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Office of the Assistant Secretary for Planning and Evaluation |
Policy Information Center |
In this evaluation report, the Public Health Service (PHS) highlights evaluations of general interest to the public health community and illustrates the diversity of PHS evaluations completed in fiscal year (FY) 1994. Presented in this chapter are summaries of 13 evaluation projects selected by a special panel of the Senior Editorial Advisors, based on criteria identified in appendix C and applied to approximately 40 reports nominated by PHS Agencies. These criteria are--
The 13 evaluations selected by the panel are summarized here in the following categories:
Each summary includes a brief abstract; a description of the study, including its purpose, background, methods, findings, and use of results; the names of any publications that resulted; and the name and address of the person to contact for additional information.
Access to Health Care for Special Populations
This report synthesizes the findings from five separate demonstration projects that evaluated the effect of offering case management and housing to the homeless mentally ill. Early findings indicate general success at reducing homelessness and at improving mental health of study participants: homeless adults with severe mental illness were willing to use accessible services targeted to their needs. The factors contributing to the success of the project include mental health treatment, receipt of entitlement income, and reliance on an interdisciplinary team of staff, including some with mental illness who were formerly homeless. These findings offer strategies for the design and management of programs for the homeless mentally ill.
The goal of the 1987 Stuart McKinney Act was to create programs to reduce homelessness. Among numerous provisions, the Act authorized demonstration grants to examine new approaches to relieving homelessness. This project was designed to explore new ways of reducing homelessness and improving the mental health of homeless people by offering distinct combinations of case management and housing to address one of the most challenging problems facing our cities.
An estimated 600,000 people are homeless in the United States, based on 1987 estimates. One-third, or 200,000, are homeless adults with severe mental illness. Besides suffering from schizophrenia, depression, or other mental disorders, they commonly are afflicted by substance abuse, tuberculosis, and HIV. This constellation of mental and physical conditions is believed to place the homeless mentally ill beyond the reach of the conventional social service and health care system.
Launched by the National Institute of Mental Health in 1990, the McKinney Research Demonstration Program for Homeless Mentally Ill Adults was funded for 3 years with a total of $16.8 million. The program was transferred to the Center for Mental Health Services in the newly created Substance Abuse and Mental Health Services Administration as a result of the ADAMHA Reorganization Act of 1992.
A total of 896 homeless adults with severe mental illnesses were studied at five sites--Boston, Baltimore, San Diego, and two sites in New York City. Fifty-seven percent of the participants had psychotic disorders (e.g., schizophrenia) and 32 percent had affective disorders (e.g., depression). More than one-third were living in shelters, slightly less than one-third were living on the street, and the remainder were living in community settings, hospitals, or jails. Across all sites, the underlying goals were to offer a combination of housing and social services that would train participants in daily living, link them to needed social and medical services, help them receive entitlements for which they are eligible, and assist them in securing housing. Study sites varied in intensity, duration, or approach. The demographic portrait that emerged was sufficiently similar to the general homeless population that the final results are expected to have widespread applicability to thousands of communities throughout the Nation.
Interventions tested varied across sites according to the level of case management, the type of housing, and the degree of client engagement with the social service or health care system at the outset of the study. The comparison group of homeless mentally ill at most sites received traditional services. Study participants were randomly assigned to the new services or to traditional services.
Five broad outcome measures unified the analysis across study sites--psychiatric symptomatology, substance abuse, quality of life, physical health, and residential stability. Participants were interviewed at several stages (at baseline and at followups at 6 months, 9 or 12 months, and 18 or 24 months) to determine their progress on these measures. They were given fairly uniform questions along with a standard battery of widely accepted measures of mental health status. Some of the interview data were corroborated by case manager reports. While investigators are performing separate analyses at each site, additional analyses are being undertaken across sites. The effectiveness of the interventions in reducing costly hospitalizations and other health expenditures was examined at two study sites.
Results are still preliminary, covering the 6- to 12-month followup to the intervention. Early findings reveal that each site's intervention was successful at reducing homelessness and improving the mental health of study participants. These preliminary findings, expected to be sustained when the study is concluded, should also hold true when the findings from all sites are combined.
These general findings were amplified by many discrete, yet interrelated, findings. Most important, it was found that the homeless who are mentally ill were willing to use accessible services targeted to their needs, repudiating the belief that these people are beyond help. When they did take advantage of mental health treatment, there was a decrease in psychiatric symptoms and in the use of costly inpatient hospitalization. In one of the projects, inpatient days were halved.
Another finding was that targeted services decreased homelessness, making permanent housing an attainable goal--as long as there were appropriate levels of support. A critical period for intervention was during the transition from the shelter to community-based housing. The receipt of entitlement income was another vital element to realizing study goals. At one of the sites, the intervention yielded a two- to threefold increase in the number of participants being supported by Supplemental Security Income and Social Security Disability Income.
Formerly homeless people with mental illnesses also were found to be a valuable staff resource: they staffed four of the five sites, helping to identify and engage participants, sensitizing professional staff to their needs, and acting as role models.
Substance abuse, which was widespread among participants when the study began (47 to 78 percent), exacerbated homelessness. Participants' substance abuse was felt by clinical staff to be more significant than their mental illness in preventing them from finding or keeping housing.
Emerging policy recommendations thus far integrate service systems at all levels for the homeless mentally ill, bringing together mental health, substance abuse treatment, social services, and the criminal justice system; emphasize substance abuse treatment as an integral part of mental health services; offer clients a greater range of housing options; and provide preventive health care and education to reduce morbidity and mortality from severe illnesses experienced by this population.
More than 30 publications had emanated from the study at the time of this report, in such journals as Community Mental Health Journal, Psychiatric Services, Hospital and Community Psychiatry, Psychosocial Rehabilitation, American Journal of Psychiatry, Evaluation Bulletin, and Schizophrenia Bulletin.
Substance Abuse and Mental Health Services Administration
Roger Straw, Ph.D.
Center for Mental Health
Services
Substance Abuse and Mental Health
Services
Administration
Parklawn Building, Room 11C26
5600 Fishers
Lane
Rockville, MD 20857
(301) 443-3606 Fax: (301) 443-0541
Anthony Lehman, M.D., The Baltimore Project, Baltimore, MD
Stephen Goldfinger, M.D., The Boston Project, Boston, MA
David Shern, Ph.D., The New York City Street Outreach Project, New York, NY
Elie Valencia, J.D., The New York City Critical Time Project, New York, NY
Richard Hough, Ph.D., The San Diego Project, San Diego, CA
This study documented the health status and access to health care services of American Indians in California, especially those in tribes that are not federally recognized. Through analysis of vital statistics and other databases, comparisons were made between California Indians who are members of federally recognized tribes and those who are not. On the basis of these and other comparisons, American Indians in non-federally recognized tribes in California generally were found to have poorer health status than those in federally recognized tribes. The health status of both groups is inferior to that of other populations, underscoring the importance of maintaining and expanding coverage to the entire American Indian population of California.
The Indian Health Service (IHS) provides comprehensive health care to American Indians and Alaska Natives throughout the United States. By Federal law, care is given to members of federally recognized tribes, except in California and a few other States, where care is given to all Indians, not just those who are members of federally recognized tribes.
This study analyzes and interprets numerous data sources to enhance understanding of the health status of American Indians in California, including members of federally recognized and non-federally recognized tribes.
In 1990, an estimated 242,000 American Indians resided in California. Approximately 100,000 are registered at California Indian tribal health clinics. According to IHS records, about 26,000, or one-fourth, are not members of a federally recognized Indian tribe of California. If they seek IHS-funded care in the State, they must rely on tribally operated facilities that operate under contract to the IHS. Throughout the State, there are a total of 21 tribally operated rural clinics, 7 Indian urban health programs, and 13 freestanding Indian alcoholism programs. Even though there are no tribally operated inpatient services, IHS provides for inpatient care through contracts with local providers.
