A comparative analysis of CHIP Perinatal policy in twelve states

The purpose of this comparative analysis of CHIP Perinatal policy (42 CFR § 457) was to provide a basis for understanding the variation in policy outputs across the twelve states that, as of June 2007, implemented the Unborn Child rule. This Department of Health and Human Services regulation expanded in 2002 the definition of “child” to include the period from conception to birth, allowing states to consider an unborn child a “targeted low-income child” and therefore eligible for SCHIP coverage. ^ Specific study aims were to (1) describe typologically the structural and contextual features of the twelve states that adopted a CHIP Perinatal policy; (2) describe and differentiate among the various designs of CHIP Perinatal policy implemented in the states; and (3) develop a conceptual model that links the structural and contextual features of the adopting states to differences in the forms the policy assumed, once it was implemented. ^ Secondary data were collected from publicly available information sources to describe characteristics of states’ political system, health system, economic system, sociodemographic context and implemented policy attributes. I posited that socio-demographic differences, political system differences and health system differences would directly account for the observed differences in policy output among the states. ^ Exploratory data analysis techniques, which included median polishing and multidimensional scaling, were employed to identify compelling patterns in the data. Scaled results across model components showed that economic system was most closely related to policy output, followed by health system. Political system and socio-demographic characteristics were shown to be weakly associated with policy output. Goodness-of-fit measures for MDS solutions implemented across states and model components, in one- and two-dimensions, were very good. ^ This comparative policy analysis of twelve states that adopted and implemented HHS Regulation 42 C.F.R. § 457 contributes to existing knowledge in three areas: CHIP Perinatal policy, public health policy and policy sciences. First, the framework allows for the identification of CHIP Perinatal program design possibilities and provides a basis for future studies that evaluate policy impact or performance. Second, studies of policy determinants are not well represented in the health policy literature. Thus, this study contributes to the development of the literature in public health policy. Finally, the conceptual framework for policy determinants developed in this study suggests new ways for policy makers and practitioners to frame policy arguments, encouraging policy change or reform. ^

Advancing the theory of collective empowerment: A qualitative study

In order to fully describe the construct of empowerment and to determine possible measures for this construct in racially and ethnically diverse neighborhoods, a qualitative study based on Grounded Theory was conducted at both the individual and collective levels. Participants for the study included 49 grassroots experts on community empowerment who were interviewed through semi-structured interviews and focus groups. The researcher also conducted field observations as part of the research protocol.^ The results of the study identified benchmarks of individual and collective empowerment and hundreds of possible markers of collective empowerment applicable in diverse communities. Results also indicated that community involvement is essential in the selection and implementation of proper measures. Additional findings were that the construct of empowerment involves specific principles of empowering relationships and particular motivational factors. All of these findings lead to a two dimensional model of empowerment based on the concepts of relationships among members of a collective body and the collective body's desire for socio-political change.^ These results suggest that the design, implementation, and evaluation of programs that foster empowerment must be based on collaborative ventures between the population being served and program staff because of the interactive, synergistic nature of the construct. In addition, empowering programs should embrace specific principles and processes of individual and collective empowerment in order to maximize their effectiveness and efficiency. And finally, the results suggest that collaboratively choosing markers to measure the processes and outcomes of empowerment in the main systems and populations living in today's multifaceted communities is a useful mechanism to determine change. ^

Patterns of alcohol and illicit substance use in the United States and Mexico. Substantive and methodologic issues in the cross-national analysis of alcohol and drug use data

