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Policy Information Center Highlights: Vol. 12, No. 3


Big Cities Health Inventory:
The Health of Urban USA

In 1994, the Chicago Department of Public Health (CDPH) assembled and prepared the first Big Cities Health Inventory (BCHI).  Seven years after the first edition, the Inventory continues to be one of the few reports presenting city-level health data in the U.S.  This current edition, also prepared by CDPH, represents a collaborative commitment to providing information for improving community health.  With funding in part by the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA), the collaborative entities consisted of the National Association of County and City Health Officials (NACCHO) and local health department partners.  In addition to the data presented in the report, this edition examines the need for and uses of city-level data to identify local health priorities, design interventions, evaluate performance, and further public health policy.

There are relatively few sources that provide health-related data specific to cities.  Most reports only present data at the state-level and those that describe low level data are often at the county or metropolitan statistical area-level (MSA).  The purpose of this report is to focus specifically on the health of large cities in the U.S.  In so doing the report intends to increase knowledge of the issues large cities face and stimulate dialogue that will lead to a healthier city population.

The report presents a broad overview of the health of more than 40,000,000 people residing in the 47 largest cities in the United States.  These cities accounted for nearly 25% of all births and deaths in the United States.  Overall, the health outcomes of these cities are less favorable than that of smaller urban and rural areas and compare poorly to the national overall.  For instance only one city, Honolulu, had a mortality rate lower than that of the U.S. overall, whereas most other cities had a rate higher than the U.S.

The data presented in this and other studies analyzing urban health suggest that there is a unique urban health profile influenced by the dynamics particular to large cities.  This information provides a benchmark for establishing current health status and highlights priority areas for reducing health disparities in minority populations.

The report focuses on 20 indicators of health: five indicators of communicable diseases, nine causes of mortality, and six indicators of maternal and child health (See Table).


Health  Indicators
These 20 health indicators were selected because they are the leading causes of morbidity and mortality and are among those commonly used in public health.
Communicable Diseases Mortality Maternal and Child Health
AIDS Overall Mortality Infant Mortality
Primary and Secondary Syphilis Heart Disease Fertility
Gonorrhea All Cancer Low Birthweight
Chlamydia Lung Cancer Mothers Under Age 20
Tuberculosis Female Breast Cancer Adequate Prenatal Care
  Motor Vehicle Injury Maternal Smoking

This report was prepared for HRSA’s Office of the Administrator by the Chicago Center for Health Systems Development.  The Project Officer, Michael Millman, may be reached at (301) 443-0368, and a copy of the report, PIC ID# 7241, can be obtained from the PIC.

Geoanalysis of HIV Prevention Services
Provided by CDC-Funded Community-Based Organizations (CBOs)

This study was conducted to construct a national, geo-referenced database of HIV prevention services provided by CDC-funded community-based organizations (CBOs).  This database was created to provide information about CBO locations, HIV prevention services provided, and geographic services areas of prevention programs.  An additional objective was to pilot the use of geographic information system (GIS) technology to examine the geographic distribution of CBO-provided HIV prevention services and identify potential gaps in service provision.

The Research Triangle Institute (RTI) conducted a mail survey of all HIV prevention service providers funded by CDC, utilizing an instrument that consisted of six questions that obtained information about intervention type, risk population, race/ethnicity of populations served, funding source, geographic units comprising the service area, and the geographic distance within which the majority of persons served were located.

To ensure a high response rate, RTI used a number of follow-up measures such as postcard reminders, letters and telephone prompting.  These measures yielded an overall response rate of 70 percent.  The 1,020 CBOs responding reported on a total of 3,028 HIV prevention programs.

A preliminary analysis of the data at the national scale revealed that while the nationwide geographic distribution of CBOs, on the whole, is not extremely localized or uneven, there are states that have less than their “expected share” of CBOs, based on general population distribution and the distribution of two sub-populations – African Americans and persons living with AIDS. 

The preliminary analysis also included service area mapping and brief descriptions of the results of a series of univariate queries that were made on intervention type, risk population and race/ethnicity served.

RTI also demonstrated the potential of integrating GIS technology with gap analysis, a methodology that is often used to assess the need of specific populations for HIV prevention services.  RTI identified the following steps for carrying out geographic gap analysis in a health services context:

  1. Map the “unmet” need for services for a given target population.  This step may require cartographic modeling of certain population distributions and known risk factors.
  2. Map the geographic service areas of programs that provide services to specified target population.
  3. Use GIS overlay to intersect the maps of unmet need and existing service areas.

