Office of the Assistant Secretary for Planning and Evaluation
	Policy Information Center

Chapter I

Results in Brief of Selected Program Effectiveness Evaluations

In this chapter of Performance Improvement 2001, the U.S. Department of Health and Human Services (HHS) presents the “results in brief” of FY 2000 completed evaluations that specifically address the effectiveness of a program or service. The evaluation may focus either on: (1) broad program strategies, which may encompass a number of authorized programs to address a particular need; (2) a single program that has it own congressional authorization and appropriation; or (3) a specific activity within a program that is essential to its overall effectiveness. These evaluations may provide important information for Congress in decisions about HHS programs. The evaluations are organized according to general HHS programs areas:

Public Health Programs

• Access to Health Care
• Drug Application and Review
• Environmental Health
• Food Safety and Nutrition
• Health Statistics
• Infectious Disease Prevention
• Injury Prevention
• Maternal and Child Health
• Occupational Health
• Public Health Infrastructure

Healthcare Financing

Human Service Programs

Welfare Reform

• Cross-Cutting
• State Welfare Reform Programs

The “results in brief” presentation for each evaluation provides the title of the final report, followed by a capsule summary of the HHS program involved, the study purpose, the major findings, and the recommendations or uses. Following the summary is a reference page number in Chapter III for additional information on the HHS agency sponsor, federal contact (including telephone number), the evaluation performer, and the project database number in the HHS Policy Information Center (PIC), where an electronic copy of the final report is accessible at the Internet address: http://aspe.dhhs.gov/pic.

PUBLIC HEALTH PROGRAMS

ACCESS TO HEALTH CARE

The National Health Service Corps

The evaluation of the effectiveness of the National Health Service Corps (NHSC) focused on mechanisms for training and recruiting providers, placement in underserved areas, and retainment in primary care and related professions. The findings showed that NHSC:

• needs to focus more sharply on the loan repayment program to meet the needs of underserved populations, based on findings that the loan repayment program has greater impact in achieving NHSC objectives.
• achieves better outcomes in rural communities, because they may enable young clinicians to make relatively important contributions in a short period, enhancing their professional gratification.
• should strategically manage the mix of health professionals it supports in response to both community requirements and NHSC health service delivery objectives.

The study concluded that underserved areas continue to need NHSC placements if they are to provide basic health care to a growing and diverse population. NHSC helps extend and expand access to basic health care services and improves the health care delivery system in underserved communities.

DRUG APPLICATION AND REVIEW

Evaluation of Written Prescription Information Provided in Community Pharmacies: An 8-State Study

This evaluation assessed the quality of written prescription information provided voluntarily to individuals receiving new prescription medicines in community pharmacies. The study tested whether fictitious patients as observers were given any written prescription information by pharmacists whom they asked for drugs prescribed (in addition to the labels and stickers on their medication containers). The quality of written information was also assessed. This pilot study produced encouraging results for consumers:

• nearly 87% of new prescriptions were dispensed with some written prescription information in addition to the label and stickers on the medication container, suggesting that the provision of written prescription information is becoming a routine practice in community pharmacies.
• expert panelists found that most written information sheets were accurate and unbiased in content and tone. They included necessary details for monitoring and interpreting adverse reactions and appeared legible and comprehensible to consumers.

The study raised several concerns: most patient information was rated low on identifying precautions, their significance, and how to avoid them, and storage instructions and general information. The study will be repeated nationally in 2001 and the results will be used to identify areas for improvement in consumer communication of prescription information.

