Race and discourse analysis: Building a dialogue in health service research and health care settings

Using a framework for discourse analysis developed by Van Dijk, the investigator will pinpoint the pathological forms of discourse on race, defined as 'race talk' in three professional domains: health services research, public health provider organizations, and literature on multiculturalism. Attention will then turn to developing an analytical strategy for building more meaningful dialogue on race. The retrieval of potential resources for dialogue will be drawn from the third domain. Analysis will focus on enhancing the prospects of converting 'race talk' into dialogue. This will be accomplished by characterizing the normative preconditions as formal procedural requirements for dialogue and then supplementing these conditions with others related specifically to race. From here, the practical implications of combining procedural requirements and resources in each of the domains will be considered. Finally, the author will attempt to determine how these selected resources might be employed to transform 'race talk' in practice and lay the groundwork for a dialogue of understanding. ^

'Reform' of the British national health service after the election of a labour government: Understanding the policy development process

The policy development process leading to the Labour government's white paper of December 1997—The new NHS: Modern, Dependable—is the focus of this project and the public policy development literature is used to aid in the understanding of this process. Policy makers who had been involved in the development of the white paper were interviewed in order to acquire a thorough understanding of who was involved in this process and how they produced the white paper. A theoretical framework is used that sorts policy development models into those that focus on knowledge and experience, and those which focus on politics and influence. This framework is central to understanding the evidence gathered from the individuals and associations that participated in this policy development process. The main research question to be asked in this project is to what extent do either of these sets of policy development models aid in understanding and explicating the process by which the Labour government's policies were developed. The interview evidence, along with published evidence, show that a clear pattern of policy change emerged from this policy development process, and the Knowledge-Experience and Politics-Influence policy making models both assist in understanding this process. The early stages of the policy development process were characterized as hierarchical and iterative, yet also very collaborative among those participating, with knowledge and experience being quite prevalent. At every point in the process, however, informal networks of political influence were used and noted to be quite prevalent by all of the individuals interviewed. The later stages of the process then became increasingly noninclusive, with decisions made by a select group of internal and external policy makers. These policy making models became an important tool with which to understand the policy development process. This Knowledge-Experience and Politics-Influence dichotomy of policy development models could therefore be useful in analyzing other types of policy development. ^

'Your Heart Can't Wait'---A worksite program: Increasing the effectiveness of worksite coordinators to implement a community-wide health education program

A worksite health education program called “Your Heart Can't Wait,” was designed by the American Heart Association Gulf Coast Area (AHA). The objectives were to educate individuals about the signs and symptoms of heart attacks and the actions they should take to improve heart attack victims' chances for survival. AHA volunteers agreed to serve as mentors for this program. ^ A study was designed to determine if worksite coordinators who had the assistance of experienced AHA volunteers had higher rates of program adoption and implementation than worksite coordinators without assistance. Ninety-seven companies participated in the study. Twelve AHA volunteers were randomly assigned to work with forty-three of the worksite coordinators. Mentor/mentee contact forms were used to assess the mentoring process during the course of the study. Program adoption forms were used to measure rates of program adoption and follow-up questionnaires were used to measure rates of program implementation after the study was completed. The twelve mentors were interviewed to provide information for improving future mentoring efforts. ^ Thirty-eight companies completed program adoption forms and fifty-one companies reported using YHCW program components. For the most part, the volunteer mentors did not spend a significant amount of time contacting or working with their assigned worksite coordinators. As a result, the planned analysis comparing the implemented programs between worksite coordinators with and without assistance could not be completed. ^ Additional analyses were performed comparing the implemented programs based upon whether the companies had existing health education/health promotion programs and whether the worksite coordinators had experience using AHA Heart At Work program components. ^ Recommendations based on the mentor interviews were made to improve the success of volunteer assistance programs in the future. ^

Planning and implementation efficacy as a determinant of health risk communication outcomes: Case studies of the U.S. Public Health Service (PHS)

