Clozapine utilization and outcomes by race in a public mental health system: 1994-2000

OBJECTIVE

This study aimed to assess racial differences in clozapine prescribing, dosing, symptom presentation and response, and hospitalization status. This study extends previous studies of clozapine by examining patient- and treatment-related factors that may help explain or eliminate reasons for differential prescribing.

METHOD

Clozapine records for 373 white and African American patients with schizophrenia or schizoaffective disorder treated between March 1, 1994, and December 31, 2000, in inpatient mental health facilities in the state of Maryland were examined. Records for this study were derived from 3 state of Maryland databases: the Clozapine Authorization and Monitoring Program, the State of Maryland Antipsychotic Database, and the Health Maintenance Information System Database.

RESULTS

A total of 10.3% of African Americans (150/1458) with schizophrenia received clozapine treatment compared with 15.3% of whites (223/1453) (chi2 = 16.74, df = 1, p < .001) during inpatient treatment in the public mental health system in Maryland. Clozapine doses were lower in African Americans relative to whites (385.3 +/- 200.6 vs. 447.3 +/- 230.3 mg/day) (t = -2.66, df = 366, p = .008). At the time of clozapine initiation, whites had more activating symptoms as measured by the Brief Psychiatric Rating Scale (BPRS) (t = -3.98, df = 301, p < .0001); however, African Americans had significantly greater improvements in BPRS total symptoms (F = 4.80, df = 301, p = .03) and in anxiety/ depressive symptoms during 1 year of treatment with clozapine (F = 10.04, df = 303, p = .002). The estimated rate of hospital discharge was not significantly different for African Americans compared to whites prescribed clozapine (log-rank chi2 = 0.523, df = 1, p = .470); however, African Americans were more likely than whites to discontinue clozapine during hospitalization (log-rank chi2 = 4.19, df = 1, p = .041).

CONCLUSION

Our data suggest underutilization of clozapine in African American populations. This racial disparity in clozapine treatment is of special concern because of the favorable outcomes associated with clozapine in treatment-resistant schizophrenia and in the specific benefits observed in African American patients. More research is needed to determine why disparities with clozapine treatment occur and why African Americans may be discontinued from clozapine at a higher rate, despite potential indicators of equal or greater effectiveness among African Americans compared with whites.

Barriers to care among American Indians in public health care programs

OBJECTIVE

We sought to examine the extent to which reported barriers to health care services differ between American Indians (AIs) and non-Hispanic Whites (Whites).

METHODS

A statewide stratified random sample of Minnesota health care program enrollees was surveyed. Responses from AI and White adult enrollees (n=1281) and parents of child enrollees (n=572) were analyzed using logistic regression models that account for the complex sample design. Barriers examined include: financial, access, and cultural barriers, confidence/trust in providers, and discrimination.

RESULTS

Both AIs and Whites report barriers to health care access. However, a greater proportion of AIs report barriers in most categories. Among adults, AIs are more likely to report racial discrimination, cultural misunderstandings, family/work responsibilities, and transportation difficulties, whereas Whites are more likely to report being unable to see their preferred doctor. A higher proportion of adult enrollees compared with parents of child enrollees report barriers in most categories; however, differences between parents of AIs and White children are more substantial. In addition to racial discrimination and cultural misunderstandings, parents of AI children are more likely than parents of White enrollees to report limited clinic hours, lack of respect for religious beliefs, and mistrust of their child's provider as barriers.

CONCLUSIONS

Although individuals have enrolled in health care programs and have access to care, barriers to using these services remain. Significant differences between AIs and Whites involve issues of trust, respect, and discrimination. Providers must address barriers experienced by AIs to improve accessibility, acceptability, and quality of care for AI health care consumers.

The provision and funding of contraceptive services at publicly funded family planning agencies: 1995-2003

CONTEXT

Publicly funded family planning agencies face significant challenges in delivering quality services to low-income women because of the higher costs of newer contraceptive methods, changes in health care financing and a growing uninsured population.

METHODS

In 2003, 627 of a nationally representative sample of 956 U.S. agencies receiving public funding for family planning services responded to an eight-page survey. Responses were compared with results from similar surveys in 1995 and 1999 to describe changes in the availability of contraceptive methods, policies on method provision and funding issues. Variation was examined by agency type and Title X funding status.

