Community-level Indicators Research Articles

Preventable hospitalization among elderly Medicare beneficiaries with type 2 diabetes.

To examine the impact of comorbid conditions on preventable hospitalizations among Medicare beneficiaries aged > or =65 years with type 2 diabetes. Data were drawn from the 1999 Medicare Standard Analytic Files, a 5% nationally representative random sample of Medicare beneficiaries. The analysis sample included 193,556 Medicare beneficiaries aged > or =65 years with type 2 diabetes (ICD-9-CM codes 250.xx) who were enrolled in fee-for-service Medicare. Preventable hospitalization was assessed by measuring ambulatory care-sensitive conditions, an accepted measure of hospitalizations that could have been prevented with appropriate outpatient care. Multivariable analyses controlled for demographics; mortality; renal, ophthalmic, or neurological manifestations of diabetes; type of physician providing the outpatient care; and per capita community-level indicators of income and hospital beds. Ninety-six percent of beneficiaries in the sample had a comorbidity, and 46% had five or more comorbidities. Among beneficiaries with type 2 diabetes, cardiovascular-related comorbidities were common and accounted for increased odds of preventable hospitalization, controlling for other factors. The likelihood of a preventable hospitalization increased in the presence of a claim for comorbid congestive heart failure, cardiomyopathy, coronary atherosclerosis, hypertension, or cardiac dysrythmias. Noncardiovascular comorbidities associated with a greater likelihood of preventable hospitalization included chronic obstructive pulmonary disease, asthma and lower respiratory disorders, Alzheimer's disease/dementia, personality/anxiety disorders, depression, and osteoporosis. Our data suggest that nearly 7% of all hospitalizations could be avoided. These findings support the need for improved outpatient care strategies to reduce the impact of comorbidity on unnecessary hospitalization in patients aged > or =65 years with type 2 diabetes.

Patterns of Variation in Levels of Hsp70 in Natural Rocky Shore Populations from Microscales to Mesoscales

An important step in connecting the organismal response to thermal stress to patterns of community structure is determining at what scale discernable levels of variation are manifested. The temperature signal to which organisms may potentially respond varies at many spatial scales including microhabitat, tidal height, site and latitude. A number of studies have taken physiological assessment of the heat shock response (HSR) into the intertidal both as a tool for examining the HSR in nature and for examining the utility of HSR molecules as population or community level indicators. Most commonly, immunodetection of the total pool of the Hsp70 family of isoforms is used. Here we present data on levels of Hsp70 in intertidal organisms from microhabitat to the mesoscale. Our data and previously published work show that Hsp70 levels vary at all scales examined, similar to other physical and biological variables of interest. This demonstrates both the potential utility of Hsp70 detection as a molecular tool for field biologists and to the care that must be taken in assessing scale of variation when looking for potential bioindicator molecules.

Community Capacity Building: A Parallel Track for Health Promotion Programs

Community capacity-building has been defined as processes that “build sustainable skills, resources, and commitments to health promotion in (various) settings and sectors (in order to) prolong and multiply health gains many times over.” Community capacity-building, like the related concepts of community development and empowerment, is about increasing the capabilities of people to articulate and address community health issues and to overcome barriers to achieve improved outcomes in the quality of their life. Interest in community capacity-building as a health promotion strategy arose primarily because many individual lifestyle-change education and social marketing programs were having only modest effects on behaviour change, especially in marginalized communities. Does the problem lie partly in the lack of certain organizational capacities within the community, as suggested by a group of expert US community practitioners and academics? If these capacities were improved, would individual and community-level health indicators improve and be sustained beyond the often time-limited program period? There is some evidence that this is the case. In the physical activity realm, research from Missouri found that where active community coalitions were established in communities, there were also significant reductions in the percentage of adults who reported no physical activity. The coalition formation and existence increased the community’s capacity to sustain the physical activity programs.

The Relationship between Socioeconomic Status, Ethnicity, and Cigarette Smoking in Urban Adolescents

Background. This study examined the relationship between community-level and school-level socioeconomic status indicators and current cigarette smoking among urban adolescents, and examined whether the socioeconomic status-cigarette smoking relationship was similar for African Americans and Whites.Methods. Participants were 3,813 seventh-graders recruited in a large school system in the United States. Independent variables included median income and mean education within zip codes of participants' residence, percentage of participants receiving lunch at reduced or no cost at school level, and ethnicity. The dependent variable was current smoking status (never smoked vs smoking one or more cigarettes per month).Results. Whites were significantly more likely than African Americans to smoke cigarettes. There was a main effect of education and lunch at reduced or no cost on cigarette smoking. Mean education by zip code was inversely associated with cigarette smoking, and lunch at reduced or no cost was directly associated with cigarette smoking. There was a significant interaction between income and ethnicity. Median income by zip code was directly associated with cigarette smoking among African Americans.Conclusions. Our findings suggest that smoking prevention efforts in this population should take both socioeconomic status and ethnicity into account.