This research examines prevalence of alcohol and illicit substance use in the United States and Mexico and associated socio-demographic characteristics. The sources of data for this study are public domain data from the U.S. National Household Survey of Drug Abuse, 1988 (n = 8814), and the Mexican National Survey of Addictions, 1988 (n = 12,579). In addition, this study discusses methodologic issues in cross-cultural and cross-national comparison of behavioral and epidemiologic data from population-based samples. The extent to which patterns of substance abuse vary among subgroups of the U.S. and Mexican populations is assessed, as well as the comparability and equivalence of measures of alcohol and drug use in these national samples.^ The prevalence of alcohol use was somewhat similar in the two countries for all three measures of use: lifetime, past year and past year heavy use, (85.0%, 68.1%, 39.6% and 72.6%, 47.7% and 45.8% for the U.S. and Mexico respectively). The use of illegal substances varied widely between countries, with U.S. respondents reporting significantly higher levels of use than their Mexican counterparts. For example, reported use of any illicit substance in lifetime and past year was 34.2%, 11.6 for the U.S., and 3.3% and 0.6% for Mexico. Despite these differences in prevalence, two demographic characteristics, gender and age, were important correlates of use in both countries. Men in both countries were more likely to report use of alcohol and illicit substances than women. Generally speaking, a greater proportion of respondents in both countries 18 years of age or older reported use of alcohol for all three measures than younger respondents; and a greater proportion of respondents between the ages of 18 and 34 years reported use of illicit substances during lifetime and past year than any other age group.^ Additional substantive research investigating population-based samples and at-risk subgroups is needed to understand the underlying mechanisms of these associations. Further development of cross-culturally meaningful survey methods is warranted to validate comparisons of substance use across countries and societies. ^

Depression, interpersonal violence and lack of social support as barriers to cervical cancer screening among recently immigrated Latinas

Background. Various psychosocial factors have been demonstrated to be barriers for cervical cancer screening among Latinas in the United States, but few studies have researched whether depression and interpersonal violence act as psychosocial barriers to cervical cancer screening. ^ Methods. The proposed study assessed whether depression, interpersonal violence, lack of social support and demographic characteristics such as age, income, education and years in the United States acted as barriers to cervical cancer screening among cantineras in Houston, TX. This secondary data analysis utilized data from a previous cross-sectional study called Project GIRASOL- Community Outreach to Prevent Cervical Cancer among Latinas. The data from the baseline survey (sample size 331) was analyzed using Pearson chi-square and multiple logistic regression. ^ Results. Multiple logistic regression indicates that none and low levels of social support from relatives, depression, and total IPV are significant predictors of non-compliance to cervical cancer screening. ^ Conclusions. Future health interventions or physicians that promote cervical cancer screening among cantineras or recently immigrated Latinas with similar socio-demographic characteristics should try to identify whether Latinas are suffering from depression, interpersonal violence or lack of social support and provide proper referrals to alleviate the problems and positively influence screening behavior. ^

Body mass index of Vietnamese children ages 6--15 years old

Childhood overweight can increase the risk of chronic diseases later in life. To determine the prevalence, trends and determinants of overweight among children ages 6-15 years old in Vietnam, we assessed data on body mass index (BMI) and demographic and socio-economic characteristics obtained from the 1992 Vietnam Living Standard Survey (1992 VLSS), the 1997 Vietnam Living Standard Survey (1997 VLSS), and the 2000 General Nutrition Survey (2000 GNS). These surveys used multi-stage cluster sample designs to produce nationally representative samples of Vietnamese children ages 6-15 years in 1992-1993, 1997-1998 and 2000. BMI classification was determined using cut-off values set by the International Obesity Task Force (IOTF). The mean prevalence of at risk of overweight and overweight among Vietnamese children rapidly increased from 0.4% in 1992 to 2.0% in 2000, along with a high prevalence of underweight (33.4% in 2000). Increases in weight, height and BMI varied according to gender, area of residence and socioeconomic status. Age, areas of residence and education of the household head are statistically significant predictors of at risk of overweight and overweight. This study identified the prevalence and trends of weight among children crucial to understanding the prevention of child overweight in Vietnam. ^

Factors associated with diabetes in tuberculosis patients in Harris County, Texas 1995--2004