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FY 2000 Performance Report to Congress for the Prescription Drug User Fee Act of 1992

The Prescription Drug User Fee Act (PDUFA) authorized FDA to collect fees from companies that produce human drug and biological products. The PDUFA annual performance report to Congress for FY 2000 focuses on the Agency's performance toward the agreed-upon numeric goals for reviewing and acting on submissions and responding to sponsors' pre-submission requests. The major accomplishments to report are:

• FDA continued to exceed nearly all the review performance goals in FY 2000—increasing numbers of applications filed; higher quality applications; quicker approvals for products with the requisite data; and outcomes that result in more quality products reaching American practitioners and consumers faster.
• application filings and quality remain high by historic standards and approval times continue to drop;
• compared to the approval rates for all new drug applications, there is a smaller increase in approval rates for new molecular entities (NMEs), unique new drugs that are approved for the first time by FDA.
• median total approval time (i.e., time from the initial submission of a marketing application to the issuance of an approval letter) for priority applications submitted in FY 99 was 6 months, less than half the median approval times for priority applications submitted in the early PDUFA years.

The FDA performance report states that since the passage of PDUFA there has been a shift in the pattern of NME introductions with more American patients now receiving the benefits of important new drugs before they are available to citizens of other countries. This shift requires that FDA be increasingly vigilant in its post-market surveillance efforts.

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Infant Immunization with Acellular Pertussis Vaccines in the US: Assessment of the First Two Years’ Data from the Vaccine Adverse Events Reporting System (VAERS)

The evaluation objective was to assess the safety of infant immunization with acellular pertussis vaccines in the United States. In 1996, the FDA approved the first acellular pertussis vaccine for use in infants in the United States. The study examined adverse events in the US after infant immunization with pertussis-containing vaccines, using the Vaccine Adverse Event Reporting System (VAERS), a national surveillance system. The overall findings showed that:

• the annual number of reported events categorized as nonfatal serious (defined as events involving initial hospitalization, prolongation of hospitalization, life-threatening illness, or permanent disability) to VAERS for all pertussis-containing vaccines declined between 1995 and 1998.
• the annual number of less serious reports to VAERS for pertussis-containing vaccines also declined.
• this evaluation did not identify any new safety concerns of the vaccine based on an analysis of VAERS data for acellular pertussis vaccines, with regards to adverse events identified in a 1991 Institute of Medicine report on the safety of diphtheria-tetanus-pertussis vaccine.

The study findings support the safety of marketed acellular pertussis vaccines. In addition, the VAERS data, although subject to the limitations of passive surveillance, support the prelicensure data with regard to the safety of the US-licensed acellular pertussis vaccines evaluated in this study.

FOOD SAFETY AND NUTRITION

Consumer Attitudes Toward Potential Changes in Food Standards of Identity

As part of the 1995Regulatory Reinvention Initiative, FDA evaluated federal food standards of identity regulations (intended to assist consumers with the identity, quality, and fill of containers for standardized foods) to guide policy decisions about which standards should be retained, revised, or revoked. Consumer attitude data toward standards of identity regulations, collected in eight focus group discussions with household grocery shoppers, were analyzed. The principal findings showed that the focus group participants:

• those who think standards are bad believe that truth-in-labeling laws are adequate protection for consumers;
• supported standards in a philosophical sense;
• did not think their choices were being unduly restricted by standards;
• had concerns about the time it takes them to find products they like in the grocery store than about a lack of product choice.

Overall, the focus group participants were wary of trying to draw generalizations about when standards would be bad, and instead, they felt that evaluating and revising standards could only be done on a case-by-case basis. Furthermore, participants felt that FDA should get input from consumers about standards and not rely on industry.

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Status of Nutrition Labeling, Health Claims, and Nutrient Context Claims on Processed Foods - 1997 Food Label and Package Survey (FLAPS)

This evaluation study analyzed data to determine the status of food labels three years after nutrition labeling rules were implemented in 1994. FDA conducted the 1997 Food Labels and Package Survey (FLAPS) as an ongoing effort to monitor the food industry’s response to the food labeling regulations. FLAPS allows FDA to characterize various aspects of the labeling of processed, packaged food products, including the prevalence and accuracy of nutrition labeling, health claims, and nutrient content claims. Product classes representing 80 percent of the sales in each of 58 product groups were included in the sample. From each product class, FDA selected the 3 top- selling product brans and randomly selected follower brands. Based on label information from a final sample of 1,267 food products and weighting by food market data, FDA determined the percentage of products sold that bearNutrition Fact labels, health claims, and nutrient content claims. The major findings of the survey were that:

• Nutrition-labeled products accounted for an estimated 96.5 percent of the annual sales of processed, packaged foods.
• An additional 3.4 percent of products sold were exempt from labeling regulations.
• Nutrient content claims and health claims appeared on a estimated 39 percent, and 4 percent respectfully, of the products sold.