In most States, IHS-funded health care is limited by law to members of federally recognized tribes. But in California, as well as some other States, there has been a longstanding tradition of providing care to all Indians, not just those in federally recognized tribes. This practice was codified in 1988 with Federal legislation, the Indian Health Care Amendments of 1988.
At the time this report was undertaken, information about IHS-funded care provided to California Indians was limited because participation in IHS reporting systems had only recently begun. In addition, the information systems of many non-Indian health care facilities either did not identify Indian clients or did not identify them correctly. Little was known about whether membership in a federally recognized tribe had an impact on health status.
The study conducted by the University of California, San Francisco, compared the health status of California Indians--including members of non-federally recognized tribes--with that of all Californians. On some measures, comparisons were made with Indians throughout the United States and/or with the U.S. population as a whole. The study relied on numerous existing sources of data, such as vital statistics, hospital discharge records, infectious disease case reports, and client and financial data (especially from California's Medicaid system). Information was also gathered from selected State and Federal health and welfare programs.
All persons identified as American Indian or Alaska Native were included in these analyses. Because federally recognized status could not be identified from vital statistics, inferential measures were used to classify California counties according to whether they were Indian or non-Indian counties. The Indian counties were further subdivided into those whose residents were primarily members of a federally recognized tribe and those whose residents were primarily not members of federally recognized tribes. Thus, residents of "non-federally recognized counties" were, for the purposes of the study, considered to be California Indians who were primarily members of non-federally recognized tribes.
In addition to using existing data sources, researchers collected information on a sample of 348 California Indians age 18 and older who were not members of federally recognized tribes. This information was collected by tribal health programs from patient registration files in tribal clinics. The information included current sources of health care, resources for payment, and availability and accessibility of alternatives to IHS-funded care.
Based on multiple measures, the health status of California Indians in non-federally recognized tribes was determined to be no better and, in some ways, worse than that of California Indians in federally recognized tribes. And those in federally recognized tribes generally had poorer health status than Californians as a whole.
From 1986 through 1988, 10.9 percent of all California births were to teenagers (women under the age of 20). Yet, 16.7 percent of all California Indian births were to teenagers, and an even higher proportion, 20.7 percent, were to Indian teenagers in non-federally recognized counties in California. Births to teenagers were most common in areas where Indian clinics were least available.
Among California Indian babies born during this time, 6.4 percent had low birth weight, compared with a statewide figure of 5.2 percent for whites and Hispanics. Only 68.3 percent of pregnant California Indians received prenatal care in their first trimester, compared with 74.4 percent of all pregnant Californians. In non-federally recognized California counties, 9.1 percent of pregnant Indians received late (third trimester) or no prenatal care, versus 7.6 percent of those in federally recognized counties.
Alcohol and tobacco use were found to have a major impact on the health of California Indians, irrespective of tribal status. Chronic liver disease and cirrhosis caused a higher proportion of deaths among California Indians (6.7 percent) than among all Indians in the United States (4.3 percent) and the total population of California (1.9 percent). Overall, 33.6 percent of deaths among Indian women and 42.1 percent of deaths among Indian men were alcohol-related, compared with 4.3 percent for women and 8.4 percent for men of all races in California.
Also in the years 1986 through 1988, 41.7 percent of deaths among Indian women and 37.4 percent of deaths among Indian men were attributed to cigarette smoking, compared with 12.4 percent and 17.8 percent of all female and male deaths, respectively, among all races in California.
Premature mortality was also a serious problem among California Indians. Deaths in that population between 1986 and 1988 were more than twice as likely to occur before the age of 45 than statewide (28.4 percent versus 13.3 percent). Mortality under the age of 25 accounted for 11.2 percent of Indian deaths, compared with 5.3 percent of all deaths in California.
The survey of members of non-federally recognized tribes revealed that 60 percent identified local tribal health programs as their usual source of care. They experienced restricted access to other sources of health care, given that 33 percent reported no health coverage. Members of non-federally recognized tribes were found to have unmet needs for a variety of health services, such as dental care, diabetic and orthopedic supplies, and eyeglasses.
The results suggest that access to IHS-funded tribal health programs and clinics in California is essential for non-federally recognized California Indians. There is no evidence that resources outside the IHS are adequate to meet their health care needs. In addition, tribally operated health services provide a valued source of care for those who prefer Indian-specific and culturally competent services. Restrictions in eligibility or inadequate levels of funding could have serious health consequences.
Study findings have broad implications for health promotion and disease prevention among California Indians. Strategies are particularly important for reducing tobacco and alcohol consumption, lowering rates of heart disease, expanding cancer screening programs, preventing accidents, and increasing early prenatal care.
Highlights are available through the Monograph Series of the Institute for Health Policy Studies, University of California, San Francisco: American Indians in California: Health Status and Access to Health Care.
Indian Health Service
Leo J. Nolan
Division Director
Division of Program
Evaluation and Policy Analysis
Indian Health Service
12300 Twinbrook
Parkway, Suite 450
Rockville, MD 20857
(301) 443-4700 Fax: (301)
443-1522
Leila Beckwith
University of California, Los Angeles, CA
This study assessed the knowledge and attitudes of high-risk youth who regularly engage in practices such as tobacco use, substance use, unprotected sex, and violence. High-risk youth were found to be fairly knowledgeable about healthy practices, yet they do not incorporate this awareness into practice. Their willingness to listen to trusted, credible adults in alternative settings was among the findings that can be incorporated into the delivery of targeted health promotion programs and the design of future research projects.
High-risk youth, who often do not attend school, are less likely than their counterparts to be reached by health promotion programs and services provided through schools and other youth-oriented community organizations. This project was undertaken to learn more about the attitudes and beliefs of these young people in order to foster the development of more effective health promotion programs and services.
Many serious health problems affect young people. For example, in 1987, approximately 2.5 million teenagers were infected with a sexually transmitted disease. In that same year, an estimated 2.5 million teenage girls became pregnant unintentionally. Many young adults with AIDS were likely infected with HIV during adolescence (because of the lag time between infection and onset of AIDS). Youth at particular risk are those ages 10 to 18 who regularly engage in a cluster of risky practices: smoking and drinking, using drugs, having unprotected sex, and/or being victims or perpetrators of violence. These risky behaviors, which begin as experimentation and may become ingrained habits, compromise the possibility of a long and healthy life.
Prevention strategies must reach and influence young people before they adopt risky behaviors, but conventional health education programs may not reach high-risk youth who do not attend school regularly or participate in community activities.
This focus group study, conducted by S.W. Morris & Company, Inc., questioned 160 high-risk youth ages 10 to 18 about their health practices. From December 1990 through March 1991, 24 focus groups were conducted with young people of various races and ethnic groups. Each focus group was composed of individuals of the same age, gender, and race/ethnicity. Community-based organizations recruited participants and provided facilities for the focus groups. The moderator followed a standard format seeking answers to questions about health as a priority; knowledge and attitudes toward smoking, AIDS, pregnancy, alcohol and other drugs, and violence; barriers to the adoption of positive health practices; and opportunities for programs to address risky behaviors.
To the extent possible, each group was led by a moderator of the same gender and race/ethnicity as the participants. To ensure confidentiality and encourage the trust of participants, moderators audiotaped and kept handwritten notes of the focus group discussions. African-American and Mexican-American participants were recruited from the inner city. Another group of Mexican Americans came from a suburban alternative school. Other African Americans, Mexican Americans, and American Indians were drawn from inner-city community-based and religious organizations and a tribal community center. White participants were identified through a rural site with countywide acces-sibility.
