Institutionalizing Intensive Family Preservation Services: A Strategy for Creating Staffing Standards Based on Projections of At-Risk Children from Referral Sources

In spite of new legislation and much public and professional interest, intensive family preservation service (IFPS) remains in a vulnerable position as compared to other child welfare services. This article details a method to project ideal IFPS caseloads as a function of children who are at-risk for placement by various referral sources. Using this approach, resource allocation for IFPS can be more nearly on equal ground with the traditional child welfare functions and help IFPS to assume its needed place as a core service in the child welfare continuum.

Revising the National Ambient Air Quality Standards: The integration of science and policy

Under the Clean Air Act, Congress granted discretionary decision making authority to the Administrator of the Environmental Protection Agency (EPA). This discretionary authority involves setting standards to protect the public's health with an "adequate margin of safety" based on current scientific knowledge. The Administrator of the EPA is usually not a scientist, and for the National Ambient Air Quality Standard (NAAQS) for particulate matter (PM), the Administrator faced the task of revising a standard when several scientific factors were ambiguous. These factors included: (1) no identifiable threshold below which health effects are not manifested, (2) no biological basis to explain the reported associations between particulate matter and adverse health effects, and (3) no consensus among the members of the Clean Air Scientific Advisory Committee (CASAC) as to what an appropriate PM indicator, averaging period, or value would be for the revised standard. ^ This project recommends and demonstrates a tool, integrated assessment (IA), to aid the Administrator in making a public health policy decision in the face of ambiguous scientific factors. IA is an interdisciplinary approach to decision making that has been used to deal with complex issues involving many uncertainties, particularly climate change analyses. Two IA approaches are presented; a rough set analysis by which the expertise of CASAC members can be better utilized, and a flag model for incorporating the views of stakeholders into the standard setting process. ^ The rough set analysis can describe minimal and maximal conditions about the current science pertaining to PM and health effects. Similarly, a flag model can evaluate agreement or lack of agreement by various stakeholder groups to the proposed standard in the PM review process. ^ The use of these IA tools will enable the Administrator to (1) complete the NAAQS review in a manner that is in closer compliance with the Clean Air Act, (2) expand the input from CASAC, (3) take into consideration the views of the stakeholders, and (4) retain discretionary decision making authority. ^

Cultural competence in an HIV dedicated dental clinic: Application of the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS)

This dissertation investigated perspectives on cultural competence among African-American women patients, staff, and the administrator of a dental clinic serving people living with HIV/AIDS; and evaluated the role of the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) in advancing the provision of culturally competent care in the clinic. ^ The study was qualitative with data collection via focus groups and individual interviews with a sample of African-American women patients, and individual interviews with a sample of staff and the clinic administrator. Transcripts were coded and themes identified using the software program ATLAS.ti. A cultural audit template was developed and applied to evaluate cultural competency. ^ Among attitudes and behaviors that contributed to the provision of culturally competent care at the clinic were respect and empathic communication. Formal cultural competency was not featured strongly in the methods by which the staff learned to work with diverse populations. Instead cultural competence among the staff was based on thoughtful hiring practices, natural aptitude and a climate that encouraged learning through informal sharing of experiences. The staff and administrator felt that an African-American dentist would be an asset in improving culturally competent care at the clinic. Previous research and national policy also promote the provider-patient racial/ethnic concordance to improve care. In this study, however, the patients were happy with the care provided regardless of the race/ethnicity of the staff, probably reflecting the well developed cultural competence skills of clinic staff overall. ^ The clinic administrator was unaware of the CLAS standards although the clinic was implicitly operated under their mandates. This occurred because the clinic is supported by federal funding and the CLAS standards were incorporated into the requirements. Incorporation into and monitoring of the CLAS standards in federally funded programs therefore appears to be an effective means for ensuring that they are implemented. ^ This study illustrates that cultural competence, though not universally understood, can be systematically investigated to identify what constitutes appropriate care and the factors that support or inhibit it. Among important elements of culturally competent care are respect and empathic communication. ^

Physician's adherence to CDC standards for physical activity counseling of older women in a cardiology practice in Texas---An exploratory study

Physical activity is an important health-promoting behavior to prevent and control chronic disease. Interventions to increase physical activity are vitally needed. Women are not meeting the recommended goals for physical activity - a behavior that has been shown to effectively reduce the incidence of chronic disease and the medical costs associated with treating it. Among many factors predicting physical activity and the different forms of interventions that have been applied, physician counseling is one potentially cost-effective approach that may produce at least modest effects on women's behavior. The Centers for Disease Control and Prevention has published standards for physician counseling of patients regarding physical activity. This study used a short questionnaire to assess the degree to which a group practice of cardiology physicians in Texas queried and discussed physical activity recommendations to older women that they treat and whether they are meeting the physical activity counseling goals of the Centers for Disease Control and Prevention. The majority of this group of physicians counseled patients without benefit of exploring patient behavior. Although these physicians "agreed" that physical activity delayed or prevented disease, the outcome suggests that low self-efficacy hampered efforts to counsel older women on this. Physicians' perceptions that counseling may be ineffective could explain the lower rate of physical activity counseling that does not meet the goals of the Centers for Disease Control and Prevention. ^