The 1997 FLAPS collected sufficient product label information to estimate the prevalence of nutrition labels for most processed, packaged foods in the US. Although regulation for nutrition labeling have changed since the survey’s start in 1976, the FLAPS data collected allow for analysis of consistent patterns and trends in food labeling practices.

HEALTH STATISTICS

Report of the Panel to Evaluate the U.S. Standard Certificates and Reports

TheNational Vital Statistics System is the Nation’s capacity to collect data maintain statistics on birth, deaths, fetal deaths, marriages, and divorces. These data come from State vital registration systems where standardize certificates are filed. The evaluation purpose was to assess current certificates for usefulness and quality for statistical and legal purposes; identify unmet data needs and determine whether the standard certificates should be changed; make recommendations for a standard vital statistics data base. Based on survey data from State vital registration and statistics executives and representative national health organizations and the work of an expert panel, the study found that:

• substantial changes were needed for the standard birth certificate, particularly the medical portion;
• additional data items are needed on the mother’s health which could linked to other health data sources;
• changes are recommended for the standard certificates on death and fetal deaths to include data items that could permit linkages to other health data systems and would improve the quality of “cause-of-death” data.

INFECTIOUS DISEASE PREVENTION

Evaluation of Effectiveness of Group B Streptococcal Disease Prevention Guidelines

Group B Streptococcus (GBS) is the leading cause of bacterial infection in newborns in the United States. To address the problem CDC developed prevention guidelines in collaboration with the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) and published the guidelines in the Morbidity and Mortality Weekly Report in 1996. This evaluation assessed the management of GBS disease in the United States, looking at the extent to which the guidelines were followed and factors associated with poor compliance. Results showed that:

• implementation of the new GBS prevention guidelines was successful at the test site (Group Health Cooperative of Puget Sound) and was accomplished in a short time period;
• more complete compliance with GBS guidelines helped to improve clinical outcomes for mothers with GBS infections; and
• a cost benefit analysis showed that the costs of delivering antibiotics is minimal compared with the potential health and economic benefits from reduced infant mortality.

This population-based evaluation is a good example of collaboration between managed care organizations and public health agencies to determine the impact of national disease prevention guidelines on health care providers.

INJURY PREVENTION

Evaluation of National Center for Injury Prevention and Control (NCIPC) Injury Control Recommendations for Bicycle Helmets

In 1995, NCIPC published recommendations on the use of bicycle helmets in preventing head injuries, including information on the magnitude of related head injuries, potential impact of increased helmet use, helmet standards and crash performance, barriers to increased helmet use by the public, and approaches to increase community-level bicycle helmet use. The evaluation purpose was to measure effective use of the recommendations by NCIPC’s injury prevention constituents (state and local health officials and national bicycle safety advocate organizations) and access the process of developing the recommendations. The study’s survey of constituents showed that:

• ninety percent of respondents found the recommendations useful for their efforts to increase bicycle helmet use, such as directing a bicycle helmet promotion program, advocating for a injury prevention program, and disseminating information to other injury prevention constituents; and
• eighty percent of respondents said that CDC should develop additional recommendations to address prevention service problems.

The evaluative survey results on bicycle helmets have helped CDC to improve the development and dissemination of injury control recommendations.

