In This Issue:
- Implementation of CSAP High Risk Youth Demonstration Grants
- Child Abuse and Neglect in American Indian and Alaska Native Communities
- Implications of Reducing Physician Residency Programs
- Problems and Prospects in Society's Response to Abuse and Neglect
STUDY OF IMPLEMENTATION AND EFFECTIVENESS OF CSAP HIGH RISK YOUTH DEMONSTRATION GRANTS
Alcohol, tobacco, and other drug use among adolescents seemed to have abated during the early 1990s. However, by 1994, much of this progress had stalled or reversed. The National Household Survey on Drug Abuse (NHSDA) survey shows that fewer adolescents perceive great risk in using illicit drugs than had perceived such risks between 1985 and 1990. In 1994, 75 to 91 percent of youth reported that they perceived great risk in using marijuana occasionally and trying cocaine or heroin. Less than one-half of the youth perceived great risk of harm in smoking one or more packs of cigarettes per day. The NHSDA also reveals that 1.4 million adolescents between the ages of 12 and 17 were current illicit drug users; more than two million were smokers; and 14.4 percent reported that they had been approached in the past month by someone selling drugs.
Most federal funding for substance abuse prevention is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Prevention (CSAP). CSAP sponsors the High Risk Youth (HRY) Demonstration Program to combat substance abuse among the adolescent population. The program funds community-based organizations, schools, and other nonprofit organizations to develop and test innovative approaches for preventing and reducing alcohol, tobacco, and drug use among youth. The first round of 130 HRY projects was funded in 1987. The second group, funded from 1989 to 1991, included 132 grants. Unlike the first round, these projects were required to conduct comprehensive evaluations. The grants were also much more diverse than the first group in terms of program designs, intervention strategies, prevention outcomes, and target populations served.
This report, Study of Implementation and Effectiveness of CSAP High Risk Youth Demonstration Grants, examines the interventions used in a sample of 64 grantees in the 1989-1991 funding group, the populations reached, and the level of service provided. It also determines the effectiveness of the interventions by synthesizing grantees' evaluation findings. The study methodology includes three broad strategies: (1) program record review; (2) site visits; and (3) analysis and synthesis of quantitative outcome data provided by the grantees and qualitative implementation and outcome data collected for the study. The study includes a literature review, an implementation assessment, and case studies.
Substantial diversity exists among the 64 grantees examined in the study. Most are community and school based, and several provide service in both settings. The target ages of participants also vary: most are in primary and middle school, but some programs target preschool and high school students. Almost 25 percent of the programs also target young adults aged 19-21. The most frequently targeted ethnic group is African American, followed by Native Americans/Alaska Natives, multiethnic youth, and Hispanic youth. Individual youths, families, communities, schools, and peer groups are the targeted program domains. Programs focused on improving parenting skills, increasing substance abuse knowledge, increasing self-esteem, improving family relations, reducing alcohol, tobacco, and drug use, improving school grades, and increasing negative attitudes toward substance abuse.
The program implementation evaluation was conducted for 38 of the 64 projects. The evaluation was accomplished through a series of five qualitative analyses of project groups (i.e., four programs serving Native Americans/Alaska Natives, four programs serving Hispanics, eight programs based in schools, nine traditional programs serving African- Americans, and 20 programs serving youth from all cultural backgrounds). The implementation evaluation found that a number of program features are important to the success of an intervention. These include (1) collaboration with the community at all levels of a project's development; (2) parental involvement and long-term family participation; (3) establishing the program as a safe haven from the violence and negative behaviors experienced in neighborhoods and homes; (4) using adult and former program participants as role models and mentors; and (5) using follow-up strategies to reinforce learning and positive outcomes.
The assessment of program effectiveness uses outcome data from 11 of the 64 projects. The results of this assessment are complicated by the fact that few grantees collected information using valid and reliable measures. Statistically significant differences between program and comparison groups across the eleven projects include: (1) two projects found that the program group held more negative attitudes toward substance abuse than the control group; (2) one project found that the program group had a lower substance abuse rate than the program group; (3) three projects found that the program group's attitudes toward school or school plans were more positive than the comparison group's attitudes; and (4) in one project, the program group achieved a higher grade point average than the comparison group. Participants in the eleven programs exhibited changed posttest behavior and perspectives in several statistically significant ways . For example: (1) in one project, participants were less likely to engage in violent acts; (2) participants in two projects showed increases in self-esteem scores; (3) participants in one project had improved peer relationships and improved attitudes toward school; (4) participants in one project improved their health knowledge; and (5) participants in one project showed increases in self-concept and other positive mental health outcomes.