RESULTS

Between 1995 and 2003, the number of contraceptive methods available to women increased and agencies reduced barriers to oral and emergency contraceptives by liberalizing policies for their provision. By 2003, many agencies offered the newest contraceptive methods available-the progestin-only IUD (58%), the patch (76%) and the vaginal ring (39%). However, more than half of agencies did not stock certain methods because of their cost, and some key funding sources had declined. Between 1995 and 2003, the proportion of agencies receiving Medicaid funding fell from 91% to 80%, and the proportion of clients paying full fee for their contraceptive services fell from 19% to 14%. The share of agencies waiving fees for adolescents fell from 66% in 1999 to 44% in 2003.

CONCLUSIONS

Continued funding challenges limit the ability of publicly funded providers to offer all available methods to all women.

Complex causal process diagrams for analyzing the health impacts of policy interventions

Causal diagrams are rigorous tools for controlling confounding. They also can be used to describe complex causal systems, which is done routinely in communicable disease epidemiology. The use of change diagrams has advantages over static diagrams, because change diagrams are more tractable, relate better to interventions, and have clearer interpretations. Causal diagrams are a useful basis for modeling. They make assumptions explicit, provide a framework for analysis, generate testable predictions, explore the effects of interventions, and identify data gaps. Causal diagrams can be used to integrate different types of information and to facilitate communication both among public health experts and between public health experts and experts in other fields. Causal diagrams allow the use of instrumental variables, which can help control confounding and reverse causation.

Sufficiency and stability of evidence for public health interventions using cumulative meta-analysis

We propose cumulative meta-analysis as the procedure of completing a new meta-analysis at each successive wave in a research database. Two facets of cumulative knowledge are considered: the first, sufficiency, refers to whether the meta-analytic database adequately demonstrates that a public health intervention works. The second, stability, refers to the shifts over time in the accruing evidence about whether a public health intervention works. We used a hypothetical data set to develop the indicators of sufficiency and stability, and then applied them to existing, published datasets. Our discussion centers on the implications of the use of this procedure in evaluating public health interventions.

Health measurement in the third era of health

When writing about "the second epidemiologic revolution," Terris discussed 2 eras in health. The first era-the communicable disease era-began during ancient times and continues today; the second era-the chronic disease era-began during the 20th century, particularly among the industrialized nations. Although neither revolution against these types of diseases is complete, we have made such considerable progress that substantial and growing segments of the population no longer regard disease as the only, or even the primary, health problem. Increasingly, the goal is a long and fruitful life, not simply the absence of disease. That potential and the effort to achieve it compose the third era of health, and a proposed new measure of health is outlined in this article.

The health status of quota refugees screened by New Zealand's Auckland Public Health Service between 1995 and 2000

Each year New Zealand accepts approximately 750 refugees from overseas for resettlement in New Zealand. Known as "Quota Refugees", these people arrive in groups of 125 six times each year. Since 1979 their first six weeks in New Zealand have been spent at the Mangere Refugee Resettlement Centre in Auckland. This Centre comprises several agencies which prepare the refugees for their life in New Zealand. Among the agencies is a Medical Clinic, which provides health screening, and management of any medical problems found. This paper describes the findings of the health screening, mainly those refugees screened between 1995 and 2000, but also includes some historical data from the opening of the Resettlement Centre.

Are public health workers aware of what they don't know?

OBJECTIVES

Training of public health workers is an important part of preparedness. Self-assessment is often used to measure how well workers are trained and whether they are ready to respond to an emergency event. The current study assessed how well self-assessment predicts actual knowledge.

METHODS

Public health workers at a Public Health Ready pilot site self-assessed their general level of confidence, answered objective knowledge items about their local response plan, and self-assessed whether they were correct on the objective knowledge items. Correlational analysis was used to assess how well workers could assess what they knew and did not know.

RESULTS

In the first analysis, for 15 objective knowledge items, the median correlation between self-assessment and actual performance was 0.18. When the average self-assessment on the core competencies was correlated with the number of correct answers to the objective knowledge items, the correlation was 0.34.

CONCLUSIONS

The modest sizes of the correlations suggest that workers are weak judges of what they know and do not know. To prepare public workers for emergency events, it is suggested that two steps are important: (1) using the core competencies, develop a local response plan, and (2) develop an objective knowledge test to assess workers' knowledge of the local response plan.

Achieving the 'good life': why some people want latrines in rural Benin

Nearly half the world's population lacks basic sanitation to protect their environment from human fecal contamination. Building a latrine is the first step on the sanitation ladder in developing countries where a majority of the population defecates in open or public areas. Public health programs to improve sanitation have consistently framed promotional messages in terms of fecal-oral disease prevention and largely fail to motivate changes in sanitation behavior. A qualitative consumer study using in-depth interviews with 40 household heads was carried out to explore the decision to install a pit latrine in rural Benin. The motives for installing a latrine are reported and variations across the interviews are examined. The paper asserts that at least one active drive (desire for change or dissatisfaction) from among 11 found is needed to motivate latrine adoption. Drives involved prestige, well-being, and situational goals. Health considerations played only a minor role, and had little if anything to do with preventing fecal-oral disease transmission. Drives varied with gender, occupation, life stage, travel experience, education, and wealth, and reflected perceptions of the physical and social geography of the village, linked to availability of open defecation sites, social structure, road access, and urban proximity. The results have broad implications for new messages and strategies to promote sanitation in developing countries.

