In “Association Between Availability and Quality of Health Services in Schools and Reproductive Health Outcomes Among Students: A Multilevel Observational Study,” Denny et al. are able to confront the sample-size and methodological issues seen in many American studies and assess the impact of New Zealand’s SBHCs on student health outcomes using a large nationally representative sample and multilevel analytical techniques.

Denny et al. used a two-stage cluster design to collect necessary data. The researchers first randomly selected 115 schools to participate in the study and then randomly selected 12,355 students from those 115 schools to participate in their study. Ninety-six of the 115 schools, and 9,107 of the 12,355 students, agreed to participate in the study. School and student demographics reflected those of New Zealand’s general population.

Administrators were asked to complete questionnaires regarding the availability and quality of their SBHCs. These questionnaires asked school administrators about a variety of access and quality indicators, including number of health practitioners, weekly hours worked by health practitioners, if health practitioners met as a team weekly, etc.

Students self-reported personal health outcomes in an anonymous survey.  Questions on this survey encompassed the following sexual health behaviors: if students were sexually active, condom use for sexually transmitted infections prevention, contraceptive use for pregnancy prevention, and history of or current pregnancy. If students stated they “always” or “most of the time” used condoms or contraception (the options being “always,” “most of the time,” “sometimes,” and “never”), this was defined as consistent contraception use. If students stated they had never been involved in a pregnancy or were not sure if they had not been involved in a pregnancy (the options being “yes,” “no,” and “not sure”), this was defined as no history of or current pregnancy.

Researchers used general linear models to assess if the accessibility and quality of school-based health services impacted sexual health outcomes as reported by students. There was a statistical association between increased weekly practitioner hours and consistent contraceptive use. Sexually active students in schools with greater than 10 weekly health practitioner hours per 100 students reported greater consistent contraception use than their sexually active peers in schools without SBHCs. However, researchers found no relationship between team-based meetings, non-health personnel-based meetings, and administration of the grade-9 health screening and consistent contraception use.

Although these findings are significant, the nuanced impacts of SBHCs are still unknown. Services vary within schools—for example, some schools give students contraception, while others do not. Second, there is variance among staff’s SBHC experience. Lastly, the particular health service that impacts reproductive health outcomes is unknown—perhaps access to mental health or substance abuse services in SBHCs is the true driver behind improvements in students’ sexual health outcomes. Understanding the impact of the nuances in school-based health service provision may be the key to improving student health outcomes. Although this research leaves some questions unanswered, it bolsters American researchers’ findings of the correlation between SBHCs and improved sexual health outcomes.

Photo credit: cc/Allen.Hillsborough

Among the general populations, the authors found that many measures of health were similar. However, Americans had higher rates of arthritis (five percentage points) and of high blood pressure (11 percentage points) than their Canadian counterparts. There were also noticeable differences in healthcare utilization between the general populations. For instance, individuals in the US were 18 percentage points less likely to have a regular medical doctor and 20 percentage points less likely to have visited a specialist within the last 12 months.

Despite the disparity in access to providers, the authors argue that the US actually utilizes preventative health care measures at a higher rate. As evidence, they show that individuals in the US are 17 percentage points and 12 percentage points more likely to have had a mammogram in their lifetime or a pap smear in the past 12 months, respectively. However, these results are not likely to be representative as they apply only to women.

The largest disparities arise when considering different segments of the US and Canadian populations. Among individuals with less than a high school degree, US residents were 33 percentage points less likely than similar Canadians to have a regular medical doctor, while Americans with some college or a college degree were only 14 percentage points less likely to have a regular medical doctor. There were similar results for having a regular medical doctor when considering income segments. Those who had negative earnings in the US were 31 percentage points less likely to have a regular medical doctor, and individuals making less than $20,000 were 24 percentage points less likely to have a medical doctor. For foreign-born residents, individuals in the US were 31-32 percentage points less likely to have a medical doctor than their Canadian equivalents.

In some cases, utilization rates among wealthy Americans were higher than the comparative category in Canada. For example, when considering dental visits, wealthy Americans (incomes greater than $59,0000) were six percentage points more likely to have visited a provider within the last 12 months, while the poorest segment was eight percentage points less likely to have visited a provider. Also, there were large disparities in the usage of preventative healthcare. Although the wealthiest Americans were 21 percentage points more likely to have had a mammogram, the poorest were only nine percentage points more likely.

