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Assessing stressful life events in large-scale epidemiologic studies is challenged by the need to measure potential stressful events in a reasonably comprehensible manner balanced with burden on participants and research staff. The aim of this paper was to create a short form of the Crisis in Family Systems-Revised (CRISYS-R) plus 17 acculturation items, a measure that captures contemporary life stressors across 11 domains. Latent class analysis (LCA) was used to segment the sample of 884 women from the PRogramming of Intergenerational Stress Mechanisms (PRISM) study experiencing different patterns of exposure to stressful events and identify items from each domain that best discriminate between individuals with different patterns of stressful-event exposures (high vs. low stress exposure). The results from the LCA, in conjunction with the expert opinions provided by the original developers of the CRISYS, yielded a 24-item item short form (CRISYS-SF) with at least one question from each of the original domains. Scores on the 24-item CRISYS-SF had high correlations with scores on the 80-item CRISYS., Author(s): Phillip Sherlock [sup.1] , Madeleine U. Shalowitz [sup.2] , Carolyn Berry [sup.3] , David Cella [sup.1] , Courtney K. Blackwell [sup.1] , Whitney Cowell [sup.4] , Karen M. Reyes [...]

PURPOSE Small independent primary care practices (SIPs) often lack the resources to implement system changes. HealthyHearts NYC, funded through the EvidenceNOW initiative of the Agency for Healthcare Research and Quality, studied the effectiveness of practice facilitation to improve cardiovascular disease-related care in 257 SIPs. We sought to understand SIP clinicians' perspectives on the benefits of practice facilitation. METHODS We conducted in-depth interviews with 19 SIP clinicians enrolled in HealthyHearts NYC. Interviews were transcribed and coded using deductive and inductive approaches. To understand whether the perceived benefits of practice facilitation differ based on the availability of internal staff for quality improvement (QI), we compared themes pertaining to benefits between practices with 3 or fewer office staff vs more than 3 office staff. RESULTS Clinicians perceived 2 main benefits of practice facilitation. First, facilitators served as a connection to the external health care environment for SIPs, often through teaching and information sharing. Second, facilitators provided electronic health record (EHR)/data expertise, often by teaching functionality and completing technical assistance and tasks. SIPs with more than 3 office staff felt that facilitators provided benefits primarily through teaching, whereas SIPs with 3 or fewer staff felt that facilitators also provided hands-on support. At the intersections of these benefits, there emerged 3 central practice facilitation benefits: (1) creating awareness of quality gaps, (2) connecting practices to information, resources, and strategies, and (3) optimizing the EHR for QI goals. CONCLUSIONS SIP clinicians perceived practice facilitation to be an important resource for connecting their practice to the external health care environment and resources, and helping their practice build QI capacity through teaching, hands-on support, and EHR-driven solutions. Key words: primary care; practice transformation; practice facilitation; organizational change; professional practice; physician perspective; small independent primary care practices; qualitative research; health information technology; practice-based research, INTRODUCTION Small independent primary care practices (SIPs), defined as those with 5 or fewer clinicians, provide primary care for a substantial proportion of the US population, (1) yet the number [...]

In 2004, the American Medical Association (AMA) approved the Performance Improvement (PI) educational process as a strategy for improving patient care. (1) Through this process, clinicians earn AMA Physician's Recognition [...]

Many policy problems require governmental leaders to forge vast networks beyond their own hierarchical institutions. This essay explores the challenges of implementation in a networked institutional setting and incentives to induce coordination between agencies and promote quality implementation. It describes the national evaluation of the Assuring Better Child Health and Development program, a state-based program intended to increase and enhance the delivery of child development services for low-income children through the health care sector, using Medicaid as its primary vehicle. Using qualitative evaluation methods, the authors found that all states implemented programs that addressed their stated goals and made changes in Medicaid policies, regulations, or reimbursement mechanisms. The program catalyzed interagency cooperation and coordination. The authors conclude that even a modest level of external support and technical assistance can stimulate significant programmatic change and interorganizational linkages within public agencies to enhance provision of child development services.

Objectives. We sought to determine whether low acculturation among Mexican American caregivers protects their children against asthma. Methods. Data were obtained from an observational study of urban pediatric asthma. Dependent variables were children's diagnosed asthma and total (diagnosed plus possible) asthma. Regression models were controlled for caregivers' level of acculturation, education, marital status, depression, life stress, and social support and children's insurance. Results. Caregivers' level of acculturation was associated with children's diagnosed asthma (P=.025) and total asthma (P=.078) in bivariate analyses. In multivariate models, protective effects of caregivers' level of acculturation were mediated by the other covariates. Independent predictors of increased diagnosed asthma included caregivers' life stress (odds ratio [OR] = 1.12, P=.005) and children's insurance, both public (OR = 4.71, P = .009) and private (OR = 2.87, P = .071). Only caregiver's life stress predicted increased total asthma (OR = 1.21, P = .001). Conclusions. The protective effect of caregivers' level of acculturation on diagnosed and total asthma for Mexican American children was mediated by social factors, especially caregivers' life stress. Among acculturation measures, foreign birth was more predictive of disease status than was language use or years in country. Increased acculturation among immigrant groups does not appear to lead to greater asthma risk.