Objective. To determine the prevalence and factors associated with diabetes in tuberculosis patients in Harris County, Texas. ^ Background. Tuberculosis and diabetes mellitus are two diseases of immense public health significance. Various epidemiologic studies have established an association between the two conditions. While many studies have identified factors associated with the conditions individually, few have looked at factors associated with their co-occurrence particularly in the United States. Furthermore, most of those studies are hospital-based and may not be representative of the population. The aim of this study was to determine the prevalence and distribution of diabetes among tuberculosis patients in Harris County, Texas and to identify the factors associated with diabetes in tuberculosis. ^ Methods. A population-based case control study was performed using secondary data from the Houston Tuberculosis Initiative (HTI) collected from October 1995 to September 2004. Socio-demographic characteristics and clinical variables were compared between tuberculosis patients with diabetes and non-diabetic tuberculosis patients. Logistic regression analysis was performed to identify associations. Survival at 180 days post tuberculosis diagnosis was assessed by Cox regression. ^ Results. The prevalence of diabetes among the tuberculosis (TB) population was 14.4%. The diabetics (cases) with a mean age 53 ± 13.3 years were older than the non-diabetics (controls) with a mean age of 39 ± 18.5 years (p<0.001). Socio-demographic variables that were independently associated with the risk of diabetes were age (OR 1.04, p<0.001) and Hispanic ethnicity (OR 2.04, p<0.001). Diabetes was associated with an increased risk of pulmonary tuberculosis disease (OR 1.33, p<0.028). Among individuals with pulmonary TB, diabetes was associated with positive sputum acid-fast bacilli (AFB) smear (OR 1.47, p<0.005) and culture (OR 1.83, p<0.018). Diabetics were more likely to have cavitary lung disease than non-diabetics (OR 1.50, p<0.002). After adjustment for age and HIV status, the risk of dying within 180 days of TB diagnosis was significantly increased in the diabetics (HR 1.51, p<0.002). ^ Conclusion. Diabetes mellitus was more prevalent in our tuberculosis patients than in the general population. The tuberculous diabetic may be more infectious and has a higher risk of death. It is therefore imperative to screen diabetics for TB and TB patients for diabetes. ^

Is sexual intimacy among older adults positively associated with mental well-being?

Background. The elderly population aged 60 and above is increasing rapidly throughout the world. The aging process affects physical health of individuals, which in turn affects sexuality and sexual activity. However, many elderly adults continue to engage in one or more forms of sexual activities well into their 70s, 80s, and even in 90s. Despite the widespread stereotypes, misconceptions, and negative attitudes surrounding sexuality in elderly adults, it has been found to be an important aspect of the health of the elderly. However, association between the frequency of sexual activity and mental well being among older adults has not been documented in the literature. ^ Methods. To test the hypotheses that mental well being indicators such as depression, anxiety, and stress were inversely associated with greater frequency of sexual intimacy, a secondary data analysis was conducted using the National Social Life Health and Aging Project (NSHAP) using multivariate logistic regression. The NSHAP was a population-based study that was conducted on a national scale including 1455 men and 1550 women aged 57-85.^ Results. Approximately 1430 (54.1%) of the total population reported being sexually intimate in the past 12 months whereas 1481 (45.9%) participants reported that they did not perform any sexual activity in the past 12 months. In addition, approximately 895(31.1%) participants reported engaging in sexual activity ≥ 2-3 times per month with 665 (78.9%) of these participants reported performing vaginal intercourse only, 14(2.0%) oral sex only, and 89(10.5%) reported performing both vaginal intercourse and oral sex. Controlling for socio-demographic characteristics, frequently (≥2-3 times per month) sexually active participants showed lower odds ratio of depression (OR= 0.60; 95%CI = 0.46, 0.78), anxiety (OR= 0.67; 95% CI= 0.53, 0.86), and stress (OR=0.73; 95% CI = 0.6, 0.88) compared to those who had less frequent sexual activity or who had no sexual activity in the past 12 months.^ Conclusion. Lower levels of depression, anxiety, and stress appear to be associated with greater frequency of sexual activity. Public health interventions should focus on educating elderly adults about their sexual health and how to seek medical help for their sexual problems. Public health professionals should also be educated on how to best assess sexual needs of the elderly adults.^

A descriptive analysis of the consumers at farm stands outside WIC clinics

Because fruit and vegetable intake remains low in low-income populations, the attention of public health researchers has focused on different strategies to reach this population. One possible method of reaching low income populations is through government food assistance programs like the WIC's Farmers Market Nutrition Program (FMNP). This program provides vouchers to WIC recipients that are redeemable only at farmers' markets. In the summer of 2010, two farm stands near WIC clinics in Austin were surveyed in order to establish socio-demographic characteristics of the clientele of the markets. The overall purpose of this pilot study was to describe the clientele of the markets and to examine associations between food insecurity, acculturation, socio-demographic factors, and farmers' market participants' fruit and vegetable intake. The sample was a convenience sample of farmers' market customers. One hundred study participants completed self-administered surveys. Independent t-tests were used to explore the differences in means of fruit and vegetable intake according to acculturation and food insecurity levels. The overall mean (SD) of daily fruit and vegetable intake was 4.20±2.69 for customers of both markets. Significant differences were reported between the two markets in overall fruit and vegetable intake and specifically in the following: 100% juice (P=.023), fruit consumption (P=.028), green salad (P=.003), and salsa (P=.044). The differences showed that customers at the market in a more busy location were on average reporting eating more fruits and vegetables than customers at another market that was located in a more secluded location. When examined by level of food security, individuals who were more food secure consumed more fruit (P=.016). When examined by level of acculturation, the overall fruit and vegetable intake was not significantly different between levels of acculturation. The overall findings in this report suggest that the population at these markets consists of individuals who are food insecure and on government assistance programs. While there were no significant differences between fruit and vegetable intake, acculturation and food insecurity, this report suggests the need for culturally tailored interventions that serve the Hispanic population and would assist this population to become more food secure.^