RTI has created a dynamic, spatially enabled database, the HIV Prevention Services Database, that will provide CDC with a wealth of information about HIV prevention services, with large potential for geographic modeling, analyses, and mapping.

While the analysis carried out by RTI is by no means exhaustive, it does demonstrate the potential of using GIS technology to 1) better understand spatial patterns of prevention service delivery, and 2) provide important information for program administration and decision making.

This report was prepared for the Centers for Disease Control and Prevention (CDC) by the Research Triangle Institute (RTI).  The project officer, Aisha Gilliam, can be reached at (404) 639-0919.  A copy of the report, PIC ID # 7840,  is available in the PIC.

Comings and Goings:
The Changing Dynamics of Welfare in the 1990s

During the 1990s, changes in the rules governing public assistance and a robust economic expansion altered both the composition of the welfare caseload and the processes by which families move on and off welfare.  By the late 1990s, families on welfare had an easier time finding jobs; low-income families not on welfare were less likely to take up welfare benefits; and an increasingly large share of families had high enough incomes that they were not likely to contemplate welfare as an option. 

Over the same time period, changes in policies such as the establishment of lifetime time limits for the receipt of public cash aid, more stringent work requirements, and sanctions for non-compliance with program requirements likely deterred people from coming onto welfare and pushed current recipients off the rolls.

To examine changes in the characteristics of families moving onto and off of welfare, the speed with which they move on and off, and the reasons for these transitions, the study compared the experiences of low-income single mothers early in the 1990s under Aid to Families with Dependent Children (AFDC) with those of similar women in the mid- to late 1990s under welfare reform (both state waiver programs and programs funded under the Temporary Assistance to Needy Families (TANF) block grant).  Single mother families were selected because there are far more one-parent welfare cases than two-parent cases, and child-only cases are not subject to the same work-related requirements and time limits as cases with an adult present.

Data from the 1990 and 1996 panels of the Survey of Income and Program Participation (SIPP) supplemented with data on state welfare policies and economic conditions were utilized for this analysis.  Each SIPP panel provides detailed information on family composition, income, work effort, and receipt of public assistance for a large, representative sample of households that is re-interviewed every four months over at least a 32-month period.

The major findings are as follows:

  • Welfare participation rates for low-income single mothers declined from 45.7 to 38.1 percent between 1990 and 1996.
  • During the 1990s welfare entry rates remained relatively stable.  Roughly one out of every eight low-income single mothers who were not on welfare at the start of the 1990s eventually entered welfare over the next 32 months.
  • Changes in welfare policies–such as the reduction in benefit levels and the introduction of policies such as the family cap–and changes in the relative importance of personal, family and environmental factors on the decision to enter welfare worked to reduce entry rates.
  • Exit rates from welfare increased sharply between 1990 and 1996.  Among low-income single mothers on welfare at the start of 1990, 26.8 percent left welfare over the next 28 months compared with 60.6 percent for those on welfare at the start of 1996.
  • Changes in economic conditions account for about 40 percent of the rise in exit rates while changes in welfare policies account for about 20 percent.
  • While the exit rates differ substantially across the 1990 and 1996 cohorts, the work behavior and food stamp receipt of exiters are quite similar.  Roughly 64 percent of welfare exiters in both the 1990 and 1996 cohorts worked in the 4-month period in which they exited the welfare program.  Similarly, it was found that 47.7 percent of exiters from the 1990 cohort received food stamps compared with 51.7 percent in the 1996 cohort.  This finding runs counter to a common impression that food stamp use among welfare exiters declined over the 1990s.

This report was prepared for the Administration on Children and Families by the Urban Institute.  The Project Officer, Girley Wright, can be reached at (202) 401-5070.  A copy of the report, PIC ID# 7530, can be obtained from the PIC.

Final Synthesis Report of Findings
from ASPE’s “Leavers” Grants

Since the Aid to Families with Dependent Children (AFDC) program was replaced by the Temporary Assistance for Needy Families (TANF) in 1996, federal cash assistance caseloads have dropped by over 55 percent, from 4.4 million in August, 1996 to 2.1 million in March, 2001.  There is interest at the federal, state, and local levels in better understanding the circumstances of the unprecedented number of families that have left welfare, including their employment status, participation in public programs, and the overall well-being of both the leavers and their children.

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) awarded competitive grants to select states and large counties in September, 1998, to conduct studies of families that have left the welfare rolls.  This report reviews and synthesizes key findings from fifteen of the ASPE-funded leavers studies.  The synthesis includes information on welfare leavers’ employment and earnings, public assistance program participation, income and poverty status, material hardships, and child well-being.  The major findings for each area are summarized below:

Employment & Earnings

  • No single barrier to work consistently affects a majority of leavers; however, a substantial minority of leavers must overcome child care and health-related problems in order to work.


