Alan W. Cross

Coalition building for prevention: lessons learned from the North Carolina Community-Based Public Health Initiative.

This article examines the four-year development of the North Carolina Community-Based Public Health Initiative consortium (NC CBPHI). The NC CBPHI consisted of four separate county coalitions and differed in both its agenda and membership from the many examples of coalitions described in the literature. This article presents and describes evaluation findings that identify six factors as important in coalition functioning and success in the CBPHI coalitions. These factors are: participation, communication, governance and rules for operation, staff/coalition member relationships, technical assistance and skills training, and conflict recognition and containment. Selected CBPHI coalition activities are also described and implications for public health practitioners are presented.

Preschool risk factors as predictors of early school performance

The relative importance of selected developmental, medical, and social factors in assessing a childs early academic potential was evaluated prospectively in a rural southern school district. Two hundred and ten (210) preschoolers were given the Sprigle School Readiness Screening Test (SSRST) and the Beery Test of Visual Motor Integration (VMI) while physicians rated the childrens attention span. A parental questionnaire assessed medical, behavioral, social, and family variables. Follow-up school data were available on 176 children (84%). Using regression techniques, reading and math achievement scores were directly correlated with maternal education, SSRST and VMI results, and lack of family history of learning problems, whereas grade failure was associated with low VMI scores, decreased maternal education, boys with late birthdays, and family history of learning problems. Medical problems and parental preschool behavior concerns were unrelated to school achievement, but physician rating of preschool attention span showed a significant correlation with reading and math scores. A 0-11 Risk Index of School Capability (RISC) scale based on data analyses was developed to rate a preschoolers early academic potential. A score of 7 or above had a 98% positive predictive value of successful grade completion, whereas a score of 3 or below had a 70% predictive value for grade failure. The value of assessing the scores of the VMI and SSRST alone was also considered, but was found less useful. This study demonstrates the importance of evaluating a number of risk factors in assessing a preschoolers early academic potential. Such data can be used to focus school resources for children at increased risk for grade failure. J Dev Behav Pediatr 7:237-241, 1986.

Effectiveness of the neonatal transport team.

This study was performed to determine the effectiveness of a hospital-based transport team in lowering mortality in newborns. The medical records of 603 outborn infants weighing from 500 to 2500 g and having primary respiratory disorders were reviewed. The infants were admitted to 1 of 3 regional neonatal centers between January 1, 1977 and September 30, 1980. The 2 centers without transport teams admitted 304 outborn infants, of whom 62 (20%) expired by 120 h of age. The center with a transport team admitted 184 team-transported infants and 115 nonteam-transported infants, of whom 38 (13%) expired by 120 h of age. Outborn infants admitted to the hospitals without a neonatal transport team had a 60% (p less than 0.01) greater mortality compared to those admitted to the hospital with a transport team. At the onset of intensive care, the babies transported to the nonteam hospitals had a greater incidence of hypothermia and acidosis which may be related to their increased mortality. We conclude that hospitals without the services of a neonatal transport team may have significantly more deaths among low birth weight infants with respiratory disease than comparable hospitals with neonatal transport teams.

Comparisons between inner-city and private school adolescents' perceptions of health problems.

A youth health survey was administered to 247 students in an inner-city ghetto high school and 404 students in a private boarding school. Significant differences between the two socioeconomic groups were found for responses about health information, health concerns and problems, and health status and service utilization. Sex-related issues were of greater concern to the private school youth and they desired more help with depression-sadness and birth control. Inner-city youth had more health worries and indicated a desire for more help with physical problems such as toothaches, headaches, and stomach aches, and social problems such as racial discrimination and parent relations. From a list of 22 health problems, the inner-city youth ranked dental problems, acne, and health worries highest while the private school youth ranked depression-sadness, tiredness, and acne highest. Regardless of social class, most adolescents perceived large gaps in their health education. One implication of our data is that the specific self-reported needs and concerns of adolescents should be considered in planning health services and education programs.

Ethical and cultural dimensions of informed consent. A case study and analysis.