Changes in sexual behaviors associated with crack cocaine cessation among African Americans in Houston, Texas

Aim To examine the association between the crack cocaine cessation and risky sexual behaviors. Design and setting Between June 2002 and March 2005, a sample of African-American residents of Houston, Texas who were using crack at the time of enrollment participated in a cohort study to evaluate per outreach interventions to reduce HIV risk behaviors. The sample for this study consisted of 351 women and men who completed structured surveys at baseline and at six months about socio-demographic characteristics, drug use, and sexual behaviors. Multivariate logistic regression was used to analyze the association between crack cessation and risky sexual behaviors at follow-up, while controlling for confounding characteristics. Measurements Crack cessation was defined as reporting no crack use in the 30 days prior to the follow-up interview. Possible associated factors included unprotected sex, having multiple sex partners, trading sex for money/drugs, crack use, and socio-demographic variables. Findings At the six-month follow-up interview, 21% of participants reported that they had not used crack in the previous 30 days. For women, crack cessation was significantly associated with having only one sex partner at follow-up; for men, crack cessation was significantly associated with being single, separated, or divorced at baseline, having only one sex partner at follow-up, and initiating protected sex by follow-up. Conclusion These findings support previous research indicating that crack use is associated with unprotected sex and multiple sexual partners, as men and women who ceased crack use were less likely to engage in these risky sexual behaviors. Findings demonstrate that treatment for crack use could have a meaningful effect on risky sexual behaviors and HIV/STI prevention.^

Factors influencing participation in individuals with disability: A secondary data analysis

Individuals with disabilities face numerous barriers to participation due to biological and physical characteristics of the disability as well as social and environmental factors. Participation can be impacted on all levels from societal, to activities of daily living, exercise, education, and interpersonal relationships. This study evaluated the impact of pain, mood, depression, quality of life and fatigue on participation for individuals with mobility impairments. This cross sectional study derives from self-report data collected from a wheelchair using sample. Bivariate correlational and multivariate analysis were employed to examine the relationship between pain, quality of life, positive and negative mood, fatigue, and depression with participation while controlling for relevant socio-demographic variables (sex, age, time with disability, race, and education). Results from the 122 respondents with mobility impairments demonstrated that after controlling for socio-demographic characteristics in the full model, 20% of the variance in participation scores were accounted for by pain, quality of life, positive and negative mood, and depression. Notably, quality of life emerged as being the single variable that was significantly related to participation in the full model. Contrary to other studies, pain did not appear to significantly impact participation outcomes for wheelchair users in this sample. Participation is an emerging area of interest among rehabilitation and disability researchers, and results of this study provide compelling evidence that several psychosocial factors are related to participation. This area of inquiry warrants further study, as many of the psychosocial variables identified in this study (mood, depression, quality of life) may be amenable to intervention, which may also positively influence participation.^

Geographic variation in the utilization and survival associated with oxaliplatin chemotherapy in patients with stage III colon cancer

