MCH Alert April 19, 2002

National Center for Education in Maternal and Child Health

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April 19, 2002

1. Report Concludes That Asthma Is on the Increase, Yet Reasons Remain Unknown

2. Authors Describe Qualitative Process Evaluation of Urban Community Work

3. Study Defines and Assesses Organizational Competence in Provision of STD Service

4. Study Cites Impact of Medicaid Managed Care on Patients and Safety-Net Providers in Rural Setting

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1. REPORT CONCLUDES THAT ASTHMA IS ON THE INCREASE, YET REASONS REMAIN UNKNOWN

Asthma: Epidemic Increase -- Cause Unknown, a report by the Public Health Advisory Board, summarizes changes in asthma trends since the board's 1999 report, Health and the American Child. Although available data reveal an epidemic increase in asthma mortality and morbidity, the authors note serious flaws in this data and urge that improved systems for monitoring trends be developed. The report includes a discussion of (1) asthma morbidity, prevalence, and mortality; (2) public health implications of the increase in asthma morbidity and mortality; (3) problems with data on asthma; and (4) health care utilization and costs related to asthma. It also includes conclusions and recommendations. The report is available at http://www.phpab.org/asthma%20report/asthma.pdf.

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2. AUTHORS DESCRIBE QUALITATIVE PROCESS EVALUATION OF URBAN COMMUNITY WORK

"The problem faced by process evaluators in this case was how to create a design that was flexible enough to accommodate the unknown, yet stable enough to track program elements consistently over time," state the authors of an article published in the April 2002 issue of Health Education and Behavior. This article reports on an attempt to design and implement a process evaluation of Seattle Partners for Healthy Communities (SPHC), a community project whose shape was not known when it first came into being. SPHC is an urban research center sponsored by the Centers for Disease Control and Prevention. SPHC's mission is to design and evaluate community-based primary prevention programs for urban and underserved communities in the greater Seattle area. In this article, the authors report on the design they constructed for the process evaluation, and how it has worked so far.

The research team included two anthropologists, two epidemiologists, and a social scientist. One anthropologist is housed in a university school of nursing, whereas the other four team members are employed at the local department of public health that administers SPHC. The authors felt that the diversity of the research team had a positive influence on data gathering and analysis, and ultimately on interpretation.

Based on their experience in creating and carrying out this process evaluation, the authors recommend that others conducting process evaluations do the following:

Use ethnographic methods, because other methods may miss too much information;
Rely on a variety of theories related to community organizing, not on just one theory; and
Engage in participatory action research, in which the basic principles of shared power, open communication, and a focus on community outcome are paramount.

In assessing why and how SPHC is successful, the authors cite "(1) the development and reinforcement of trust among disparate partners because people adhere to an ethic of shared power; (2) the consistent opportunities for participants and participant agencies to benefit from funding, evaluation research, and growth in the skills of community work; and (3) the genuine personal and professional relationships generated through working together."

Chrisman NJ, Senturia K, Tang G, et al. 2002. Qualitative process evaluation of urban community work: A preliminary view. Health Education and Behavior 29(2):232-248.

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3. STUDY DEFINES AND ASSESSES ORGANIZATIONAL COMPETENCE IN PROVISION OF STD SERVICE

"Much of public health interventions occur through organizations, yet little attention has been paid to developing theories and interventions to increase their competence," state the authors of an article published in the April issue of Health Promotion Practice. This article reports on the authors' investigation of institutional factors associated with the prevention and control of STDs. The purposes of their study (conducted in a Southern rural county [referred to as Step County] inhabited primarily by low-income African Americans and with a high incidence of STDs) were to (1) define the organizational competence of health agencies serving communities at risk for STDs and (2) develop a method to assess an agency's organizational competence.

