A Two-Generation, Early Childhood Advanced Primary Care Model

It is well recognized that early experiences produce long-term impacts on health outcomes, yet many children are at risk of not achieving their full potential because of health and service disparities related largely to poverty and racism. Although many pediatric primary care (PPC) models address these needs, most are isolated, add-on efforts that struggle to be scalable and sustainable. We describe 3-2-1 IMPACT (Integrated Model for Parents and Children Together), an initiative to transform the model of PPC delivered within New York City Health + Hospitals, the largest public hospital system in the United States, to address the full range of child and family needs in early childhood. Taking advantage of the frequent contact with PPC in the early years and linking to prenatal services, the model assesses family mental, social, and physical health needs and offers evidence-based parenting supports and integrated mental health services. Launching and sustaining the model in our large health system has required coalition building and sustained advocacy at the state, city, and health system levels. Long-term sustainability of the IMPACT model will depend on the implementation of early childhood-focused advanced payment models, on which we have made substantial progress with our major contracted Medicaid managed care plans. By integrating multiple interventions into PPC and prenatal care across a large public-healthcare system, we hope to synergize evidence-based and evidence-informed interventions that individually have relatively small effect sizes, but combined, could substantially improve child and maternal health outcomes and positively impact health disparities.

Management of depression during the perinatal period: state of the evidence

BACKGROUND

Perinatal depression (PND) is a prevalent ailment that affects both the woman and her family. Addressing PND in primary health care, such as pediatrics and obstetric care settings, has been proposed as an effective way to identify and treat women.

OBJECTIVE

The purpose of this study is to examine best practices for management of PND in obstetric and pediatric settings, as well as investigate the evidence that supports the guidelines.

METHODS

Guidelines were identified through a literature search and discussion with experts in the field of perinatal depression, while evidence was examined through a literature search of reviews and thereafter experimental studies.

RESULTS

Twenty-five guidelines, across 17 organizations were retained for analysis. Findings suggest that there is little or varied guidance on the management of PND, as well as a lack of specificity. Treatment was the topic most frequently reported, followed by screening. However best practices vary greatly and often contradict one another. Across all areas, there is inadequate or contrasting evidence to support these guidelines.

CONCLUSIONS

Although there was consensus on the key steps in the pathway to care, the review revealed lack of consensus across guidelines on specific issues relating to identification and management of depression during the perinatal period. Clinicians may use these recommendations to guide their practice, but they should be aware of the limitations of the evidence supporting these guidelines and remain alert to new evidence. There is a clear need for researchers and policymakers to prioritize this area in order to develop evidence-based guidelines for managing perinatal depression.

Applying an Innovative Model of Disaster Resilience at the Neighborhood Level : The COPEWELL New York City Experience

Community resilience is a community's ability to maintain functioning (ie, delivery of services) during and after a disaster event. The Composite of Post-Event Well-Being (COPEWELL) is a system dynamics model of community resilience that predicts a community's disaster-specific functioning over time. We explored COPEWELL's usefulness as a practice-based tool for understanding community resilience and to engage partners in identifying resilience-strengthening strategies. In 2014, along with academic partners, the New York City Department of Health and Mental Hygiene organized an interdisciplinary work group that used COPEWELL to advance cross-sector engagement, design approaches to understand and strengthen community resilience, and identify local data to explore COPEWELL implementation at neighborhood levels. The authors conducted participant interviews and collected shared experiences to capture information on lessons learned. The COPEWELL model led to an improved understanding of community resilience among agency members and community partners. Integration and enhanced alignment of efforts among preparedness, disaster resilience, and community development emerged. The work group identified strategies to strengthen resilience. Searches of neighborhood-level data sets and mapping helped prioritize communities that are vulnerable to disasters (eg, medically vulnerable, socially isolated, low income). These actions increased understanding of available data, identified data gaps, and generated ideas for future data collection. The COPEWELL model can be used to drive an understanding of resilience, identify key geographic areas at risk during and after a disaster, spur efforts to build on local metrics, and result in innovative interventions that integrate and align efforts among emergency preparedness, community development, and broader public health initiatives.