This study was conducted under the auspices of the Subcommittee on Risk Communication and Education of the Committee to Coordinate Environmental Health and Related Programs (CCEHRP) to determine how Public Health Service (PHS) agencies are communicating information about health risk, what factors contributed to effective communication efforts, and what specific principles, strategies, and practices best promote more effective health risk communication outcomes.^ Member agencies of the Subcommittee submitted examples of health risk communication activities or decisions they perceived to be effective and some examples of cases they thought had not been as effective as desired. Of the 10 case studies received, 7 were submitted as examples of effective health risk communication, and 3, as examples of less effective communication.^ Information contained in the 10 case studies describing the respective agencies' health risk communication strategies and practices was compared with EPA's Seven Cardinal Rules of Risk Communication, since similar rules were not found in any PHS agency. EPA's rules are: (1) Accept and involve the public as a legitimate partner. (2) Plan carefully and evaluate your efforts. (3) Listen to the public's specific concerns. (4) Be honest, frank, and open. (5) Coordinate and collaborate with other credible sources. (6) Meet the needs of the media. (7) Speak clearly and with compassion.^ On the basis of case studies analysis, the Subcommittee, in their attempts to design and implement effective health risk communication campaigns, identified a number of areas for improvement among the agencies. First, PHS agencies should consider developing a focus specific to health risk communication (i.e., office or specialty resource). Second, create a set of generally accepted practices and guidelines for effective implementation and evaluation of PHS health risk communication activities and products. Third, organize interagency initiatives aimed at increasing awareness and visibility of health risk communication issues and trends within and between PHS agencies.^ PHS agencies identified some specific implementation strategies the CCEHRP might consider pursuing to address the major recommendations. Implementation strategies common to PHS agencies emerged in the following five areas: (1) program development, (2) building partnerships, (3) developing training, (4) expanding information technologies, and (5) conducting research and evaluation. ^

HEALTH STATUS - HEALTH SERVICE RESOURCES - ECONOSOCIOCULTURAL DEVELOPMENT: IMPLICATIONS FOR HEALTH CARE POLICY IN AFRICA

Rational health services planning requires an examination of the effects of various factors on the health status of a population within a given set of socioeconomic circumstances. The commonly accepted explanations for improved health in the less developed countries (LDCs) are: Health Service Resources available to a population, Environmental and Life conditions, and the Econosociocultural Characteristics of the population.^ In the context of the low economic base from which many LDCs initiate development activities, a strong imperative exists for identifying in which of these major areas public health policy would be most effective in terms of improving health. A new conceptual model is proposed that would be used for future policy analyses to assess what changes in health status of populations in LDCs can be expected as direct functions of increased health service resources, and of improved environmental and econosociocultural conditions.^ While direct policy analysis is ill-advised at this time due to data inadequacy, the model is illustrated using data presently available for twenty-five relatively homogeneous Sub-Sahara African countries. Within the limitations of available data, study findings indicate that while econosociocultural conditions were the most important explanatory factors of the three major independent variables in 1970, health service resources became the most important in 1975. Study findings are inconclusive at this time with regards to the relative contributions of physicians and medical assistants in explaining variances in mortality in these countries.^ Because of the deficient nature of available data, study findings should be interpreted very cautiously. Tests of statistical significance of study findings were by-passed because of their situational technical inappropriateness. This study is significant in being the first of its kind and scope to focus on the Sub-Sahara African region of the World Health Organization, using the Wroclaw Taxonomic Method in conjunction with a stepwise regression technique. It is desirable, therefore, to examine the observed magnitude and directional consistency of all hypothesized relationships, even if evidence is inconclusive. ^

Using service-learning to encourage community health advocacy among high school students

The project outlined throughout this program management plan aims to develop a health-focused student advocacy group in the San Antonio Independent School District (SAISD). At its core, this project will be an opportunity for SAISD students to engage in service-learning, through which they will learn and develop by designing, organizing and participating in meaningful public health service experiences. ^ This program management plan addresses the genuine need for public health community education by using the service-learning model as a framework to engage students to effect change. The plan delineates the process by which the student advocacy group is to be assembled, selection of service-learning project, project objectives, technical objectives, and communication requirements. Ideally, the plan should help to facilitate project coordination, communication, and planning, and to support the direction of resources. The appendices that follow also provide useful tools with which to follow through with project implementation. ^ The plan is about more than providing a tool to educate students about the health issues in their community. It is about providing a way to teach health advocacy and self-interest and encourage civic engagement via public health. Students have the potential to positively effect lasting change among their peers, in their schools and in the community.^