The report concludes that: (1) a sound evaluation design is necessary to identify measurable sets of prevention programs on substance abuse variables; (2) the same valid and reliable measures should be used for every program; (3) intermediate variables, such as school performance and family and peer relationships, as well as terminal outcomes (i.e., alcohol, tobacco, and drug use, attitudes, and knowledge) must be measured; and (4) outcome evaluation should not be conducted until program implementation has stabilized. Based on these conclusions, the report makes four policy and program recommendations for future funding, monitoring, and evaluation of prevention demonstration projects. These concern the prevention grant review process, program research, measurement development, and program evaluation.
This report was sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) and was prepared by CSR, Incorporated. The report's project officer, Soledad Sambrano, Ph.D. may be reached at 301-443-0353. Copies of the executive summary, PIC ID No. 4525, may be obtained from the Policy Information Center.
PHASE III FINAL REPORT: CHILD ABUSE AND NEGLECT IN AMERICAN INDIAN AND ALASKA NATIVE COMMUNITIES AND THE ROLE OF THE INDIAN HEALTH SERVICE
Although the abuse and neglect of Native American/Alaska Native (NA/AN) children and adolescents is an issue of widespread concern, no reliable statistics on its prevalence exist. Recent data have indicated that more than 6,500 referrals for suspected child abuse and neglect were made to the Bureau of Indian Affairs (BIA) in 1988; this number reflects a minimum of 1 percent of Indian children in the BIA service area. However, this figure does not reflect the true numbers of abused or neglected Indian children for several reasons. First, referrals do not reflect all cases, since social services agencies handle suspected cases in some states. Furthermore, there is a lack of formal systems for reporting cases, and data do not include Indians living in urban areas.
The report, Child Abuse and Neglect in American Indian and Alaska Native Communities and the Role of the Indian Health Service, is the first study to provide national information regarding the incidence of child abuse or neglect in Indian communities. It also provides comprehensive assessments of the effectiveness of Indian Health Service (IHS) and tribal policies, procedures, and personnel in the recognition and treatment of child abuse and neglect. The report also designs an intervention program flexible enough to be used by NA/AN communities across the country.
The project described in the report was conducted in three phases. Each phase contained several distinct, but interrelated, components. Phase I included a review of IHS policy and procedures on child abuse and neglect, and a survey and on-site data collection regarding the incidence of child abuse and neglect. Phase II included evaluation of the data obtained in Phase I, additional research and on-site assessments, and the development of a model intervention program. Phase III involved surveying tribal service providers, implementing the model program (New Beginnings) at a pilot site, and disseminating information about this project to Indian communities.
BIA and IHS agree that 34.4 percent of Indian children are at risk of becoming victims of child abuse or neglect. They also estimate that only one in five reported cases is ever substantiated and that, without independent confirmation, many cases are considered unsubstantiated, even if they are strongly suspected by professionals. Only 25 percent of survey respondents have computerized records, severely limiting the availability of baseline and case management information. Respondents indicated that substance abuse was a factor in more than 70 percent of the cases in which such data were collected.
Case specific information was gathered nationwide for 2035 reported cases of Indian child abuse and neglect in 17 states and 10 regional IHS service areas. This information shows that neglect cases (48.9 percent) outnumber those of sexual (28.1 percent) and physical (20.8 percent) abuse. Almost 80 percent of cases occurred in the child's home; 3.9 percent occurred at school, 3.0 percent occurred in a friend's home, and 8.0 percent in other locations. A disproportionate number of victims are under the age of five, with a substantial number less than one year of age. While girls and boys are equally likely to be victims of physical abuse and neglect, sexual abuse victims are primarily girls. Most (90.2 percent) sexual abuse offenders are male, while 74.7 percent of neglect offenders are female. In the case of physical abuse, 59.3 percent of physical abusers are male.
The model intervention program, New Beginnings in Indian Country, was pilot-tested in one site, the Wind River Service Unit, located in Fort Washakie, Wyoming. The program was based on the Hawaii Healthy Start program, and targeted families at risk of child abuse or neglect. This secondary prevention approach included home visitor services, and the promotion of healthy child growth and development. Members of the local community were recruited and trained to provide services to at-risk families and these families were receptive to participation in the program. Eighteen families received intensive in-home services for ten months. None of the parents in the program were referred for child abuse or neglect during their participation and no subsequent pregnancies occurred. Fifteen of the families showed improvement in the use of formal and informal social support networks. Eleven of the families attended parenting classes, and all families showed improvement in the quality of parent-child interactions. Four participants passed their GED examinations, and one couple planned to attend college. All infants in the program were up to date on well-baby visits and immunizations and all were developing normally. In contrast, one of the two families who declined services was subsequently referred for suspected abuse and neglect. Despite its success, the program was unable to secure additional funding and was forced to close after its funding period.