HIV prevention community planning: challenges and opportunities for data-informed decision-making

The use of data in decision-making by the Massachusetts Prevention Planning Group (MPPG) was assessed using multiple methods: in-depth interviews, member surveys, directed observations, and archival review. Three factors known to influence group decision-making were of interest: (1) member characteristics, (2) group structure, and (3) data inputs. Membership characteristics were not related to reliance on data. However, group structure factors and data inputs were directly related to reliance on data. Most members accepted an advisory role and felt participation was worthwhile. About half were dissatisfied with decision-making processes, citing member conflicts and distrust. Incompleteness of data, inadequate presentation quality, and lengthy intervals between presentations and actual decision-making were identified as deficits. Although most members reported skills with HIV- and intervention-related data, most also reported deficiencies in interpreting evaluation and cost-effectiveness studies. Member trust and use of data in decision-making could be improved by clarifying decision-making structures and processes, assuring high-quality data presentations, and supporting or training members to better interpret and use data.

Supporting health impact assessment in practice

Health impact assessment (HIA) is a process that aims to predict potential positive and negative effects of project, programme or policy proposals on health and health inequalities. It is recommended by national government and internationally. Supporting health impact assessment is one of the roles of English Public Health Observatories. The few centres in England with accredited health impact training centres have inadequate resources to meet demand. Currently, the London Health Observatory is providing the bulk of the training nationally. Some Public Health Observatories are currently investigating the preferences for support of those commissioning or conducting health impact assessment within their regions. The availability of published guidance on how to conduct health impact assessments has increased substantially over the past few years. The Department of Health has funded a research project led by the London Health Observatory to develop advice for reviewing evidence for use in health impact assessment. Completed health impact assessments can be useful resources. Evaluation of the process and impact of health impact assessment is important in order to demonstrate its usefulness and to learn lessons for the future. The focus for Public Health Observatories is to train and support others to conduct health impact assessment according to good practice, rather than undertaking health impact assessments themselves. The aim is to create sufficient skilled capacity around the country to undertake health impact assessments. The London Health Observatory plans to share its support models and to roll out a train the trainer programme nationally to enable effective local delivery of their national health impact assessment programme.

Media advocacy and newspaper coverage of tobacco issues: A comparative analysis of 1 year's print news in the United States and Australia

Tobacco control advocates now recognize the value of influencing news coverage of tobacco; news coverage influences attitudes and behavior as well as policy progression. It is, however, difficult to assess the progress of such efforts within a single national and temporal context. Our data represent the first systematic international comparison of press coverage of tobacco issues. Tobacco articles from major daily newspapers in Australia (12 newspapers; 1,188 articles) and the United States (30 newspapers; 1,317 articles) were collected over 1 year (2001). The analysis shows that coverage in the two countries was similarly apportioned between hard news (>70%) and opinion pieces. Similarly, stories in both countries were most likely to recount positive events. The substantive focus of coverage, however, differed, as did the expression of hostile opinion toward tobacco control efforts (United States, 4%; Australia, 7.1%). Although secondhand smoke and education, cessation, and prevention efforts were covered widely in both settings, these topics dominated coverage in Australia (29.2%) more than in the United States (17.6%), where a more diffuse set of tobacco topics gained relative prominence. The difference in policy conditions seems to offer contrasting opportunities for advocates in the two countries to use newspapers to promote helpful tobacco control messages for both behavior and policy change.

Gender and Medicines: An International Public Health Perspective

Despite outstanding progress in the area of medicines, their access and use have not been equitable throughout the world. Fifteen percent of the world's population consumes 91% of the world's production of pharmaceuticals. Only one third of the world population has access to essential medicines. Additionally, studies carried out in developing countries reveal that gender-related barriers in access to health services and medicines are greater for women than men because of social and cultural factors. In high-income settings, women are reported to use more medicines than men. Moreover, the current devastating human immunodeficiency virus (HIV) epidemic impacts women disproportionately. Women are more vulnerable to HIV infection than men biologically but also because of gender inequalities. More social and statistical data, in both developing and developed countries, are needed to fully understand the impact of gender on access to and use of medicines. Improving access to essential medicines will be possible only if countries introduce a gender perspective in their medicine policies.

