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.

Ethnic Minority Children’s Active Commuting to School and Association with Physical Activity and Pedestrian Safety Behaviors

Background: Children's active commuting to school, i.e. walking or cycling to school, was associated with greater moderate-to-vigorous physical activity, although studies among ethnic minorities are sparse. Objectives: Among a low-income, ethnic minority sample of fourth grade students from eight public schools, we examined (1) correlates of active commuting to school and (2) the relationship between active commuting to school and moderate-to-vigorous physical activity. Methods: We conducted a cross-sectional analysis of baseline measurements from a sample of participants (n=149) aged 9-12 years from a walk to school intervention study in Houston, Texas. The primary outcome was the weekly rate of active commuting to school. Daily moderate-to-vigorous physical activity, measured by accelerometers, was a secondary outcome. Child self-efficacy (alpha=0.75), parent self-efficacy (alpha=0.88), and parent outcome expectations (alpha=0.78) were independent variables. Participant characteristics (age, gender, race/ethnicity, distance from home to school, acculturation, and BMI percentile) were independent sociodemographic variables. We used mixed-model regression analyses to account for clustering by school and a stepwise procedure with backward elimination of non-significant interactions and covariates to identify significant moderators and predictors. School-level observations of student pedestrians were assessed and compared using chi-square tests of independence. Results: Among our sample, which was 61.7% Latino, the overall rate of active commuting to school was 43%. In the mixed model for active commuting to school, parent self-efficacy (std. beta = 0.18, p=0.018) and age (std. beta = 0.18, p=0.018) were positively related. Latino students had lower rates of active commuting to school than non-Latinos ( 16.5%, p=0.040). Distance from home to school was inversely related to active commuting to school (std. beta = 0.29, p<0.001). In the mixed model for moderate-to-vigorous physical activity, active commuting to school was positively associated (std. beta = 0.31, p <0.001). Among the Latino subsample, child acculturation was negatively associated with active commuting to school (std. beta = -0.23, p=0.01). With regard to school-level pedestrian safety observations, 37% of students stopped at the curb and 2.6% looked left-right-left before crossing the street. Conclusion: Although still below national goals, the rate of active commuting was relatively high, while the rate of some pedestrian safety behaviors was low among this low-income, ethnic minority population. Programs and policies to encourage safe active commuting to school are warranted and should consider the influence of parents, acculturation, and ethnicity.

Polymorphisms of the DNA repair gene MGMT and risk and progression of head and neck cancer.

Methylating agents are involved in carcinogenesis, and the DNA repair protein O(6)-methylguanine-DNA methyltransferase (MGMT) removes methyl group from O(6)-methylguanine. Genetic variation in DNA repair genes has been shown to contribute to susceptibility to squamous cell carcinoma of the head and neck (SCCHN). We hypothesize that MGMT polymorphisms are associated with risk of SCCHN. In a hospital-based case-control study of 721 patients with SCCHN and 1234 cancer-free controls frequency-matched by age, sex and ethnicity, we genotyped four MGMT polymorphisms, two in exon 3, 16195C>T and 16286C>T and two in the promoter region, 45996G>T and 46346C>A. We found that none of these polymorphisms alone had a significant effect on risk of SCCHN. However, when these four polymorphisms were evaluated together by the number of putative risk genotypes (i.e. 16195CC, 16286CC, 45996GT+TT, and 46346CA+AA), a statistically significantly increased risk of SCCHN was associated with the combined genotypes with three to four risk genotypes, compared with those with zero to two risk genotypes (adjusted odds ratio (OR)=1.27; 95% confidence interval (CI)=1.05-1.53). This increased risk was also more pronounced among young subjects (OR=1.81; 95% CI=1.11-2.96), men (OR=1.24; 95% CI=1.00-1.55), ever smokers (OR=1.25; 95%=1.01-1.56), ever drinkers (OR=1.29; 95% CI=1.04-1.60), patients with oropharyngeal cancer (OR=1.45; 95% CI=1.12-1.87), and oropharyngeal cancer with regional lymph node metastasis (OR=1.52; 95% CI=1.16-1.89). In conclusion, our results suggest that any one of MGMT variants may not have a substantial effect on SCCHN risk, but a joint effect of several MGMT variants may contribute to risk and progression of SCCHN, particularly for oropharyngeal cancer, in non-Hispanic whites.