After the focus groups were completed, two meetings were conducted with staff from national youth organizations and local youth programs. The staff recommended that discussion groups be conducted with the parents and caregivers of high-risk youth. In December 1992, eight mixed-gender adult discussion groups were conducted at the same sites as the youth focus groups.
Focus group methodology has several limitations. Because population sampling procedures are not used, results are not generalizable. Moreover, Mexican-American youth were the only Hispanic participants, and no Asian/Pacific Islander Americans were included in this study. White participants were drawn from a rural area, while all other groups were recruited from suburban and inner-city communities. Estimates of health-related behaviors were based on participant self-reports. The findings of the study represent an analysis of moderators' observations, transcripts, and other information derived from the study. As such, the findings are qualitative, not quantitative, in nature.
Approximately two-thirds of the focus group participants resided in households receiving public assistance. Nearly one-half lived with a single parent. The majority were truants or school drop-in/dropouts. About one-third reported substance abuse or arrest records. Adult supervisors estimated that over 40 percent were involved in gangs.
Participants were fairly knowledgeable about many current health issues, such as smoking, unprotected sexual activity, and alcohol and other drug use. They were not as knowledgeable about HIV infection and AIDS. Their knowledge resulted from high exposure to health information from many channels, especially from parents, families, and friends. There was little reported reliance on mass media as a source of health information.
Despite awareness of the consequences, many participants reported engaging in behaviors that pose health risks. In this population, risk, violence, and death were seen as a normal part of life, and there was a lack of faith in the future. Therefore, potential future benefit offered little motivation to discontinue a risky practice experienced as enjoyable. Of 12 life priorities, participants selected "being loved" and "having a family" as the top two. "Being healthy" ranked eighth, suggesting a relative lack of emphasis.
Participants reported having much unstructured, unsupervised time. Many expressed a desire to talk with a nonjudgmental adult they could trust, someone who understands what they are experiencing in life, but they did not have such a person at home or at school. Adult focus group participants identified numerous influences on youth, including friend/peer pressure, media and popular culture, and racism/prejudice. Many parents found it difficult to initiate discussions about risky behaviors with their children. Many parents and caregivers reported practicing risky health behaviors themselves. They recognized that their actions conveyed a mixed message when they tried to discourage youth from adopting the same behaviors. While acknowledging responsibility for the young people in their care, these adults also felt that communities should do more for at-risk youth.
The focus group findings reinforced the tenet that knowledge alone is insufficient to change health practices. Participants' emphasis on linkages between health problems (e.g., substance abuse and AIDS) underscored the need for a multiple risk factor approach in the design of outreach programs. Any approach must also incorporate the provision of specific services to help at-risk youth develop the skills to adopt healthier lifestyles. Outreach programs must also take advantage of trusted, credible adults who can help youth make difficult changes.
Findings suggest that health information, programs, and services might be effectively provided in alternative settings that high-risk youth view as "safe havens," that is, those outside mainstream institutions. Nevertheless, a family outreach component should be included, since at-risk youth identified family as an important and trusted influence. Parents need services and support to become better role models and to enhance their communication skills.
Music may have potential as a communication channel to high-risk youth. High-risk youth were suspicious about messages from celebrities, who they thought were interested only in money or exposure. They expressed concern about subtle racial and ethnic stereotyping in health messages, even those intended to be culturally relevant. Therefore, the report recommended careful message crafting, testing, and targeting. Because at-risk youth cannot envision their own future, they cannot be motivated to avoid or discontinue risky health behaviors on the basis of future benefits. Health communications need to impart the belief that there will be a future.
Not yet published.
U.S. Department of Education, U.S. Department of Health and Human Services, U.S. Department of Justice, and U.S. Department of Transportation
Mary Jo Deering, Ph.D.
Office of Disease Prevention and Health
Promotion
Office of the Assistant Secretary for Health
Switzer Building,
Room 2132
330 C Street SW
Washington, DC 20201
(202) 205-5968 Fax:
(202) 205-9478
Ruth Karimi
S.W. Morris & Company, Inc., Bethesda, MD
Evaluating Educational Outcomes of School Health Programs
This study addressed the role of school health programs in improving academic performance. It described the available evaluation literature, analyzed the benefits and limitations of alternative research designs, and offered two major approaches to the design of an evaluation. With this guidance, schools can justify not only the health importance but also the academic importance of their health programs.
This study was undertaken to provide guidance to educators in evaluating the effects of health programs on students' school performance. School performance includes grades and other indicators of educational achievement, attendance and dropout rates, and educational expectations. The three specific goals were (1) to review the state-of-the-art of school health program evaluations; (2) to describe the kinds of measures used and their feasibility for assessing educational achievement following participation in health programs; and (3) to provide two research options for evaluating the relationship between school health programs and educational performance.
There are eight general types of school health programs: health education, health services, efforts to promote a healthy school environment, school food service, physical education and fitness, integrated school and community health promotion, school counseling, and health promotion for school faculty and staff. Both the national education agenda, Goals 2000, and the national health agenda, Healthy People 2000, explicitly recognize the relationship between education and health. Although it is generally accepted that good health is necessary for effective learning, a lack of well-designed evaluations has resulted in little empirical evidence on the link between school health interventions and educational outcomes. The absence of evidence has led to retrenchment and the shifting of resources from health programs to academic programs. To maintain present school health programs and to encourage new programs, strong empirical evidence is needed on how these programs affect students' academic performance. This study offers educators the tools to collect this empirical evidence.
This study, conducted by Mathematica Policy Research, Inc., provides a framework for assessing educational outcomes of school health interventions through the following methods: (1) a literature review of both the current knowledge about the effectiveness of school health interventions and the important design issues for evaluating health and educational outcomes of school health programs; and (2) consultation with an advisory panel of researchers and policymakers on the types of health interventions likely to affect school performance, the relevant educational outcomes, data sources for evaluation, and the types of evaluation designs that are feasible in school settings. "Intervention" was defined as a specific plan, program, program component, or strategy aimed at changing students' health attitudes, behavior, or health status and, subsequently, their school performance.
In review of the evaluations of eight types of school health programs, programs varied in effectiveness for student health outcomes. Gains were moderate to large in students' health knowledge and smaller for changes in attitudes, behaviors, and health status. In addition, programs generally required ongoing intervention to sustain positive behavioral effects. The health interventions that have been most thoroughly evaluated are nutrition programs, physical activity programs, and drug abuse prevention programs.
Fewer studies examined the educational outcomes of health programs. Of these studies, a handful demonstrate improvements in basic academic skills, reductions in tardiness and absenteeism, and reductions in use of drugs.
The study provided a list of the data requirements for measuring student short-term educational performance and descriptive information about students, schools, communities, and school health interventions. Issues and problems about data collection, availability of data from student surveys, and obtaining and using these data are also thoroughly reviewed. Some problems related to data collection are (1) obtaining the release of sensitive data on student behaviors; (2) gaining cooperation of school officials whose schools are not receiving health intervention funds; (3) obtaining informed consent from students and parents; and (4) designing a format to gather data. Gaps in school records regarding health interventions, student demographics, school characteristics, and teachers' evaluation of student behaviors make assessments more difficult.
The study proposes two major alternative designs for evaluating school health interventions: (1) analysis of existing data collected from previous school health program evaluations, including nationally representative samples of students, and (2) large-scale multischool demonstrations using experimental and comparison-group designs and random assignment. The study describes the benefits and limitations of each approach and the most appropriate type of statistical analysis.
This report is expected to provide educators and school health researchers with a blueprint for a well-designed evaluation of health programs and their impact on academic performance. Evaluations of this kind can provide justification for continuing or enhancing school health programs for academic and health reasons.
In press under the title Evaluating Educational Outcomes of School Health Programs.
