State-level Systems Research Articles

Multi-State Implementation of Go NAPSACC to Support Healthy Practices in the Early Care and Education Setting.

Childhood obesity in the United States is a serious problem that puts children at risk for poor health. Effective state-wide interventions are needed to address childhood obesity risk factors. Embedding evidence-based initiatives into state-level Early Care and Education (ECE) systems has the potential to improve health environments and promote healthy habits for the 12.5 million children attending ECE programs. Go NAPSACC, an online program that was adapted from an earlier paper version of Nutrition and Physical Activity Self-Assessment for Child Care (NAPSACC or NAP SACC), provides an evidence-based approach that aligns with national guidance from Caring for Our Children and the Centers for Disease Control and Prevention. This study describes approaches undertaken across 22 states from May 2017 to May 2022 to implement and integrate Go NAPSACC into state-level systems. This study describes challenges encountered, strategies employed, and lessoned learned while implementing Go NAPSACC state-wide. To date, 22 states have successfully trained 1,324 Go NAPSACC consultants, enrolled 7,152 ECE programs, and aimed to impact 344,750 children in care. By implementing evidence-based programs, such as Go NAPSACC, ECE programs state-wide can make changes and monitor progress on meeting healthy best practice standards, increasing opportunities for all children to have a healthy start.

Caregiving Across the Life Course: A Health Policy Priority for North Carolina

At least one in five North Carolinians is an informal caregiver for a relative or friend with a serious health problem, illness, or disability. Existing state-level systems are inadequate to support caregivers’ needs. We propose 10 recommendations for adopting a life course perspective to address caregiver needs across North Carolina’s diverse population.

Japan’s pursuit of meritocracy, cosmopolitanism, and global rankings in higher education: a Bourdieusian interpretation

ABSTRACT Through the market-based conception of neoliberal performativity, an interlocking set of socio-economic agendas integrate higher education (HE) in state-level systems of production and accumulation. Within the scope of globalism, the capacity to develop competitive human capital emerges as a proxy indicator of achievement amongst institutions of higher learning. Through this elaborate symbolic structure, Japanese reforms aimed at bolstering “global” soft skills, including English, cosmopolitanism, and interculturality, function alongside an ideological arms race to enhance university rankings and individual investment in education. Invoking a Bourdieusian perspective, this conceptual inquiry suggests that stakeholders consider the secondary effects of asymmetrical efforts towards “élite” education, globalism, and world-class attainment, whereby accompanying policy reform propagates hegemony both locally and internationally. Additionally, the emergence of global soft skills as essential cultural capital challenges the supposed meritocracy of Japan’s HE system. Indeed, the “effort-based-reward” symbolic contract permeating much of the neoliberal discourse fails to account for the functional reality of class-distinguished taste. From this perspective, valuable cultural resources orientate towards a globally conscious, highly-credentialed middle-class privileged in social, economic, and cultural capital, thereby disadvantaging the majority of learners inevitably excluded from study at prestigious, brand-name universities.

Exploring the Research Priorities for Occupational Therapy in India: A Descriptive Review.

BackgroundOccupational therapists are considered an important workforce for the rehabilitation of persons with disabilities globally. However, in India, the profession is just beginning to gain recognition within the national and state-level systems for health care. One of the reasons for this could be the paucity of specific research related to the development of occupational therapy (OT) and its benefits to the health systems. Therefore, it is of immense public health importance to explore the priorities and gaps in OT research in India. A vast majority of the OT research in India is promoted and disseminated through the All-India Occupational Therapists Association (AIOTA) and its annual national conference (ANC).ObjectivesThe objective of this study is to descriptively review the conference abstracts of the AIOTA ANC published in the Indian Journal of OT (IJOT), an official publication of the AIOTA, from 2017 to 2021.Study DesignThe study design was a descriptive, nonsystematic review.MethodsReview of the abstracts selected for the AIOTA ANC published in the IJOT from 2017 to 2021. A data extraction form was developed and used to synthesize data related to the clinical and demographic characteristics of OT research in India.ResultsThe search yielded 218 abstracts. State-level trends indicated that close to 85% of the research submissions were from four states and no submissions from the northeastern states until 2020. Nearly 60% of the abstracts were clinical research with OT interventions. About 40% of these research abstracts were related to pediatrics, followed by neurology (17%), musculoskeletal (15%), mental health (10%), and ergonomics and assistive technology (8%). There were 1%-2% of research abstracts submitted related to coronavirus disease-2019 (COVID-19) and geriatrics. About 85% of the research abstracts were related to impairment (39%), activity limitation (26%), and social participation (22%).ConclusionThis review highlights the need for diversifying the research in OT in India. This is particularly important in relation to expanding from selected states to pan-India research and development, especially in the northeastern states. Furthermore, the focus of OT research must move beyond impairments and approach disability from the biopsychosocial perspective. It is also very important to diversify the research in OT to areas that are of public health importance such as COVID-19, geriatrics, noncommunicable diseases, and rehabilitation in health systems. Priority setting for research in OT in India is an important implication of this review.