Excess stroke in Mexican Americans compared with non-Hispanic Whites: the Brain Attack Surveillance in Corpus Christi Project.

Mexican Americans are the largest subgroup of Hispanics, the largest minority population in the United States. Stroke is the leading cause of disability and third leading cause of death. The authors compared stroke incidence among Mexican Americans and non-Hispanic Whites in a population-based study. Stroke cases were ascertained in Nueces County, Texas, utilizing concomitant active and passive surveillance. Cases were validated on the basis of source documentation by board-certified neurologists masked to subjects' ethnicity. From January 2000 to December 2002, 2,350 cerebrovascular events occurred. Of the completed strokes, 53% were in Mexican Americans. The crude cumulative incidence was 168/10,000 in Mexican Americans and 136/10,000 in non-Hispanic Whites. Mexican Americans had a higher cumulative incidence for ischemic stroke (ages 45-59 years: risk ratio = 2.04, 95% confidence interval: 1.55, 2.69; ages 60-74 years: risk ratio = 1.58, 95% confidence interval: 1.31, 1.91; ages >or=75 years: risk ratio = 1.12, 95% confidence interval: 0.94, 1.32). Intracerebral hemorrhage was more common in Mexican Americans (age-adjusted risk ratio = 1.63, 95% confidence interval: 1.24, 2.16). The subarachnoid hemorrhage age-adjusted risk ratio was 1.57 (95% confidence interval: 0.86, 2.89). Mexican Americans experience a substantially greater ischemic stroke and intracerebral hemorrhage incidence compared with non-Hispanic Whites. As the Mexican-American population grows and ages, measures to target this population for stroke prevention are critical.

Ethnic differences in do-not-resuscitate orders after intracerebral hemorrhage.

OBJECTIVE: To explore ethnic differences in do-not-resuscitate orders after intracerebral hemorrhage. DESIGN: Population-based surveillance. SETTING: Corpus Christi, Texas. PATIENTS: All cases of intracerebral hemorrhage in the community of Corpus Christi, TX were ascertained as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed for do-not-resuscitate orders. Unadjusted and multivariable logistic regression were used to test for associations between ethnicity and do-not-resuscitate orders, both overall ("any do-not-resuscitate") and within 24 hrs of presentation ("early do-not-resuscitate"), adjusted for age, gender, Glasgow Coma Scale, intracerebral hemorrhage volume, intraventricular hemorrhage, infratentorial hemorrhage, modified Charlson Index, and admission from a nursing home. A total of 270 cases of intracerebral hemorrhage from 2000-2003 were analyzed. Mexican-Americans were younger and had a higher Glasgow Coma Scale than non-Hispanic whites. Mexican-Americans were half as likely as non-Hispanic whites to have early do-not-resuscitate orders in unadjusted analysis (odds ratio 0.45, 95% confidence interval 0.27, 0.75), although this association was not significant when adjusted for age (odds ratio 0.61, 95% confidence interval 0.35, 1.06) and in the fully adjusted model (odds ratio 0.75, 95% confidence interval 0.39, 1.46). Mexican-Americans were less likely than non-Hispanic whites to have do-not-resuscitate orders written at any time point (odds ratio 0.37, 95% confidence interval 0.23, 0.61). Adjustment for age alone attenuated this relationship although it retained significance (odds ratio 0.49, 95% confidence interval 0.29, 0.82). In the fully adjusted model, Mexican-Americans were less likely than non-Hispanic whites to use do-not-resuscitate orders at any time point, although the 95% confidence interval included one (odds ratio 0.52, 95% confidence interval 0.27, 1.00). CONCLUSIONS: Mexican-Americans were less likely than non-Hispanic whites to have do-not-resuscitate orders after intracerebral hemorrhage although the association was attenuated after adjustment for age and other confounders. The persistent trend toward less frequent use of do-not-resuscitate orders in Mexican-Americans suggests that further study is warranted.

