Anne C. Beal

Social influences on health-risk behaviors among minority middle school students

PURPOSE To determine whether parent social influences are associated with health-risk behaviors more than peer social influences among young minority adolescents. METHODS We conducted a cross-sectional survey of seventh-grade students in a public urban magnet middle school using a survey instrument adapted from the Centers for Disease Control and Prevention Youth Risk Behavior Survey. The sample consisted of all seventh-grade students in the school, and the survey was part of a needs assessment for a school-based health education program. We measured four health-risk behaviors: use of (a) tobacco, (b) alcohol, (c) onset of sexual activity, and (d) marijuana use; and five social influences: (a) parent disapproval of health-risk behaviors, (b) parent modeling of health-risk behaviors, (c) parent monitoring of health-risks, (d) peer disapproval of health risks, and (e) peer modeling of health-risk behaviors. The analyses included measures of the prevalence of health-risk behaviors, bivariate analyses to evaluate relationships between health-risk behaviors and social influences, and regressions analyses to determine the independent associations of the social influences with the four health-risk behaviors. RESULTS Twenty percent of respondents reported using tobacco, over 50% used alcohol in the past year, 13.3% were sexually active, and 12% reported marijuana use. Parent influences were associated with differences in alcohol use, whereas peer influences were associated with differences in all measured health-risk behaviors: tobacco and alcohol use, sexual activity, and marijuana use. Regression analyses demonstrated that peer social influences were the only measures independently associated with abstinence from tobacco (p < .05), alcohol (p < .01), sexual activity (p < .05), and marijuana use (p < .05). In all analyses, peers emerged as the most consistent social influence on health-risk behavior. CONCLUSION This study suggests peers and peer group behavior may be better predictors of adolescent health-risk behaviors than parental social influences among young adolescents.

Breastfeeding advice given to African American and white women by physicians and WIC counselors.

Objective. This study determined rates of breastfeeding advice given to African American and white women by medical providers and WIC nutrition counselors, and sought to determine whether racial differences in advice contributed to racial differences in rates of breastfeeding. Methods. The study used data from the 1988 National Maternal and Infant Health Survey, a cross-sectional survey of a nationally representative sample of mothers with a live birth, infant death, or fetal death in 1988. The authors compared white women (n=3,966) and African American women (n=4,791) with a live birth in 1988 on self-reported rates of medical provider and WIC advice to breastfeed, WIC advice to bottlefeed, and breastfeeding. Results. Self-reported racial identification did not predict medical provider advice. However, being African American was associated with less likelihood of breastfeeding advice and greater likelihood of bottlefeeding advice from WIC nutrition counselors. In multivariate analyses controlling for differences in advice, being African American was independently associated with lower breastfeeding rates (odds ratio [OR] = 0.41, 95% CI 0.32, 0.52). Conclusions. African American women were less likely than white women to report having received breastfeeding advice from WIC counselors and more likely to report having received bottlefeeding advice from WIC counselors. However, African American and white women were equally likely to report having received breastfeeding advice from medical providers. Lower rates of breastfeeding advice from medical or nutritional professionals do not account for lower rates of breastfeeding among African American women.

Patient-Powered Research Networks Aim To Improve Patient Care And Health Research

The era of big data, loosely defined as the development and analysis of large or complex data sets, brings new opportunities to empower patients and their families to generate, collect, and use their health information for both clinical and research purposes. In 2013 the Patient-Centered Outcomes Research Institute launched a large national research network, PCORnet, that includes both clinical and patient-powered research networks. This article describes these networks, their potential uses, and the challenges they face. The networks are engaging patients, family members, and caregivers in four key ways: contributing data securely, with privacy protected; including diverse and representative groups of patients in research; prioritizing research questions, participating in research, and disseminating results; and participating in the leadership and governance of patient-powered research networks. If technical, regulatory, and organizational challenges can be overcome, PCORnet will allow research to be conducted more efficiently and cost-effectively and results to be disseminated quickly back to patients, clinicians, and delivery systems to improve patient health.

Comparing a Diagnosis List With a Survey Method to Identify Children With Chronic Conditions in an Urban Health Center

OBJECTIVE To compare a diagnosis list to the Questionnaire for Identifying Children with Chronic Conditions (QuICCC) to assess their relative usefulness as measures for identifying children with chronic conditions. METHODS Comparison of health encounter data and survey data for a cohort of 304 children aged 0-18 years at an urban health center affiliated with a teaching hospital. We used 2 strategies to identify children with a chronic condition: 1) identification by the existence of an encounter with an International Classification of Diseases, Ninth Revision code indicating a chronic condition and 2) identification by the QuICCC. We compared the characteristics of children identified by the diagnosis list with those of children identified by the QuICCC. RESULTS This population had high rates of chronic conditions, with 44% identified by the diagnosis list and 36% identified by the QuICCC. These 2 methods jointly identified 66% of children, yet only half (53%) of the children who had a diagnosis of a chronic condition in the encounter data were identified by the QuICCC. Asthma, anorexia, developmental delay, and adjustment reaction were among the common chronic conditions for children identified by the diagnosis list approach only. CONCLUSIONS We found only moderate concordance among the children identified as having chronic conditions by a diagnosis list and by the QuICCC in this high-risk urban population. These different results indicate that encounter data and survey approaches do not serve as simple substitutes for identifying children with chronic conditions for clinical or monitoring purposes.

