Methods for identifying and assessing groups in health behavioral research.

Methods to study groups developed in other fields have much to contribute to the study of health behavior, including alcohol and substance use. This paper surveys group methods in order to demonstrate how attention to group levels of analysis can provide new insights about the context and causes of health behavior. The first major section of this paper focuses on the influences on health behavior associated with "naturally occurring groups" such as peer networks, families, workplaces, neighborhoods, churches, treatment groups and residential settings. Different aspects of group influence are discussed in terms of seven different features of social groups: history, structure, function, resources, process, norms and climate. The second major part of this paper is concerned with methods to identify meaningful subgroups in heterogeneous samples. Following an overview of taxonomic methods to identify and assign cases to groups, we highlight the potential for these methods to help address a number of fundamental theoretical problems in health behavioral research, including: describing cultural diversity, distinguishing response sets in survey research, controlling error in outcomes scores related to baseline differences, tracking trajectories of change, and revealing interactions among determinants of health behavior. The third and final section of the paper highlights specific applications of taxonomic and group-influence methodologies in intervention research, including design and analysis of randomized trials, studies of existing treatment settings and group-level variables involved in translational research.

The relationship between health and human services and the personal goal-directed activities of persons living with AIDS.

This study evaluates the relationship between the social climate from different services and the personal goal-directed activities of 224 individuals with AIDS. The study's results supported the main hypothesis that "recipient" and "participatory" service involvement uniquely influence personal goal-directed activities, even after considering individuals with AIDS' physical symptoms, psychological distress, income, and recruitment site. Income and involvement with participatory services were both positively related to the amount of personal goal-directed activity. Longitudinal analyses suggest that personal initiative contributes to the subsequent amount of personal goal-directed activities a person pursues. These results suggest further examination of factors contributing to the selection of different service types and of the processes underlying the relationship between participatory services and positive outcomes for clients with AIDS.

Markers for primary care: missed opportunities to immunize and screen for lead and tuberculosis by private physicians serving large numbers of inner-city Medicaid-eligible children.

OBJECTIVE: This study examines coverage levels for immunization, missed opportunities to immunize, and extent of lead and tuberculosis screening in inner-city storefront physician offices and then relates child, visit, and physician characteristics to missed opportunities. METHODOLOGY: With the use of a nested sampling strategy, 232 charts were selected for review in 31 physicians' offices. Charts selected were for children 0 to 35 months of age who had three or more visits in more than 3 months. Physicians were selected from those in specific low-income New York inner-city neighborhoods who submitted large volumes of Medicaid billing claims. Variables examined were missed opportunities to immunize, immunization coverage levels, lead, and tuberculosis screening. The outcome measure was missed opportunities to immunize. RESULTS: Only 26% of the children were up to date for their age for diphtheria, tetanus, pertussis (DTP), oral polio vaccine (OPV), and measles, mumps, rubella (MMR) compared with a city-wide coverage level of 49%. Children who were not up to date for immunization coverage were more likely not to be up to date for lead (RR = 1.24, CI 0.96 to 1.60) or tuberculosis (RR = 1.54, CI 1.14 to 2.08) screening. Physicians miss opportunities to immunize in 84% of the eligible visits. Opportunities to immunize are missed more frequently at sick care or follow-up visits (95% and 91% missed opportunities) than at well care visits (41% missed opportunities). CONCLUSIONS: The quality of pediatric primary care given by these inner-city storefront physicians is suboptimal. Sick and follow-up visits predominate; well care visits are infrequent. If care is to be improved, Medicaid reimbursement policies, which make delivery of well care unprofitable, will need to be changed. In addition, monitoring the quality of care will need to be more aggressive. In the near future children who receive Medicaid in New York will be in managed care. If reimbursement and monitoring policies that provide incentives for delivering pediatric primary care are to be in place, it will be the managed care plans that implement this.

New York City's 1993 child immunization day: planning, costs, and results.

OBJECTIVES: This study evaluates New York City's Child Immunization Day (1993), with emphasis on the cost and effects of a mass campaign and the use of strategies from developing nations in an inner-city context. METHODS: The methodology was designed to (1) document the planning and implementation process, (2) analyze the number and characteristics of children in the target group, and (3) estimate costs. RESULTS: Neither the social mobilization nor the political will that characterize successful campaigns in developing nations occurred in New York City's campaign. Despite substantial time and effort from both private and public agencies, turnout for the event was low. In total, 2647 families and 5237 children were assessed for health care and insurance needs, 2949 children were immunized at a cost of about $279 per immunized child, and 7236 vaccines were administered. CONCLUSIONS: The differences between inner cities and developing nations have a bearing on strategies used in planning and implementing mass campaigns. New strategies need to be forged from a blending of these contexts to create effective campaigns in industrialized inner cities.

New York City physicians serving high volumes of Medicaid children: who are they and how do they practice?

This study examined, in 1993, the characteristics and practices of New York City physicians who submit large numbers of Medicaid claims for children. Of our sample of 33 physicians, more than 90% were educated outside the United States; fewer than half were board certified or had hospital staff appointments. These physicians saw a clientele who were 98% Medicaid; most visits (82%) were at a time of acute illness. With the rapid advent of mandatory, Medicaid managed care in New York City, and with the large estimated gap in primary care capacity in the inner city, policy questions arise as to whether these physicians should be integrated into managed care plans. If they are not, the question becomes: how will they be replaced?