Primary care of long-stay nursing home residents: approaches of three health maintenance organizations.

OBJECTIVE: To describe the innovative programs of three health maintenance organizations (HMOs) for providing primary care for long-stay nursing home (NH) residents and to compare this care with that of fee-for-service (FFS) residents at the same NHs. DESIGN: Cross-sectional interviews and case-studies, including retrospective chart reviews for 1 year. SETTING: The programs were based in 20 community-based nursing homes in three regions (East, West, Far West). PARTICIPANTS: Administrative and professional staff of HMOs in three regions and 20 NHs; 215 HMO and 187 FFS residents at these homes were studied. MAIN OUTCOME MEASURES: Emergency department (ED) and hospital utilization. RESULTS: All HMO programs utilized nurse practitioner/physician's assistants (NP/PA), but the structural configuration of physicians' (MD) practices differed substantially. At nursing homes within each region, all three HMO programs provided more total (MD plus NP/PA) visits per month than did FFS care (2.0 vs 1.1, 1.3 vs .6, and 1.4 vs .8 visits per month; all P < .05). The HMO that provided the most total visits had a significantly lower percentage of residents transferred to EDs (6% vs 16%, P = .048), fewer ED visits per resident (0.1 vs .4 per year, P = .027), and fewer hospitalizations per resident (0.1 vs .5 per year, P = .038) than FFS residents; these differences remained significant in multivariate analyses. However, the other two programs did not achieve the same benefits on healthcare utilization. CONCLUSIONS: HMO programs for NH residents provide more primary care and have the potential to reduce ED and hospital use compared with FFS care. However, not all programs have been associated with decreased ED and hospital utilization, perhaps because of differences in structure or implementation problems.

Physician response to prenatal substance exposure.

OBJECTIVES: To examine physician responses to suspected prenatal substance exposure and the reasons underlying these responses. METHODS: National mail survey of practicing obstetricians and pediatricians who see neonates. Response rate: 63%. RESULTS: More than 70% of physicians reported having ever suspected prenatal substance exposure. Response rates did not vary by specialty. Twenty-seven percent reported that they had never suspected prenatal substance exposure. The most common lifetime pattern (60%) was some response whenever prenatal substance exposure was suspected; next most common was no suspicion (27%). Just over 10% had a discretionary response: acting in some cases of suspected prenatal substance exposure but ignoring others. Two percent consistently ignored their suspicions. Getting help for the patient and protecting the fetus were the most common reasons to act. Among those who had ignored their suspicions, lack of sufficient evidence of substance use was the most often cited reason. There were some important specialty differences in reasons for response and non-response and in specific responses likely to be taken. Obstetricians are far more likely to provide the patient with information and get a substance use history; pediatricians are more inclined to involve outsiders. CONCLUSIONS: Obstetricians and pediatricians seem quite willing to act on their suspicions of prenatal substance exposure, and generally respond by taking positive actions. Specialty differences are few and reflect practice differences.

Influencing physician response to prenatal substance exposure through state legislation and work-place policies.

Little research attention has focused on ways to encourage physician response to prenatal substance exposure. We report initial results from a study examining the impact of state laws and work-place policies on physician response by combining legal analyses and data from a national physician survey. Our findings indicate that the message that laws and policies exist usually does not reach physicians. However, when the message does come through, some physician behaviors are influenced. In particular, physicians in states with clearer policies and behavioral expectations are significantly more likely to know and understand the law than physicians in other states. Further, believing that a work-place protocol on prenatal substance exposure exists is associated with significantly increased likelihood of an active response in case vignettes portraying prenatal substance exposure. The findings suggest that state legislative behaviors may increase physician response to prenatal substance exposure, but that response depends on the nature of the policy and on efforts to disseminate it.

The impact of case characteristics on child abuse reporting decisions.