PROJECTION OF HEALTH DEMAND IN TERMS OF HOSPITAL ADMISSIONS FOR SELECTED DIAGNOSES IN HEALTH SYSTEMS AGENCY SERVICE AREAS

The National Health Planning and Resources Development Act of 1974 (Public Law 93-641) requires that health systems agencies (HSAs) plan for their health service areas by the use of existing data to the maximum extent practicable. Health planning is based on the identificaton of health needs; however, HSAs are, at present, identifying health needs in their service areas in some approximate terms. This lack of specificity has greatly reduced the effectiveness of health planning. The intent of this study is, therefore, to explore the feasibility of predicting community levels of hospitalized morbidity by diagnosis by the use of existing data so as to allow health planners to plan for the services associated with specific diagnoses.^ The specific objectives of this study are (a) to obtain by means of multiple regression analysis a prediction equation for hospital admission by diagnosis, i.e., select the variables that are related to demand for hospital admissions; (b) to examine how pertinent the variables selected are; and (c) to see if each equation obtained predicts well for health service areas.^ The existing data on hospital admissions by diagnosis are those collected from the National Hospital Discharge Surveys, and are available in a form aggregated to the nine census divisions. When the equations established with such data are applied to local health service areas for prediction, the application is subject to the criticism of the theory of ecological fallacy. Since HSAs have to rely on the availability of existing data, it is imperative to examine whether or not the theory of ecological fallacy holds true in this case.^ The results of the study show that the equations established are highly significant and the independent variables in the equations explain the variation in the demand for hospital admission well. The predictability of these equations is good when they are applied to areas at the same ecological level but become poor, predominantly due to ecological fallacy, when they are applied to health service areas.^ It is concluded that HSAs can not predict hospital admissions by diagnosis without primary data collection as discouraged by Public Law 93-641. ^

Follow-up care after a health fair screening in three Houston neighborhoods in 2008

Background. Each year thousands of people participate in mass health screenings for diabetes and hypertension, but little is known about whether or not those who receive higher than normal screening results obtain the recommended follow-up medical care, or what barriers they perceive to doing so. ^ Methods. Study participants were recruited from attendees at three health fairs in low-income neighborhoods in Houston, Texas Potential participants had higher than normal blood pressure (> 90/140 mgHg) or blood glucose readings (100 mm/dL fasting or 140 mm/dL random). Study participants were called at one, two, and three months and asked if they had obtained follow-up medical care; those who had not yet obtained follow-up care were asked to identify barriers. Using a modified Aday-Andersen model of health service access, the independent variables were individual and community characteristics and self-perceived need. The dependent variable was obtaining follow-up care, with barriers to care a secondary outcome. ^ Results. Eighty-two study participants completed the initial questionnaire and 59 participants completed the study protocol. Forty-eight participants (59% under an intent to treat analysis, 81% of those completing the study protocol) obtained follow-up care. Those who completed the initial questionnaire and who reported a regular source of care were significantly more likely to obtain follow-up care. For those who completed the study protocol the relationship between having a regular source of care and obtaining follow-up care approached but did not reach significance. For those who completed the initial questionnaire, self-described health status, when examined as a binary variable (good, very good, excellent, or poor, fair, not sure) was associated with obtaining follow-up care for those who rated their health as poor, fair, or not sure. While the group who completed the study protocol did not reach statistical significance, the same relationship between self-described health status of poor, fair, or not sure and obtaining follow-up care was present. The participants who completed the study protocol and described their blood pressure as OK or a little high were statistically more likely to get follow-up care than those who described it as high or very high. All those on oral medications for hypertension (12/12) and diabetes (4/4) who were told to obtain follow-up care did so; however, the small sample size allows this correlation to be of statistical significance only for those treating hypertension. ^ The variables significantly associated with obtaining follow-up care were having a regular source of care, self-described health status of poor, fair, or not sure, self-described blood pressure of OK or a little high, and taking medication for blood pressure. ^ At the follow-up telephone calls, 34 participants identified barriers to care; cost was a significant barrier reported by 16 participants, and 10 reported that they didn’t have time because they were working long hours after Hurricane Ike. ^ The study included the offer of access assistance: information about nearby safety-net providers, a visit to or information from the Health Information Center at their Neighborhood Center location, or information from Project Safety Net (a searchable web site for safety net providers). Access assistance was offered at the health fairs and then again at follow-up telephone calls to those who had not yet obtained follow-up care. Of the 48 participants who reported obtaining follow-up care, 26 said they had made use of the access assistance to do so. The use of access assistance was associated with being Hispanic, not having health insurance or a regular source of care, and speaking Spanish. It was also associated with being worried about blood glucose. ^ Conclusion. Access assistance, as a community enabling characteristic, may be useful in aiding low-income people in obtaining medical care. ^