Coordinating Systems of Care for HIV and Opioid Use Disorder: A Systematic Review of Enablers and Barriers to Integrated Service Access, and Systems and Tools Required for Implementation.

Individuals who have HIV who also use drugs experience increased age-matched morbidity and mortality in comparison with those with HIV who do not use drugs. A systematic review was conducted to describe models of integrated HIV and opioid use disorder (OUD) services, enablers of and barriers to integrated service access, and the coordinated systems and tools at the state and service delivery levels required for implementation. Database searches yielded 235 candidate articles, of which 22 studies met the inclusion criteria. Analysis found that integrated programs operated with minimal coordinated policy and systems guidance at the state level. Service delivery systems and tools used for integration, including use of integrated protocols, risk assessment tools, case management tools, and referral systems, were similar across integration models. Concerted efforts to coordinate state-level systems and develop supportive policies, guidelines, and standardized tools may facilitate integration at the service delivery level.

Using Occupancy Models to Estimate the Number of Duplicate Cases in a Data System without Unique Identifiers

Data systems collecting information from different sources or over long periods of time can receive multiple reports from the same indi vidual. An important example is public health surveillance systems that monitor conditions with long natural histories. Several state-level systems for surveillance of one such condition, the human immunodeficiency virus (HIV), use codes composed of combinations of non-unique personal charac teristics such as birth date, soundex (a code based on last name), and sex as patient identifiers. As a result, these systems cannot distinguish between several different individuals having identical codes and a unique individual erroneously represented several times. We applied results for occupancy models to estimate the potential magnitude of duplicate case counting for AIDS cases reported to the Centers for Disease Control and Prevention with only non-unique partial personal identifiers. Occupancy models with equal and unequal occupancy probabilities are considered. Unbiased estimators for the numbers of true duplicates within and between case reporting areas are provided. Formulas to calculate estimators’ variances are also provided. These results can be applied to evaluating duplicate reporting in other data systems that have no unique identifier for each individual.

Framing the front door: co-creating a home health care assessment of service need for children with disabilities

ABSTRACT This paper details the co-creation of a home health assessment tool for children with disabilities in the context of state-level systems change from traditional Medicaid to Medicaid managed care. A community based, sequential, mixed methods design was used to co-develop the assessment. A process evaluation highlighted community members’ experiences with Medicaid managed care. Community members identified issues related to appropriateness of items and loss of services and recommended a dual assessment process to address concerns. Results indicated that 72% of items functioned well. Community members felt that organizational policies and the accuracy of clinical information obtained during assessment processes led directly to loss of services. Co-creating the assessment with caregivers of children with disabilities led to a comprehensive, person-centered, and holistic tool. The process buttressed several concrete systems and policy actions to improve home health care for children with disabilities in Medicaid managed care.

Assessing fiscal distress in small county governments

Assessing fiscal distress in small county governments

The Leaders’ Dilemma

The threat of a pandemic places P-20 educational leaders in the difficult position of having to make decisions with incomplete information that affect the welfare of students, employees, and the community. Due to extraneous factors, pandemics are almost impossible to plan for in detail. In an effort to illustrate the unique position P-20 educational leaders find themselves in during the threat of a pandemic, a leaders’ dilemma matrix is presented to illustrate possible outcomes based on leaders’ responses. While educational leaders may feel a need to take unilateral actions, national- and state-level systems exist to guide appropriate responses. Ultimately, some preparatory steps are enumerated.

Lessons Learned from Applying a Modified Learning Collaborative Model to Promote Change in Regional and Statewide HIV Care Systems.

The Health Resources and Services Administration Special Projects of National Significance launched the Systems Linkage and Access to Care for Populations at High Risk of HIV Infection Initiative in 2011. Six state departments of health were funded to utilize a modified Learning Collaborative model to develop and/or adapt HIV testing, linkage to care and retention in care system-level interventions. More than 60 Learning Sessions were held over the course of the Learning Collaborative. A total of 22 unique interventions were tested with 18 interventions selected and scaled up. All interventions were created to impact services at a systems level, with standardized protocols developed to ensure fidelity. Our findings provide key lessons and present considerations for replication for use of a modified Learning Collaborative to achieve state-level systems change.