The authors limited the study to individuals under 65, so we cannot see the effects of Medicare. Also, it does not appear that those individuals who are poorest in America benefitted much from Medicaid, but it would have been interesting to use an indicator for Medicaid enrollment status to discern any positive health effects from increased access to healthcare. Additionally, the study does not identify if the foreign-born immigrants it studies are legal or illegal immigrants, which, especially in America, would have had a large effect on individuals’ ability to receive healthcare. Still, a follow up study noting any changes from the expansion in Medicaid in some states will be an interesting comparison group to this study, and will enable discernment of any positive effects.

Feature Photo: cc/David Paul Ohmer

Patrick Meier, Computing Research Institute

Patrick Meier is an expert on the application of new technologies to crisis earlywarning, humanitarian response and resilience. He currently serves as Director of Social Innovation at the Qatar Foundations’ Computing Research Institute and blogs at www.iRevolution.net. He co-founded the Harvard Humanitarian Initiative’s Program on Crisis Mapping and Early Warning, CrisisMappers, Digital Humanitarians, and the award-winning Standby Task Force. He served as Director of Crisis Mapping at Ushahidi and has consulted extensively for many international organizations and programs. He received his PhD from the Fletcher School.

While a fast and comprehensive means of reporting breaking news, social media brings with it the risk of misreporting, which in some cases can be quite dangerous, as with Reddit’s misidentification of the Boston bombing culprit. How can authorities determine what’s credible? What is the relationship between law enforcement and social media?

So the first thing to keep in mind is that the need to verify information is not new: 911 is a crowdsourcing system. And just because some people either misdial the number or play a hoax and abuse the system does not mean that the system itself is not useful.

In the UK, only 25 percent of 999 calls are actually relevant. But the system is still very important because of that 25 percent for whom it will make a difference between life and death. So it is a question of how you manage this as best as possible, even with current traditional systems.

One issue is whether you can apply some of the legal issues around current traditional systems to social media. It is illegal to make hoax calls to 911. There is no reason why that shouldn’t happen in the case of Twitter as well. Not for everything you tweet, obviously, but if you are tweeting at the Boston Police with information, and they have solicited that information, then the same law should apply.

The London Fire Brigade, in December, publicly announced that they would add Twitter as a communication channel for people to report fires, and what’s really interesting about that is that London was also the first in the world to set up the emergency phone number. And now, 80 plus years later, you have the London Fire Brigade saying it’s time to upgrade the system and allow people to report via Twitter. In the US, we are also seeing a move to using mobile technology. In fact, people will be able to report by SMS to 911 by 2014. So this move to mobile technology is new, but the crowd-sourcing is not new.

Part of the problem is the sheer amount of data and the small proportion of it that is actually relevant. How can the process be managed in order to pull out the relevant and accurate parts?

Long story short, the technologies needed to determine relevance already exist, but they’re usually highly proprietary. It is very expensive to obtain licenses, and they are usually really complicated to use. What we at the Qatar Computing Research Institute want to do is make this technology free, open sourced, and easy to use.

One of my favorite quotes by William Gibson is, “The future is already here, it’s just not evenly distributed yet.” We know a big data solution is possible and now it’s about democratizing access to those technologies so that end users in the field can also make use of this technology in order to understand what’s happening around them, and hopefully to make better decisions.

One of the projects we’re working on to do this kind of verification is trying to crowdsource critical thinking during crises on social media. We need to find a way to crowdsource more critical thinking during disasters so that people think twice before tweeting. One way we’re doing this is by developing a platform called Verily, with some colleagues at the Masdar Institute, based on the red balloon DARPA challenge. We think that if you can do that for an entire country, surely you can do that in a far more geographically bounded area like Boston, where the social networks are even more interwoven so that the degrees of separation between individuals is very small.

We see more and more from disaster to disaster that there are these, what I call good digital Samaritans, who take it upon themselves to try and verify content. We saw three or four main individuals during Hurricane Sandy doing that, but they did this on their own and completely disconnected. What if instead of these individuals, we could open it up to the crowd and provide a platform that rationalizes the collection of evidence for and against a particular rumor? We systematize it, and we try and design the interaction with the platform in order to lend some more rigorous thinking about the kind of content.