Background: Overall objectives of this dissertation are to examine the geographic variation and socio-demographic disparities (by age, race and gender) in the utilization and survival of newly FDA-approved chemotherapy agents (Oxaliplatin-containing regimens) as well as to determine the cost-effectiveness of Oxaliplatin in a large nationwide and population-based cohort of Medicare patients with resected stage-III colon cancer. Methods: A retrospective cohort of 7,654 Medicare patients was identified from the Surveillance, Epidemiology and End Results – Medicare linked database. Multiple logistic regression was performed to examine the relationship between receipt of Oxaliplatin-containing chemotherapy and geographic regions while adjusting for other patient characteristics. Cox proportional hazard model was used to estimate the effect of Oxaliplatin-containing chemotherapy on the survival variation across regions using 2004-2005 data. Propensity score adjustments were also made to control for potential bias related to non-random allocation of the treatment group. We used Kaplan-Meier sample average estimator to calculate the cost of disease after cancer-specific surgery to death, loss-to follow-up or censorship. Results: Only 51% of the stage-III patients received adjuvant chemotherapy within three to six months of colon-cancer specific surgery. Patients in the rural regions were approximately 30% less likely to receive Oxaliplatin chemotherapy than those residing in a big metro region (OR=0.69, p=0.033). The hazard ratio for patients residing in metro region was comparable to those residing in big metro region (HR: 1.05, 95% CI: 0.49-2.28). Patients who received Oxalipaltin chemotherapy were 33% less likely to die than those received 5-FU only chemotherapy (adjusted HR=0.67, 95% CI: 0.41-1.11). KMSA-adjusted mean payments were almost 2.5 times higher in the Oxaliplatin-containing group compared to 5-FU only group ($45,378 versus $17,856). When compared to no chemotherapy group, ICER of 5-FU based regimen was $12,767 per LYG, and ICER of Oxaliplatin-chemotherapy was $60,863 per LYG. Oxaliplatin was found economically dominated by 5-FU only chemotherapy in this study population. Conclusion: Chemotherapy use varies across geographic regions. We also observed considerable survival differences across geographic regions; the difference remained even after adjusting for socio-demographic characteristics. The cost-effectiveness of Oxaliplatin in Medicare patients may be over-estimated in the clinical trials. Our study found 5-FU only chemotherapy cost-effective in adjuvant settings in patients with stage-III colon cancer.^

Risk factors for metabolic syndrome among overweight and obese Hispanic children attending a pediatric clinic in New Braunfels, Texas

Childhood obesity is a persistent problem in the U.S., especially among Hispanics. Health complications like hypertension, type II diabetes, and metabolic syndrome (Met-S) are being seen at younger ages, and current screening procedures may be inadequate. This study sought to describe the risk factors for Met-S present in a sample of 106 overweight and obese Hispanic children, aged 5-14 years, participating in Nutrition and Exercise Start Today (NEST), a randomized weight management intervention trial at a rural health clinic in New Braunfels, Texas; and to determine associations between these factors and other clinical and socio-demographic characteristics linked to obesity. Baseline data was analyzed for the prevalence of large waist circumference (WC), elevated blood pressure (BP), high fasting serum glucose and serum triglycerides (TG), and low serum HDL cholesterol, in relationship with selected sample characteristics. Main findings included high baseline prevalence rates of large WC (77%), reduced HDL (57%), and elevated BP (30%). WC was significantly associated with BMI percentile and the serum liver function test alanine aminotransferase (ALT) by Fisher's exact test (p<0.001 and p=0.032, respectively), while there were significant relationships between HDL and both female gender and ALT. BMI percentile and ALT were associated with all sets of Met-S diagnostic criteria examined. BMI percentile also had a strong association (p=0.005) with total number of Met-S risk factors, while ALT had a weaker association (p=0.093). WC is a low-cost, simple measure whose use may improve clinic surveillance for childhood obesity and complications like Met-S. WC, BP, HDL and ALT may be used as part of targeted screening for obesity complications like Met-S, particularly in situations where resources are limited.^

Community diagnosis: A working tool for developing culturally appropriate diarrhea intervention programs

Most studies related to diarrhea have been focused narrowly on the etiological and pathophysiological factors involved in inducing the disease. Such studies have often failed to consider other facets contributing to and possibly prolonging the problem, namely: socio-economic conditions, educational opportunities and attainments, cultural characteristics and beliefs, and the political administration and its commitment towards fulfilling its moral and ethical obligations in responding to and fostering human development.^ This study utilized the diagnostic approach of the PRECEDE model. The acronym stands for the predisposing reinforcing, and enabling constructs in educational diagnosis and evaluation. The constituents of this model were identified by utilizing participant observation field methods, traditionally applied by ethnographers to collect data describing the multiple facets of a culture, and linguistic anthropology used to capture and define characteristic semantics and viewpoints. The household study sample was randomly selected from a defined list of households known to have at least one child less than five years of age. An open-ended questionnaire format was used to interview the 115 mothers in the selected households sample.^ Kalama, the study community, is characteristically an agricultural village, situated in the Governorate of Kaliobia and located approximately 25 Km (about 15.5 miles) from the capital, Cairo, Egypt. The 1986 census indicates a population size of 13,328 people in 4,818 households. There were 65 deaths occurring among children less than five years in 1986. The causes of death were primarily related to diarrhea, followed by upper respiratory infections, congenital anomalies and birth injuries.^ This study outlines (a) practices related to the management of diarrhea, including the administration of foods and drinks during such episodes; (b) influences of governmental policies; and (c) recommended strategies for overcoming barriers and promoting effective diarrhea intervention programs. ^