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion
James Harrell
Office of Disease Prevention and Health
Promotion
Office of the Assistant Secretary for Health
Switzer Building,
Room 2132
330 C Street SW
Washington, DC 20201
(202) 401-6295 Fax:
(202) 690-7054
Barbara Devaney
Mathematica Policy Research, Inc., Princeton,
NJ
Evaluating the Effects of School-Based Intervention Programs To Prevent Teenager Drug Use and Abuse
This study provided followup to a large-scale, randomized, controlled field trial of school-based training in substance abuse prevention. It examined the effectiveness of Life Skills Training (LST), an approach that teaches social resistance and other personal and coping skills. The study provides the first evidence that school-based intervention programs conducted by regular classroom teachers can produce durable reductions in tobacco, alcohol, and illicit drug use. These salutary effects were sustained 6 years after the introduction of the program, providing impetus for the widespread adoption of similar programs.
This followup study evaluated the long-term effectiveness of a New York school-based substance abuse prevention program started 6 years earlier. It surveyed high school seniors who had been trained in the seventh grade in a substance abuse prevention program called Life Skills Training. This approach teaches social resistance skills and general personal and social skills, that is, ways to improve self-esteem, decisionmaking, and problemsolving. The study also analyzed what types of adolescents were at risk for drug use.
Substance use patterns established in adolescence have serious consequences for the Nation's health. In 1993, 76 percent of high school seniors used alcohol and 31 percent used illicit and/or illegal drugs. In addition, of those seniors surveyed, 29.9 percent had smoked cigarettes within the last 30 days and 10.7 percent had used smokeless tobacco within the last 30 days. Providing students with factual information about drugs and drug abuse was the most common prevention approach up to 1985, but it did not appear to be effective in changing behaviors.
The rationale for this study was to evaluate newer approaches aimed at increasing awareness of the social influences that encourage drug use and improve social resistance, personal, and coping skills. In 1985, the National Institute on Drug Abuse (NIDA) funded a study in 56 schools in New York State to determine the long-term effectiveness of a substance abuse prevention program for students in seventh grade, with booster sessions in the eighth and ninth grades. Earlier followups (when students were in the ninth grade) revealed that LST was effective at reducing the use of gateway drugs: tobacco, alcohol, and marijuana. The use of tobacco, for example, declined by over 50 percent.
The followup study described here examined whether the training continued to be effective in the senior year of high school and whether its effectiveness extended to illicit drugs in addition to marijuana. The 6 years of followup data also enabled researchers to analyze what types of students were more prone to drug use.
The New York State study was also begun to overcome a dearth of information about the effectiveness of substance abuse prevention programs. Little evidence had been accumulated on (1) the durability of program effects more than a year afterward; (2) program effects on multiple drug use and/or use of illicit drugs other than marijuana; or (3) programs using techniques of random assignment, with the school as the unit of assignment and analysis.
The initial program, offered in 1985, consisted of 12 curriculum units
taught in 15 class periods in the seventh grade, with booster classes in the
eighth and ninth grades. The intervention was based on an LST curriculum that
taught cognitive-behavioral skills for increasing awareness of the causes and
effects of substance use, resisting peer and advertising pressure, making
decisions, managing anxiety, communicating effectively, asserting one's rights,
and developing personal relationships and other psychological skills. The
curriculum was randomly assigned to schools under two conditions: (1) teachers
received training materials, training, and staff support;
or (2) teachers
received only packaged training materials. A third group of schools, the
control group, did not receive any substance abuse training.
The original study, conducted by Cornell University Medical College, used a true experimental randomized design and analyzed outcomes as well as measures of curriculum implementation. To ensure comparability of results across different schools, the schools were selected on the basis of similar demographic variables such as gender, age, and ethnicity. The sample was approximately 52 percent male and 91 percent white.
Followup data presented in this part of the study were collected on a cohort of 3,597 participants (60 percent of the original 5,954 students) at the end of the 12th grade. Separate analyses were performed on a restricted sample of 2,752 students from 50 schools who received at least 60 percent of the prevention program to determine the effectiveness of the two preventive interventions when implemented with an acceptable degree of fidelity. Two questionnaires were used: the first was exactly the same as an earlier followup, and the second was a brief, anonymous survey of illicit drug use. Data on illicit drug use were collected anonymously from 454 individuals using a mailed survey.
The probability of smoking, drinking immoderately, or using marijuana was significantly lower--as much as 40 percent lower--for students who received the prevention program than for those in the control group. The strongest prevention effects were found among students who received at least 60 percent of the intervention and for students whose teachers received the most staff support.
The probability of using multiple drugs was significantly lower--by as much as 60 percent--for weekly use. Long-term prevention effects were found 6 years after initial assessment for tobacco, alcohol, and marijuana use, and after 6 \xba for illicit drug use. Booster sessions were found to contribute to the reduction in substance use.
The students least likely to engage in drug use had better knowledge of drug use prevalence, better skills for refusing drug offers, fewer expectations about the benefits of drug use, and increased life skills and psychological adjustment, among other factors.
The results of this long-term followup provide empirical support for the efficacy of a school-based prevention strategy based on LST in preventing drug use and abuse. Because the study population was primarily white, research is needed to determine the effectiveness of this type of program for inner-city minority students.
To produce durable prevention effects, the study revealed that school-based drug abuse prevention programs must (1) increase knowledge of drug use prevalence rates, and improve skills for refusing drug offers as well as general life skills; (2) decrease expectations and positive attitudes and beliefs about the benefits of drug use; (3) be properly and completely implemented; and (4) include booster sessions.
Botvin, Gilbert, et al. 1995. Long-term followup results of a randomized drug abuse prevention trial in a white middle-class population. Journal of the American Medical Association, 273(14): 1106-1112.
National Institutes of Health
Larry A. Seitz, Ph.D.
Division of Epidemiology and Prevention
Research
National Institute on Drug Abuse
National Institutes of
Health
5600 Fishers Lane, Room 9A-53
Rockville, MD 20857
(301)
443-1514 Fax: (301) 443-2636
Gilbert J. Botvin, Ph.D.
Cornell University Medical College,
Ithaca, NY
This study assessed the relationship between indoor allergens and allergic diseases such as asthma and hay fever. It found the indoor environment to have many allergens that cause allergic disease. African Americans and children were found to be at greatest risk of adverse effects. By recommending relatively simple control strategies, the study provided practical guidance to patients and professionals, many of whom have little or no information about the adverse health effects of indoor allergens. It also proposed an agenda for further research.
An expert committee of the Institute of Medicine (IOM) at the National Academy of Sciences was charged with providing an independent, comprehensive, state-of-the-science evaluation of the impact of nonindustrial indoor allergens on the development of adverse health effects in humans (e.g., asthma and other allergic conditions). Its report was designed to assess the extent of the problem in the United States, to define the populations commonly affected, and to identify specific indoor airborne agents responsible for inducing asthma and/or other allergic reactions.
More than 50 million Americans--about 20 percent of the population--will develop an allergy-related disease at some point in their lives. Asthma alone afflicts an estimated 10 to 20 million Americans. Asthma is a major reason for trips to the emergency room and for work and school absenteeism. The economic burden of asthma in 1990 was estimated at $6.2 billion, a 39 percent increase since 1985. This information, combined with steady increases in the occurrence and severity of asthma and other allergic diseases, raises concerns about the potential adverse health effects of indoor air and the extent to which the indoor environment can be controlled.
Indoor allergens may be responsible for a large proportion of allergic diseases, including asthma, hay fever, chronic bronchitis, "sick building" syndrome, and allergic skin reactions. The increased incidence, prevalence, and severity of these conditions may be the result of Americans' spending more than 90 percent of the day inside buildings that are increasingly airtight and that frequently contain numerous sources of allergens, including dust mites, fungi, house pets, rodents, cockroaches, and certain chemicals.