It is almost an educational platform at the same time as it is a platform for time-critical crowdsourcing of evidence. The way that the platform would be triggered is by a verification request. Somebody who has heard about something or has a question would pose a verification request in the form of a yes or no question, such as “has this bridge been destroyed due to the earthquake”, and then they invite their social network to post any evidence that they might have.

The idea is that for any piece of content that somebody posts, you are invited to add a few sentences to describe why they might think it might be authentic or why they think it might not be, and then crowdsource to do this.

Private companies and individuals have been the primary users of this technology in crises, informing people about evacuation routes, medical assistance, etc. Should this timely dissemination of information be the government’s responsibility or is it best left to the “crowd”?

Can you stop the crowd from tweeting what they want? I think that you are best off assuming the crowd will continue sharing content, and what we need to do is find a way to encourage responsible sharing during disasters.

Before the bombings in Boston, the number of Boston Police Department followers was around 30 or 40 thousand. I checked again a couple days ago and there were a quarter of a million. There’s clearly a lot of interest for information from a trusted source. That has always been the case, but now there are different communication channels that one can use in order to obtain that information.

The Boston Police Force was also very on top of things in terms of regularly sharing information through social media channels to support their own efforts. I think it’s not necessarily an either/or; I think you want both of them to learn how to better use these technologies systems, to use better strategies to encourage more responsible use of social media during disasters.

How do you think we’ll be employing technology and social media in crisis management in the future, say, 15 years from now?

I don’t even know a year from now! One of my overarching goals is to try and build more resilient communities through the use of global technologies and social media. By resilience I mean the capacity for self-organization. We know that in disasters, the real first responders are the disaster-affected communities themselves. I want to find a way to empower the crowd to help itself during these disasters, get out of harm’s way, and mitigate the impact of the disaster. I hope that technology will go into the hands of those on the streets in the next year or two so that they are more empowered to survive a crisis.

In the future, I think there will be real-time content, real-time information, and real-time analysis specifically catered to where you are. We already have a “check in” system on social media. What about emergency “check-in”? When you check in, you would get highly customized information to you such as your medical history, where you live, and more.

How can government agencies or humanitarian responders better use social media and technology in emergency situations? Does public policy in its current form impede or promote innovation in this field?

I think what usually happens is that policy and regulation lag far behind innovation. That will probably always be the case, but we do need to update our policy to catch up with today’s world. There is a hugely important role for policy here to make better use of social media during disasters. We need to enlighten leadership to fully grasp the potential of these new technologies.

There is a very strong and important role for policy to educate the public. At schools, students are taught to duck and cover in case of an earthquake. Now we need to know how to tweet in case of an earthquake. There’s a responsibility that comes with tweeting during a crisis, and people need to understand what’s appropriate to tweet, what’s not appropriate to tweet, and especially what’s not appropriate to re-tweet. That all has to become part of our educational system moving forward.

We also need to look at what other countries are doing with respect to disasters and social media. I already mentioned the London Fire Brigade using Twitter. Another example is the Philippines. During the typhoon in the Philippines last December the government actually used Twitter and even suggested hashtags for people to use. Now that is brilliant. That is the kind of enlightened leadership that we need.

Another policy that I think is particularly enlightened is in Australia. The police in Queensland set up a hashtag called “mythbusters” in order to manage and respond to rumors. Every time they came up with a false piece of information or rumor, they would tweet that information out with the hashtag mythbusters. Then if people had any questions about a tweet that they saw, they could go to the hashtag and see if the police have mentioned it as a rumor.

There are some very clever ways that we have seen disaster and emergency services use technology, from the UK to the Philippines to Australia. It then becomes a matter of taking these really interesting innovations and turning them into standard operating procedures in the US.

Feature Photo: cc/gailjadehamilton

The authors acknowledge the many health benefits shown to result for women and children who breastfeed. However, they note that amidst increased debate over whether “breast is best” for all women and children, one issue has been largely ignored—the economic impacts for a woman who chooses to breastfeed. To better understand this issue, the authors analyzed data from the National Longitudinal Survey of Youth on over 1,000 mothers who had their first child between 1980 and 1993. They tracked whether these mothers, all of whom were employed in the year before they had their child, faced changes in earnings in the years after giving birth and compared differences between mothers who breastfed and those who used formula.