The report also discusses the role of IHS in addressing issues of child maltreatment and makes recommendations about how IHS can better fulfill its responsibilities in this area. The report concludes that IHS should promote individual, family, and community wellness; identify families at-risk and provide needed services and links to community resources; and provide adequate treatment and services for identified cases.
This report was sponsored by the Indian Health Service (IHS) and was prepared by the National Indian Justice Center. The report's project officer, Leo J. Nolan, may be reached at 301- 443-4245. Copies of the executive summary, PIC ID No. 6009, may be obtained from the Policy Information Center.
POLICY ANALYSIS: IMPLICATIONS OF REDUCING PHYSICIAN RESIDENCY PROGRAMS
In recent years, much debate has centered on the issue of Graduate Medical Education (GME), the specialty distribution of physicians, and Medicare's funding of physician education. Many critics feel that medical students are concentrating on the highly paid specialties, leaving primary care specialties without enough qualified practitioners. Critics have also proposed modifying Medicare's support for GME, due to concerns over growing program costs and it's lack of workforce policy reforms.
The report, Policy Analysis: Implications of Reducing Physician Residency Programs, examines a number of issues surrounding GME and illustrates how various policy alternatives would change the number and distribution of residency positions.
The report provides details on residents, residency programs, and institutions sponsoring residencies on the state and local level. Using data supplied by the American Medical Association (AMA), the report details the distribution of residents and programs by various characteristics. Information on 7,277 GME programs and 97,370 medical residents was included in the AMA data. These data show that
- primary care residencies account for 38 percent of all residents, while obstetrics and gynecology accounts for 5 percent, and surgery for 18 percent. Other specialties and medical/pediatric specialties account for 40 percent of all residents;
- programs vary in size from those containing one to three residents to those enrolling well over fifty. Eighty-five percent of all residents in primary care are in programs with twenty or more residents, while 85 percent of those in medical/pediatric specialties are in programs with less than twenty;
- only 76.6 percent of residents in United States programs are graduates of U.S. or Canadian medical schools. Furthermore, 2.7 percent of this total are not U.S. citizens. The remaining 23.4 percent of residents are international medical graduates (IMGs);
- Over 40 percent of residency programs have no IMGs, and more than half have less ten percent or fewer IMGs;
- About one-fifth of residency programs and institutional sponsors are dominated by IMGs: these programs train one-fifth of all residents. 733 programs have at least 80 percent IMGs, and 481 programs have no graduates of U.S. or Canadian medical schools.
The report also analyzes several policy options for reducing the number of residents in the United States GME system. This include: (1) reductions applied pro rata to programs according to size; (2) reductions based on the proportion of residents who are graduates of U.S. medical schools and (3) reductions in GME positions based on certain potential indicators of the quality or other key characteristics of training programs. In the first option, each program would be reduced by 12.5 percent of its total enrollment. This strategy is anticipated to encourage programs to reduce their numbers of IMGs, since unmatched positions are filled by these graduates. The second option would also reduce the numbers of IMGs by ensuring that all programs reduce their IMG enrollment by 51 percent.
According to Accreditation Council for Graduate Medical Education (ACGME) rules, programs must maintain a minimum enrollment size. If programs lost residents through either of these options, then they would be eliminated. Applying the current minimum standards in a strict manner would reduce the number of residents from 92,494 to 86,051 without any further action. Reducing residencies by 12.5 percent across the board would not greatly alter the percentage distribution of programs or residents in different regions of the country. However, reducing IMG residencies by 51 percent would shift a small number of residents out of the Northeast and North Central regions and into the South and West regions of the country. Some states would be disproportionately affected by IMG reductions, particularly New York, New Jersey, Michigan, and Illinois.
Most specialty enrollments would not be greatly affected by a 12.5 percent cutback, although the number of programs and residents in medical/pediatric specialties would be substantially reduced. Even more dramatic changes in specialty distribution would occur if IMG enrollment only were cut: internal medicine and pediatrics would have substantially fewer residents, while obstetrics and gynecology, general surgery, and orthopedic surgery programs would have a greater relative share of residents.
The report also discusses making cuts in residency programs according to various program characteristics related to quality. Unfortunately, although the report concedes that lower quality programs should be cut first, it concludes that available data are not adequate to measure program quality in a satisfactory way. Instead, the report uses indicators that distinguish the characteristics of programs without making a valuative judgement of quality. These characteristics include: accreditation status and certification rate; size by program specialty; IMG proportion; and the urbanicity, affluence, and concentration of physicians among the local population living within the service area of the program. The report concludes that none of the variables currently measured is a reliable indicator of program quality, except for accreditation status.
