Applying cost analysis methods to school-based prevention programs.

In order to efficiently allocate scarce prevention resources, policymakers need information about the economic costs of school-based substance use prevention programs. The objective of this paper is to outline economic cost analysis methods and demonstrate their applicability to school-based prevention programs. As an example, the paper focuses on estimating the economic cost of ALPHA, an intensive school-based substance use prevention program. The cost of ALPHA is compared to the costs of 3 elementary school programs that were alternatives to ALPHA. We collected cost information for 3 years, using a cost questionnaire that was completed by program and school budget officers and school principals. The program costs obtained from these sources were modified to conform to well-established economic cost analysis principles.

Race, ethnicity, and the health care system: public perceptions and experiences.

To assess the public's perceptions and attitudes about racial and ethnic differences in health care, the Kaiser Family Foundation surveyed a nationally representative sample of 3,884 whites, African Americans, and Latinos in 1999. The survey found that the majority of Americans are uninformed about health care disparities--many were unaware that blacks fare worse than whites on measures such as infant mortality and life expectancy, and that Latinos are less likely than whites to have health insurance. Views on whether the health system treats people equally were strikingly different by race. For example, most minority Americans perceive that they get lower quality care than whites, but most whites think otherwise. Nonetheless, more minority Americans were concerned about the cost of care than racial barriers. Efforts to eliminate disparities will need to improve public awareness of the problems as well as address racial and financial barriers to care.

Managed care in three states: experiences of low-income African Americans and Hispanics.

This article examines the experiences of low-income, nonelderly Hispanics, African Americans, and whites in managed care (MC), and compares them to their racial/ethnic counterparts enrolled in fee-for-service (FFS) health plans. Survey findings from Florida, Tennessee, and Texas show that MC and FFS enrollees do not differ substantially on most access and satisfaction measures, with a few notable exceptions. When compared with their FFS counterparts, African-American MC enrollees are twice as likely to report problems in obtaining needed care, and Hispanic MC enrollees are nearly twice as likely to rate the extent to which their providers care about them as "fair" or "poor." In contrast, whites in MC are less likely to be without a regular provider than their FFS counterparts, but report greater dissatisfaction with the extent to which providers care about them.

Managed care and low-income populations: recent state experiences.

This DataWatch examines the relationship between managed care enrollment and access to care for low-income adults with Medicaid and compares their experience with that of low-income, privately insured managed care enrollees. Medicaid managed care enrollees are more likely than low-income, privately insured managed care enrollees to be poorer, have health problems, and experience access problems. Compared with low-income populations in fee-for-service care, managed care enrollees, whether in Medicaid or privately insured, are not appreciably different in having a usual source of care, having a regular provider, or emergency room use but report more problems in obtaining care and are more likely to be dissatisfied with their health plans.

The influence of self-esteem on smoking among African-American school children.

This study provides some evidence, although not very strong, that self-esteem is associated with the likelihood of smoking among African-American children. In a sample of 1,256 children, those with lowest levels of self-esteem were twice as likely to have ever smoked as those with highest level of self-esteem (95% C.I. = 1.10-7.78). Girls, more so than boys, have an increased risk of smoking at the lowest level of self-esteem. Girls with the lowest level of self-esteem were 2.8 times (95% C.I. = 3.85-16.59) as likely to have smoked when compared to girls with higher self-esteem. The findings suggest preventive interventions that seek to build self-esteem may reduce the likelihood of smoking among girls, although perhaps only modestly. Further study is needed to identify potentially effective methods for reducing the likelihood of smoking among African-American boys.

Neighborhood environment and opportunity to use cocaine and other drugs in late childhood and early adolescence.

We hypothesized that neighborhood disadvantage might function as a determinant of "exposure opportunity', an intermediate step on a path toward starting to use drugs illicitly. Testing this hypothesis, we analyzed self-report data gathered in 1992 by means of confidential interviews with 1416 urban-dwelling middle-school participants in a longitudinal field study. Within this epidemiologic sample, 50 youths said that someone actively had offered them a chance to take cocaine or smoke crack; tobacco had been offered to 395 youths; alcohol to 429 youths. Using multiple logistic regression to hold constant grade, sex, minority status, and peer drug use, we found a moderately potent association between neighborhood disadvantage and exposure to cocaine: youths living in the most disadvantaged neighborhoods (highest tertile) were an estimated 5.6 times more likely to have been offered cocaine, as compared to those in relatively advantaged neighborhoods (P = 0.001). By comparison, there were weaker but statistically significant associations involving tobacco exposure opportunity (odds ratio, OR = 1.7, P = 0.004) and alcohol exposure opportunity (OR = 1.9, P = 0.0005). Future research will clarify the etiologic significance of neighborhood disadvantage in pathways leading toward illicit drug use.

