Michael E. Samuels

Person and Place: The Compounding Effects of Race/Ethnicity and Rurality on Health

Rural racial/ethnic minorities constitute a forgotten population. The limited research addressing rural Black, Hispanic, and American Indian/Alaska Native populations suggests that disparities in health and in health care access found among rural racial/ethnic minority populations are generally more severe than those among urban racial/ethnic minorities. We suggest that disparities must be understood as both collective and contextual phenomena. Rural racial/ethnic minority disparities in part stem from the aggregation of disadvantaged individuals in rural areas. Disparities also emerge from a context of limited educational and economic opportunity. Linking public health planning to the education and economic development sectors will reduce racial/ethnic minority disparities while increasing overall well-being in rural communities.

Physician leadership styles and effectiveness: an empirical study.

The authors study the association between physician leadership styles and leadership effectiveness. Executive directors of community health centers were surveyed (269 respondents; response rate = 40.9 percent) for their perceptions of the medical director’s leadership behaviors and effectiveness, using an adapted Multifactor Leadership Questionnaire (43 items on a 0-4 point Likert-type scale), with additional questions on demographics and the center’s clinical goals and achievements. The authors hypothesize that transformational leadership would be more positively associated with executive directors’ ratings of effectiveness, satisfaction with the leader, and subordinate extra effort, as well as the center’s clinical goal achievement, than transactional or laissez-faire leadership. Separate ordinary least squares regressions were used to model each of the effectiveness measures, and general linear model regression was used to model clinical goal achievement. Results support the hypothesis and suggest that physician leadership development using the transformational leadership model may result in improved health care quality and cost control.

Potentially preventable care: ambulatory care-sensitive pediatric hospitalizations in South Carolina in 1998.

Objective We examined pediatric hospitalizations to assess personal and community factors affecting potentially preventable ambulatory care-sensitive condition (ACSC) hospitalizations. Methods Data came from the South Carolina 1998 Hospital Inpatient Encounter Database, which yielded 10,156 ACSC discharges among 81,808 pediatric hospitalizations. Analyses were performed at three levels: ACSC as a percentage of all hospitalizations, ACSC patients compared with other patients, and county ACSC rates. Results Younger, male, and nonwhite children; children with Medicaid insurance coverage; and children living in rural areas, health professional shortage area-designated counties, and poorer counties with fewer heath care resources were more likely to be hospitalized with ACSCs. A high percentage of children living in poverty and an absence of federally qualified community health centers were predictive of high county ACSC rates. Conclusion Poverty and the absence of a provider serving low-income children increase ACSC rates. Monitoring changes in ACSC rates can be a tool for studying the effects of policy change.

Reliability of Katz's Activities of Daily Living Scale When Used in Telephone Interviews.

The reliability of afive-item Katzs Activities of Daily Living (ADL) scale collected by selfreport telephone interview is presented. A random sample of 6,472 South Carolina residents over 55 years of age selected from a statewide population is used. Factor structure, Guttman properties, internal consistency reliability, Mokkens index of test homogeneity, and Spearmans coefficient of rank-order correlation are used to show that ADL data gathered by telephone interview are reliable. Because telephone interviewing methods are faster, cheaper, and safertheyare recommended as a viable wayfor researchers, policymnakers, and practitioners to gather ADL information.

Dietary Behavior in Relation to Socioeconomic Characteristics and Self-Perceived Health Status

The purposes of this study were to examine the relationship between dietary behavior and self-perceived health status and to demonstrate the relative significance of peoples socioeconomic characteristics in relation to their dietary behavior. Data came from the 1994 Behavioral Risk Factor Surveillance System of South Carolina. Descriptive statistics were performed to provide a profile of the general characteristics of the sample. Multivariate linear regression modeling was used to examine the relative significance of socioeconomic status in relation to dietary behavior and the association between dietary behavior and self-perceived general, physical, and mental health status, controlling for other behavioral risk factors, such as smoking and sedentary lifestyle. Socioeconomically disadvantaged individuals with low income and low educational level were more likely to engage in poor dietary practice than were their counterparts. Dietary behavior was found strongly associated with self-perceived general and mental health status.

Socioeconomic Differences in Health: How Much Do Health Behaviors and Health Insurance Coverage Account For?