Return on Investment From Co-locating Tax Assistance for Low-Income Persons at Clinical Sites

This study characterizes net dollars low-income persons received from participation in tax preparation services co-located at clinical sites in New York City intended to maximize credits and reduce poverty.

Social work interest in prevention: A content analysis of the professional literature

Every day in the United States, over halfa million social workers provide services to people with health, mental health, and substance abuse problems in a fragmented system that emphasizes disease treatment over prevention. Powerful issues--including health inequities, population aging, globalization, natural disaster, war, and economic downturn--make the need for preventive approaches more critical than ever. Despite social work's historic commitment to enhancing human well-being and public health involvement, little is known about how social work currently views prevention or whether it is being addressed in the social work professional literature. To determine whether, and to what extent, prevention is addressed, discussed, and published in social work journals, the authors--all public health social work researchers-undertook a content analysis of nine peer-reviewed journals, analyzing all articles published from 2000 to 2005. A total of 1,951 articles were reviewed and coded for prevention according to specified criteria. A relatively small number--109 (5.6 percent)--were found to meet the criteria for being a prevention article, suggesting that prevention is still a minority interest area within social work.A renewed conversation about prevention in social work can enhance opportunities for strong social work participation in the transdisciplinary collaboration needed in this new era of health reform.

Public health and social work: training dual professionals for the contemporary workplace

OBJECTIVES

The emergence of new, complex social health concerns demands that the public health field strengthen its capacity to respond. Academic institutions are vital to improving the public health infrastructure. Collaborative and transdisciplinary practice competencies are increasingly viewed as key components of public health training. The social work profession, with its longstanding involvement in public health and emphasis on ecological approaches, has been a partner in many transdisciplinary community-based efforts. The more than 20 dual-degree programs in public health and social work currently offered reflect this collaborative history. This study represents an exploratory effort to evaluate the impact of these programs on the fields of public health and social work.

METHODS

This study explored motivations, perspectives, and experiences of 41 graduates from four master of social work/master of public health (MSW/ MPH) programs. Four focus groups were conducted using traditional qualitative methods during 2004.

RESULTS

Findings suggest that MSW/MPH alumni self-selected into dual programs because of their interest in the missions, ethics, and practices of both professions. Participants highlighted the challenges and opportunities of dual professionalism, including the struggle to better define public health social work in the workplace.

CONCLUSIONS

Implications for academic public health focus on how schools can improve MSW/MPH programs to promote transdisciplinary collaboration. Increased recognition, better coordination, and greater emphasis on marketing to prospective employers were suggested. A national evaluation of MSW/MPH graduates could strengthen the roles and contributions of public health social work to the public health infrastructure. A conceptual framework, potentially based on developmental theory, could guide this evaluation of the MSW/MPH training experience.

Predictors of influenza vaccination in an urban community during a national shortage

Little is known about the impact of vaccine shortages on vaccination rates among disadvantaged populations in the United States. We compared factors associated with influenza vaccination rates during a vaccine shortage (2004-2005) and a non-shortage (2003-2004) year among adults in predominantly minority New York City neighborhoods. Thirty-one percent of participants received influenza vaccine during the non-shortage year compared with 18% during the shortage. While fewer people received the influenza vaccine during the shortage, a higher proportion of the vaccinated were in a high-risk group (68% vs. 52%, respectively). People were less likely to have been vaccinated during the shortage if they were Black. This study suggests that vaccination rates were lower during the shortage period among Blacks and those who are not explicitly a focus of national vaccination outreach campaigns. Such groups are less likely to be vaccinated when vaccines are scarce.

Project VIVA: a multilevel community-based intervention to increase influenza vaccination rates among hard-to-reach populations in New York City

OBJECTIVES

We sought to determine whether the work of a community-based participatory research partnership increased interest in influenza vaccination among hard-to-reach individuals in urban settings.