Race/ethnicity, the social environment, and health.

International and national research has documented the relations between socio-economic conditions and health. Nonetheless, racial/ethnic group comparisons of health indices frequently are presented in the United States without stratifying or adjusting for socio-economic conditions that could affect interpretation of the data. This paper examines how racial/ethnic group identifiers have been used in past research. While some studies assume biologic differences; others presume that race/ethnicity is a proxy for socio-economic race factors. One consequence of these presumptions has been an underdevelopment of knowledge about racial/ethnic minority populations that could help shape public policies and preventive interventions to reduce disparities in health. Findings from studies that examine the influence of both race and social class on health are reviewed in an effort to clarify the state-of-knowledge. Although the findings vary for particular health indices, the studies provide considerable evidence that socio-economic conditions are a powerful, although not necessarily exclusive, explanatory variable for racial disparities in health. The findings are used as the basis for encouraging more theoretically grounded and methodologically rigorous research rather than avoiding an assessment of the influence of race/ethnicity on health.

Racial differences in health: not just black and white, but shades of gray.

Explanations for racial/ethnic disparities in health are varied and complex. This paper reviews the literature to assess the extent to which current disparities are a consequence of racial differences in the social class composition of the US population. We focus this review on African Americans and examine studies that provide information on the effect of race on four outcome measures: infant mortality, hypertension, substance use, and mortality from all-causes. Twenty-three studies were identified that met criteria for inclusion in this review. As expected, most studies provide evidence that socioeconomic conditions are a major factor explaining racial differences in health. Findings, however, vary for the different health indices. Research in the area of substance abuse provides the most consistent evidence that socioeconomic conditions account for observed racial differences. In contrast, studies on infant mortality and hypertension provide a compelling case that the effects of socioeconomic status are important, but not sufficient to explain racial differences. Evidence on mortality from all-causes is equally divided between studies showing no significant race effect and those in which racial differences persist after adjusting for social class. The paper offers possible explanations for the seemingly divergent results and identifies conceptual and methodologic issues for future research seeking to disentangle the complex relations between race, social class, and health.

Conducting an assessment of health needs and resources in a racial/ethnic minority community.

This article examines strategies and methodologic issues for researchers to consider when conducting community-based research within a racial/ethnic minority community. Members of minority communities have considerable skepticism about the health care system and researchers who work under its auspices. To facilitate quality research, it is necessary to build a mutually beneficial partnership between the community and researchers. Suggested strategies for accomplishing this goal, such as seeking out information on the social and political forces shaping the community and developing the community's capacity to undertake research of this type, are described. Methodologic issues include the importance of community input in defining the minority population group and its leadership, the benefits and limitations of conducting comparative analysis, and the need for measurement tools and techniques that are culturally and socially appropriate. Minority and nonminority researchers must make a concerted effort to gain knowledge of and respect for a community whose culture, values, and beliefs may differ from their own.

Probing the meaning of racial/ethnic group comparisons in crack cocaine smoking.

OBJECTIVE: To probe the meaning of reported racial and ethnic group differences in the prevalence of crack cocaine smoking and to estimate the degree to which crack cocaine smoking is associated with personal factors specific to race/ethnicity. DESIGN: Through reanalysis of data from the 1988 National Household Survey of Drug Abuse (NHSDA), we compared racial/ethnic group differences in crack cocaine smoking. To hold constant social and environmental risk factors that might potentially confound racial comparisons, we used an epidemiologic strategy that involves poststratification of respondents into neighborhood risk sets. A conditional logistic regression model was used to estimate the relative odds of crack use by race/ethnicity. PATIENTS OR OTHER PARTICIPANTS: The 1988 NHSDA interviewed 8814 individuals residing within households in the United States. Subjects were selected using a multistage area probability sampling of all residents aged 12 years and older. RESULTS: Once respondents were grouped into neighborhood clusters, the relative odds (RO) of crack use did not differ significantly for African Americans (RO, 0.85; 95% confidence interval [Cl], 0.37 to 1.93) or for Hispanic Americans (RO, 0.88; 95% Cl, 0.47 to 1.67) compared with white Americans. CONCLUSION: Findings of race-associated differences are often presented as if a person's race has intrinsic explanatory power. This analysis provides evidence that, given similar social and environmental conditions, crack use does not strongly depend on race-specific (eg, biologic) personal factors. Although the study finding does not refute the previous analysis, it provides evidence that prevalence estimates unadjusted for social environmental risk factors may lead to misunderstanding about the role of race or ethnicity in the epidemiology of crack use. Future research should seek to identify which characteristics of the neighborhood social environment are important and potentially modifiable determinants of drug use.