Drawing distinctions on the basis of at least some case characteristics in making reporting decisions makes considerable sense. Using data from a national survey of mandated reporters that included vignettes in which case and personal characteristics were systematically varied, this paper examines the impact of selected characteristics while controlling for others. The data reveal that respondents noticed and responded to case characteristics. Abuse-relevant judgments and reporting intentions varied, often substantially, as a function of case characteristics. Three case characteristics--previous abuse, severity of abuse, and recantation--were powerful predictors of vignette outcomes. A history of previous abuse led to judgments of greater seriousness, a more salutary impact of a report, and greater likelihood of reporting. More severe abuse was more likely to be labelled as abuse, and was more likely to be reported. When the alleged victim retracted her accusation upon questioning by an authority figure, respondents were significantly less likely to intend a report. Child age, perpetrator intent and family socioeconomic status also influenced abuse-relevant judgments and reporting intentions. Respondents were more likely to intend a report when younger children, lazy or angry perpetrators and children from poorer families were portrayed.

A Health Belief Model-Social Learning Theory approach to adolescents' fertility control: findings from a controlled field trial.

We evaluated an 8- to 12-hour Health Belief Model-Social Learning Theory (HBM-SLT)-based sex education program against several community- and school-based interventions in a controlled field experiment. Data on sexual and contraceptive behavior were collected from 1,444 adolescents unselected for gender, race/ethnicity, or virginity status in a pretest-posttest design. Over 60% completed the one-year follow-up. Multivariate analyses were conducted separately for each preintervention virginity status by gender grouping. The results revealed differential program impacts. First, for preintervention virgins, there were no gender or intervention differences in abstinence maintenance over the follow-up year. Second, female preintervention Comparison program virgins used effective contraceptive methods more consistently than those who attended the HBM-SLT program (p less than 0.01); among males, the intervention programs were equally effective. Third, both interventions significantly increased contraceptive efficiency for teenagers who were sexually active before attending the programs. For males, the HBM-SLT program led to significantly greater follow-up contraceptive efficiency than the Comparison program with preintervention contraceptive efficiency controlled (p less than 0.05); for females, the programs produced equivalent improvement. Implications for program planning and evaluation are discussed.

PIP: Between June 1986-August 19867, social scientists conducted 1 year controlled field trial of a pilot community or school based sexuality and contraceptive education program based on a Health Belief Model-Social Learning Theory (HBM-SLT) among 1444 adolescents from Texas and California. This program aimed to increase their knowledge of probability of conception, negative personal consequences of pregnancy, personal and interpersonal benefits of delayed and/or protected sexual intercourse, and to decrease misperceptions about abstinence and consistent contraceptive use. 60% of the youth were not lost to follow up. For preintervention virgins, no gender or intervention differences in maintaining virginity over the year existed between the HBM-SLT and programs other than the HBM-SLT program (comparison programs). Female preintervention virgins attending comparison programs tended to use an effective contraceptive at most recent intercourse and be more capable of using contraceptive than those who went to the HBM-SLT program (p.01). Yet they depended highly on condoms. For males, both programs proved to be equally effective at contraceptive use. Both programs significantly improved contraceptive efficiency for preintervention nonvirgins. For males, the HBM-SLT program resulted in a more significant improvement in contraceptive efficiency than the comparison programs (p.05). For females, both programs equally improved efficiency. The proportion of variance explained by the intervention programs and time 2 HBM-SLT programs was not as great for males and females as the researchers expected. Contributing factors to this included sexual activity was relatively low (52% of follow up participants remained virgins), HBM-SLT was assessed against other programs rather than a no treatment group, and the length of the HBM-SLT was shorter than the comparison programs.

Evaluating the impact of a theory-based sexuality and contraceptive education program.