On the basis of these concerns, several Federal agencies requested that IOM evaluate the public health significance of indoor allergens. The Committee on the Health Effects of Indoor Allergens was created by the IOM Board on Health Promotion and Disease Prevention, in collaboration with the U.S. Environmental Protection Agency, the National Institutes of Health[1], and the Agency for Toxic Substances and Disease Registry. This multidisciplinary committee included nationally renowned allergists, immunologists, biomedical engineers, epidemiologists, psychologists, physicians, and other health professionals.
The 16-member committee conducted an extensive review of published information, including population studies, medical case reports, basic research studies, and engineering and architectural documents, as they related to the design and operation of heating, ventilation, and air-conditioning systems. The committee also evaluated the methods used to (1) diagnose asthma and other allergic diseases, (2) measure levels of indoor allergens, and (3) reduce the concentrations of these allergens. Where possible, committee members used quantitative risk assessment methods to identify relationships between specific indoor allergens and allergic reactions.
The committee's review of research revealed African Americans and children (particularly those under age 5) to be at greatest risk for developing complications associated with exposure to indoor allergens. Children under 18 years old account for nearly 50 percent of all emergency room visits for asthma. Asthma mortality rates for African Americans are two to three times greater than rates for whites.
The committee found that allergens produced by these organisms cause allergic disease: house dust mites, fungi and other microorganisms, cats, dogs, cockroaches, and rodents. Dust mites--microscopic organisms that live primarily in carpeting and upholstery--appear to be critical for the development of allergic asthma in children. Allergens shed by house pets cause hay fever and asthma and can persist for a long time after a pet has left the premises.
The diagnosis of allergic disease is based primarily on a medical history linking exposure to symptoms. Laboratory studies, including skin tests or in vitro tests for allergic antibodies (immunoglobulin E [IgE]) or other classes of antibodies, are important for confirming a diagnosis of allergy. Pulmonary function tests are helpful for following the course of disease. Peak flow meters, because they are portable and can be used by patients, are particularly useful for the diagnosis and management of asthma.
Research suggests steps to markedly reduce exposure to indoor allergens, thus lowering the health risks and medical needs and costs of asthma/allergy patients. Relatively simple measures, such as washing bedding regularly at high temperatures, keeping carpeting to a minimum, and using special air filters, can significantly improve indoor environmental conditions. Well-designed and maintained heating, vacuuming, and air-conditioning equipment will eliminate most indoor allergens.
Panel members found that physician and other health care providers had little or no information about the adverse health effects of indoor allergens. Awareness was similarly low among patients, the general public, and those involved in the design and maintenance of residential and commercial buildings.
The committee's report contained numerous recommendations for patient education and treatment, research, and environmental controls.
One of the recommendations for those diagnosed with asthma is to determine whether they are among the 50 percent of cases whose asthma can be attributed to allergic factors. The committee recommends allergy testing of asthmatics who require more than occasional treatment. If these patients are found to be allergic to one or more indoor allergens, the committee recommends that they be given specific, practical information about how to reduce their exposure to indoor allergens.
Control of indoor allergens also requires engineering control strategies to improve the use of heating, vacuuming, and air-conditioning equipment; to consider the serious problem of carpeting as a reservoir of indoor allergens; and to define moisture control in naturally and mechanically ventilated buildings.
The research agenda developed by the committee represents a variety of approaches to understand and control indoor allergens. Research recommendations range from improvement of testing methods and identification of new allergens to developing more allergen-free products and determining the effects of long-term allergen avoidance on the quality of life.
The report has stimulated the development of a research program announcement, "Environmental Agents and Asthma," prepared by NIEHS in collaboration with NIAID and NHLBI. An announcement of this kind is one vehicle NIH uses to channel research on specific topics of public health importance. Within the Healthy People 2000 Environmental Health Subcommittee, the report has served as a springboard for extensive discussions on effective ways to alter indoor environmental conditions and on additional research needs.
Pope, A.M., R. Patterson, and E. Burge, eds. Indoor Allergens: Assessing and Controlling Adverse Health Effects. Washington, DC: National Academy Press, 1993.
National Institutes of Health
Marshall Plaut, M.D.
Asthma and Allergy Branch
Division of
Immunology, Allergy, and Transplantation
National Institute of Allergy and
Infectious Diseases
National Institutes of Health
Solar Building, Room
4A23
6003 Executive Boulevard
Rockville, MD 20892
(301) 496-8973 Fax:
(301) 402-2571
Andrew Pope, Ph.D.
National Academy of Sciences, Washington,
DC
This study was undertaken to help States enhance the quality, availability, and organization of services for rural residents with HIV. It was also intended to provide information to the Federal Government and Congress to use in designing and funding HIV programs in rural areas. The study examined (1) how different rural areas plan, organize, and deliver HIV-related services; (2) what gaps and barriers exist to providing care; and (3) how Title II grant funds can be used more effectively in developing rural HIV-related service networks. Title II of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 authorizes formula grants to the States to provide outpatient medical and support services to people with HIV and AIDS. In many States these grants are the only source of funding for services in lower incidence areas.
Although about 20 percent of Americans reside in rural areas, they account for only about 5 percent of total U.S. AIDS cases. However, the number of new cases in rural areas is growing faster than in urban areas. Little is known about the epidemiology of AIDS in rural areas or how these areas have organized to plan for and deliver HIV-related services. To obtain preliminary answers to these questions, the Bureau of Health Resources Development in the Health Resources and Services Administration (HRSA) funded a study of HIV-related service delivery in four rural areas.
According to the Centers for Disease Control and Prevention (CDC) classification system, AIDS cases in nonmetropolitan areas are classified as "rural." Rural areas exhibit great variation with respect to population density, proximity to urban areas, the prevalence of AIDS, and the populations most affected by HIV. There is great heterogeneity in AIDS prevalence (cases per 100,000 population) in rural areas.
At regional meetings, representatives of the South Atlantic and Mountain Census Divisions discussed the characteristics and needs of people with HIV/AIDS, the organization and delivery of HIV-related services, and the financing of HIV/AIDS care in rural areas of their States. They also helped develop an AIDS-specific typology for categorizing different rural environments, formulating study questions, obtaining information to design case studies, and developing the discussion guide for site visits. Information from the literature review also was used to develop the discussion guide. During the site visits, information was gathered on community attitudes toward HIV/AIDS, HIV-related service gaps and barriers, service utilization patterns, outreach activities, and funding mechanisms.
Case studies were used to investigate rural areas with dramatically different AIDS prevalence rates. The South Atlantic Census Division was selected for its high AIDS prevalence and high access to HIV-related services. The Mountain Census Division was selected for its low AIDS prevalence and low access to services. In each division, two sites were identified: the Mountain Division was represented by sites in southeast Idaho and southeast New Mexico, and the South Atlantic Division was represented by the Edisto Health District of South Carolina and the Treasure Coast area of Florida.
Each case study included (1) a literature review of the characteristics of rural residents with HIV/AIDS and rural HIV-related service delivery systems; (2) a review of HRSA grantees' applications, HIV service plans, and rural HIV service delivery models; (3) site visits, including interviews of State and local officials, service providers, people with HIV, community leaders, and others; and (4) a review of data from State and local programs, reports, and Census Bureau information.
The report provided extensive descriptions of the epidemiology of HIV/AIDS, HIV-related service networks, barriers and gaps in service, and funding mechanisms in the four rural settings. To distinguish among rural areas, a typology was developed to classify areas based on degree of rurality, prevalence of AIDS, and the epidemiological and demographic characteristics of the infected populations. The typology can be used to select study sites for epidemiological and health services research on rural AIDS and to analyze variations in the development and organization of HIV service networks. It also identifies key attributes of rural environments that can influence program implementation and the transferability of service delivery models.