Latina and African American women: continuing disparities in health.

Women of all races have faced incredible challenges as they sought to realize the promises of America. For women of color, these challenges were compounded by the second-class citizenship of U.S. racial and ethnic minority population groups. In an effort to assess the quality of life experienced by Latina and African American women, this article provides descriptive information on racial/ethnic differences in women's social conditions, health status, exposure to occupational and environmental risks, and use of health services. When possible, indices are stratified by family income to limit the effects of social class on the comparison of racial differences. The authors provide evidence that Latina and African American women are more likely than nonminority women to encounter social environments (e.g., poverty, densely populated neighborhoods, hazardous work conditions) that place them at risk for ill-health and injury. Although persistent racial disparities in health are often attributed to the lifestyle behaviors of racial minority populations, they are undoubtedly a consequence of poorer social conditions as well as barriers in access to quality health services. To achieve further gains, public policies must reduce social inequalities (i.e., by gender, race, and social class) and assure greater equity in access to resources that facilitate healthier environments and lifestyles. Public health initiatives should be community-based, reflecting a shared partnership that actively engages minority women in decision-making about their lives.

Rural and urban hospital closures, 1985-1988: operating and environmental characteristics that affect risk.

Due to congressional concern that rural hospitals were particularly disadvantaged by Medicare's Prospective Payment System, the U.S. General Accounting Office investigated the role of Medicare and other factors in hospitals' risk of closure. This paper reports on the findings of that study, which compared the risk of closure among urban and rural hospitals during 1985 to 1988, the period after implementation of PPS. When hospital operating and environmental characteristics were held constant, the odds of closure in rural and urban areas differed significantly only for private nonprofit hospitals. Although a number of factors were associated with hospitals' higher risk of closure, we did not find evidence that Medicare was a major factor associated with financial distress or closure during the 1985 to 1988 period.

"Race" in the epidemiologic literature: an examination of the American Journal of Epidemiology, 1921-1990.

The routine presentation of epidemiologic data by "race" has been challenged as impeding identification of modifiable risk factors and fostering an unsubstantiated belief in the biologic distinctness of the "races." This study examines the past and current uses of "race" in US epidemiologic research. The authors reviewed every paper published in the 1921, 1930, 1940, 1950, and 1960 volumes of the American Journal of Hygiene and in the 1965, 1970, 1975, 1980, 1985, and 1990 volumes of the American Journal of Epidemiology. Of the total of 1,200 papers published during the sample years, 558 reports of original epidemiologic research conducted in the United States were identified. The proportion of these papers containing a reference to "race" rose steadily from 1975. However, the proportion of papers reporting inclusion of "nonwhite" populations did not show a parallel increase. Exclusion of "nonwhite" subjects and description of predominantly "white" study populations increased instead. Recommendations for future epidemiologic practice include the following: 1) greater inclusion of "nonwhite" populations in epidemiologic research and 2) vigorous investigation of the root causes of observed "race"-associated differences.

Black-white differences in alcohol use by women: Baltimore survey findings.

Although black women suffer disproportionately from alcohol-related illnesses and causes of death, little is known about the extent to which poorer outcomes are a function of differences in drinking, the use of health services, or some combination of these factors. This study, using interview data obtained in the Baltimore Epidemiologic Catchment Area household survey, compares racial differences in alcohol use and abuse among a sample of 2,100 women. After controlling for differences in sociodemographic characteristics, black women were found to be at no greater risk than whites for heavy drinking or for suffering from alcohol abuse or dependence. Racial differences, however, were observed in heavy drinking by years of education. A similar percentage of black women and white women who had not completed high school were heavy drinkers, but black women with 12 or more years of education were less likely to be heavy drinkers than whites with comparable education. These findings raise questions about the extent to which differences in drinking contribute to the poorer alcohol-related health outcomes of black women in Baltimore. Additionally, the finding that education was inversely related to heavy drinking among black women may be helpful in shaping early alcohol abuse intervention and treatment services that target black women.

Health care for black Americans: the public sector role.

Most of the improvement--both absolute and relative--in the health status of black Americans over the past two decades can be traced to major gains in access to health care services. Public payment programs, most notably Medicaid and Medicare, have not only reduced financial barriers, but have also combatted those of racial discrimination. Other federal programs supporting targeted local services have been especially effective in reducing infant mortality. But the redistributive effects have been uneven and unequal across populations; many categorical gaps remain and increasing numbers are potentially without access to essential primary care services.