“Sometimes, Somebody Just Needs Somebody – Anybody – to Care:” The power of interpersonal relationships in the lives of domestic minor sex trafficking survivors

Domestic minor sex trafficking (DMST) is the recruitment, harboring, transportation, provision, or obtaining of U.S. minors for the purposes of a commercial sex act. DMST victims and survivors often become involved with state-level systems including the child welfare and/or juvenile justice systems. This study presents exploratory qualitative findings regarding the role of interpersonal relationships in the lives of system-involved DMST survivors from the perspectives of DMST survivors. Results indicate survivors perceive interpersonal relationships as key to promoting risk, providing protection, and fostering resiliency over DMST. Findings from the current study not only provide a context for understanding the role of interpersonal relationships in the lives of DMST survivors but also point to directions for development of interventions targeted toward this population.

“What Does It Matter How We Define It?”: Exploring Definitions of DMST Among Service Providers and Victims/Survivors

ABSTRACTDomestic minor sex trafficking (DMST) is one of the most prevalent yet hidden forms of child abuse in the United States. DMST victims are diverse in age, race, and socioeconomic status. Many DMST victims are involved in state-level systems including the child welfare and/or juvenile justice system. State-level systems are federally mandated to identify children who are at risk or survivors of DMST. Unfortunately, DMST victim/survivor identification is inconsistent and often ineffective and is based on service providers’ and DMST victims’/survivors’ de facto definitions of DMST. This study presents exploratory, qualitative findings regarding service provider and DMST victim/survivor de facto definitions of DMST. In addition, it explores how these definitions are different from and/or similar to extant federal and state legal definitions. Content analysis revealed three key qualitative themes, including force/fraud/coercion, commercialization, and DMST as a form of child sexual abuse. Importantly, DMST victim/survivor and service provider definitions of DMST are different, which may be contributing to ineffective DMST victim/survivor identification protocols. Furthermore, there are several important differences between participants’ definitions of DMST and extant federal and state legal definitions. Implications for policy and practice are discussed.

Michigan and Ohio K–12 Educational Financing Systems: Equality and Efficiency

We consider issues of equality and efficiency in two different school funding systems—a state-level system in Michigan and a foundation system in Ohio. Unlike Ohio, the Michigan system restricts districts from generating property or income tax revenue to fund operating expenditures. In both states, districts fund capital expenditures with local tax revenue. Our results indicate that although average revenue and expenditures per pupil in Michigan and Ohio are almost identical, the distributions of the various revenue sources are quite different. Ohio’s funding system has greater equality in terms of total revenue, largely due to Ohio redistributing state funds to the least wealthy districts while Michigan does not. We find relatively wealthy Michigan districts spend more on capital expenditures, whereas relatively wealthy Ohio districts spend more on labor and materials. This suggests that constraints on raising local revenue to fund operating expenditures in Michigan could create efficiency issues.

State-Level Cancer Quality Assessment and Research

Over a decade ago, the Institute of Medicine called for a national cancer data system in the United States to support quality-of-care assessment and improvement, including research on effective interventions. Although considerable progress has been achieved in cancer quality measurement and effectiveness research, the nation still lacks a population-based data infrastructure for accurately identifying cancer patients and tracking services and outcomes over time. For compelling reasons, the most effective pathway forward may be the development of state-level cancer data systems, in which central registry data are linked to multiple public and private secondary sources. These would include administrative/claims files from Medicare, Medicaid, and private insurers. Moreover, such a state-level system would promote rapid learning by encouraging adoption of near-real-time reporting and feedback systems, such as the Commission on Cancer's new Rapid Quality Reporting System. The groundwork for such a system is being laid in the state of Georgia, and similar work is advancing in other states. The pace of progress depends on the successful resolution of issues related to the application of information technology, financing, and governance.

The Effect of Ignoring Classroom-Level Variance in Estimating the Generalizability of School Mean Scores

Contemporary educational accountability systems, including state-level systems prescribed under No Child Left Behind as well as those envisioned under the “Race to the Top” comprehensive assessment competition, rely on school-level summaries of student test scores. The precision of these score summaries is almost always evaluated using models that ignore the classroom-level clustering of students within schools. This paper reports balanced and unbalanced generalizability analyses investigating the consequences of ignoring variation at the level of classrooms within schools when analyzing the reliability of such school-level accountability measures. Results show that the reliability of school means cannot be determined accurately when classroom-level effects are ignored. Failure to take between-classroom variance into account biases generalizability (G) coefficient estimates downward and standard errors (SEs) upward if classroom-level effects are regarded as fixed, and biases G-coefficient estimates upward and SEs downward if they are regarded as random. These biases become more severe as the difference between the school-level intraclass correlation (ICC) and the class-level ICC increases. School-accountability systems should be designed so that classroom (or teacher) level variation can be taken into consideration when quantifying the precision of school rankings, and statistical models for school mean score reliability should incorporate this information.