Adolescent Victims of Violence in a Welfare State : Sociodemography, Ethnicity and Risk Behaviours

In a normal population sample of Norwegian adolescents, 6 per cent reported to have been victims of violent victimization during the last year. The sample consisted of three cohorts of adolescents from Oslo, aged 13–18, who had filled out a survey at school. Further, we had at our disposal community-level indicators of welfare in the home city districts of the adolescents. Boys were more often victimized than girls. Individual level demographic indicators (immigrant, working-class background, parents unemployed or on social welfare), were associated with victimization risk. However, the impact of community-level sociodemographic variables (education, income, single parenthood, death rates) were of greater magnitude. Further, there were effects from general lifestyle (unorganized leisure, evenings in town), but risk behaviours were more important. In particular alcohol problems, own aggression and carrying a weapon were associated with high risk for victimization. There were small differences in predictors between genders, but adolescents with immigrant background were less vulnerable for contextual level factors than adolescents without such a background. The findings are discussed in relation to other recent findings and theoretical developments as regards research on violent victimization.

Community-level indicators of chronic health conditions and services.

Programs targeted toward chronic conditions provide a stimulus for development of program performance indicators. This paper illustrates how existing information can be organized at community and health plan levels to produce these indicators. Data compiled by claims and encounter systems are emphasized. Survey data can be incorporated in the indicator system on a targeted basis, particularly for information on community services and linkages to healthcare and also for caregiver perspectives.

Promising community-level indicators for evaluating cardiovascular health-promotion programs.

Rigorous evaluation of community-based programs can be costly, particularly when a representative sample of all members of the community are surveyed in order to assess the impact of a program on individual health behavior. Community-level indicators (CLIs), which are based on observations of aspects of the community other than those associated with individuals, may serve to supplement individual-level measures in the evaluation of community-based programs or in some cases provide a lower-cost alternative to individual-level measures. Because they are often based on observations of the community environment, CLIs also provide a way of measuring environmental changes--often an intermediate goal of community-based programs. The Centers for Disease Control and Prevention convened a panel of experts knowledgeable about community-based program evaluation and cardiovascular disease (CVD) prevention to develop a list of CLIs, and rate their feasibility, reliability and validity. The indicators developed by the panel covered tobacco use, physical activity, diet and a fourth group that were considered 'cross-cutting' because they related to all three behaviors. The indicators were subdivided into policy and regulation, information, environmental change, and behavioral outcome. For example, policy and regulation indicators included laws and ordinances on tobacco use, policies on physical education, and guidelines for menu and food preparation. These indicators provide a good starting point for communities interested in tracking CVD-related outcomes at the community level.

The impact of family planning service provision on contraceptive-use dynamics in Morocco.

This article uses linked data from the 1995 Morocco DHS calendar and the 1992 Morocco DHS service-availability module to study the effect of service environment on contraceptive discontinuation, switching, and adoption of a modern method following a birth. The 1995 Morocco DHS also collected information on the source of supply for each episode of use of a modern method recorded in the calendar, allowing study of the association between the source of supply and discontinuation and switching rates. Multilevel event-history models are used to evaluate the impact of individual-level sociodemographic characteristics and community-level indicators of family planning service provision. The findings show that the presence of a nearby public health center is associated with higher modern-method adoption after a birth and lower method-failure rates; the presence of a pharmacy is associated with lower discontinuation due to side effects or health concerns. The degree of method-choice potential has a positive impact on both the rate of switching from the pill to another modern method and on modern-method adoption after a birth.

Community-Level Socioeconomic Status Effects on Adult Health

Do the socioeconomic characteristics of a community affect one's health? This research examines whether the socioeconomic characteristics of communities are associated with the health of community residents, over and above the socio-economic characteristics of individual residents and their families. This is the first study to examine the independent associations between community-level socio-economic status (SES) and individual-level health using a nationally representative sample of adults in the United States. Results indicate that a person's health is associated with SES characteristics of the community over and above one's own income, education, and assets. However, individual-level and family-level SES indicators are stronger predictors of health than community-level SES indicators. This research suggests that improving individual-level and family-level socioeconomic circumstances may be the more direct way to improve the health of individuals, but that understanding the community context in which a person lives may also ultimately be important to improving health.