To capture the nuances of how feeding choice affects women economically, the researchers divided women into three categories: those who never breastfed, those who breastfed for less than six months, and those who breastfed for six months or longer. They find that mothers who formula-fed or only breastfed for a short duration faced similar earning prospects after giving birth, while women who breastfed for six months or longer saw a significantly steeper decline in income in the five years following childbirth and were making about $5,000 less per year than they had before the birth of their child.

The authors attribute this sharp difference in economic outcomes to differences in labor supply: women who breastfed for six months or longer were about twice as likely to be unemployed as short-duration breastfeeders one year after giving birth. Those who were employed worked about 500 fewer hours per year compared to their peers after giving birth. Five years after giving birth, they still worked about 200 hours fewer than short-term breastfeeders and formula feeders. However, they admit that it is not clear why these labor differences occur. One factor may be convenience. Breastfeeding is not conducive to a job that requires frequent travel or meetings, and it also demands breaks, which may not be available to women in more labor-intensive jobs. Many women lack a place to express or store milk in the workplace. According to the authors, having a baby might change women’s attitudes toward work or there may be other unobserved variables at play.

Some of the authors’ observed impacts could be caused by differences among the women who chose to breastfeed and those that did not. Indeed, the researchers’ data show that, on average, women who breastfeed are more likely to be white, married, slightly older at the time of their first child, and tend to earn more than non-breastfeeders.

Regardless of what drives long-term breastfeeders to reduce their work hours, the authors demonstrate an important pattern. In the current conversation around whether breastfeeding or formula feeding is more beneficial, policymakers should acknowledge the economic impacts that feeding choices have on mothers.

Feature Photo: cc/Valley Image WERX

Jennifer Sullivan, Enroll America

Jennifer Sullivan is the Director of the Best Practices Institute at Enroll America, a nonprofit, nonpartisan organization whose mission is to ensure that all Americans are enrolled in and retain health coverage. The Best Practices Institute identifies, develops, and disseminates information on policies that will promote American enrollment in health coverage. Prior to joining Enroll America, Ms. Sullivan was a Project Officer in the Division of Children’s Health Insurance Programs (CHIP) at the Centers for Medicare and Medicaid Services, where her work focused on crafting CHIP eligibility regulations for the Affordable Care Act. Ms. Sullivan holds an M.H.S. in Health Policy from the Johns Hopkins Bloomberg School of Public Health and a B.A. in Sociology from Kalamazoo College.

The recent national survey that Enroll America conducted with Lake Research Partners outlines the difficulties ahead in convincing people of the affordable and high-quality health insurance options available for them through the Affordable Care Act. Did any of the survey results surprise you?

We had seen similar surveys completed before our survey was fielded that suggested a real public knowledge gap in terms of the new coverage that is coming, so I wouldn’t say that it was necessarily surprising to us. I think there were a lot of things in the survey that were comforting to know.

I would say the first is that the vast majority of the folks we surveyed recognize the value of health insurance. And they wanted it. If you think about our campaign as a marketing campaign, people want our product. That is a huge positive step in the right direction; you might not know it’s available or how to buy it, and you might want help learning how to buy it, but you want the product. And that is a tremendous hurdle we have overcome that we otherwise would have really struggled with.

The last thing was how much we could move the dial about the affordability of coverage when we did not talk about how much the coverage would cost out of pocket for somebody. We instead gave them the cost of coverage in the exchange as compared to the amount per month if there was no exchange. When you compare it with what they would have been faced with in the private market absent the health insurance exchange and premium tax credits, you really were able to significantly increase the percentage of respondents who thought that coverage was now affordable. This is key because affordability is the number one barrier they have encountered when trying to get health insurance in the past.

As you explain to the general public (or advise others in their attempts to educate the general public) about the pending changes, what are the key messages you are trying to convey?