EFFECT OF ANCHORING ON PERCEIVED AMNIOCENTESIS RELATED MISCARRIAGE RISK WITHIN A LATINA POPULATION

Most recognized pregnancies are completed without difficulty, yet there is always a 3-5% background risk to have a child with a birth defect. Amniocentesis, the most common type of prenatal diagnostic test, is used to detect chromosomal abnormalities, such as Down syndrome. Amniocentesis is associated with a risk of complications that can lead to a miscarriage, which is typically quoted to be between 1 in 300 and 1 in 500. Amniocentesis uptake rates are typically lowest within the Latina community, and although the factors related to this have been studied before, no specific conclusions have been reached. The general population has a difficult time interpreting risks, as individuals vary in numeracy skills as well as personal factors that can influence risk perception. A recent study by Nuccio (2010) investigated the effect of anchoring, where a patient’s prior knowledge about a subject affects her risk perception, and how it relates to the uptake of amniocentesis within a diverse population in Houston, TX. The effect of anchoring on perceived amniocentesis-related miscarriage risk within the Latina population has not been previously examined. A two-part questionnaire was completed by 96 Latinas receiving prenatal genetic counseling due to an increased risk to have a baby with a chromosome abnormality at various clinics in Houston, TX. The genetic counselor involved in the session completed a separate survey. This population was largely unfamiliar with surveys, risk figures, and prenatal testing. Only one individual was able to quantify the risk associated with amniocentesis prior to the genetic counseling. While the majority of women felt that the risk association with amniocentesis is very low to average, only 7 individuals pursued diagnostic testing through amniocentesis. Most women did not feel like the information gained from an amniocentesis would change the management of their pregnancy and/or they did not believe that their baby had a problem. Women, regardless of ethnicity, deserve individualized genetic counseling sessions that cater to their needs and desires regarding their prenatal care.

Grandparents in Kinship Care: Help or Hindrance to Family Preservation

The phenomenon of grandparents and other relatives raising children is a tradition rooted in the African American culture. However, a substantial increase in the number of relatives raising children has drawn attention to the child welfare system. Many of the biological parents are incarcerated for drugs or suffering from other social ills. Kinship care is an important component of family preservation and prevents court intervention based on child protection concerns and avoids formal placement of children in the child welfare system (Wilkerson, 1999). The child welfare system, however, is not conducive to this phenomenon. Placing children with grandparents and relatives allows them to live with people they know and trust; reduces the initial trauma of living with unknown persons; supports the transmission of identity, culture, and ethnicity; facilitates connections with brothers and sisters, and strengthens a family’s ability to provide the support they need.

Addressing Obesity: Fear of Crime, Perceptions of Disorder and Disaparities in Child and Adolescent Use of Public Parks

Abstract The objectives of this study were: 1) To determine factors which inhibit and facilitate child and adolescent use of outdoor spaces for healthy physical activity by race and ethnicity in four Houston communities and 2) To propose guidelines for encouraging and maintaining child and adolescent outdoor physical activity. Using local health data and Houston Police Department crime statistics, four communities were identified for the study that had the highest concentration of crime and the racial/ ethnic groups of interest. The researchers then identified public parks in the communities. At least two parks were observed in each of the four communities from 2010 to 2011 during spring, summer, fall and winter. The parks were observed for use by children and adolescents and to describe the condition of the park spaces. The communities were Alief (Asian), Sunnyside (Black), Eldridge- West Oaks (White) and Northside- Northline (Hispanic). Observations were made at varying hours of both day and night, weekdays and weekends. Photographs were taken and the condition of the spaces noted in detail. One hundred and twenty persons, 18 years and over, using the spaces or otherwise in these communities were conveniently sampled and interviewed about their health and the extent to which they, or any children or adolescents under their care, used the outdoor spaces of interest. Data were analyzed qualitatively and with basic descriptive statistics. The photographs, journal notes and observation notes of all investigators and key personnel were analyzed. Interview data were also coded to identify patterns and themes in the responses. The findings indicate disparities in the quality and quantity of park equipment and the maintenance of the areas. Where perceptions of disorder were described, there was often visible evidence to support the perceptions. In many cases, residents' perceptions of crime were corroborated by police data. While interview reports did not seem to support the expectation that the condition of the parks was a significant deterrent to their use by children and adolescents, the condition of the parks might be said to limit the extent of that use. Specific reports of disorder that inhibited use included hearing gunfire, seeing drug dependent homeless persons and/or suspected prostitutes in an area.