Sudden Infant Death disparities: A systematic review on health education and policy recommendations for decreasing Sudden Infant Death in the African-American community

Objective: To perform a systematic review of the literature on SIDS and SUID deaths concentrated in the African-American community, describe health education and policy recommendations and recommend a new approach that may aid in decreasing the disparity of infant mortality in the African-American community. ^ Methods: The PubMed database was systematically searched to identify relevant articles for final review and analysis. Using the CASP 2006 system to critique literature, twelve articles were found that met inclusion and exclusion criteria. ^ Results: Evidence in the literature confirmed there was a current disparity among African Americans' infant mortality rates in comparison to other US ethnic groups. The underlying reasons for these disparities included the following maternal and infant characteristics: mothers younger than eighteen, having more than one live infant, having a high school education or less, never been married, and have infants born preterm or with low birth weight. Maternal smoking, substance abuse, and breastfeeding did not have a significant impact on infant sleep environments among African Americans. ^ Conclusion: Tailored health education programs at the community level, better access to pre-pregnancy and prenatal care, and increased maternal perception of risk that is relevant to the infants sleeping environment are all possible solutions that may decrease African American infant mortality rates.^

Intensive Family Preservation in Children's Mental Health: Predictors of Placement

This article examines the predictors of placement following IFPSfor a sample of child mental health service recipients and their families. Risk and protective factors vary depending on the time frame under consideration. Immediately following service, children 's level of Social/Legal functioning, a previous group home placement, and the presence of mental health problems for other family members increase risk of placement, while the number of follow-up services serves to lessen risk. Three to six months after service, the presence of a child behavior presenting problem and a projected placement in foster care serve as protective factors, while two service targets, alcohol monitoring and time management, serve to increase risk. Appropriate use of results for program design and for structuring access to services is discussed.

Home care service utilization in British Columbia: Substitute or complement to acute care?

The desire to promote efficient allocation of health resources and effective patient care has focused attention on home care as an alternative to acute hospital service. in particular, clinical home care is suggested as a substitute for the final days of hospital stay. This dissertation evaluates the relationship between hospital and home care services for residents of British Columbia, Canada beginning in 1993/94 using data from the British Columbia Linked Health database. ^ Lengths of stay for patients referred to home care following hospital discharge are compared to those for patients not referred to home care. Ordinary least squares regression analysis adjusts for age, gender, admission severity, comorbidity, complications, income, and other patient, physician, and hospital characteristics. Home care clients tend to have longer stays in hospital than patients not referred to home care (β = 2.54, p = 0.0001). Longer hospital stays are evident for all home care client groups as well as both older and younger patients. Sensitivity analysis for referral time to direct care and extreme lengths of stay are consistent with these findings. Two stage regression analysis indicates that selection bias is not significant.^ Patients referred to clinical home care also have different health service utilization following discharge compared to patients not referred to home care. Home care nursing clients use more medical services to complement home care. Rehabilitation clients initially substitute home care for physiotherapy services but later are more likely to be admitted to residential care. All home care clients are more likely to be readmitted to hospital during the one year follow-up period. There is also a strong complementary association between direct care referral and homemaker support. Rehabilitation clients have a greater risk of dying during the year following discharge. ^ These results suggest that home care is currently used as a complement rather than a substitute for some acute health services. Organizational and resource issues may contribute to the longer stays by home care clients. Program planning and policies are required if home care is to provide an effective substitute for acute hospital days. ^

An evaluation of the personal response system program for the elderly in Harris County, Texas