I think the overarching message is extremely simple: there is new coverage available and there is help with the cost of it. When we try to dig deeper to lure folks in and get them interested in and intrigued to apply, the four messages are:

• All insurance plans will have to cover doctor visits, hospitalization, maternity care, emergency room care, and prescriptions.
• If you have a preexisting condition, insurance plans cannot deny coverage.
• You might be able to get financial help to pay for a plan.
• All insurance plans will have to show the cost and what’s covered in simple language and no fine print.

From the survey, we saw that 89 percent of the population, regardless of geography, income, race/ethnicity, educational background, and gender, hears the most important motivator to them from one of these four messages.

How do you employ family and friends in the outreach strategies you recommend to other groups? Furthermore, how is Enroll America utilizing this group in the large campaign you announced in January?

We are very much still in the creative process of figuring out how the campaign is going to look, but you can check out a preview at our newly launched campaign website, Get Covered America. When we look at the research results, people do want to hear from a family member. So there are different ways for us to think about what that means for the campaign. Does that mean that the voice in the advertisement or article is somebody that is a relatable family member? Or do we make sure that we cast a wide net and communicate with as many people and members of the community as possible?

Although there is a question about who the messenger should be, when we ask people in the survey where they are going to go for information, most folks say online. So even though they might want to hear about it from a family member or partner, when it actually comes to taking that step, they are probably going to go online.

Which items on Enroll America’s checklist, Seven Things to Do in 2012 to Keep Enrollment Progress on Track, have been most difficult for states to carry out?

We created the list with the idea of helping every stakeholder that might have a place in the outreach effort. For example, there are roles for state agencies, hospitals, health educators, and consumer advocates. Hopefully they can see themselves in that list somewhere.

When I think about which one is the most challenging to execute, it is probably the auto-enrollment piece for Medicaid and the Children’s Health Insurance Program (CHIP) because that usually requires legislative authority. The authority is not just from the state legislative level, but possibly also at the federal level, depending on what a state wants to do.

The federal government has been very supportive of  novel approaches to this, but there are still a lot of hoops to jump through to make auto-enrollment something that a state can actually do. Auto-enrollment is on the list is because it is such a powerful tool: it could possibly connect the largest volume of folks to coverage. It allows you to potentially reach thousands of people if every parent of a child already on Medicaid or CHIP should automatically be connected to the coverage option that is available and suits them.

Are there any elements on the checklist you feel have not been given adequate attention? Are there any low hanging fruit of which stakeholders should be aware?

First, we recently submitted a round of comments to the federal government on the model, streamlined application they are creating for every state. The idea with this new application is that your family or the household fills out one application and then everybody in the household gets connected to the coverage programs for which they are eligible.

The federal government has done a good job with their model application, but of course there is always room for improvement. We have encouraged them to do as much usability testing as possible because it is one of the best ways to catch problems and correct them.

We are also making sure there is as much collaboration as possible. We have tried to convene large and inclusive groups of stakeholders at the national level and in a number of states, but there are always groups that are late to the table. All of these perspectives, whether it’s consumer groups, tax preparers, hospitals, health centers, health insurance companies, pharmaceutical companies, or drug stores, are relevant. If the messages aren’t consistent or if the referrals don’t work, consumers could get lost in the system and fail to enroll. We know that bad news travels much more quickly than good news. If somebody has a problem with the process, they are going to go tell ten friends. But it might take ten successful processes for one person to tell one friend that it went well.

In terms of more general challenges, we also cannot overestimate the need for assistance. As simple as the new process will be, people are still going to need a lot of help. They think they are going to need help, they expect it, and they are going to be looking for help enrolling. Making sure that states and the federal government are able to leverage enough resources to get enough really well-trained folks on the ground and be able to provide that assistance is one of our number one challenges right now. Thinking about the role for private philanthropies and funding, outreach efforts, and training actual on the ground assistors is really important because I think we are going to need a lot of private efforts to augment what the states and federal government are going to be able to do.

Feature Photo: cc/Luca Rossato

The researchers identify four ways to reduce costs. First, they suggest implementing and expanding telemedicine. This would decrease patient transportation costs and increase access to specialists. Second, they recommend implementing new technologies to decrease the amount of time nurses spend dispensing medication. Automating these repetitive tasks could help decrease medical errors and could ultimately improve the quality of care. Third, by working with other prisons to increase their economies of scale, prisons could improve their bargaining power and negotiate lower cost deals for medications.

