fundamental changes in structures of traditional health care organizations, shifts in authority and relationships of professionals and institutions, and the increasing influence of managed care contributed to a relatively stable industry entering into a state of turbulence. The dynamics of these changes are recurring themes in the health services literature. The purpose of this dissertation was to examine the content of this literature over a defined time period and within the perspective of a theory of organizational change. ^ Using a theoretical framework based upon the organizational theory known as Organizational Ecology, secondary data from the period between 1983 and 1994 was reviewed. Analysis of the literature identified through a defined search methodology was focused upon determining the manner in which the literature characterized changes that were described. Using a model constructed from fundamentals of Organizational Ecology with which to structure an assessment of content, literature was summarized for the manner and extent of change in specific organizational forms and for the changes in emphasis by the environmental dynamics directing changes in the population of organizations. Although it was not the intent of the analysis to substantiate causal relationships between environmental resources selected as the determinants of organizational change and the observed changes in organizational forms, the structured review of content of the literature established a strong basis for inferring such a relationship. ^ The results of the integrative review of the literature and the power of the appraisal achieved through the theoretical framework constructed for the analysis indicate that there is considerable value in such an approach. An historical perspective on changes which have transformed the health care system developed within a defined organizational theory provide a unique insight into these changes and indicate the need for further development of such an analytical model. ^

AN OCCUPATIONAL INJURY MANAGEMENT INFORMATION SYSTEM FOR THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT HOUSTON

The purpose of this research and development project was to develop a method, a design, and a prototype for gathering, managing, and presenting data about occupational injuries.^ State-of-the-art systems analysis and design methodologies were applied to the long standing problem in the field of occupational safety and health of processing workplace injuries data into information for safety and health program management as well as preliminary research about accident etiologies. The top-down planning and bottom-up implementation approach was utilized to design an occupational injury management information system. A description of a managerial control system and a comprehensive system to integrate safety and health program management was provided.^ The project showed that current management information systems (MIS) theory and methods could be applied successfully to the problems of employee injury surveillance and control program performance evaluation. The model developed in the first section was applied at The University of Texas Health Science Center at Houston (UTHSCH).^ The system in current use at the UTHSCH was described and evaluated, and a prototype was developed for the UTHSCH. The prototype incorporated procedures for collecting, storing, and retrieving records of injuries and the procedures necessary to prepare reports, analyses, and graphics for management in the Health Science Center. Examples of reports, analyses, and graphics presenting UTHSCH and computer generated data were included.^ It was concluded that a pilot test of this MIS should be implemented and evaluated at the UTHSCH and other settings. Further research and development efforts for the total safety and health management information systems, control systems, component systems, and variable selection should be pursued. Finally, integration of the safety and health program MIS into the comprehensive or executive MIS was recommended. ^

CATCH across Texas: Building a model for the diffusion of effective school-based health promotion programs

The impact of health promotion programs is related to both program effectiveness and the extent to which the program is implemented among the target population. The purpose of this dissertation was to describe the development and evaluation of a school-based program diffusion intervention designed to increase the rate of dissemination and adoption of the Child and Adolescent Trial for Cardiovascular Health, or CATCH program (recently renamed the Coordinated Approach to Child Health). ^ The first study described the process by which schools across the state of Texas spontaneously began to adopt the CATCH program after it was tested and proven effective in a multi-site randomized efficacy trial. A survey of teachers and administrator representatives of all schools on record that purchased the CATCH program, but were not involved in the efficacy trial, was used to find out who brought CATCH into the schools, how they garnered support for its adoption, why they decided to adopt the program, and what was involved in deciding to adopt. ^ The second study described how the Intervention Mapping framework guided the planning, development and implementation of a program for the diffusion of CATCH. An iterative process was used to integrate theory, literature, the experience of project staff and data from the target population into a meaningful set of program determinants and performance objectives. Proximal program objectives were specified and translated into both media and interpersonal communication strategies for program diffusion. ^ The third study assessed the effectiveness of the diffusion program in a case-comparison design. Three of the twenty Education Service Center regions in Texas were chosen, selected based on similar demographic criteria, and were followed for adoption of the CATCH curriculum. One of these regions received the full media and interpersonal channel intervention; a second received a reduced media-only intervention, and a third received no intervention. Results suggested the use of the interpersonal channels with media follow-up is an effective means to facilitate program dissemination and adoption. The media-alone condition was not effective in facilitating program adoption. ^

Texas dental hygiene/dietitian occupational health study

Occupational asthma is the most common form of reported occupational respiratory disease in many industrialized countries. Recent studies show that environmental exposures account for up to 40% of the cases of asthma and that 2% to 15% of all cases of asthma are attributable to occupational exposures. In the dental workplace, dental hygienists are exposed to hazardous substances. Among these hazards are respiratory sensitizers, irritants and infectious agents. A cross-sectional study of Texas dental hygienists was conducted to assess the prevalence of occupational asthma. Registered dietitians were surveyed as a comparison group, because this group is similar in demographic makeup to dental hygienists, but conducts no clinical treatment with associated hazardous exposures. Neither the questionnaire survey nor the cover letter revealed the focus of this investigation. Three hundred and thirty five dental hygienists licensed to practice in the state of Texas as of January 1, 1999, and 320 dietitians that are also licensed by the state of Texas were randomly selected. (Abstract shortened by UMI.)^