MATERNAL AND CHILD HEALTH

Effect of Healthy Start on Infant Mortality and Birth Outcomes

TheHealthy Start program was launched in 1991 by the Health Resources and Services Administration (HRSA) of the U.S. Public Health Service to demonstrate innovative ways to reduce infant mortality in some of the areas with the highest infant mortality rates in the country. Strategies used in the selected fifteen high-risk communities included outreach, case management, public information campaigns, support services, health education, and enhanced clinical services. Thirteen of the fifteen sites were urban. This evaluation analyzed the effects ofHealthy Start on pregnancy- related outcomes by comparing the original fifteenHealthy Start sites with comparison communities from 1991 thorough 1996. Infant mortality related outcomes – prenatal care utilization, pre-term birth rate, incidence of low and very low birth weight infants, and infant mortality rates–for the fifteenHealthy Start communities were compared with two comparison communities pre site for fourteen of the sites. Conclusions of the study suggest thatHealthy Start communities showed:

• increased use of any prenatal care in five project sites;
• increases in first trimester care in three communities;
• improved adequacy of prenatal care in eight communities;
• increases in the adequacy of prenatal care in four projects;
• improved adequacy of the number of prenatal care visits in nine projects; and
• and improvements in all prenatal care measures in three of the project areas.

As for health outcomes, Healthy Start was associated with lower pre-term births in four sites; reductions in low birth weight in three project areas; and reductions in infant mortality rates, neonatal mortality, and post neonatal mortality in two sites each.

PUBLIC HEALTH INFRASTRUCTURE

Evaluation of the National Electronic Telecommunication System for Surveillance

The National Telecommunications System for Surveillance (NETSS) is a computerized public health surveillance system that assembles, analyzes and disseminates weekly data on about 50 nationally notifiable diseases, provided by state and territorial health agencies and transmitted to CDC's Epidemiology Program Office (EPO). Providers, clinical laboratories, and public health officials collect NETSS data at the state and local level. The evaluation purpose was to examine the effective use of communicable disease data transmitted to CDC over NETSS by state and local public health officials, as well as CDC officials. Identification of barriers to effective use and ways to make improvements was and another study objective. The results showed that:

• state health officials said they are making effective use of NETSS data to track trends in communicable diseases, detect epidemiological patterns, and compare observed levels of disease to expected levels;
• these officials had encountered some technical barriers to the use of NETSS data; and
• some major problems identified concerned outdated computer technology or incompatibilities with other electronic disease surveillance systems, including unresolved software malfunctions.

The state epidemiologists recommended that disease data from other states be available for analysis.

HEALTHCARE FINANCING

Report to the President: Prescription Drug coverage, Spending, Utilization, and Prices.

Although the use of prescription drugs are increasingly improving health outcomes and quality of life, these drugs, and in particular new drugs, are not available to everyone. The elderly and disabled Medicare beneficiaries in particular have either inadequate or no coverage for drugs. The purpose of this study is to examine drug costs and trends for Medicare beneficiaries, using a combination of public and private databases, data on coverage, effects of coverage on spending and utilization, and prescription drug prices. The principal findings are:

• although 85% of Medicare beneficiaries use at least one prescription drug annually, only 54% were covered for a full year during 1996, and 25% had no coverage. Most sources of drug coverage for these individuals are unstable; and drug benefits are becoming less generous.
• the very old, those who live outside a metropolitan area, and those at the higher end of the poverty spectrum are the least likely to be covered.
• rates for prescriptions are currently higher for those with five or more chronic conditions.
• there are very significant differences in drug utilization and out-of-pocket spending between those with coverage and those without, regardless of health status.
• prescription drugs represent a significant source of spending, taking up about one-sixth of all health spending by the elderly (cash customers pay more for drugs than do those with third party payments).

The study provides a detailed examination of multiple factors related to coverage, utilization, and spending for prescription drugs, particularly for the Medicare population.