METHODS

A partnership of researchers and community members carried out interventions for increasing acceptance of influenza vaccination in disadvantaged urban neighborhoods, focusing on hard-to-reach populations (e.g., substance abusers, immigrants, elderly, sex workers, and homeless persons) in East Harlem and the Bronx in New York City. Activities targeted the individual, community organization, and neighborhood levels and included dissemination of information, presentations at meetings, and provision of street-based and door-to-door vaccination during 2 influenza vaccine seasons. Participants were recruited via multiple modalities. Multivariable analyses were performed to compare interest in receiving vaccination pre- and postintervention.

RESULTS

There was increased interest in receiving the influenza vaccine postintervention (P<.01). Being a member of a hard-to-reach population (P=.03), having ever received an influenza vaccine (P<.01), and being in a priority group for vaccination (P<.01) were also associated with greater interest in receiving the vaccine.

CONCLUSIONS

Targeting underserved neighborhoods through a multilevel community-based participatory research intervention significantly increased interest in influenza vaccination, particularly among hard-to-reach populations. Such interventions hold promise for increasing vaccination rates annually and in pandemic situations.

Access to influenza vaccine in East Harlem and the Bronx during a national vaccine shortage

In October 2004, one of the major producers of the U.S. influenza vaccine supply announced that their vaccine would not be available because of production problems, resulting in approximately half of the anticipated supply suddenly becoming unavailable. This study was part of a larger effort using community-based participatory research (CBPR) principles to distribute influenza vaccine to hard-to-reach populations. Given the extant literature suggesting economic and racial disparities in influenza vaccine access in times of adequate supply and our inability to distribute vaccine due to the shortage, we sought to examine vaccine access as well as awareness of the vaccine shortage and its impact on health-seeking behaviors in eight racially-diverse and economically-disadvantaged neighborhoods in New York City (NYC) during the shortage. In our study few people had been vaccinated, both among the general community and among high risk groups; vaccination rates for adults in priority groups and non-priority groups were 21.0% and 3.5%. Awareness of the 2004 vaccine shortage was widespread with over 90% being aware of the shortage. While most attributed the shortage to production problems, almost 20% said that it was due to the government not wanting to make the vaccine available. Many respondents said they would be more likely to seek vaccination during the current and subsequent influenza seasons because of the shortage. The target neighborhoods were significantly affected by the national influenza vaccine shortage. This study highlights the challenges of meeting the preventive health care needs of hard-to-reach populations in times of public health crisis.

Strengthening field education in aging through university-community agency partnership: the Practicum Partnership Program

The Practicum Partnership Program (PPP), an innovative field education model developed and implemented by six demonstration sites over four years (2000-2004), uses a structured university-community partnership, or consortium, as the foundation for designing, implementing, and evaluating internships for graduate social work students specializing in aging. This paper describes the site consortia and PPP programs, presents evaluation findings, and identifies future directions for the PPP. Student learning outcomes were positive and both students and consortia agencies reported positive PPP experiences. The PPP model underscores the value of the community agencies as equal partners in educating future geriatric social workers.

Multilevel community-based intervention to increase access to sterile syringes among injection drug users through pharmacy sales in New York City

OBJECTIVES

Research has indicated that there is minimal use of pharmacies among injection drug users (IDUs) in specific neighborhoods and among Black and Hispanic IDUs. We developed a community-based participatory research partnership to determine whether a multilevel intervention would increase sterile syringe access through a new policy allowing nonprescription syringe sales in pharmacies.

METHODS

We targeted Harlem, NY (using the South Bronx for comparison), and disseminated informational material at community forums, pharmacist training programs, and counseling or outreach programs for IDUs. We compared cross-sectional samples in 3 target populations (pre- and postintervention): community members (attitudes and opinions), pharmacists (opinions and practices), and IDUs (risk behaviors).

RESULTS

Among community members (N = 1496) and pharmacists (N = 131), negative opinions of IDU syringe sales decreased in Harlem whereas there was either no change or an increase in negative opinions in the comparison community. Although pharmacy use by IDUs (N=728) increased in both communities, pharmacy use increased significantly among Black IDUs in Harlem, but not in the comparison community; syringe reuse significantly decreased in Harlem, but not in the comparison community.