HIV testing and counseling were provided in all settings, primarily in health departments. Reporting by name and partner notification varied considerably. Primary care in the low-HIV-prevalence and sparsely populated Mountain Census Division was usually provided by private practice physicians. In the South Atlantic Census Division sites, which had higher rates of HIV infection and a more concentrated population, most HIV-related services were provided through public health clinics and community health centers.
Stigma against HIV/AIDS patients, men who have sex with men, intravenous drug users, and persons with low-income status, as well as lack of practitioner knowledge about the treatment of HIV infection, appeared to limit the number of private practitioners willing to diagnose and treat AIDS patients in rural areas. In Idaho and New Mexico, stigma was compounded by a shortage of primary care physicians.
Gaps in services varied with the type of rural setting. Service gaps found in most rural settings were in primary medical care, dental care, mental health counseling, substance abuse services, professional training on the treatment and management of HIV infection, transportation, and housing. Hospital-based secondary and tertiary care were available at all sites, but accessibility was limited by lack of transportation, a shortage of well-trained staff, and patients' inability to pay. Implementing case management services was difficult in some rural areas because of widely dispersed clientele, lack of experienced providers, and an inadequate reimbursement system for rural case management. In the Treasure Coast area of Florida, where the number of AIDS cases is growing rapidly, the main gap was the limited capacity of the public health system to care for all patients and to intervene at an early stage of infection.
Financing mechanisms also varied. Funds for patient care came from
Federal grants, State legislatures, local governments, private insurance,
Medicaid, and Medicare. In Florida, most of the State HIV funds were going to
urban areas. However, the Ryan White CARE Act, Title II
formula grants
benefited rural areas by giving priority to reported AIDS cases in the most
recent years rather than using cumulative totals. Some programs, such as the
Edisto HIV clinic, were completely dependent on Federal funds. Medicaid was the
major financing mechanism for low-income residents. Although the coverage was
fairly comprehensive, the criteria for eligibility and benefits varied by
State, and many low-income persons did not qualify.
Planning functions, using Title II funds, were assumed by some State governments and, in two areas, by regional HIV care consortia. Regional consortia in the Mountain States had problems recruiting members because of the large distances between communities. The increase in rural AIDS cases suggests that more funding is needed to build a systematic body of knowledge about HIV infection in rural populations and to plan and develop rural HIV-related service delivery systems.
The case studies identified two distinct approaches to providing medical
care to rural residents with HIV: (1) an HIV clinic, located in a rural health
department or community health center, that develops cooperative working
agreements with physicians in private practice, and (2) care provided by
primary care physicians who are linked with a medical school or rural-based
regional care facility for training and backup consultation. Such regionalized
approaches to HIV service delivery make it easier for rural residents to access
services and appear to be more cost effective than urban-based outreach
programs. The case studies also documented the need to place more emphasis on
HIV training and education in rural areas in order to create more positive
environments for the development of medical and support services. Targeted
Federal funding, through the Ryan White CARE Act and other programs,
can
help rural areas plan for the development of HIV services and experiment with
new ways of delivering HIV care.
The study's findings and recommendations are being used to design a national study of HIV care in rural areas that will be funded by HRSA through an interagency agreement with the Agency for Health Care Policy and Research (AHCPR). The rural study will be integrated into the design of a larger HIV Cost and Services Utilization Study that AHCPR is funding through a cooperative agreement with the RAND Corporation. A probability sample of 500 rural residents with HIV will be interviewed at two time points about their use of health and support services, barriers to care, unmet service needs, and satisfaction with service quality. Case study findings also are being used to formulate HRSA policies on rural HIV care and to provide technical assistance to States with large rural populations.
Not yet published.
Bureau of Health Resources Development, Health Resources and Services Administration
Katherine Marconi, Ph.D.
Office of Science and
Epidemiology
Bureau of Health Resources Development
Health Resources and
Services Administration
Room 7A07 Parklawn Building
5600 Fishers
Lane
Rockville, MD 20857
(301) 443-6560 Fax: (301) 443-2511
David E. Berry, Dr.P.H.
University of Nevada, Las Vegas,
NV
This study assesses the effectiveness of innovative community-based outreach intervention/prevention programs for reducing HIV-related risk behaviors of injection drug users (IDUs) and their sexual partners. Under the sponsorship of the National AIDS Demonstration Research (NADR) Project, the outreach programs offer information about HIV infection, strategies for reducing the risk, counseling, support groups, and training in cognitive and social skills. Significant increases are found in the use of new rather than reused needles, bleach for cleaning injection equipment, and condoms--all behaviors that reduce HIV risk. Study findings are so noteworthy that a permanent program has been created.
This study sought to assess the effectiveness of community-based outreach programs to curtail high-risk behaviors leading to HIV infection. The outreach programs were designed and sponsored by the National AIDS Demonstration Research Project, a demonstration program striving to reduce the risk of HIV infection among intravenous drug users and their sexual partners.
As of 1995, about 0.4 percent of the U.S. population are estimated to be infected with HIV. Innovative strategies are needed to reach elusive populations and motivate them to change their high-risk behaviors. Educational campaigns and the mass media have increased awareness about the dangers of HIV transmission through shared injection equipment. While some IDUs have changed behaviors, many continue to share their injection equipment and engage in high-risk sexual behaviors, which places them, their sexual partners, and their infants at risk. Knowledge of effective interventions was so limited that many public officials doubted that IDUs would participate in AIDS prevention programs and were reluctant to spend public funds to reach them.
In 1987, the Community Research Branch of the National Institute on Drug Abuse (NIDA) initiated the NADR Project as a demonstration program. The program was restricted to IDUs who were not currently in drug treatment programs and to their sexual partners. Its purpose was to design and implement innovative outreach intervention/prevention strategies and to determine program effectiveness through a built-in evaluation component.
The NADR Project was discontinued in 1992, but it was a model for the inauguration of a formal program of cooperative agreements to communities to help them curb risky behaviors of IDUs that lead to HIV infection.
Interventions at each of the 28 sites studied by NOVA Research Company varied somewhat but shared key elements. Community outreach workers, often former IDUs, contacted and recruited IDUs and their sexual partners to participate. Participants were offered voluntary HIV testing and received counseling and education that was culturally relevant. The counseling was delivered and reinforced by a credible source who also provided skills training and/or material resources.
The program collected and analyzed data on 13,475 IDUs and 1,637 sexual partners of IDUs. Investigators used a before/after design, collecting information at baseline and comparing it to that obtained at 6-month followup. Standardized baseline and followup assessment instruments were used to collect comparable data across all sites. Clients were assigned--either randomly or through systematic sampling--to a standard or enhanced intervention at most sites. The standard intervention generally included education and referral for needed community services. The enhanced intervention included a variety of more intensive services, such as couples counseling, development of peer networks, and social skills training.
Three summary risk scales were developed for use as outcome measures: needle risk behavior, sex risk behaviors, and total frequency of drug injection. Specific behaviors such as cleaning needles with bleach or using condoms were used for assessing the impact of the intervention.
Analyses focused on the participants' demographic characteristics, their behaviors and knowledge before and after interventions, the relationship of the type and intensity of intervention modalities to HIV-related risk behaviors, and other risk factors related to the level of risk. Analysis indicated that participants reliably reported demographic factors, injection drug use, and use of alcohol and marijuana. The reliability of reported needle use and sexual behaviors was more difficult to measure.
IDUs reported significant decreases in HIV-related risk behaviors after interventions. Significant increases were observed in the use of new needles, bleach for cleaning injection equipment, and condoms. Changes in needle-related behaviors of IDUs were more dramatic than changes in sexual behaviors.