HUMAN SERVICE PROGRAMS

The Potential of the Child Support Enforcement Programs to Avoid Costs to Public Programs: A Review and Synthesis of the Literature

The Child Support Enforcement Programs ensures that non-custodial parents provide appropriate financial support for their children through four major services: locating absent parents, establishing paternity, establishing child support and medical support obligations, and enforcing support orders. One of the goals of the program is to reduce government expenditures on means-tested public assistance programs by increasing the amount of child support paid to custodial households by non- custodial parents. This study synthesizes the theoretical and empirical literature on cost avoidance to build a comprehensive and coherent framework to evaluate the intricacies of child support cost avoidance. The main findings drawn from the literature are:

• several studies present estimates of cost avoidance, but differences in methodology, populations analyzed and assumptions by the authors make comparability and generalizations difficult to estimate;
• although realized cost avoidance is relatively modest under the current child support enforcement system, the potential for cost avoidance is unknown;
• evaluations of several demonstrations found that periodic review and updating of support orders for AFDC cases was effective in avoiding state and federal government costs, that is the overall cost of the process was less than the increase in dollars collected; the literature indicates that child support enforcement has, at most, a limited indirect effect on cost avoidance by changing the marital and childbearing behavior of custodial and noncustodial parents.

The current research focuses on custodial parents and suggests that child support enforcement has a small deterrent effect on divorce and little or no deterrent on out-of-wedlock childbearing. The few published studies on the effect of child support on the labor force participation of custodial mothers find mixed results.

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Evaluation of Head Start Family Child Care Demonstration: Final Report

This evaluation assessed, over a three-year period, the effectiveness of the Head Start Family Child Care Homes (HSFCCH) demonstration projects, funded by the Administration for Children, Youth, and Families (ACYF) during Fiscal Year 1992. It also compares services delivered in family child care homes to those delivered in Head Start centers. The findings showed: on

• no significant differences in child cognitive, physical, and social-emotional outcomes between family child care homes and center classrooms;
• the kindergarten followup did not show any significant differences as a result of the family child care homes versus center classroom;

The study concluded that family child care homes can meet Head Start standards of quality and can produce similar outcomes in children and families.

WELFARE REFORM

CROSSCUTTING PROGRAMS

Welfare Leavers and Medicaid Dynamics: Five States in 1995

State welfare caseloads have been declining at an unprecedented rate since 1994, partly as a result of state and federal welfare reform efforts and partly because of a strong economy. Medicaid enrollment for children and their parents has been shrinking as well (although less so than welfare), in spite of state efforts to expand their Medicaid eligibility policies. This study analyzed the 1995 Medicaid enrollment patterns of children and their parents in five states--Alabama, California, Florida, Michigan and New Jersey--to assess the impact of welfare declines on overall Medicaid enrollment. The findings showed that:

• declines in the welfare caseload which began in 1995 are likely to have a noticeable effect on state Medicaid programs, in terms of overall enrollment, caseload mix, and per capita expenditure levels.
• some of the states were able to increase enrollment through the non-welfare eligibility groups by making greater use of the child poverty-related, transitional assistance, and medically needy groups.
• many welfare leavers are not staying on Medicaid and are at risk of becoming uninsured.
• states are experiencing considerable turnover in their Medicaid caseloads.
• since state welfare caseloads declined at much greater rates after 1995, there is concern that Medicaid enrollment will drop even more, and that Medicaid reductions may be contributing to the continuing problem of the uninsured.
• state officials report that many families leave welfare without providing the information needed to redetermine their continued eligibility for Medicaid.

One conclusion of the study is that while states may continue to make policy changes to expand Medicaid coverage provisions in an effort to reduce the number of uninsured, these changes are not likely to be effective unless steps are also taken to improve individual continuity in Medicaid coverage.