Syphilis testing in association with gonorrhea/chlamydia testing during a syphilis outbreak

We used an electronic medical records system retrospectively to evaluate how frequently, in a public hospital and its clinics, combined gonorrhea/chlamydia tests were accompanied by a syphilis test before and during a syphilis outbreak. Among 70,330 gonorrhea/chlamydia tests (1996-2000), the proportion with a syphilis test increased from 13% (preoutbreak) to 50% (intervention period) for men and from 6% to 13% for nonpregnant women. The increased syphilis testing coincided with a multifaceted public health intervention.

How Much Public Health in Public Health Nursing Practice?

Public health nursing (PHN) practice is defined by an emphasis on population health issues rather than individually focused clinical interventions, but the actual scope and focus of PHN practice have not been well documented. The purpose of this survey was to investigate the practice activities, priorities, and education of public health nurses in California. Public health nurses in five counties were surveyed about interventions targeted at individual-family, community, and system levels. Summary scales (range: 1-4) were created to measure self-rated PHN activity, importance, and education at each level. Staff were most likely to perform individual-family level interventions (mean score, m=2.55), followed by community (m=1.86) and system-level interventions (m=1.46). Managers rated individual-family level interventions as most important (m=2.91) and community-level interventions (m=2.42) as more important than those at the system level (m=1.99). Individually focused case management was the most frequently performed and highly valued intervention. Staff and manager-directors deemed individual-family interventions as the area in which public health nurses were best educated, followed by community and then system interventions. Results indicate that the population health focus of public health nursing is not reflected in the practice activities, management priorities, or educational preparation of public health nurses.

[The present state of paediatric neurology in the Autonomous Community of Madrid: variability in the distribution of resources]

INTRODUCTION

Paediatric neurology (PN) lies halfway between neurology and paediatrics, with no official acknowledgment. It is therefore difficult to determine exactly how resources are shared out.

AIMS

The aim of this study is to analyse the public resources devoted to PN in the different health care areas within the Autonomous Community of Madrid (ACM).

MATERIALS AND METHODS

In May 2002 we carried out a survey among child neurologists (CN) from the 9 independent health care districts within the ACM.

RESULTS

A total of 28 CN work for the public health service in the ACM, eight of whom are employed on a part time basis. Only 53% are owners. The ratio of CN per 100000 inhabitants (inhab.) is 0.55 (0.45 after correction for part time work). The figure varies from one area to another from 0.07 to 1 CN/100000 inhab. (1/12000 1/220000 children). Part time neurologists work in the outer districts of the ACM. In most areas it is difficult to carry out diagnostic tests and these become even complicated when the child is small and requires some anaesthetic procedure. Neuropsychological assessment is one of the basic evaluations performed in PN and this is not easily performed in most centres.

CONCLUSIONS

The CN/100000 inhab. ratio in the ACM is lower than that commonly recommended. The distribution of resources varies greatly and does not match demographic criteria. Temporary and part time jobs are commonplace in the peripheral areas. It is difficult for most centres to perform diagnostic tests.

The local public health workforce in rural communities

This work describes the public health workforce and training needs of rural local public health agencies (LPHAs) in comparison with suburban and metropolitan LPHA jurisdictions. A survey was sent to 1,100 LPHAs nationwide. The rural urban commuting area codes (RUCAs) defined LPHAs as rural or urban, and the Standard Occupational Classification system enumerated the workforce. Most occupational classifications had significantly fewer staff in rural LPHAs. Public health nurses ranked as the most needed staff and serve in various important capacities in rural LPHAs. In terms of training, job-specific or programmatic continuing education was identified as the most important training need. Developing leadership and public health workforce capacity within rural public health is an essential agenda item for rural America. Decision makers may need to consider different organizational structures while balancing the need for local input and control. Regionalization and collaborative approaches to difficult workforce issues may present potential solutions to workforce challenges.

A history of public health workforce enumeration

During the 20th century, the United States' public health workforce has been of sufficient interest to policy makers that regular efforts have been made to enumerate it. Limited enumeration is found as early as 1908; the last direct federal survey occurred in 1964. After 1964, workforce size was estimated. The ratio of public health workers to population reached an estimated 220/100,000 in 1980. Data collected in 2000 yielded a ratio of 158/100,000--a 10 percent decrease. In the absence of a system to reliably collect public health workforce data such information is problematic to interpret or use for infrastructure planning and development.