As evidence accumulates that both unhealthy behaviors and inadequate access to health care are responsible in part for poor health, there is a tendency to attribute the differences in health status between the poor and the affluent to the higher prevalence of unhealthy behaviors and inadequate access to health care among people of low socioeconomic status (SES). The purpose of this study is to determine quantitatively how much health behaviors and health insurance coverage account for the SES disparity in health. The study employed secondary analysis of data collected through the Kentucky Behavioral Risk Factor Surveillance System for 2000. After adjusting for health behaviors and health insurance coverage, the differences in health among different levels of SES (measured by education and income) remained strong and significant. Health behaviors and health insurance coverage accounted for 10-16% of the socioeconomic differences in health.

Prenatal Care and Infant Birth Outcomes Among Medicaid Recipients

Infant morbidity due to low birth weight and preterm births results in emotional suffering and significant direct and indirect costs. African American infants continue to have worse birth outcomes than white infants. This study examines relationships between newborn hospital costs, maternal risk factors, and prenatal care in Medicaid recipients in an impoverished rural county in South Carolina. Medicaid African American mothers gave birth to fewer preterm infants than did non-Medicaid African American mothers. No differences in the rates of preterm infants were noted between white and African American mothers in the Medicaid group. Access to Medicaid services may have contributed to this reduction in disparities due to race. Early initiation of prenatal care compared with later initiation did not improve birth outcomes. Infants born to mothers who initiated prenatal care early had increased morbidity with increased utilization of hospital services, suggesting that high-risk mothers are entering prenatal care earlier.

Potentially Violent Disagreements and Parenting Stress Among American Indian/Alaska Native Families: Analysis Across Seven States

Objectives We examined the prevalence and correlates of potentially violent disagreements among AI/AN families with children. Methods We conducted a cross-sectional examination of data from the 2003 National Survey of Children’s Health, limited to seven states for which AI/AN race/ethnicity was available in public use files (Alaska, Arizona, Montana, New Mexico, North Dakota, Oklahoma, and South Dakota). Disagreements were classified based on how the family deals with conflict. If disagreements involved actual (hitting) or symbolic (throwing) violence, even rarely, the household was categorized as having “potentially violent disagreements,” with heated argument and shouting being classified as “heated disagreement.” Parenting stress and demographic characteristics were included as potential correlates. Results Potentially violent disagreements were reported by 8.4% of AI/AN and 8.4% of white families. The odds for potentially violent disagreements were markedly higher among parents reporting high parenting stress, in both AI/AN (OR 7.20; CI 3.45–15.00) and white (3.59, CI 2.71–4.75) families. High parenting stress had similar effects on the odds for heated discussion. Having a child with special health care needs was associated with parenting stress. Conclusions Questions about disagreement style may be useful as potential screens for domestic violence.

The National Health Service Corps and Medicaid Inpatient Care: Experience in a Southern State

Background Since 1970, the National Health Service Corps (NHSC) has worked to increase primary care access among underserved groups. This study examined whether NHSC alumni physicians were likely to treat a high proportion of Medicaid patients in their practices. Methods Using licensure files and hospital discharge data, we identified all physicians practicing in South Carolina who attended at least one discharge in 1998, excluding physicians who graduated before 1969, residents, and current NHSC-obligated physicians. The outcome studied was ranking in the highest quartile for Medicaid participation. Results Former NHSC participants, after adjustment for personal characteristics, education, and specialty, were nearly twice as likely to fall into the category of high Medicaid participation. NHSC physicians were more likely to practice in community health centers and to locate in areas with a health professions shortage and counties with high percentages of minorities and people living in poverty. Conclusion NHSC alumni make career choices leading them to serve low-income patients.

Enhancing the Care Continuum in Rural Areas: Survey of Community Health Center-Rural Hospital Collaborations

CONTEXT Community Health Centers (CHCs) and Critical Access Hospitals (CAHs) play a significant role in providing health services for rural residents across the United States. PURPOSE The overall goal of this study was to identify the CAHs that have collaborations with CHCs, as well as to recognize the content of the collaborations and the barriers and facilitators to collaborations. METHODS The target population was CAHs within 60 miles of CHCs. Surveys were mailed to 386 chief executive officers of CAHs in 41 states who met the study criteria. The response rate was 40.9%. A descriptive analysis using chi-square tests compared the status of partnerships along with factors identified as barriers and facilitators to collaboration. FINDINGS Out of the 161 CAH respondents, 24 (14.9%) reported having a collaborative agreement with a CHC, and 2 indicated that they planned to develop a collaborative agreement. A common reason given for not collaborating was lack of awareness of a CHC within the service area. Other barriers identified were competition with CHCs and organizational differences. External funding to start a collaborating service was the most frequently cited factor to facilitate collaborations. CONCLUSIONS The findings indicate that collaborations between CAHs and CHCs are a largely untapped resource. The rural health care services continuum may benefit from increased collaborations.