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Dynamics of Children’s Movement Among the AFDC, Medicaid, and Foster Care Programs Prior to Welfare Reform: 1995-1996

This study examined patterns of program utilization by children before and after welfare reform to assess how the social safety net programs and human service utilization have been affected by ending the entitlement to cash assistance and placing new work-related requirements on their parents. Three programs affected by welfare reform were studied: Temporary Assistance for Needy Families (TANF), Medicaid, and foster care during 1995-1996, or the years immediately prior to welfare reform, which was implemented first in 1997. The major findings were:

• the consistency across states in the numbers participating in AFDC and Medicaid prior to foster care entry suggests that poverty, or perhaps participation in welfare program, plays an important role in the entry of children into foster care.
• transitions from AFDC to a system exit are most likely among the oldest children in all three states, suggesting that families with the youngest children are the most acutely needy and likely to remain on AFDC longer than families with older children.
• With the emphasis on work and time limits, welfare reform is likely to result in more and earlier exits from cash assistance.

The major conclusions of the study are that welfare reform is likely to have many effects on children and their families. Each state will differ based on its program practice and policies, economy, demographic characteristics and other factors. Each state will have to tailor its plans accordingly.

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STATE WELFARE REFORM PROGRAMS

Final Results from Florida’s Family Transition

In 1994, Florida started the Family Transition Program (FTP) in Escambia Country as a pilot test site, the first welfare reform initiative to test time limits for eligibility and continued benefits. Families were limited to only 24 months of assistance during a 60-month period (36 months out of 72 for the least job-ready persons) and were provided services and incentives to find work. The evaluation was a random assignment comparison group study of welfare recipients placed in FTP and others receiving traditional Aid to Families with Dependent Children (AFDC) benefits. The findings showed that:

• FTP recipients, compared to those in the AFDC group spent less time on welfare over the four follow-up periods. There were fewer impacts on children, with the exception of some negative impacts on adolescents’ school performance; and
• FTP families gained in income more than they lost in welfare payments. Slightly less than half of the FTP families who reached their time limits worked steadily in the subsequent18 months, many relying on family, friends, Food Stamps, and housing assistance.

The conclusion was that time limits can be imposed without widespread impact on families, but that the robustness of the local economy may be a strong contributing factor.

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Reforming Welfare and Rewarding Work: Final Report on the Minnesota Family Investment Program (Summary; Volume I: Impact on Adults; Volume II: Impact on Children)

The Minnesota Family Investment Programs (MFIP) combined financial work incentives with participation or work requirements for long-term welfare recipients. The MFIP evaluation examined ways that states could increase the probability that long-term welfare recipients will be able to support themselves before they reach their time limit on welfare benefits; how states support the efforts of low-income workers to stay in their jobs and provide for their families in this era of time-limited welfare; how social policies avoid penalizing marriage; and the policy adjustments that states have made in changing their welfare systems from Aid to Families with Dependent Children (AFDC) to Temporary Assistance to Needy Families (TANF) affect families and children. The evaluation findings show that:

• single-parent, long-term welfare recipients benefitted most from the MFIP program, mainly in employment and increased earnings compared to AFDC participants. However, total costs were higher, since families retained their welfare benefits even as their earnings increased.
• MFIP families showed improvements in family well-being, as evidenced by positive parental reports on children’s behavior, decreases in reported domestic abuse, and modest increases in marriage rates.
• For two-parent recipient families, the proportion of parents who stayed married increased, compared to AFDC families, and the program enabled second earners to work less.
• Results on parent or child outcomes between the experimental and control groups were not significantly different for more recent welfare applicants for whom job preparation services were not mandatory.

Lessons learned from this evaluation concern types of families for which the experiment is most effective (e.g., single-parent and two-parent long-term recipients versus single parent and two-parent recent applicants); which program components (financial incentives, mandatory employment and training) contribute most to economic outcomes and social impacts on both families and children.