Adoption of reminder and recall messages for immunizations by pediatricians and public health clinics

OBJECTIVE

Strong scientific evidence and national recommendations support the use of reminder and recall messages to improve immunization coverage rates, yet reports have suggested that only a minority of pediatric practices use such messages. Our aims were to 1) determine the proportions of pediatric practices and public clinics that currently use practice-based reminder or recall messages and routinely undergo immunization assessment efforts, 2) evaluate barriers and supports to implementing these practices, and 3) identify predictors of either current use or plans for future adoption of these practices.

METHODS

This study combined qualitative and quantitative methods in sequential phases. In the qualitative phase, we conducted semistructured, open-ended interviews with a convenience sample of 18 clinician-administrators representing adopters and nonadopters of these messages in both private practices and public health clinics. In the subsequent quantitative phase, we mailed a structured, closed-ended survey to national samples of randomly selected pediatricians (n = 600) and public clinics (n = 600).

RESULTS

Response rates were 75% for pediatricians and 77% for public clinics. Among pediatricians, 38% were conducting regular assessments of immunization coverage but only 16% were currently using routine reminder or recall messages. Among public clinics, 85% were conducting regular assessments and 51% were using reminder or recall messages. Among pediatricians' practices, the most commonly reported barriers to the adoption of reminder or recall messages were lack of time and funding and the inability to identify children at specified ages. For pediatricians' practices, the strongest predictors of current use of reminder or recall messages were having a champion who led efforts to improve immunization delivery (odds ratio: 1.85; 95% confidence interval: 1.08-3.18) and current use of regular immunization assessments (odds ratio: 2.30; 95% confidence interval: 1.33-3.84). Likewise, for public health clinics, having a champion to lead immunization improvement efforts and believing that their current system needed improvement was associated with current use of reminder or recall messages.

CONCLUSIONS

Reminder and recall messages remain underused by both pediatricians and public health clinics. Promising strategies to promote adoption of these approaches in both the private and the public sectors include identifying and training champions to promote immunization delivery improvement efforts and helping practices develop methods to identify children at specific ages.

Services for men at publicly funded family planning agencies, 1998-1999

CONTEXT

Men's reproductive health needs are receiving increased attention, but most family planning clinic clients are female, and clinics have reported barriers to serving men.

METHODS

A 1999 survey of publicly funded agencies that administer family planning clinics asked several questions about current policies and services and the number of men served in 1998. Data on 17 services were collected, as well as the proportion of clients who were male and agencies' barriers to serving men.

RESULTS

The services most commonly offered to men in 1999 were condom provision and sexually transmitted disease (STD) counseling (95% of all agencies), contraceptive counseling (93%), and STD treatment (90%) and testing (89%). The proportions offering various male reproductive health services were lowest among hospital-based clinics. Eighty-seven percent of agencies served some male contraceptive or STD clients in 1998; those that did served a mean of 255 men and a median of 50. The male client caseload increased between 1995 and 1998 at 53% of agencies, and four out of five agencies were interested in serving more men in the future. The most commonly reported barriers to serving men were men's unawareness that services were available (58%) and inadequate agency funding (55%).

CONCLUSIONS

Although most clients of publicly funded family planning agencies are women, a nonnegligible number are men. Additional efforts are needed to determine the best way to deliver reproductive health services to men.

The other half of the equation: Serving young men in a young women's reproductive health clinic

CONTEXT

Efforts to improve reproductive health typically target women. Family planning agencies serving high-risk young women may be particularly suited to integrating young men in their health promotion efforts.

METHODS

In 2001, a family planning clinic in San Francisco serving primarily young women opened a male clinic as part of a male involvement program that includes education and outreach components. Client volume was assessed by reviewing billing data. New male clients completed questionnaires on their demographic characteristics, sexual and health-seeking behavior, and reason for clinic visit. Before and after the male clinic opened, female clients completed questionnaires assessing their satisfaction with services and their attitudes on males' being served at the clinic. Data were analyzed by using descriptive and chi-square statistics.

RESULTS

In the first year of the male clinic, the number of adolescent and adult male clients served at the facility increased by 192% and 119%, respectively, over the previous year. Among 110 males making first visits, 88% came for sexually transmitted disease testing or treatment. Three-quarters had learned of the clinic by word of mouth--from a sexual partner (37%), friend (29%) or sibling (6%)--rather than directly from outreach efforts. The proportion of female respondents very or mostly satisfied with their care was similarly high before (98%) and after (92%) the male clinic opened.

CONCLUSIONS

Increasing capacity within the female reproductive health model to serve males is feasible. To reach at-risk males, "in-reach" efforts with female clients may be as important as targeted outreach efforts.