Generalist and subspecialist care for children with chronic conditions.

OBJECTIVE To determine, among Medicaid-enrolled children with chronic conditions, associations of indicators of morbidity and expenditures with different patterns of generalist, subspecialist, and pediatric subspecialist use. DESIGN AND SETTING Cross-sectional analysis of Medicaid claims, enrollment, and provider data from 4 states (California, Georgia, Michigan, and Tennessee). SAMPLE All children enrolled in Supplemental Security Income (aged 0-21 years) and a sample of other Medicaid-enrolled children matched for age and gender. We included 11 chronic conditions, including both uncommon conditions (eg, spina bifida, hemophilia) and common ones (eg, asthma, attention deficit hyperactivity disorder). MAIN OUTCOME MEASURES We determined the number of visits per year to generalists and subspecialists (pediatric and other), using only subspecialists relevant to that condition. We categorized patterns of care as generalist only, predominantly generalist, or predominantly subspecialist, and examined patterns by condition and an indicator of morbidity. Among children seeing subspecialists, we also compared morbidity by pediatric and other subspecialists. We used linear regression to determine per-year total expenditures, controlling for demographic characteristics and morbidity. RESULTS Most children (60.7%) saw generalists only. Twenty-eight percent were in predominantly generalist arrangements, and 11% were in predominantly subspecialist arrangements. Children in predominantly generalist arrangements had higher morbidity than children in generalist-only or predominantly subspecialist arrangements. Among children seeing subspecialists, those seeing pediatric subspecialists had generally higher morbidity than those seeing other subspecialists. Mean yearly expenditures varied from 1306 dollars (attention deficit hyperactivity disorder) to 11,633 dollars (acquired immunodeficiency syndrome). Children who saw only generalists had significantly lower expenditures for 6 of the 11 conditions, after adjusting for morbidity. CONCLUSIONS Medicaid-enrolled children in predominantly generalist arrangements appear to have more complicated conditions than children in generalist-only or predominantly subspecialist arrangements, engendering also higher expenditures. Although children who saw generalists only had lower expenditures than those seeing subspecialists, this finding may reflect unmeasured variations in morbidity.

Child Health Disparities: Framing a Research Agenda

THE COMMONWEALTH FUND ONE EAST 75TH STREET NEW YORK, NY 10021-2692 TEL 212.606.3800 FAX 212.606.3500 E-MAIL cmwf@cmwf.org http://www.cmwf.org Children are affected by widespread disparities in health status and in the quality of the health care they receive. Given the increasing number of minority children in the U.S., research on these disparities is very important. Paying heed to the inequalities in child health research, however, is easier said than done.

Patient Reports of the Quality of Care in Community Health Centers: The Importance of Having a Regular Provider

Objective. To examine the importance of having a regular provider in community health centers (CHCs) for high quality care. Methods. Analyses of a national survey—the Commonwealth Fund 2006 Health care Quality Survey—among patients with a private doctors (PMD) office (n=1,743) or CHC (n=275) as their regular source of care. Outcomes include prevention measures, and measures of patient experience. Results. Patients at CHCs are less likely than patients who use a PMD to report having a regular doctor (53% vs. 95%, p≤.001). They also report lower rates for all the preventive care and patient experience measures. However, the differences in quality are eliminated when CHC patients have a regular provider. Conclusions. When CHC patients have a regular provider, they receive higher quality care. Policymakers should support expansions of the CHC health care workforce to ensure patients have access to a regular provider, which leads to higher quality care.

The path to equitable health care.

The path to achieving equity for racial and ethnic underserved communities, which are at risk for experiencing health and health care disparities, has not been an easy one. The challenges of these disparities came to national attention in 1985 with the Report of the Secretarys Task Force on Black and Minority Health during President Reagans administration (often referred to as the Heckler Report; Heckler 1985; Gamble and Stone 2006). In 1989, the American Medical Association (AMA) noted “unjustifiable” differences in treatments provided to African Americans that “must be eliminated” (AMA, 1990). And in 2003, the Institute of Medicines landmark report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care comprehensively documented continuing, pervasive disparities in our health care system (Smedley et al. 2003).

A Single Source of Health Care: Does It Affect Health Experiences for Inner-City Children?

This study was designed to determine whether having a single source of health care affects the health experiences of inner-city children. Seventy-five women were interviewed about the health experiences of their preschool-aged children (range 10-58 months) and were asked about utilization, emergency room use, preventive care, delays in care, and availability of a provider for the childs various medical needs. While most (94.7 percent) of the mothers identified a regular source of care for fair childs preventive care, 74.7 percent named the same source for their childs sick care. There were no differences in most measures between mothers with a single source of care and those with multiple sources. However, those with a single source of care reported feeling their providers were more available (p < 0.05). Thus, naming a single source of health care may not be a useful indicator of better health experiences for inner-city children.