Objectives. We examined racial and ethnic disparities in the total potential burden of asthma in low-income, racially/ethnically heterogeneous Chicago schools. Methods. We used the Brief Pediatric Asthma Screen Plus (BPAS+) and the Spanish BPAS+, validated, caregiver-completed respiratory questionnaires, to identify asthma and possible asthma among students in 14 racially/ethnically diverse public elementary schools. Results. Among 11 490 children, we demonstrated a high lifetime prevalence (12.2%) as well as racial and ethnic disparities in diagnosed asthma, but no disparities in prevalences of possible undiagnosed asthma. Possible asthma cases boost the total potential burden of asthma to more than 1 in 3 non-Hispanic Black and Puerto Rican children. Conclusions. There are significant racial and ethnic disparities in diagnosed asthma among inner-city schoolchildren in Chicago. However, possible undiagnosed asthma appears to have similar prevalences across racial/ethnic groups and contributes to a high total potential asthma burden in each group studied. A better understanding of underdiagnosis is needed to address gaps in asthma care and intervention for low-income communities. doi: 10.2105/AJPH.2005.071514

Increasing the representation of Spanish-speaking study participants requires development and dissemination of reliable and valid translated scales. In the current study the construct validity was assessed of the Spanish version of the Crisis in Family Systems--Revised, a measure of contemporary life stressors, with a convenience sample of 377 parents interviewed in a study of childhood asthma, although over half of the respondents did not have children with asthma. Most respondents were foreign-born women between 20 to 60 years old (M = 35, SD = 7). 52% had not completed high school or its equivalent, and 55% reported a household income of $15,000 or less. For a subsample of 25 respondents test-retest reliability was .86 over 2 wk. Reporting more life stressors was associated with greater depressive symptomatology, poorer physical and mental health function, and lower household income. These relationships support the construct validity of the test in Spanish. This study provided strong evidence that this version is a valid and reliable measure of life stressors for a Spanish-speaking population living in the United States.

Understanding the impact of training on the development of physicians' attitudes toward AIDS is important to furthering our knowledge of the mechanisms through which socialization affects professional outlook, as well as promoting an adequate supply of providers to treat people with AIDS (PWAs). This prospective panel study collected data on 383 physicians at two critical stages: as fourth-year medical students and as third-year residents. Aspects of residency training (e.g., residents' morale and positive faculty role models) were the most powerful predictors of increase in willingness to treat PWAs. Decline in willingness was primarily a product of negative social attitudes - homophobia and IVDU-phobia (aversion to intravenous drug users). Cynicism toward patient care acted as a trigger, activating the negative effects of IVDU-phobia; having an acquaintance who is HIV positive mediated the negative impact of homophobia. Notably, cynicism was associated with basic aspects of training (specific characteristics of the faculty and of the educational milieu). The findings support a view of socialization as a pervasive process implicating intrinsic aspects of training and having an impact on a broad spectrum of outlooks. Accordingly, interventions must address structural characteristics that transcend AIDS-specific concerns.

Physicians' responses to AIDS at different career stages and in different specialties were studied by surveying house staff (N = 438), faculty (N = 363), and applicants (N = 487) at six residency programs in internal medicine and six in surgery. House staff had more negative outlooks than senior medical students and faculty, reporting greater fear of exposure to AIDS and greater unwillingness to treat AIDS patients. Surgeons were more negative than internists on these dimensions. For all groups, concern about possible negative educational consequences of treating AIDS patients was largely a function of their amount of contact with AIDS patients. Comparing willingness to treat AIDS and nine other conditions, AIDS consistently ranked low, along with Alzheimer's disease, alcoholism, and drug dependency. The findings have practical implications for hospitals and training programs. In addition, they raise issues concerning the impact of training on professional socialization, and call into question physicians' commitment to the professional norm of treating all patients regardless of provider self-interest, patient social characteristics, or medical uncertainty.

In this paper, the health needs and health care utilization patterns of home attendants and their families have been studied as an illustration of those likely to be found among working poor, immigrant women and their children. Despite tremendous growth in the number of immigrants, studies to date provide only limited information regarding the specific health needs and patterns of health care utilization among such women and their children. As part of a longitudinal study on the impact of insurance on health status and health care utilization, 387 female, immigrant home attendants were interviewed. Data were also gathered on 355 of their minor children. These women and children were found to be less likely than other Americans to make use of basic health services, despite the fact that they are more likely to indicate fair or poor health status. This is true even in comparison to poor or uninsured Americans. Immigrant attendants in fair or poor health report an average annual visit rate of 4.1 ambulatory care visits for themselves and 2.2 for their children, as compared to 8.4 for poor adults and 4.4 for poor children in national samples. These findings illustrate the likelihood that poor, immigrant women make limited use of American medical care, and face barriers to health care that appear even greater than those faced by the uninsured and the poor.