The researchers also encourage prisons to continuously seek out less expensive yet equally effective medications to prescribe to patients and increase their prescription of generic drugs. Finally, the researchers recommend cross-training prison employees and hiring lower-paid medical positions, like nurse practitioners or physician assistants, for treating non-critical patients. The researchers find that cross-training often results in improved relationships between correctional officers and inmates and provides more staffing flexibility.

The researchers also suggest five key approaches for reducing inmates’ need for healthcare. First, inmates should be screened upon their intake to identify any pre-existing conditions and treat any current diseases. Better screening can help prevent the spread of infection. Second, patients who are likely to miss their arraignment, due to mental illness or chronic physical health problems, should be sent a reminder note. In Coconino County, Arizona, a reminder system was able to help reduce court no-shows from 25 percent of cases to six percent. Third, many jails have implemented small co-pays for medical visits, which serve as “low-threshold deterrents” for excessive sick calls. These co-pays would not be enforced for patients who are indigent, suffer from chronic diseases, need emergency care, have suffered work-related injuries, or are seeking staff-ordered care. They are easiest to enact if the prison has an in-house bank or canteen system, which would expedite payment and minimize transaction costs. According to the authors, these programs are strongly discouraged by the National Commission on Correctional Health Care (NCCHC), as they are concerned they can deter patients from seeking care to avoid payment. Fourth, some prisons have implemented pharmacies where inmates can purchase over the counter (OTC) drugs, in lieu of seeking medical attention. This recommendation is moderately supported by the NCCHC, although there are concerns that patients may misdiagnose themselves, delay treatment, or suffer from interaction effects between the OTC drugs and other drugs they are currently taking. Finally, prisons could expand or modify their utilization management programs. These programs are used to evaluate the appropriateness, medical efficiency, and need of health care services provided against an established set of guidelines.

The researchers were limited in their data collection due to lack of a centralized database, standardized metrics, and benchmarks for comparing programs. Currently there is no list of “best practices” for prisons, and these programs are implemented on an ad hoc basis. The researchers conclude there is no “one-size fits all solution,” and that more research needs to be done to determine which cost saving strategies provide the most effective results.

 Feature Photo: cc/(Tim Pearce)

An efficient allocation of funds for public health services requires careful consideration of citizen demand and the appropriate type of institutionalization. Is it more efficient to have local public health departments institutionalized independently? Or is it better when public health departments function as agencies of the municipal governments (that is, to be regionalized)?

In the paper “Does Regionalization of Local Public Health Services Influence Public Spending Levels and Allocative Efficiency?” Laurie Bates and Rexford Santerre explore public health service funding and regionalization issues. Because funding for these services comes from taxes and intergovernmental grants, Bates and Santerre assume that demand for community public health services will respond to changes in tax-share, income, and other public spending on education and other municipal services. To explore the allocation of resource efficiency with respect to the type of institutionalization of public health departments, the authors compared the spending levels of the local and regional demands for public health services, then examined if resources for public health services are more efficiently allocated to independent public health departments or regional public health departments.

In a study of 169 Connecticut towns and cities from 2001 to 2008, the authors found that the change of demand for public health services responds more to the change in tax-share than the change in other types of public services, like education. The results also showed that demand for public health services does not respond much to a change in citizen income level and that a change in education spending and other municipal spending is not associated with change in intergovernmental aid on public health spending. According to the authors, such findings imply that there is no spillover effect of public health-directed intergovernmental aid services to other types of public services.

And how does the spending on public health services change in response to the change on institutional structure of public health departments? Research results show that when a public health department in a region shifts from a local independent institution to a regionalized department acting as a governmental agency, there is a corresponding increase in spending on public health services in the region.

To test the allocation efficiency for public health resources, the authors proposed that the efficiency of public health spending in a region be determined by the aggregate property values. The underlying rationale is that public officials decide the level of spending on public health services in order to maximize aggregate property value in the region. The authors found that a 10 percent increase in local public health spending reduces aggregate property values, on average, by 1.2 percent. According to authors, this result indicates that regionalizing independent public health departments may not be the preferred policy goal from the perspective of resource allocation efficiency. In addition, the authors explained that the efficiency loss resulting from additional public health spending is larger in regions with a greater population.