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Evaluation of North Dakota’s Training, Education, Employment, and Management (TEEM) Program

The North Dakota Training, Education, Employment and Management (TEEM) program is the state’s Temporary Assistance to Needy Families (TANF) program to families, providing the following cash assistance and supportive services: a computerized assessment that results in a social contract and referrals to needed services; incentives to promote work and work effort; sanctions for non-compliance with the program requirements; increased asset limits allowing families to save while on aid; and a benefit cap that precludes TEEM recipients who get pregnant while on aid from receiving additional cash benefits for that child. The evaluation of TEEM monitored program implementation and examined client caseload trends and client characteristics between 1997 and 1999 to measure outcomes. The monitoring effort identified programs improvements needed in providing information to recipients on Earned Income tax Credit, more training for TEEM staff on case manager role; and changes in the client assessment process. The client outcome trend data showed that:

• TEEM families retained substantial public assistance from other sources after finding employment;
• Native Americans increased as the proportion of TEEM adults cases between 1998-1999 and had higher TEEM recidivism rates;
• the child-only cases increased proportionately and were living with parents receiving disability payments;
• and the proportion of case closures due to employment declined over time, which may have been due to problems with the closure codes.

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Analysis of Administrative Data on Families Receiving Welfare and Diversion Assistance under the Work First Program: Third Quarterly Report

TheNorth Carolina Work First Program’s third quarterly report analyzing administrative data examined patterns of welfare participation, employment, earnings, and other key outcomes among families who enter and leave theWork First program, and persons who receive Diversion Assistance. The findings show that:

• families in the AFDC entry cohort were more likely to be still on assistance 36 months after going on welfare compared to families in the Work First entry cohort;
• Work First program has had far less impact on child-only cases than on other cases;
• length of stay on welfare for all entry cohorts was longer for persons without a work history, persons without a work history and a high school diploma, families that were younger, African American, and living in large cities; and
• fewer families in theWork First program, compared to the AFDC exit cohorts returned to cash assistance in the followup study period.

No major differences were found between the exit cohorts in employment rates, which seemed to be more influenced by seasonal factors. All cohorts showed evidence of earning progression after leaving welfare, controlling for seasonal variations.

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Study of Families Receiving Diversion Assistance Payments Under the Work First Program

TheNorth Carolina Work First Diversion Assistance program serves families eligible forWork First cash assistance but instead receive diversion assistance in the form of cash payments equal to as much as three months ofWork First benefits. The program goal is to provide assistance to families when they need short-term help to become or remain self-sufficient, as an alternative to going on welfare. The evaluation consists of telephone interviews with 242 families receiving assistance between May 1999 and August 1999. The study found that:

• client household characteristics, plus prior welfare use and employment, varied by county which was interpreted as variations in the county’s approach to targeting diversion assistance.
• one quarter of respondents said they were not working;
• there was evidence of food deprivation among 22 percent of respondents but no evidence of major problems of hunger, homelessness, poor housing conditions, or placement of children.

The results suggest that county administration of the programs should take caution in using diversion for applicants that do not have a recent work experience.

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Study of Families Leaving Work First Due to Time Limits: Results of the Second Round of Follow-up Surveys

The evaluation of theNorth Carolina Work First program includes a report on results of the second round of follow-up surveys in late 1999 on the status of families who left the programs in August 1998 as a result of reaching the 24-month time limit. The first round of surveys were conducted between December 1998 and March 1999. Between the first and second survey rounds, the employment changes experienced by leaving families showed that:

• employment was slightly higher; the rates of job turnover were not significant; almost half of respondents said they received a raise between interviews (however, the earning progress ion may be unique to the sample and all welfare leavers).
• as for employer health insurance, participation in such plan when available increased for respondents, but largely because they became eligible to participate in plans by reason of increase time on the job and increased work hours;
• the two reasons given by respondents who were unemployed at the second round were-- could not find a job or get one after applying, and could not take work because of disability or illness.
• There was an increase in the number of respondents who said they had experienced adverse events since leaving, with ability to buy food as the one most often mentioned.
• No significant differences were found for access to health care, child care, and housing, nor differences in children’s school performance.
• Employed respondents with higher incomes thought they were better off without welfare, but the pattern was inconsistent at the lower income levels.