The authors engaged Step County's African-American community research group (CRG) as co-investigators to identify and define the dimensions of organizational competence. Four agencies participated in the study: (1) the health department, (2) a community health center, (3) the hospital, and (4) a community college. The authors identified nine dimensions of organizational competence: community participation, assessment, access to prevention and care, cultural competence, community outreach, interagency collaboration, policy development, resource acquisition, and organizational commitment to serve. The authors then used key informant interviews, observations, and document review to assess agencies' organizational competence.

As a result of their study, the authors came up with the following definition of an agency that is competent to serve communities at risk for STDs: "one that (a) is committed to serve the at-risk communities, (b) works with those communities, (c) understands and appropriately responds to the needs of those communities, and (d) advocates on behalf of those communities." They propose that an agency that develops the capability to perform these four functions will effectively prevent and control STDs.

The authors comment that "it is anticipated that these methods can be used to asses the competence of other organizations about other health issues," and that "this model of organizational competence may help guide other organizations interested in assessing their responsiveness to the needs of client communities."

Thach SB, Eng E, Thomas JC. 2002. Defining and assessing organizational competence in serving communities at risk for sexually transmitted diseases. Health Promotion Practice 3(2):217-232.

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4. STUDY CITES IMPACT OF MEDICAID MANAGED CARE ON PATIENTS AND SAFETY-NET PROVIDERS IN RURAL SETTING

"Difficulties encountered by some rural Medicaid recipients and by safety-net providers suggest that managed care in rural environments creates challenges that require attention to policy," state the authors of an article in the April 2002 issue of the American Journal of Public Health. The authors note that few studies have evaluated the impact of Medicaid managed care on rural populations or on the safety-net institutions that have historically provided services to low-income patients. The authors used a long-term, multimethod approach to study the impact of Medicaid managed care in New Mexico, a predominantly rural state. Survey techniques measured the impact on patients, and ethnographic methods assessed the impact on safety-net institutions.

Data from the population-based survey suggested that

Patients experienced no major changes resulting from Medicaid managed care in terms of access and use, barriers to care, or satisfaction and communication; and
Although lack of insurance remained the single most important predictor of access and use and of barriers to care, both before and after Medicaid managed care was implemented, the implementation of Medicaid managed care had no major effect on access for low-income, non-Medicaid-eligible patients.

The authors' ethnographic research, on the other hand, pointed to the following specific barriers for patients:

Transportation became a barrier, particularly in rural areas, because some patients were assigned to more distant primary care providers;
Language became a greater barrier for some patients owing to changes in pharmacies; and
For a relatively small number of patients with severe disabilities or mental health problems, major disruptions and access barriers resulted from the implementation of Medicaid managed care.

The ethnographic data also raised the following major concerns about safety-net institutions:

While safety-net institutions have buffered patients from some of the effects of the implementation of Medicaid managed care, pressures experienced by staff members at those institutions have greatly increased; and
Organizational changes affecting mental health providers have been so extensive that their ability to buffer patients has been constrained.

"We have found that Medicaid managed care can exert major effects on safety-net providers, while creating little impact on patients, partly because providers seek to buffer the impacts of policy changes," conclude the authors. They suggest that "policymakers should consider the effects of Medicaid reform on safety-net providers and should recognize that such reform does not address the problems of the uninsured."

Waitzkin H, Williams RL, Bock JA, et al. 2002. Safety-net institutions buffer the impact of Medicaid managed care: A multi-method assessment in a rural state. American Journal of Public Health 92(4):598-610.

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MCH Alert © 2002 by National Center for Education in Maternal and Child Health and Georgetown University. MCH Alert is produced by MCH Library Services at the National Center for Education in Maternal and Child Health under its cooperative agreement (U02 MC 0001-01) with the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services. The Maternal and Child Health Bureau reserves a royalty-free, nonexclusive, and irrevocable right to use the work for federal purposes and to authorize others to use the work for federal purposes.

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EDITORS: Jolene Bertness, Tracy Lopez

COPYEDITOR: Ruth Barzel

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