A multiplicative model for standardizing vital rates without using external standards

Standardization is a common method for adjusting confounding factors when comparing two or more exposure category to assess excess risk. Arbitrary choice of standard population in standardization introduces selection bias due to healthy worker effect. Small sample in specific groups also poses problems in estimating relative risk and the statistical significance is problematic. As an alternative, statistical models were proposed to overcome such limitations and find adjusted rates. In this dissertation, a multiplicative model is considered to address the issues related to standardized index namely: Standardized Mortality Ratio (SMR) and Comparative Mortality Factor (CMF). The model provides an alternative to conventional standardized technique. Maximum likelihood estimates of parameters of the model are used to construct an index similar to the SMR for estimating relative risk of exposure groups under comparison. Parametric Bootstrap resampling method is used to evaluate the goodness of fit of the model, behavior of estimated parameters and variability in relative risk on generated sample. The model provides an alternative to both direct and indirect standardization method. ^

A feasibility study for assessing building occupants' indoor air quality expectations compared to nationally recognized standards

Indoor Air Quality (IAQ) can have significant implications for health, productivity, job performance, and operating cost. Professional experience in the field of indoor air quality suggests that high expectations (better than nationally established standards) (American Society of Heating, Refrigerating, and Air-conditioning Engineers (ASHRAE)) of workplace indoor air quality lead to increase air quality complaints. To determine whether there is a positive association between expectations and indoor air quality complaints, a one-time descriptive and analytical cross-sectional pilot study was conducted. Area Safety Liaisons (n = 330) at University of Texas Health Science Center – Houston were asked to answer a questionnaire regarding their expectations of four workplace indoor air quality indicators i.e., (temperature, relative humidity, carbon dioxide, and carbon monoxide) and if they experienced and reported indoor air quality problems. A chi-square test for independence was used to evaluate associations among the variables of interest. The response rate was 54% (n = 177). Results did not show significant associations between expectation and indoor air quality. However, a greater proportion of Area Safety Liaisons who expected indoor air quality indicators to be better than the established standard experienced greater indoor air quality problems. Similarly, a slightly higher proportion of Area Liaisons who expected indoor air quality indicators to be better than the standard reported greater indoor air quality complaints. ^ The findings indicated that a greater proportion of Area Safety Liaisons with high expectations (conditions that are beyond what is considered normal and acceptable by ASHRAE) experienced greater indoor air quality discomfort. This result suggests a positive association between high expectations and experienced and reported indoor air quality complaints. Future studies may be able to address whether the frequency of complaints and resulting investigations can be reduced through information and education about what are acceptable conditions.^

The assumptions and effects of conservative procedures in low -dose risk assessment for setting safety standards

Conservative procedures in low-dose risk assessment are used to set safety standards for known or suspected carcinogens. However, the assumptions upon which the methods are based and the effects of these methods are not well understood.^ To minimize the number of false-negatives and to reduce the cost of bioassays, animals are given very high doses of potential carcinogens. Results must then be extrapolated to much smaller doses to set safety standards for risks such as one per million. There are a number of competing methods that add a conservative safety factor into these calculations.^ A method of quantifying the conservatism of these methods was described and tested on eight procedures used in setting low-dose safety standards. The results using these procedures were compared by computer simulation and by the use of data from a large scale animal study.^ The method consisted of determining a "true safe dose" (tsd) according to an assumed underlying model. If one assumed that Y = the probability of cancer = P(d), a known mathematical function of the dose, then by setting Y to some predetermined acceptable risk, one can solve for d, the model's "true safe dose".^ Simulations were generated, assuming a binomial distribution, for an artificial bioassay. The eight procedures were then used to determine a "virtual safe dose" (vsd) that estimates the tsd, assuming a risk of one per million. A ratio R = ((tsd-vsd)/vsd) was calculated for each "experiment" (simulation). The mean R of 500 simulations and the probability R $<$ 0 was used to measure the over and under conservatism of each procedure.^ The eight procedures included Weil's method, Hoel's method, the Mantel-Byran method, the improved Mantel-Byran, Gross's method, fitting a one-hit model, Crump's procedure, and applying Rai and Van Ryzin's method to a Weibull model.^ None of the procedures performed uniformly well for all types of dose-response curves. When the data were linear, the one-hit model, Hoel's method, or the Gross-Mantel method worked reasonably well. However, when the data were non-linear, these same methods were overly conservative. Crump's procedure and the Weibull model performed better in these situations. ^