Fundamental Differences Between Conventional and Organic Tomato Agroecosystems in California

In an integrated, multidisciplinary study we compared ecological characteristics and productivity of commercial farms categorized as either organic (ORG) or conventional (CNV) based on their use of synthetic fertilizers and pesticides or reliance on organic soil amendments and biological pest control. We measured belowground parameters: various soil chemical and biological properties and root disease severity; common agronomic indicators: biomass, fruit yield and insect pest damage; and community level indicators, including arthropod diversity and soil microbial activity and diversity. CNV and ORG production systems could not be distinguished based on agronomic criteria such as fruit yield and arthropod pest damage levels. However, differences were demonstrated in many soil, plant, disease, and diversity indicators suggesting that the ecological processes determining yields and pest levels in these two management systems are distinct. In particular, nitrogen mineralization potential and microbial and parasitoid abundance and diversity were higher in ORG farms. Differences between the agroecosystems were sufficiently robust to be distinguished from environmental variation and suggest that biological processes compensated for reductions in the use of synthetic fertilizers and pesticides.

Poverty, Crack, and Crime: A Cross-City Analysis

Many observers have attributed recent increases in violent crime rates to the arrival of crack cocaine on the urban scene. However, little hard evidence exists to support this contention. This study examines the relationship between arrestee cocaine use and homicide, robbery, and burglary rates for the 24 cities participating in the Drug Use Forecasting (DUF) Program. To isolate the effects of rates of cocaine use among arrestees on crime rates, the analysis incorporates controls for additional city-level characteristics, including population composition and selected indicators of economic deprivation and social disorganization. Multivariate analyses reveal that arrestee cocaine use has a positive and significant effect on city robbery rates, net of other predictors. The effect of arrestee cocaine use on homicide is more modest, and no effect was found for burglary. Although these results must be interpreted cautiously, they do suggest that cocaine use elevates city violent crime rates beyond levels expected on the basis of known sociodemographic determinants. Serious consideration should be given to community-level indicators of drug use in formulating theories to explain inner-city violence and policies to reduce it.

Species Richness in Streams of Different Size from the Same Drainage Basin

The species richness of stream benthic invertebrates was studied along a longitudinal profile of the Salmon River, Idaho, during spring, summer, and autumn. Sampling was done using replicate rocks and the analytical approach of Stout and Vandermeer (1975) was used to calculate theoretical number of species present, relative immigration rate, and relative spatial heterogeneity. Species richness varied with stream size, being highest in midorder streams and lower in headwater and high order streams. This downstream shift in species richness conforms to the river continuum concept (Vannote et al. 1980). Possible cause is associated with varying temperature regimes in the different-sized streams as well as other factors. Species richness also varied with season depending on stream size. Low order streams were more individualistic, probably because of a greater influence of local (terrestrial) environmental conditions, but showed a higher richness in summer than in autumn. Larger streams were more similar and showed a higher richness in autumn than in summer. Other community-level indicators, such as relative immigration rate and extinction rate, also showed seasonal differences. We conclude that different macroinvertebrate community types having characteristics of either nonequilibrium (density-independent, opportunistic) or equilibrium conditions can be found in streams from the same drainage basin depending on location along the river continuum and time of the year. These findings have important implications for future studies of stream communities as well as for those of predation and competition in streams. Among other things, we propose that the interactive/noninteractive model of Wilson (1969) may be more appropriate for stream invertebrate communities than those assuming strictly nonequilibrium or equilibrium conditions. We further suggest that any attempt to classify or compare stream communities, such as was done for tropical versus midlatitude streams by Stout and Vandermeer (1975), must take seasonality and position along the downstream gradient into account.

Measuring Accessibility to Family Planning Services in Rural Thailand

There are a variety of ways to conceptualize and measure accessibility to contraceptive services and supplies. Using detailed data for rural Thailand, a multiplicity of reasonable measures are developed that reflect time and/or distance to various government program outlets. Many of these are only moderately correlated with one another, and to an important extent, different measures show different associations with levels of contraceptive prevalence. Clearly there is a general need in this area of investigation to pay more attention to the measurement of accessibility as a community characteristic and to consider the sensitivity of results to alternate measures.