This report was sponsored by the Health Resources and Services Administration (HRSA) and was prepared by the Center for Health Policy Research at the George Washington University. The study's project officer, Carol Bazell, M.D. may be reached at 301-443-6920. Copies of the executive summary, PIC ID Number 5948, may be obtained from the Policy Information Center.
PROBLEMS AND PROSPECTS IN SOCIETY'S RESPONSE TO ABUSE AND NEGLECT
Until the mid-twentieth century, child welfare services concerned themselves with the care of orphaned, abandoned, or otherwise dependent children, including those who had suffered severe abuse and neglect. Beginning in the 1960s, this role was expanded to extend protection from abuse and neglect to at-risk children; and, in 1974, reporting and investigation of abuse and neglect became mandatory.
This report, Problems and Prospects in Society's Response to Abuse and Neglect, discusses the foundations of the United States system for responding to child abuse and neglect and suggests some directions for reform.
First, the report discusses foster care caseloads and the reasons for their alarming growth rate. The current child welfare system encourages people who suspect that children are being harmed or that they are at-risk of harm to report their suspicions to the authorities. Some professionals are required by law to report suspected child maltreatment, while everyone is encouraged to do so. Data from the Voluntary Cooperative Information System (VCIS) of the American Public Welfare Association show that there was in increase of 60 percent in the substitute care population between the beginning of 1985 and the end of 1992. The most substantial increases occurred in 1988 and 1989. During this period, more children entered substitute care than left, which indicates that children were spending more time in foster care. Several factors contributed to the explosion in foster care caseloads during the period: (1) the expansion of kinship care; (2) multiple placements; (3) children reentering the foster care system after reunification with parents; (4) an expansion of the definition of abuse and neglect; and (5) changes in reporting practices, in the condition of families; and in broader social conditions.
The report notes that the current child welfare system is predicated upon three general principles: (1) that the care of children should be guided by a plan for their permanent placement; (2) that the placement should be the least restrictive among available alternatives; and (3) that reasonable efforts to maintain families must be made before a child is removed from the family. The report discusses the operation of these principles in the current child welfare system, especially in regard to family preservation efforts. However, because family preservation has little effect on family and child functioning, the report suggests alternative principles that should underpin child welfare programs. These principles concern (1) the responsibility of the government; (2) the dichotomy between in-home and out-of-home services; (3) staffing and administrative restructuring; and (4) a realignment of the services available to families in crisis.
The report asserts that the role expected of the government in child welfare services is both too narrowly and too broadly defined. On one hand, the public does not demand that government realign its priorities to solve the social problems contributing to child maltreatment. On the other hand, the government is also expected to prevent and respond to all harms to children, a task it clearly cannot complete.
The child welfare system's sharp differentiation between in-home and out-of-home services should also be softened, according to the report. This division is not helpful to families or to children. The report suggests that in- home and out-of-home services should be seen as part of a continuum. Out-of- home placements should not always be regarded as evidence of parental failure; rather, they could be regarded as a respite from caretaking responsibilities. To this end, voluntary out-of-home placements should be encouraged where they are appropriate.
The report also notes that many of the problems with the child welfare system, such as poor coordination and communication and inadequate staffing levels could be ameliorated if sufficient resources were invested. Finally, the report recommends that child welfare policy makers honestly recognize that the current system is not working well. Family preservation efforts, in particular, have not yielded the major results that had been expected. Thus, child welfare systems should be willing to experiment with different service approaches, including family preservation services.
This report was sponsored by the Administration for Children, Youth, and Families (ACYF) and was prepared by the Chapin Hall Center for Children at the University of Chicago. The study's project officer, Cecelia Sudia, may be reached at 202-205-8764. Copies of the Executive Summary, PIC ID No. 4377.1, may be obtained from the Policy Information Center.
Recently Acquired Reports
- Cost of Domestic Violence to the Health Care System
- Cost Sharing Under the Older Americans Act
- Report of the Roundtable on the Role of Academic Health Centers in Clinical Research and Training
- Minority HIV/AIDS Programs Community-Based Organization Evaluation: HIV/AIDS Education/Prevention Grant Program 1988-1989, A Cross-Site Evaluation
SERVICES AVAILABLE FROM THE PIC
The Policy Information Center (PIC) is a centralized source of information on in-process, completed, and on-going evaluations; short-term evaluative research; and policy-oriented projects conducted by HHS as well as other federal departments and agencies. The PIC on-line database, which is updated daily, provides project descriptions of these studies. The on-line database is now accessible via the Internet on the HHS HomePage. Inquiries regarding PIC services should be directed to PIC Central Mailbox,or to (202) 690-6445