Cancer patients' attitudes toward cancer trials

Background. Accurate measurement of attitudes toward participation in cancer treatment trials (CTs) and cancer prevention trials (CPTs) across varied groups could assist health researchers and educators when addressing attitudinal barriers to participation in these trials. ^ Methods. The Attitudes toward Cancer Trials Scales (ACTS) instrument development was based on a conceptual model developed from research literature, clinical practice experience, and empirical testing of items with a sample of 312 respondents. The ACTS contains two scales, the Cancer Trials (CT) scale (4 components; 18 items) and the Cancer Prevention Trials (CPT) scale (3 components; 16 items). Cronbach's alpha values for the CT and CPT scales, respectively, were 0.86 and 0.89. These two scales along with sociodemographic and cancer trial history variables were distributed in a mail survey of former patients of a large cancer research center. The disproportionate stratified probability sampling procedure yielded 925 usable responses (54% response rate). ^ Results. Prevalence of favorable attitudes toward CTs and CPTs was 66% and 69%, respectively. There were no significant differences in mean scale scores by cancer site or gender, but African Americans had more favorable attitudes toward CTs than European Americans. Multiple regression analysis indicated that older age, lower education level, and prior CT participation history were associated with more favorable attitudes toward CTs. Prior CT participation and prior CPT participation were associated with more favorable attitudes toward CPTs. Results also provided evidence of reliability and construct validity for both scales. ^ Conclusions. Middle age, higher education, and European American ethnicity are associated with less positive attitudes about participating in cancer treatment trials. Availability of a psychometrically sound instrument to measure attitudes may facilitate a better understanding decision making regarding participation in CTs and CPTs. It is this author's intention that the ACTS' scales will be used by other investigators to measure attitudes toward CTs and CPTs in various groups of persons, and that the many issues regarding participation in trials might become more explicit. ^

Patient satisfaction and nursing staff work satisfaction in an urban public teaching hospital

This study examined the level of patient satisfaction and nursing staff work satisfaction at an urban public hospital in the Southwestern United States. The primary objectives of this study were to determine: (1) the level of overall patient satisfaction and satisfaction with specific dimensions of hospital care; (2) the differences in patient satisfaction according to demographic characteristics (age, gender, ethnicity, and education completed) and predispositional factors (perceived health status, perceived level of pain, prior contact with the hospital, and hospital image) and the relative importance of each variable on patient satisfaction; (3) the level of overall work satisfaction and satisfaction with specific dimensions of work experienced by the medical/surgical nursing staff; (4) the differences in work satisfaction experienced by the nursing staff based on demographic variables (age, gender, ethnicity, and marital status) and professional factors (education completed, staff position, the number of years employed with the hospital, and number of years employed in nursing) and the relative importance of each variable on work satisfaction; and (5) to determine the effect of the nursing work milieu on patient and staff satisfaction.^ The study findings showed that patients experienced a moderate to low level of satisfaction with the dimensions of hospital care (admission process, daily care, information, nursing care, physician care, other hospital staff, living arrangements, and overall care). Of the eight dimensions of care, patients reported a relatively positive level of satisfaction (75 percent or better) with only one dimension: physician care. Ethnicity, perceived health status, and hospital image were significantly related to patient satisfaction. Hispanic patients, those who were in good health, and those who felt the hospital had a good image in their community were most satisfied with hospital care. Patients also reported areas of hospital care that needed the most improvement. Responses included: rude staff, better nursing care, and better communication.^ Findings from the nursing satisfaction survey indicated a low level of satisfaction with the dimensions of work (autonomy, pay, professional status, interaction, task requirements, and organizational policies). Only one dimension of work, professional status, received a mean satisfaction score in the positive range. Additionally, staff members were unanimously dissatisfied with their salaries. Frequently mentioned work-related problems reported by the staff included: staffing shortages, heavy patient loads. and excessive paperwork.^ The nursing milieu appeared to have had a significant effect on the satisfaction levels of patients nursing staff employees. The nursing staff were often short staffed, which increased the patient-to-nurse ratio. Consequently, patients did not receive the amount of attention and care they expected from the nursing staff. Crowded patient rooms allowed for little personal space and privacy. Dissatisfaction with living conditions served to influence patients' attitudes and satisfaction levels. These frustrations were often directed toward their primary caregivers, the nursing staff. Consequently, the nursing milieu appeared to directly affect and influence the satisfaction levels of both patients and staff. (Abstract shortened by UMI). ^