The enhanced interventions were slightly more effective than standard interventions in reducing risk. However, this difference was not uniform across all sites and was related to the duration, format, and content of the enhanced intervention at each site. Specific components that were important to reducing risk were providing condoms and/or bleach and demonstrating the proper use of both. Around 33 percent of IDUs entered drug treatment during the followup period, thus reducing their risk for HIV and drug-related illnesses. At followup, subjects who were long-time IDUs, Hispanic, previously in drug treatment, unemployed, and heroin injectors reported greater use of injected drugs than did other IDUs.
The analysis at 17 sites revealed increased use of condoms, reduced number of sex partners, and reduced use of noninjected drugs. Average sex risk scale scores were not significantly different between the standard and enhanced interventions.
While both IDUs and their sexual partners began with high levels of AIDS-related knowledge, the project further enhanced this knowledge. AIDS knowledge levels were significantly higher among white than among African-American or Hispanic IDUs and sex partners. Females scored higher than males on sex risk knowledge, general risk knowledge, and total knowledge. No significant differences were revealed in knowledge scale scores between subjects in the standard and enhanced interventions.
This evaluation provides evidence that IDUs and their sexual partners can successfully take advantage of education and counseling to reduce the risk of becoming infected with HIV. The interventions were found to be so effective that they have been incorporated into formal programs administered by NIDA.
The study contained numerous suggestions for further research. Since the interventions varied across sites and had different impacts on subgroups, greater use of process measures was recommended for future research to document intervention exposure and to relate exposure to changes in behavior. Further investigation is needed into the efficacy of specific components dealing with bleach and condoms over more costly enhanced interventions. Methods to improve response rates at followup need further development. Long-term analysis of the data is needed to assess lasting impact on risk reduction.
NIDA, the NIDA/NADR research consortium, and individual project sites are disseminating the results through articles in refereed journals, training manuals and videotapes, and national database tapes for secondary data analysis.
National Institutes of Health
Richard Needle, Ph.D., M.P.H.
Community Research
Branch
Division of Epidemiology and Prevention Research
National
Institute on Drug Abuse
National Institutes of Health
5600 Fishers Lane,
Room 9A-42
Rockville, MD 20857
(301) 443-6720 Fax: (301) 443-2636
NOVA Research Company, Bethesda, MD
An expert panel was convened to evaluate whether certain childhood vaccines cause adverse events. Vaccines against tetanus, diphtheria, measles, mumps, polio, Haemophilus influenzae type b (Hib), and hepatitis B were reviewed. By weighing the available evidence, researchers determined which adverse events can be caused by each vaccine, which cannot, and which are undetermined. The findings are being incorporated into information given to all parents and into proposals to compensate victims.
An expert assessment was sought of the scientific and medical literature on the health risks to children from the administration of vaccines or vaccine components against tetanus, diphtheria, measles, mumps, polio, Haemophilus influenzae type b, and hepatitis B.
Background Concerns about the safety and potential risks of vaccination have been raised by the media, the public, and the medical community. In response to these concerns, Congress passed the National Childhood Vaccine Injury Compensation Act of 1986 (P.L. 99-660). One component of the law requires the Department of Health and Human Services, with the help of the Institute of Medicine (IOM), to investigate the adverse effects of childhood vaccines. This mandate led to the development and publication of two evaluation reports, one of which was completed earlier and focused on adverse effects from pertussis and rubella vaccines. The second report focuses on adverse events to the following childhood vaccines: tetanus, diphtheria, measles, mumps, polio, Hib, and hepatitis B. The report was prepared by the Vaccine Safety Committee constituted by the IOM. The report did not examine risk-benefit comparisons between vaccines nor did it make recommendations about immunization schedules, vaccine purity, or vaccine production techniques.
Methods During an 18-month period, the multidisciplinary 14-member committee reviewed more than 7,000 abstracts, more than 2,000 published books and articles, and public testimony to determine whether the available scientific and medical evidence supported or rejected a causal relationship between specific vaccines and adverse health effects in children. Members of the expert panel included immunologists, pediatricians, internists, neurologists, virologists, microbiologists, epidemiologists, and public health specialists.
Findings The committee studied a total of 49 conditions in which childhood vaccines were suspected of leading to adverse health events; most incidents were reported in uncontrolled studies and case reports. Of the 49 cases, the evidence for 12 cases favored or established a causal relation; the evidence for 4 cases rejected a causal relation; and the evidence for the remaining 33 cases was equivocal. The cause-and-effect relationships identified by the committee are detailed in figure 2.
Use of Results The findings of this report have already been incorporated into proposals to revise the list of injuries presumed to have been caused by selected vaccines. This list, called the Vaccine Injury Table, identifies conditions for which automatic compensation is provided to victims and families under the National Childhood Vaccine Injury Compensation Act. The findings have already been used by the Centers for Disease Control to revise the information that practitioners are required to give parents before vaccination. Finally, changes are expected in the Food and Drug Administration's regulation of vaccine labeling.
Publication Stratton, K.R., C.J. Howe, and R.B. Johnston, Jr., eds. Adverse Effects Associated With Childhood Vaccines: Evidence Bearing on Causality. Washington, DC: National Academy Press, 1994.
Agency sponsor: National Institutes of Health
Federal contact: Regina Rabinovich,
M.D.
Division of Microbiology and Infectious Diseases
National
Institute of Allergy and Infectious Diseases
National Institutes of
Health
Solar Building, Room 3A07
6003 Executive Boulevard
Rockville,
MD 20892
(301) 496-5893 Fax: (301) 480-4528
Committee chair: Richard B.
Johnson, M.D.
The March of Dimes Birth Defects Foundation, White Plains,
NY
Purpose Healthy People 2000 targets having more than 90 percent of the Nation's children vaccinated for all recommended diseases by their second birthday and eliminating domestic cases of measles, polio, and rubella. Meeting these targets requires a continuous supply of safe and effective vaccines at stable prices.
Background Vaccinating children against infectious diseases is one of the most effective means of preventing disease. Vaccinations for nine diseases are recommended for healthy children. While the United States does an excellent job of vaccinating school-age children, only about 37 to 56 percent of 2-year-olds are fully immunized against preventable childhood diseases, well short of the goal of at least 90 percent. Currently, only two domestic firms and two State laboratories manufacture and sell vaccines for nine childhood diseases. Three of the recommended childhood vaccines--OPV, HBV, and MMR[2]--are each produced by only one domestic firm. The shelf life of a vaccine is short (10 to 18 months), and vaccine production time can range from 7 to 13 months. As a result, the loss of even one manufacturer can result in a vaccine shortage. When shortages occur, vaccine prices escalate.
Methods This study consisted of several policy papers that analyze the economic and commercial aspects of ensuring an adequate supply and distribution of vaccines. Specifically, the study investigated (1) alternative models for the purchase and distribution of vaccines; (2) the effect of scientific advances on research, development, and purchase of vaccines; (3) the application of economic theory to the vaccine market; (4) comparisons of vaccine distribution systems administered by vaccine manufacturers and State agencies; and (5) the implications of purchasing vaccines from foreign firms. The papers developed for the project were presented at the Annual Meeting of the American Academy of Pediatrics held in Washington, D.C., in November 1993.
Findings In 1992, all doses of DTP[3], oral polio, and MMR needed to vaccinate a 2-year-old cost about $95 in the private sector, a 12-fold increase since 1977. Vaccine suppliers attribute the price increases to increases in their costs, but others believe the strong market power of U.S. vaccine manufacturers is at least partly responsible.