SOCIO-ENVIRONMENTAL FACTORS ASSOCIATED WITH THE DISTRIBUTION OF DRACUNCULUS MEDINENSIS (GUINEA WORM DISEASE) AND SUGGESTED METHODS FOR CONTROL, IBARAPA, NIGERIA, 1982 (AFRICA)

A population-based cross-sectional survey of socio-environmental factors associated with the prevalence of Dracunculus medinensis (guinea worm disease) was conducted in Idere, a rural agricultural community in Ibarapa, Oyo state, Nigeria, during 1982.^ The epidemiologic data were collected by household interview of all 501 households. The environmental data were collected by analysis of water samples collected from all domestic water sources and rainfall records.^ The specific objectives of this research were to: (a) Describe the prevalence of guinea worm disease in Idere during 1982 by age, sex, area of residence, drinking water source, religion and weekly amount of money spent by the household to collect potable drinking water. (b) Compare the characteristics of cases with non-cases of guinea worm in order to identify factors associated with high risk of infection. (c) Investigate domestic water sources for the distribution of Cyclops. (d) Determine the extent of potable water shortage with a view to identifying factors responsible for such shortage in the community. (e) Describe the effects of guinea worm on school attendance during 1980/1982 school years by class and location of school from piped water supply.^ The findings of this research indicate that during 1982, 31.8 percent of Idere's 6,527 residents experienced guinea worm infection, with higher prevalence of infection recorded in males in their most productive years and females in their teenage years. The role of sex and age to risk of higher infection rate was explained in the context of water related exposure and water intake due to dehydration from physical occupational actitives of subgroups.^ Potable water available to residents was considerably below the minimum recommended by WHO for tropical climates, with sixty-eight percent of water needs of the residents coming from unprotected surface water which harbour Cyclops, the obligatory intermediate host of Dracunculus medinensis. An association was found between periods of relative high density of Cyclops in domestic water and rainfall.^ Impact of guinea worm infection on educational activities was considerable and its implications were discussed, including the implications of the research findings in relation to control of guinea worm disease in Ibarapa. ^

U.S. school based sealant programs: Review of their most common characteristics

In the United States, dental caries is the most common chronic illness in children, occurring five to eight times as frequently as asthma. 11 Dental caries is an unmet health need, disproportionately affecting minority groups and individuals with low socio-economic status.15,34,36 School-Based Sealant Programs were developed to target children at risk, to provide dental services in a closer geographic area, to offer low cost preventive dental services, and to educate families about oral health and prevention.1 There is scientific, evidence based literature that shows the effectiveness of dental sealants preventing dental decay. 13^ Currently, there is no central source for cataloging School-Based Sealant Programs (SBSPs). Information is scattered around publications and documents. For instance, the National Health and Nutrition Examination Survey (NHANES) does not have information about all the existing SBSPs. ^ This literature review determined which are the most common characteristics of SBSPs in the U.S. and determined the extent to which these programs provide sealants to children of low socio-economic status. The method utilized was an electronic database search. Pubmed and EBESCO host databases were searched with Mesh terms like “dental school sealant programs”, “community dentistry”, “school based sealant programs” and “oral preventive programs”. Results were organized in terms of location, population served, providers, funding source and data shared. ^ The searches produced 77 studies, from which 40 were included in this work. Only 18 U.S. states were represented in the results; however these findings are very consistent with the Best Practice Approach – School Based Sealant Programs3. Most of the SBSPs provide their services to children from low income families, and utilized the lower labor cost providers permitted by their state regulations. The author intends that this thesis work will become an aide in the development of future programs, and as evidence for the sustainability of these programs.^