Evaluation of a date rape prevention program for new students in a university setting

The purpose of this study was to design, implement and evaluate the effectiveness of a date rape prevention program among new students at Rice University. Six-hundred and fifteen new students were randomly assigned to one of eight residential colleges or dormitories. The distribution of students to each of the dormitories was carried out in accordance with a stratified random sampling procedure. The study population was divided into strata based on ethnicity, gender, geographical region, and academic major. The number of students randomly assigned to each of the eight dormitories was approximately 75. After this procedure was completed, each of the colleges was randomly selected to either the intervention or control group. A randomized pretest and posttest control group design was used to assess changes in attitudes, self-efficacy, and behavior with regard to date rape. All participants were given an anonymous pretest and posttest measuring attitudes, self-efficacy, and behavior immediately prior to and following the intervention. The intervention group attended the play Scruples, designed to promote date rape prevention, after which they were immediately posttested. After this initial posttest the intervention group also participated in an interactive group role-playing activity led by trained peer instructors. The control group was pretested and subject to the placebo intervention of a multiculturalism play and was posttested immediately afterwards. Later in the week this group saw the Scruples play only. Both control and intervention groups were sent a two month follow-up survey questionnaire, to measure any changes in attitudes, self-efficacy, and behavior over time. As hypothesized students who saw the play Scruples showed a change in attitudes immediately posttest but no difference in self-efficacy or behavior. The two month follow-up survey showed no change in attitudes, self-efficacy, or behavior. There was a difference at pretest in males and females attitudes, with males showing significantly more rape tolerant attitudes than females. Thus, the proposed research findings will provide a better understanding of the attitudes that perpetuate date rape, and will inform strategies for prevention programs. ^

Content of prenatal care and spontaneous preterm birth: Findings from the 1988 National Maternal and Infant Health Survey

The purposes of this study were to examine (1) the relationship between selected components of the content of prenatal care and spontaneous preterm birth; and (2) the degree of comparability between maternal and caregivers' responses regarding the number of prenatal care visits, selected components of the content of prenatal care, and gestational age, based on analyses of the 1988 National Maternal and Infant Health Survey conducted by the National Centers for Health Statistics. Spontaneous preterm birth was subcategorized into very preterm and moderately preterm births, with term birth as the controls. The study population was limited to non-Hispanic Anglo- and African-American mothers. The racial differences in terms of birth outcomes were also compared.^ This study concluded that: (1) there was not a high degree of comparability (less than 80%) between maternal and prenatal care provider's responses regarding the number of prenatal care visits and the content of prenatal care; (2) there was a low degree of comparability (less than 50%) between maternal and infant's hospital of delivery responses regarding gestational age at birth; (3) there were differences in selected components of the content of prenatal care between the cases and controls, overall and stratified by ethnicity (i.e., hemoglobin/hematocrit test, weight measurement, and breast-feeding counseling), but they were confounded with missing values and associated preterm delivery bias; (4) there were differences in selected components of the content of prenatal care between Anglo- and African-American cases (i.e., vitamin/mineral supplement advice, weight measurement, smoking cessation and drug abuse counseling), but they, too, were difficult to interpret definitively due to item nonresponse and preterm delivery biases; (5) no significant predictive association between selected components of the content of prenatal care and spontaneous preterm birth was found; and (6) inadequate/intermediate prenatal care and birth out of wedlock were found to be associated with moderately preterm birth.^ Future research is needed to examine the validity of maternal and prenatal care providers' responses and identify the sources of disagreement between their responses. In addition, further studies are needed to examine the relationship between the quality of prenatal care and preterm birth. Finally, the completeness and quality of patient and provider data on the utilization and content of prenatal care needs to be strengthened in subsequent studies. ^