Use of Results The study has provided the Public Health Service (PHS) with fundamental knowledge about vaccine pricing over the past 20 years. This knowledge has placed PHS in a better position to negotiate contracts with vaccine manufacturers, a role that has been enhanced as a result of 1993 legislation giving CDC the authority to negotiate prices for States participating in the CDC State Immunization Grant and Vaccines for Children programs. These two programs were designed to eliminate price as a barrier to immunization for selected groups of usually low-income children.
Publication The National Vaccine Program Office and CDC plan to publish the manuscript in 1995 under the working title "A Study of the Economic Underpinning of Vaccine Supply."
Agency sponsor: National Vaccine Program Office
Federal contact: Stephen
Sepe
National Vaccine Program Office
Centers for Disease Control and
Prevention
1600 Clifton Road NE, MS D-24
Atlanta, GA 30333
(404)
639-4450 Fax: (404) 639-6036
Principal investigator: Craig
Thornton, Ph.D.
Mathematica Policy Research, Inc., Princeton, NJ
Purpose This study was undertaken to inform policy-makers about the growing need to finance the education of advanced practice nurses. In light of expected shortages in the supply of APNs, the study created and analyzed four options and their estimated costs for ensuring a stable source of funds.
Background APNs are trained at the master's level, while basic nurse training typically consists of 2 to 4 years of undergraduate education. Many States permit APNs to provide primary care and to refer patients to more specialized care, if necessary. Compared with physicians, APNs are less costly to educate, receive lower salaries, and more frequently practice in medically underserved areas. These features make APNs an attractive investment to policymakers interested in expanding access to primary care services.
Methods This study by the University
of Pennsylvania provided an analysis of policy options and developed estimates
for each. The policy analysis, compiled from published sources, contained data
on APN student characteristics, supply, overall education costs, and financing.
The analysis contrasted APN students with medical residents, since the proposed
Health Security Act modeled the funding for APN education after that for
graduate medical education. The impact of previous legislation was also
documented. The study provided four alternative options
for structuring and
distributing the proposed account. Each option contained a cost estimate based
on published data on tuition, fees, stipends, and program costs.
Findings The available evidence suggests a scarcity in the supply of APNs under health care reform scenarios. For example, the University of Pennsylvania Division of Nursing estimated an additional 31,000 nurse practitioners would be needed by 2000, an increase of about 60 percent beyond the current supply. In 1986, a study by the Congressional Budget Office estimated that there were an estimated four job openings for every graduating certified nurse-midwife and nurse practitioner. The study documented that about 75 percent of APN students are enrolled part-time and pointed out that full-time status would hasten the flow of graduates.
The study examined four options for allocating the funds to targeted subsets of students. The four options, which students they cover, what charges they cover, and what they cost are presented in table 2. Advantages and disadvantages of the options are discussed in the study.
Use of Results The study results provide critical information to policymakers as they continue to consider options for ensuring the supply of advanced practice nurses as alternative primary caregivers.
Publication Aiken, L.H., M.E. Gwyther, and E.M. Whelan. "Federal Support of Graduate Nursing Education: Rationale and Policy Options." Health Affairs.
Agency sponsor: Department of Health and Human Services
Federal contact: Marcy
Gross
Senior Associate
Office of the Assistant Secretary for
Health
Department of Health and Human Services
Room 740G, Hubert H.
Humphrey Building
200 Independence Avenue SW
Washington, DC
20201
(202) 690-5824 Fax: (202) 690-5432
Principal investigator: Linda
Aiken, Ph.D, R.N., F.A.N.
University of Pennsylvania School of Nursing,
Philadelphia, PA
Evaluation of CDC and ATSDR Training Activities
Purpose In light of the dramatic changes occurring throughout the public health system, this evaluation had two goals: to determine the current and emerging needs of local health departments and to determine whether CDC and ATSDR training activities not only meet these needs but also anticipate future needs. Training produced and delivered by CDC[4], is intended to improve the performance of the public health workforce at the State and local level. Training activities provided through workshops, conferences, regional training centers, and other vehicles cover a range of scientific, technical, and managerial topics.
Background The public health system, especially at the local level, is endangered by shrinking budgets and shortsightedness about the value of public health, according to a widely respected 1988 report, The Future of Public Health, by the Institute of Medicine. The three major functions of public health--assurance, assessment, and policy development--are undergoing change. While most resources are currently devoted to delivering services--assurance activities--more emphasis is expected to be needed on assessment (i.e., investigation and surveillance of health hazards) and policy development.
Methods Macro Systems International conducted site visits at nine selected local health departments and, using focus groups with health department staff, identified training needs. A uniform discussion guide was used at each site to uncover training needs, training activities, and approaches that might enhance training.
Findings Training plays an important role in the mission of all CIOs, yet the nature and content of training varied widely. In general, training appropriately emphasized assessment, but its additional emphasis on assurance contrasts with the expectation that public health is moving away from this activity.
Use of Results The study and its recommendations updated CDC's on-line training catalog and stimulated its nationwide availability. CDC also is hastening the development of a computer-based job aid that will enable CDC to be aware of the training needs of local health departments.
Publication Not yet published. Final report is available through the HHS Policy Information Center in the Office of the Assistant Secretary for Planning and Evaluation.
Agency sponsor: Centers for Disease Control and Prevention
Federal contact: Dennis
McDowell
Public Health Practice Program Office
Centers for Disease
Control and Prevention
1600 Clifton Road NE, MS E-20
Atlanta, GA
30333
(404) 639-3707 Fax: (404) 639-3982
Principal investigator: Thomas
Chapel
Macro Systems International, Atlanta, GA
Evaluation of the Morbidity and Mortality Weekly Report Series
Purpose The Morbidity and Mortality Weekly Report, published every week by CDC, is the agency's major vehicle for communicating timely public health information. As the mission of CDC has expanded beyond concern for infectious diseases to chronic disease and environmental health, this study sought to evaluate the utility of the MMWR in meeting the needs of all of its public health constituencies.
Background The MMWR has been published weekly since 1961 as an extension of CDC's surveillance activity. More recently, the MMWR has been the first source of information on such public health issues as outbreaks and etiology of AIDS, legionella, and hantavirus, as well as studies of toxic shock syndrome. The MMWR's goal is to document events of public health interest, to disseminate information to those who need it, and to communicate with CDC constituents. MMWR articles have the potential not only of informing, but also of directly helping to prevent disease.
Methods Battelle conducted a mail/telephone readership survey with 375 individuals on the MMWR mailing list, 375 subscribers to the MMWR through the Massachusetts Medical Society, and 250 primary care physicians who subscribe to JAMA, which publishes MMWR excerpts in a section called "Notes from CDC: Leads from the MMWR." The survey sought to identify reading habits, readership characteristics, use of MMWR information, feedback on publication content and format, and interest in electronic access.
Findings The MMWR is read with great regularity: two-thirds of respondents had read three or more MMWR issues in the months prior to the survey, and most readers had read the MMWR for 5 years or more. Because the MMWR is often distributed to institutions, it is frequently passed along to additional readers. The actual readership is estimated at more than twice the number of issues distributed. The professional backgrounds of MMWR readers are diverse, and the two dissemination modes evaluated (the CDC mailing list and those who subscribe through the Massachusetts Medical Society) complement each other in terms of professional distribution.
Use of Results The study recommended that the MMWR maintain the breadth of its coverage, possibly enlarge the format, increase outreach efforts, and improve electronic access.
Publication Not yet published. Final report is available through the CDC Policy Information Center.
Agency sponsor: Centers for Disease Control and Prevention
Federal contact: Richard A.
Goodman, M.D., M.P.H.
Epidemiology Program Office
Centers for Disease
Control and Prevention
Building 1, Room 5104
1600 Clifton Road
NE
Atlanta, GA 30333
(404) 639-3636 Fax: (404) 639-3950
Principal investigator: James
Hersey
Battelle, Arlington, VA