A case of a patient with angina who was considered for coronary bypass surgery illustrates the issue of informed consent. Ethical and legal aspects and the inherent limitations of achieving consent must be considered. Physicians may have personal biases, which may lead to coerced consent, or may overwhelm the patient with information on potential complications of a proposed procedure, which may lead to consent without hope. Patient bias or misinformation may lead to misunderstood consent or, if the patients judgment is distorted, to crisis consent. The patients desire to defer the decision to the physician raises the question of whether such requested paternalism violates patient self-determination and invalidates consent or is an exercise of the patients right to have his physician decide. The case presented exemplifies the patient-physician interaction needed for responsible paternalism.

State Health Department and University Evaluation of North Carolina’s Maternal Outreach Worker Program

INTRODUCTION The Maternal Outreach Worker (MOW) Program is a social support intervention using lay helpers to provide support, health education, and outreach to Medicaid eligible women at risk for poor pregnancy and parenting outcomes. State Health Department and University collaborators designed a two-pronged evaluation comprised of programwide and interview study components to assess the impact of the program on pregnancy outcomes, health behaviors, and infant health status. METHODS Programwide evaluation data are based on 1992-1995 N.C. birth files for the original 24 participating counties and include 1,726 MOW participant births and 12,988 comparison births whose records were linked to birth files and met the study criteria. For the interview study 373 MOW participants and 332 comparison women were personally interviewed three times: during pregnancy, one month postpartum, and one year after delivery. RESULTS Risk factors associated with poor pregnancy and parenting outcomes were greater among MOW participants than comparisons in both the programwide and intensive study components. Caucasian MOW participants had slightly higher rates of adequate prenatal care. African Americans were found to have less adequate prenatal care. Fewer than expected LBW and VLBW births were observed for African-American MOW participants. MOW Program participation did not affect the utilization of health and social services for infants. African Americans, regardless of whether they received MOW services, fared better than Caucasians in terms of having their pregnancy needs fulfilled. CONCLUSIONS Findings show the need to further explore appropriate measures of maternity support program outcomes and indicate inconsistent program benefit among subpopulations.

Comprehensiveness of well child checkups for children receiving medicaid: A pilot study

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a Medicaid program designed to provide comprehensive well child care for children from low-income families. Each EPSDT checkup should include a physical examination; medical history; assessment of development, nutrition, and immunizations; assessment of hearing, vision, and dental status; and anticipatory guidance. This pilot study of the medical records of 76 children receiving EPSDT checkups in six rural counties in North Carolina provided a preliminary assessment of whether EPSDT checkups included the required components. The study showed that health care providers frequently did not provide adequate documentation of the care provided at the checkup, and it raised questions as to whether children received the required components of the EPSDT checkup.

Moralist, technician, sophist, teacher/learner: Reflections on the ethicist in the clinical setting

The ethicists role in the clinical context is not presently well defined. Ethicists can be thought of as moralists, technicians, Sophists, or as teachers and learners. Each of these roles is examined in turn. An argument is made for the ethicist as a teacher who must also learn a great deal about the clinical setting in order to encourage an effective critical examination of basic values. Four specific tasks of this teaching role are discussed: describing moral experience, eliciting assumptions, considering multiple alternatives and justifying choices.

Health outcomes of children receiving EPSDT checkups: a pilot study.

This pilot study used medical records to examine the health outcomes of children receiving care in Medicaids Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program. Medical records from 76 children seen for EPSDT visits during a 6-month period were reviewed to assess whether health problems were identified and whether treatment, follow-up, or referral care was provided. Health problems were identified for 43% of the children; 22% received treatment, and 18% were referred for specialty care. Checkups uncovered fewer problems than would be expected in a poor, largely minority population. Almost one third of the children referred for specialty care apparently did not receive such care. The study verified the need for further research and provides direction for future study.

The early and periodic screening, diagnosis and treatment program: opportunities for nurse practitioners.

The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program is intended to provide comprehensive preventive health care services for children and young adults from low-income families on Medicaid. Unfortunately, only a fraction of the individuals eligible for care actually receive EPSDT services, often because of a shortage of providers who offer these services. Nurse practitioners are ideally suited to offer such services and, in states where they are allowed to function independently, can receive direct Medicaid reimbursement for them. Because many nurse practitioners are unfamiliar with the EPSDT program, this article describes the key components of the program and explains how nurse practitioners can provide EPSDT services.