The Personal Response System Program at Huffington Center on Aging, Baylor College of Medicine, provides emergency call systems for elderly people living independently in Houston, Texas. The goal of the project was to complete a formative evaluation of the Personal Response System Program. The specific aims of the evaluation were three-fold. One aim was to evaluate participant health status and level of disability. The second aim was to develop a health care cost estimation strategy. Finally, a preliminary cost-effectiveness analysis was completed to evaluate the program's impact on health care costs and health status among the elderly target population. ^ The evaluation was a longitudinal, randomized experimental design. After the screening of 120 volunteers for eligibility, clients were asked to complete a written questionnaire and a monthly health service contact diary. Volunteers were contacted by telephone interviewers to collect health status information from 100 eligible clients (83%) on three occasions during the six months of follow-up. ^ Initially, volunteers were randomized to two experimental groups. The two groups were found to be comparable at the beginning of the study. No significant differences were detected related to health status, level of disability, or history of physician visits at baseline. However, the group with the Personal Response System (PRS) device had more adverse health events, higher IADL scores, more frequent use of walkers, lower average health status scores, and fewer community volunteers hours than the usual care comparison group. ^ The health care costs were estimated based on an algorithm adapted from the American Medical Association guidelines. Average total health care costs for the group with the PRS device ($912) were greater than the usual care group ($464). However, median health care values for the PRS group ($263) were similar to the usual care comparison group ($234). The preliminary findings indicated that the use of the PRS device was not associated with health care cost savings. ^ In the preliminary cost-effectiveness analysis, use of the personal response system was found to be associated with increased mental health status among elderly clients. The cost-effectiveness evaluation indicated that the associated cost for six months was $710 per unit increase in mental component score when the $150 PRS subscription was included. However, clients with the PRS device were found to have a greater decline in physical health status during the six-month follow-up. The beneficial effect on mental health status was found to be in contrast to negative findings associated with changes in physical health status. The implications for future research relate to the need to identify risk factors among geriatric populations to better target groups that would most likely benefit from PRS Program enrollment. ^

Using small area estimation and geographic information systems technology to target health services for the uninsured

The three articles that comprise this dissertation describe how small area estimation and geographic information systems (GIS) technologies can be integrated to provide useful information about the number of uninsured and where they are located. Comprehensive data about the numbers and characteristics of the uninsured are typically only available from surveys. Utilization and administrative data are poor proxies from which to develop this information. Those who cannot access services are unlikely to be fully captured, either by health care provider utilization data or by state and local administrative data. In the absence of direct measures, a well-developed estimation of the local uninsured count or rate can prove valuable when assessing the unmet health service needs of this population. However, the fact that these are “estimates” increases the chances that results will be rejected or, at best, treated with suspicion. The visual impact and spatial analysis capabilities afforded by geographic information systems (GIS) technology can strengthen the likelihood of acceptance of area estimates by those most likely to benefit from the information, including health planners and policy makers. ^ The first article describes how uninsured estimates are currently being performed in the Houston metropolitan region. It details the synthetic model used to calculate numbers and percentages of uninsured, and how the resulting estimates are integrated into a GIS. The second article compares the estimation method of the first article with one currently used by the Texas State Data Center to estimate numbers of uninsured for all Texas counties. Estimates are developed for census tracts in Harris County, using both models with the same data sets. The results are statistically compared. The third article describes a new, revised synthetic method that is being tested to provide uninsured estimates at sub-county levels for eight counties in the Houston metropolitan area. It is being designed to replicate the same categorical results provided by a current U.S. Census Bureau estimation method. The estimates calculated by this revised model are compared to the most recent U.S. Census Bureau estimates, using the same areas and population categories. ^

Has implementation of integrated mental health services in primary care programs positively impacted health outcomes among the mentally ill in developing countries?

Objective. The World Health Organization (WHO) estimates that nearly 450 million people suffer from a mental disorder in the world. Developing countries do not have the health system structure in place to support the demand of mental health services. This study will conduct a review of mental health integration in primary care research that is carried out in low-income countries identified as such from the World Bank economic analysis. The research follows the standard of care that WHO has labeled appropriate in treatment of mental health populations. Methods. This study will use the WHO 10 principles of mental health integration into primary care as the global health standard of care for mental health. Low-income countries that used these principles in their national programs will be analyzed for effectiveness of mental health integration in primary care. Results. This study showed that mental health service integration in primary care did have an effect on health outcomes of low-income countries. However, information did not lead to significant quantitative results that determined how positive the effect was. Conclusion. More ethnographic research is needed in low-income countries to truly assess how effective the program is in integrating with the health system currently in place.^ ^