Adverse drug effects following oseltamivir mass treatment and prophylaxis in a school outbreak of 2009 pandemic influenza A(H1N1) in June 2009, Sheffield, United Kingdom

During the containment phase of the 2009 influenza A(H1N1) pandemic, mass treatment and prophylaxis with oseltamivir was used to control an outbreak of pandemic influenza in a primary school in Sheffield, United Kingdom, where ten cases of pandemic influenza had been laboratory confirmed over a three day period in June 2009. A subsequent cross-sectional survey showed that 51 of 297 (17%) pupils and 10 of 58 (17%) reported an influenza-like illness. The most common symptoms were headache, cough, fever, tiredness, sore throat and nausea. Fifty-three staff and 273 pupils took oseltamivir for treatment or prophylaxis. Of this group, 41% (113/273) of pupils and 47% (25/53) of staff reported adverse effects. Overall, 14% (37/273) of pupils and 20% (11/53) of staff did not complete the course of oseltamivir, primarily due to adverse effects. Nausea, vomiting and rash were statistically significantly associated with failing to complete the course of oseltamivir. Given the potential for side effects from oseltamivir, particularly among those without influenza who receive the drug for prophylaxis, our findings have two important implications. Firstly, the benefits of mass treatment in an outbreak setting must clearly be greater than the benefits of targeted treatment. Secondly, any large scale regional or state level system for distribution of antiviral drugs for treatment should ideally include a robust quantification of an individual s probability of infection with influenza virus in order to avoid unnecessary treatment.

Building a System of Care for Children With Special Healthcare Needs

This article describes current efforts to (a) define best practices and desired systems-level outcomes for a system of care for Children with Special Health Care Needs (CSHCN) and their families; (b) describe the interconnections between Part C early intervention programs and those for CSHCN; and (c) develop measuring and monitoring strategies for implementing a state-level system for all CSHCN. The importance of working in partnership with states and family representatives with respect to defining, measuring, and monitoring progress toward a system of care will be illustrated through a description of a federally funded Participatory Action Research project. Results of the project include the development of national indicators for the 6 performance measures to guide states in their efforts to achieve a system of care.

Parental Participation in Transition Systems Change

This article describes the results of a national survey that investigated parent participation in transition systems change activities. The purpose of the article is to illustrate the multiple ways in which parents have become major participants in supporting state-level systems change activities on transition for youth with disabilities. The most frequently reported activities in which parents were involved included serving as members on transition planning boards and identifying transition information and training needed by parents and families. The findings indicate that subcontracts between transition systems change project and parent organizations increased the types of systems change activities in which parents were involved.

Community-Level Service Integration Within Home Visiting Programs

National surveys were obtained from 193 programs serving children eligible for Part H who were identified by state-level administrators as demonstrating successful efforts in integrating services for families. Descriptive analyses were conducted to determine the service system models in place, the strategies used to facilitate service integration, the perceived barriers, and the relationship between the state-level systems and the community-level systems. A variety of successful strategies to facilitate integrated services were reported as being implemented at the community level, although there was limited coordination with hospitals, medical specialists, and mental health services. Insufficient funding for lower caseloads and compensation for service coordination efforts were perceived as the greatest barriers to system integration efforts. States supported communities primarily through the provision of information concerning policies and regulations; the use of other support strategies (e.g., needs assessments for obtaining community input) was less prevalent.

The first 18 months of mental health reform in Kansas.

The effects of the first 18 months of implementation of the Kansas Mental Health Reform Act were evaluated. The act designated community mental health centers as gatekeepers for admission to mental health services, created screening and diversion services for state hospital admission, allocated state hospital bed days to each center, and reallocated funds from hospitals to communities. Data from the catchment area in which reform was implemented in the 18-month study period, January 1991 to June 1992, were compared with data for that area before reform, and with data for the two state hospital catchment areas in which reform was not yet implemented. In the catchment area in which reform was implemented, state hospitalization decreased by about 29 percent, and state mental health funds allocated to the area's mental health centers almost doubled. Service utilization by patients discharged from the state hospital was higher than in the other two catchment areas, and most indicators of living status and vocational or educational involvement reflected improvement. The first 18 months of implementation suggest that state-level systems change can decrease state hospitalization and improve the utilization of community services while improving the quality of life for people with severe and persistent mental illness.