A controlled field study involving 1,444 adolescent males and females 13-19 years of age was performed to compare a sexuality education program based on the health belief model and social learning theory with several publicly funded community-based and school-based interventions. Among males who had never had intercourse prior to participating in the study, those in the experimental program were more likely than those in the comparison programs to maintain abstinence over the next year; there was no program effect, however, among females. Among female adolescents who initiated intercourse after the start of the study, attendees of the comparison programs were more likely to have used an effective contraceptive at most recent intercourse and to have used an effective method more consistently than were those who attended the experimental program; no such association was seen among comparable young men. Both experimental and comparison programs significantly increased the consistent use of effective methods among teenagers who had been coitally active before attending the programs. Among males, however, when preintervention contraceptive efficiency was held constant, the experimental program led to significantly greater contraceptive efficiency during the follow-up year than did the comparison programs; among females, the two approaches produced an equivalent degree of improvement. Finally, prior exposure to sexuality education was associated with greater contraceptive efficiency at the one-year follow-up among almost all sexual-experience and gender groups, regardless of the type of intervention program attended.

PIP: A controlled field study involving 1444 adolescent males and females ages 13-19 was performed to compare a sexuality education program based on the health belief model and social learning theory with several publicly funded community and school-based intervention. Among males who has never has intercourse prior to their participation in the study, those in the experimental program were more likely than those in the comparison programs to maintain abstinence over the next year. There was no program effect, however, among females. Among female adolescents who initiated intercourse after the start of the study, attendees of the comparison programs were more likely to have used an effective contraceptive at most recent intercourse and to have used an effective method more consistently than were those who attended the experimental program. No such association was seen among comparable young men. Both experimental and comparison programs significantly increased the consistent use of effective methods among teenagers who has been coitally active before attending the programs. Among males, however, when preintervention contraceptive efficiency was held constant, the experimental program led to significantly greater contraceptive efficiency over the follow-up year than did the comparison programs. Among females, however, the 2 approaches produced an equivalent degree of improvement. Finally, prior exposure to sex education was associated with greater contraceptive efficiency at the 1-year follow-up among almost all sexual experience and gender groups, regardless of the type of intervention program attended.

Report decision-making patterns among mandated child abuse reporters.

The goal of this investigation was to examine whether reporting decisions could be described by a coherent process that was consistent across incidents of suspected abuse. Using case vignettes imbedded in a national mail survey of mandated reporters, we examined the relationship between a series of judgments about the cases described in the vignettes and reporting intentions. These judgments included seriousness of the incident; whether the incident should be labeled "abuse" or "neglect"; whether the law would require a report; and whether the child and, separately, the rest of the family would benefit from a report. These five abuse-relevant judgments were strongly related to each other and together accounted for a substantial amount of the variance in reporting intentions. The law's demands most closely related to reporting intentions; benefits of reports were least closely related. Varimax rotation of a factor analysis revealed two factors: The first included seriousness, the abuse label, and the law's requirements, along with reporting intentions. The two benefit judgments loaded on the second factor. There were small differences in reporting judgments and patterns as a function of type of abuse. The implications of these findings for mandated reporter behavior are discussed.

The role of health belief attitudes, sex education, and demographics in predicting adolescents' sexuality knowledge.

As part of a pretest-posttest design to evaluate a 15-hour Health Belief Model (HBM)-based sex education program, we interviewed 203 teenagers (aged 13-17) of both genders regarding their preintervention sexual and contraceptive knowledge, attitudes toward pregnancy and contraception, and prior sex education and sexual activity experiences. A multiitem sexual and contraceptive knowledge measure yielded several specific topic area scales and a total knowledge score, and a multiitem attitudes measure also yielded five reliable HBM-based scales. A series of regression analyses that used teenagers' previous sexuality-related experiences, demographic information, and attitudes predicted knowledge scores well (R2 = 0.22-0.54). Across specific knowledge areas, HBM-based attitudes (e.g., perceived serious consequences of teen pregnancy) were consistently significant predictors. Interestingly, neither previous sex education nor personal sexual experiences were significantly associated with specific knowledge areas (e.g., venereal disease), although they were related to total knowledge scores. Similarly, age and gender were poor predictors of specific areas of knowledge, but minority ethnic status was consistently associated with less sexual and contraceptive knowledge. Our model was highly successful in accounting for a substantial portion of the variance in total knowledge scores (R2 = 0.54). Results are discussed in terms of their implications for designing sex education programs that focus on motivation for pregnancy avoidance and contraception as well as factual information for teenagers.