Program Participation

  • About half of leaver families receive food stamps in the first quarter after exit and about two thirds receive these benefits at some point in the year after exit.
  • About three out of five leaver families have an adult enrolled in Medicaid in the first quarter after exit.  Medicaid coverage of children is generally higher, ranging from 60 to 90 percent after exit.


Household Income

  • Across all leaver families, own earnings are the most important single source of income, and own earnings plus the earnings of other family members together comprise over three-quarters of leaver families’ incomes on average.
  • Average monthly family income for leavers generally hovers near the poverty line.


Material Hardship

  • A quarter or more families experience food hardships at some point after exiting TANF such as having enough money for food or having food last until the next paycheck.  A similar proportion experience trouble paying rent or utilities.
  • Although some studies show that leavers experience the same or lower levels of food and housing-related hardship after exit relative to when on TANF, other studies show that hardships increase after exit.


Child Well-Being

  • One-tenth to one-quarter of leaver families have children without health insurance.
  • A substantial percentage of leaver families rely on their parents for child care.  Extended family members are by far the most common sources of care for children when parental care is not available.


This report was prepared by the Urban Institute, for the Assistant Secretary for Planning and Evaluation (ASPE), Office of Human Services.  The Project Officer, Matthew Lyon, can be reached at (202) 401-3953, or you may obtain a copy of the report, PIC ID# 7368 from the PIC.

Professional Nurse Traineeship Grants:
Who Gets Them and Where Do They Work After Graduation?


Graduate nurses, nurse practitioners, nurse anesthetists, and nurse midwives, play a vital role in serving the needs of vulnerable populations in isolated rural and disadvantaged urban areas that qualify as medically under-served communities.

The Health Resources and Services Administration (HRSA) has designated geographic and practice sites as medically under-served and health professional shortage areas.  HRSA gives priority funding to training programs that support professionals who are likely to practice in these areas.

The Professional Nurse Traineeship (PNT) Program authorizes grants to pay all or part of the tuition, books, fees and reasonable living expenses for students in advanced nurse education programs.  It is one of the HRSA programs that give special consideration to an eligible entity (School of Nursing) that agrees to expend the award to train advanced education nurses who will practice in health professional shortage areas. The Government Performance and Results Act of 1993 (GRPA) requires government agencies to set objective performance standards.  In compliance with this act, HRSA set a goal for the PNT Program of placing 40 percent of its graduate recipients in medically under-served communities.

The study included a survey of 5,184 nurses who graduated during the two academic years 1996 to 1997 and 1997 to 1998 from schools receiving PNT funds.  The survey asked questions about graduate training and experiences, employment after graduation, and education before entering graduate school and demographic information.   The response rate was 74.5 percent (3,219 of the 4,332 eligible nurses).  The overall findings are:

  • The PNT program appears to be meeting the goal of 40 percent placement rate of nurse graduates in medically under-served communities. In fact, 45 percent of the graduates worked in a medically under-served community.
  • Previous residence or employment in a medically under-served community was correlated with increased placement rates after graduation.
  • The study did not show that schools receiving preferential funding had higher placement rates than non-preference schools (they had less).
  • The study did show that schools that require students (1) to take courses on providing health care in rural or medically underserved communities, or (2) to sign a statement of commitment to practice in a rural or medically underserved community as a requirement for receiving financial assistance have higher rates of current employment in medically underserved communities than nurse granduates from schools without these requirements.

The report recommends that schools should recruit and target for PNT support more students who have lived or recently worked in medically under-served communities. 

Schools should openly discuss the purpose of PNT support in order to engage recipients in thinking about practice in an underserved community.

The report also recommends an increase in exposure of students to the mission and the reality of serving these populations during their graduate training.

This report was prepared for HRSA’s Bureau of Health Professions by Mathematica Policy Research, Inc.  The Project Officer, Madeline Turkeltaub, can be reached at 301-443-6334, or you may obtain a copy of the report, PIC ID# 7130 in the PIC.

About the Policy Information Center

The Policy Information Center (PIC) at the Department of Health and Human Services (HHS), is a centralized source of information on policy research and program evaluation studies, completed as well as in progress, that are supported by HHS agencies or staff offices. PIC also includes studies on HHS programs that are conducted by other organizations. The PIC on-line database at provides project descriptions of these studies. Inquiries about PIC services should be directed to (202) 690-6445 or

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