HIV-related malignancies: A community-based study using a linkage of cancer registry and HIV registry data

Background. Increased incidence of cancer is documented in immunosuppressed transplant patients. Likewise, as survival increases for persons infected with the Human Immunodeficiency Virus (HIV), we expect their incidence of cancer to increase. The objective of this study was to examine the current gender specific spectrum of cancer in an HIV infected cohort (especially malignancies not currently associated with Acquired Immunodeficiency Syndrome (AIDS)) in relation to the general population.^ Methods. Cancer incidence data was collected for residents of Harris County, Texas who were diagnosed with a malignancy between 1975 and 1994. This data was linked to HIV/AIDS registry data to identify malignancies in an HIV infected cohort of 14,986 persons. A standardized incidence ratio (SIR) analysis was used to compare incidence of cancer in this cohort to that in the general population. Risk factors such as mode of HIV infection, age, race and gender, were evaluated for contribution to the development of cancer within the HIV cohort, using Cox regression techniques.^ Findings. Of those in the HIV infected cohort, 2289 persons (15%) were identified as having one or more malignancies. The linkage identified 29.5% of these malignancies (males 28.7% females 60.9%). HIV infected men and women had incidences of cancer that were 16.7 (16.1, 17.3) and 2.9 (2.3, 3.7) times that expected for the general population of Harris County, Texas, adjusting for age. Significant SIR's were observed for the AIDS-defining malignancies of Kaposi's sarcoma, non-Hodgkin's lymphoma, primary lymphoma of the brain and cancer of the cervix. Additionally, significant SIR's for non-melanotic skin cancer in males, 6.9 (4.8, 9.5) and colon cancer in females, 4.0 (1.1, 10.2) were detected. Among the HIV infected cohort, race/ethnicity of White (relative risk 2.4 with 95% confidence intervals 2.0, 2.8) or Spanish Surname, 2.2 (1.9, 2.7) and an infection route of male to male sex, with, 3.0 (1.9, 4.9) or without, 3.4 (2.1, 5.5) intravenous drug use, increased the risk of having a diagnosis of an incident cancer.^ Interpretation. There appears to be an increased risk of developing cancer if infected with the HIV. In addition to the malignancies routinely associated with HIV infection, there appears to be an increased risk of being diagnosed with non-melanotic skin cancer in males and colon cancer in females. ^

An evaluation of a community-based program for homeless adults with mental disorders and comorbid alcohol drug and mental disorders