A health belief model approach to adolescents' fertility control: some pilot program findings.

We report initial findings from a community-based intervention intended to strengthen unmarried teenagers' fertility control behaviors (i.e., abstinence or consistent contraceptive usage). The Health Belief Model (HBM) was used as a conceptual framework for developing curriculum materials and for evaluating a 15-hour educational program targeted at 13- to 17-year-olds of both genders. Interview data pertaining to sexual and contraceptive perceptions, knowledge, and behaviors were collected three times in a no-control, short-term, longitudinal study design: (1) just before; (2) immediately after; and (3) three to six months following the intervention. Dependent variables of major interest were changes in perceptions, knowledge, and self-reported fertility control behaviors. Based on data from the 120 teenagers who completed the followup (80% of those completing the intervention), we found: (1) consistent contraceptive usage increased significantly; (2) changes in HBM-based contraceptive perceptions and sexual knowledge at immediate post-testing were predictive of increases in contraceptive usage at longer followup; and (3) the majority (62%) remained abstinent from pre-intervention to followup. These findings, study limitations, and suggestions for a future controlled study are then discussed.

Factors predicting pregnancy resolution decision satisfaction of unmarried adolescents.

Premaritally pregnant Caucasian and Mexican-American adolescents (N = 299) aged 13 to 19 years who received pregnancy counseling, pregnancy termination, or prenatal services at a county clinic were reinterviewed six months after delivery or abortion to assess postdecision satisfaction. More than 80% making each decision (i.e., abortion, single-motherhood, marriage) said they would make the same decision again. There were no significant effects of decision alternative, ethnicity/religion, or age on satisfaction. Among aborters, four factors--positive preprocedure abortion opinion, more liberal attitudes towards abortion for others, consistent contraceptive use following abortion, and their mothers' higher educational attainment--accounted for about 20% of the variance in satisfaction. Among single mothers positive preprocedure attitude towards single motherhood and lack of attempts to attend school in the six months after delivery were associated in bivariate analyses with decision satisfaction. Implications of these findings for adolescent pregnancy counseling are discussed.

Factors discriminating pregnancy resolution decisions of unmarried adolescents.

Pregnancy resolution decisions of unmarried adolescents were studied with the use of an expected utility decision model that included psychological, background, and economic variables. Discriminant function analysis of the decision to have an abortion or to deliver the child indicated that psychological, background, and economic variables each made significant contributions to the successful classification of teenagers (approximately 87.5% of the women were classified correctly). A four-item Abortion Approval Index, the women's perception of the prospective fathers' abortion opinion, personal knowledge of other unmarried teenagers who delivered, self-reported grade average, and receipt of state financial aid in the form of AFDC or Medicaid payments were the most powerful discriminators. For adolescents who chose to deliver, a second discriminant function indicated that only one economic factor--receipt of state financial aid--successfully discriminated those who married from those who became single mothers (approximately 72% of the women were classified correctly). Results are discussed in terms of possible decision strategies and sequences used by adolescents and the value of using a decision framework that incorporates psychological, background, and economic factors.

Public school programs for adolescent pregnancy and parenthood: an assessment.

PIP: Study of the response of public schools to the 1972 federal law forbidding discrimination against pregnant students. The author examined special programs for pregnant teens and teenage parents in 11 school districts. Schools were found neither to seek nor want an active role in dealing with these students. Programs lack strong administrative support. While most do a good job providing teenagers with information about pregnancy, childbearing, and parenthood, they are seriously flawed academically and do little to make use of outside funding sources.^ieng