The research by Bates and Santerre has many useful implications for public health funding. The results of their study may help public health officials better understand citizen demand for public health services and find more efficient allocations of resources to serve the public.

Feature Photo: cc/(PNNL – Pacific Northwest National Laboratory)

The authors interviewed patients in two hospitals, which had instituted smoke-free grounds policies three years prior. Study interviews focused on patients’ perceptions in four key areas: policy perspectives, experiences with tobacco during hospitalization, tobacco dependence treatment (primarily nicotine replacement therapy), and enforcement and compliance.

The grounds of the hospitals themselves were evaluated, and the authors found that the layout of both hospitals’ grounds made actually getting “off-campus” to smoke prohibitively difficult. This coupled with long, cold winters in both hospital locations made actually utilizing smoking areas very undesirable for smokers.

Among patients, there was common confusion on the specifics of the non-smoking policies. Almost all patients reported knowing the hospital grounds were smoke-free, but reported confusion on specifically what that meant. Some patients thought just being a certain distance from a hospital door, for example, was satisfactory.

The sentiments of both former-smokers and non-smokers reflected the concern that some patients did not go off the hospital property to smoke, and this resulted in second-hand and third-hand smoke risks to all patients. Policy enforcement was commonly cited as a problem, although most patients agreed that hospital staff who smoked did actually go off the property to smoke.

In some cases, the policy did promote cessation. Many patients reported that the inconvenience of going off the property to smoke made it easier to abstain from smoking during their hospital stay. However, current and former smokers reported inadequate treatment options for their tobacco dependence and withdrawal symptoms. Neither hospital combined their non-smoking policies with cessation program options for patients who were smokers, a weakness cited by the authors.

Overall, the authors report study participants acknowledged “the potential for positive health messages, the importance of de-normalization of smoking in health care settings, and their appreciation for personal protection from second-hand smoke.”

This study is limited in its scope; the authors only investigated two hospitals, and did not consider the perspectives of staff members or other patrons who are affected by a non-smoking policy. However, despite its limitations, the authors still conclude that second-hand smoke is a problem in hospitals, and a variety of individuals do feel the repercussions of existing, and sometimes problematic, smoke-free policies. This is especially salient in the two hospitals studied, since patients cannot safely or easily get off hospital property to smoke.

It will take greater enforcement of non-smoking policies for hospital goals to be fully realized. The authors conclude it will only be in the union of cessation or abstinence support, treatment options to help with smoking withdraw symptoms, and non-smoking policies, that safe and healthy hospital environments can be created for all patients.

Feature Photo: cc/(lanier67)

The widespread scope of this income transfer, in tandem with a decline in influence of traditional cash assistance through the Temporary Assistance for Needy Families (TANF) program has motivated a growing body of literature about the program. Researchers at the University of California, Davis recently added to it by looking into one often overlooked benefit of the EITC: improved infant health outcomes. As the authors note, infant health outcomes, particularly infant birth weight, is an important predictor of future health and economic success.

During the late 1980s and early 1990s the EITC underwent three expansions. One of the largest occurred in the Omnibus Reconciliation Acts of 1993 (OBRA93), which phased in an increase in the maximum credit for families with two or more children of $2,160 (in 1999 dollars). Using the change in the EITC credit under OBRA93, authors Hoynes, Miller, and Simon attempt to isolate the impact of the tax refund on infant health outcomes, especially infant birth weight, by comparing the trends before and after the expansion.

The authors used US Vital Statistics Natality Data, which includes a full census of births from the National Center for Health Statistics, from years around the expansions (1983 to 1999). Limiting the sample to mothers age 18 and older, the authors examined women by state of residence, month and year of birth, parity of birth, education of the mother, and marital status of the mother. After separating the sample by some of these characteristics, they calculated different group statistics, including average birth weight and fractions of births below different birth weight levels. Finally, the authors examined how timing of a mother’s birth coincided with the receipt of tax refund payments.