Limited research has been conducted evaluating programs that are designed to improve the outcomes of homeless adults with mental disorders and comorbid alcohol, drug and mental disorders. This study conducted such an evaluation in a community-based day treatment setting with clients of the Harris County Mental Health and Mental Retardation Authority's Bristow Clinic. The study population included all clients who received treatment at the clinic for a minimum of six months between January 1, 1995 and August 31, 1996. An electronic database was used to identify clients and to track their program involvement. A profile was developed of the study participants and their level of program involvement included an examination of the amount of time spent in clinical, social and other interventions, the type of interventions encountered and the number of interventions encountered. Results were analyzed to determine whether social, demographic and mental history affected levels of program involvement and the effects of the levels of program involvement on housing status and psychiatric functioning status.^ A total of 101 clients met the inclusion criteria. Of the 101 clients, 96 had a mental disorder, and five had comorbidity. Due to the limited numbers of participants with comorbidity, only those with mental disorders were included in the analysis. The study found the Bristow Clinic population to be primarily single, Black, male, between the ages of 31 and 40 years, and with a gross family income of less than $4,000. There were more persons residing on the streets at entry and at six months following treatment than in any other residential setting. The most prevalent psychiatric diagnoses were depressive disorders and schizophrenia. The Global Assessment of Functioning (GAF) scale which was used to determine the degree of psychiatric functioning revealed a modal GAF score of 31--40 at entry and following six months in treatment. The study found that the majority of clients spent less than 17 hours in treatment, had less than 51 encounters and had clinical, social, and other encounters. In regard to social and demographic factors and levels of program involvement, there were statistically significant associations between gender and ethnicity and the types of interventions encountered as well as the number of interventions encountered. There was also a statistically significant difference between the amount of time spent in clinical interventions and gender. Relative to outcomes measured, the study found female gender to be the only background variable that was significantly associated with improved housing status and the female gender and previous MHMRA involvement to be statistically associated with improvement in GAF score. The total time in other (not clinical or social) interventions and the total number of encounters with other interventions were also significantly associated with improvement in housing outcome. The analysis of previous services and levels of program involvement revealed significant associations between time spent in social and clinical interventions and previous hospitalizations and previous MHMRA involvement.^ Major limitations of this study include the small sample size which may have resulted in very little power to detect differences and the lack of generalizability of findings due to site locations used in the study. Despite these limitations, the study makes an important contribution to the literature by documenting the levels of program involvement and the social and demographic factors necessary to produce outcomes of improved housing status and psychiatric functioning status. ^

Incidence, etiology and risk factors of neonatal seizures Harris County, Texas, 1992--1994

This study was conducted to determine the incidence and etiology of neonatal seizures, and evaluate risk factors for this condition in Harris County, Texas, between 1992 and 1994. Potential cases were ascertained from four sources: discharge diagnoses at local hospitals, birth certificates, death certificates, and a clinical study of neonatal seizures conducted concurrent with this study at a large tertiary care center in Houston, Texas. The neonatal period was defined as the first 28 days of life for term infants, and up to 44 weeks gestation for preterm infants.^ There were 207 cases of neonatal seizures ascertained among 116,048 live births, yielding and incidence of 1.8 per 1000. Half of the seizures occurred by the third day of life, 70% within the first week, and 93% within the first 28 days of life. Among 48 preterm infants with seizures 15 had their initial seizure after the 28th day of life. About 25% of all seizures occurred after discharge from the hospital of birth.^ Idiopathic seizures occurred most frequently (0.5/1000 births), followed by seizures attributed to perinatal hypoxia/ischemia (0.4/1000 births), intracranial hemorrhage (0.2/1000 births), infection of the central nervous system (0.2/1000 births), and metabolic abnormalities (0.1/1000 births).^ Risk factors were evaluated based on birth certificate information, using univariate and multivariate analysis (logistic regression). Factors considered included birth weight, gender, ethnicity, place of birth, mother's age, method of delivery, parity, multiple birth and, among term infants, small birth weight for gestational age (SGA). Among preterm infants, very low birth weight (VLBW, $<$1500 grams) was the strongest risk factor, followed by birth in private/university hospitals with a Level III nursery compared with hospitals with a Level II nursery (RR = 2.9), and male sex (RR = 1.8). The effect of very low birth weight varied according to ethnicity. Compared to preterm infants weighing 2000-2999 grams, non-white VLBW infants were 12.0 times as likely to have seizures; whereas white VLBW infants were 2.5 times as likely. Among term infants, significant risk factors included SGA (RR = 1.8), birth in Level III nursery private/university hospitals versus hospitals with Level II nursery (RR = 2.0), and birth by cesarean section (RR = 2.2). ^