In a study of the link between physical disability and social relationships among the elderly, questions about social network and social support evoked a surprisingly large number of group responses. People mentioned 'my grandchildren,' 'the people in my building,' 'people at the senior center,' and other groups in ways that suggested that the real unit of support was extraindividual and could not be accurately understood by reference to individual people within those groups. This paper describes the frequency of such responses and the circumstances under which they emerged. Definitions of social support and of social network should not be restricted to dyadic relationships between individuals; better understanding of social support processes would derive from consideration of the kinds of social support functions best offered by groups vs. individuals and consideration of differences in the ways in which support is derived from group and individuals.

The usefulness of the Rand Mental Health Inventory (MHI) is reconfirmed while assessing the mental health of a large number of adolescents who participated in a community based Rand Health Insurance Study. Results confirmed the reliability and readability of the MHI. Factor analyses reveals subscales reflecting psychological well-being and psychological distress. With its adolescent norms, the MHI is recommended for the assessment of adolescent mental health particularly in comparison with nonpsychiatric, normative adolescents.

The objectives of this study were to establish the validity of the Crisis in Family Systems-Revised, a recently developed measure of contemporary life stressors, using the same validation technique as in the original validation and to provide further evidence of construct validity by assessing its relationship to socioeconomic status and residential location. We conducted 124 in-person interviews with parents in three outpatient pediatric asthma clinics affiliated with an academic medical center. The design was cross-sectional and correlational. Total count of life stressors accounted for 19% of the variance in scores on the Center for Epidemiologic Studies-Depression. Respondents using Medicaid and living in the city experienced more objective stressors, but the proportions of stressors rated as negative or positive (Valence), and ongoing (Chronicity) were fairly constant across subsamples, as was the Difficulty rating. Psychologists and health and mental health services researchers are in need of constructs relevant to contemporary society and its issues and tools to measure these constructs. Life stressors appears to be such a construct and the Crisis in Family Systems-Revised a measure with considerable utility.

Objective. We sought to understand why certain Medicaid managed care organizations (MMCOs) implemented child development services or programs and how they had done so. We also sought to identify barriers and facilitators to successful initiation and implementation of child development programs. Methods. We conducted 9 key informant interviews and 4 site visits, and performed qualitative analyses to identify major themes across responses. Results. We identified a small number of MMCOs with child development services. High-level support was crucial for program initiation; physician buy-in, staff support, and strong working relationships with outside health professionals or agencies were principal factors in successful program implementation. Conclusions. MMCOs that were committed to implementing child development services were successful in doing so, without external funding or regulatory mandate. The results provide valuable strategies for MMCOs interested in developing programs and for researchers and advocates interested in promoting child development services for low-income children. Pediatrics 2000; 106:191-198; Medicaid managed care, child development services., ABBREVIATIONS. MMCO, Medicaid managed care organizations; HCFA, Health Care Financing Administration; CEO, chief executive officer; ER, emergency room; PCP, primary care provider. BACKGROUND A substantial body of evidence demonstrates the [...]

OBJECTIVE. Recent national survey data indicate an overall asthma prevalence of 12.2% for children who are younger than 18 years. Previous research in clinical samples of children with asthma suggests that their mothers are at greater risk for symptoms of depression. We describe the relationship between maternal symptoms of depression and having a child with asthma in a community-based sample. METHODS. After a school-based ascertainment of asthma and asthma symptoms in 15 low-income, racially/ethnically diverse public elementary schools, 1149 eligible mothers agreed to participate in a longitudinal study. Mothers either had a child with previously diagnosed asthma or a child with symptoms consistent with possible asthma or were in the randomly selected comparison group in which no child in the household had asthma. During the first interview, mothers responded to questions about their own life stressors, supports and mental health, and their children's health. RESULTS. In bivariate analyses of a community-based sample of children who share low-income neighborhoods, mothers of children with diagnosed or with possible undiagnosed asthma had more symptoms of depression than did mothers of children who have no asthma. Mothers of children with diagnosed or with possible undiagnosed asthma also experienced more life stressors than did mothers of children without asthma. Using nested linear regression, we estimated a model of maternal symptoms of depression. Most of the variation in Center for Epidemiologic Studies-Depression score was accounted for by life stressors and social support. There were no independent effects of either asthma status or asthma status-specific child health status on maternal symptoms of depression. CONCLUSION. Children who are under care for chronic conditions such as asthma live and manage their illness outside the clinical setting. Their social context matters, and maternal mental health is related to their children's physical health. Although having a child with asthma may be "just" another stressor in the mother's social context, complex treatment plans must be followed despite the many other pressures of neighborhood and family lives. KEY WORDS. asthma, stress, social support, maternal depression.