Since the OBRA93 expansion varied by family size, the authors compared births of different orders (second and higher to first births), while controlling for factors such as unemployment rate, welfare reform and other social program eligibility thresholds. In other words, without the expansion, a mother’s first child (the control group), should have similar outcomes to a mother’s second and third children (the treatment group). Focusing on a high impact sample, single women with a high school education or less, as other literature does, they find this is not the case – low birth weight status is reduced for second and higher births compared to first births as well as the mean. The results of an event study analysis suggests that there was not a pre-trend of decreasing birth weights prior to the expansion that could explain some of the observed changes. Finally, in attempt to quantify the treatment, the authors estimated the “impact of $1,000 treatment on the treated.” They find that for single low education mothers, $1,000 is associated with a 6.7 to 10.8 percent reduction in low birth weight.

The authors find the largest improvements in child health are associated with the groups with greater increases in the EITC – higher births, greater socioeconomic risks, or both. While they can only postulate why the income increase impacts the birth weight and other health outcomes – less stress, and increased access to health services to name a few – they make a case for additional research on health impacts from non-health safety net programs. They conclude that any discussions about the value of the US safety net should be broader than the immediate impacts of the program and instead include external program effects such as these non-trivial health ones.

Feature Photo: cc/DFID – UK Department for International Development

In their annual report “F as in Fat: How Obesity Threatens America’s Future,” the Robert Wood Johnson Foundation examines how obesity could impact the future health and wealth of our country. The report uses data from the CDC’s publicly available Behavioral Risk Factor Surveillance System (BRRFS), described by the CDC as the “world’s largest, on-going telephone health survey system, tracking health conditions and risk behaviors in the United States yearly since 1984.” The report also draws heavily upon forecasting models used in a peer-reviewed article, “Health and Economic Burden of the Projected Obesity Trends in the USA and the UK,” in order to analyze and predict future obesity trends by state.

The report projects that obesity could contribute to more than 6 million cases of type 2 diabetes, 5 million cases of heart disease and stroke, and more than 400,000 cases of cancer in the next two decades nationwide. If current trends continue, by 2030, there will be, on average, approximately 12,000 new cases of Type II diabetes, 25,000 new cases of coronary heart disease, 25,000 new cases of hypertension, 16,000 new cases of arthritis, and 4,000 new cases of obesity-related cancer in every state. Not surprisingly, these trends vary by state. For example, by 2030, forecasts for the number of new cases of Type II diabetes range from 8,658 in Utah to 15,208 in West Virginia. Find the obesity rates in your state by clicking here.

If that is not alarming enough, these diseases come at an enormous economic cost. By 2030, in conjunction with the increase in obesity-related illnesses, medical costs could rise to between $48 and $66 billion per year. Economic productivity would also be affected and between $390 and $580 million could be lost by 2030. In their state-by-state analysis, the report predicts that 40 states will have increases in health care costs higher than 10%. Illinois, for example, is expected to see obesity-related health care costs rise by 16% by 2030 and would rank 21^st in health care costs out of all 50 states.

But it’s not all bad news. The report estimates that if states could reduce the average adult BMI by 5% (or about 10 pounds), they could save billions of dollars. Nearly every state would save between 6.5 and 7.8 percent in obesity-related health costs. Cash-strapped Illinois, for example, could save nearly $10 billion in health care costs by 2020 and $30 billion by 2030, potential health care savings of 7.5 percent, if the average adult BMI were reduced by 5 percent.

The Foundation advocates several policy responses to this pressing public health issue, targeting children, adults, and communities. Some of the many policy responses listed include full implementation of the USDA’s school meal nutrition standards, protection of the “Prevention and Public Health Fund” (the nation’s largest single investment in preventative medicine), increased investments in effective evidence-based obesity-prevention programs, and expanding opportunities to promote physical education and activity in schools.

Notably, many of these interventions are preventative in nature. For example, amongst several other obesity-related issues that might be supported by policy, the authors highlight the Surgeon General’s call for more breastfeeding as an important preventative intervention. In addition to a range of other health benefits, children who are breastfed have lower rates of obesity later in life. Mothers lose pregnancy weight more quickly and are at a reduced risk of breast cancer and postpartum depression.

As our country continues to grow heavier and heavier, the F as in Fat report is a reminder of what is at stake. The severity of the obesity crisis calls for policy makers and families alike to rise to the challenge and to become a healthier, happier, more productive nation.

Feature photo: cc/Pink Sherbet Photography