CONCLUSIONS

Targeting the individual and the social environment through a multilevel community-based intervention reduced high-risk behavior, particularly among Black IDUs.

Determinants of influenza vaccination in hard-to-reach urban populations

OBJECTIVE

Influenza vaccination rates among disadvantaged minority and hard-to-reach populations are lower than in other groups. We assessed the barriers to influenza vaccination in disadvantaged urban areas.

METHODS

We conducted a cross-sectional study, using venue-based sampling, collecting data on residents of eight neighborhoods throughout East Harlem and the Bronx, New York City.

RESULTS

Of 760 total respondents, 461 (61.6%) had received influenza vaccination at some point in their life. In multivariable models, having access to routine medical care, receipt of health or social services, having tested positive for HIV, and current interest in receiving influenza vaccination were significantly associated with having received influenza vaccination in the previous year. Of participants surveyed, 79.6% were interested in receiving an influenza vaccination at the time of survey. Among participants who had never previously received influenza vaccination in the past, 73.4% were interested in being vaccinated; factors significantly associated with an interest in being vaccinated were minority race, lower annual income, history of being homeless, being uninsured/underinsured, and not having access to routine medical care.

CONCLUSIONS

Participants who are unconnected to health or social services or government health insurance are less likely to have been vaccinated in the past although these persons are willing to receive vaccine if it were available.

Reducing Disparities in Vaccination Rates Between Different Racial/Ethnic and Socioeconomic Groups

There are well-documented disparities in vaccination rates between different socioeconomic and racial/ethnic groups in the United States. These disparities persist in spite of an overall increase in vaccination rates during the last decade and the implementation of several interventions that have aimed to increase vaccination rates in disadvantaged groups. Although many interventions are efficacious at improving vaccination rates under trial conditions, these interventions when extended to the general population frequently do not appreciably improve its health. Explanations for this limited intervention efficiency include poor adherence to protocols in real life versus idealized trial situations, changes in baseline so that the trial conditions are no longer replicable, and the contribution of other community-level factors that make it difficult to extend the trial methods to other communities. Multilevel community intervention trials recognize and address the multiple competing forces that shape the health of the population in cities and have the potential to increase vaccination rates among minorities and marginalized groups.

Mental health status among ethnic albanians seeking medical care in an emergency department two years after the war in Kosovo

STUDY OBJECTIVE

The long-term psychological effects of war are under appreciated in clinical settings. Describing the postwar psychosocial burden on medical care can help direct public health interventions. We performed an emergency department (ED)-based assessment of the mental health status of ethnic Albanian patients 2 years after the North Atlantic Treaty Organization-led bombing of Serbia and Kosovo in 1999.

METHODS

This study was conducted July 30, 2001, to August 30, 2001, in the ED of a hospital in Pristina, Kosovo. Investigators collected data through systematic sampling of every sixth nonacute ED patient presenting for care; 87.7% of patients agreed to participate. Respondents completed a structured questionnaire, including demographic characteristics, the Short Form-36, and the Harvard Trauma Questionnaire.

RESULTS

All 306 respondents were ethnic Albanians; mean age was 39 years (SD 17.9 years). Of respondents, 58% had become refugees during the war. Two hundred ninety-six (97%) reported experiencing at least one traumatic event during the war; the average number of traumatic events encountered by participants was 6.6. Forty-three (14%) reported symptoms that met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for posttraumatic stress disorder; mean Short Form-36 Mental Component Summary score was 42.1 (SD 12.5). Separate multivariable linear regression models confirmed our belief that older age, female sex, less than a high school education, and having experienced a greater number of traumatic events would be associated with more posttraumatic stress disorder symptoms and lower Mental Component Summary scores.

CONCLUSION

Mental health problems among ED patients in Kosovo, particularly among specific vulnerable populations, are a significant public health concern 2 years after the conflict.