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OBJECTIVE: This study evaluated the impact of a community-based mobile crisis intervention program on the rate and timing of hospitalization. It also explored major consumer characteristics related to the likelihood of hospitalization. METHODS: A quasi-experimental design with an ex post matched control group was used. A community-based mobile crisis intervention cohort (N=1,696) was matched with a hospital-based intervention cohort (N=4,106) on seven variables: gender, race, age at the time of crisis service, primary diagnosis, recency of prior use of services, indication of substance abuse, and severe mental disability certification status. The matching process resulted in a treatment group and a comparison group, each consisting of 1,100 subjects. Differences in hospitalization rate and timing between the two groups were assessed with a Cox proportional hazards model. RESULTS: The community-based crisis intervention reduced the hospitalization rate by 8 percentage points. A consumer using a hospital-based intervention was 51 percent more likely than one using community-based mobile crisis services to be hospitalized within the 30 days after the crisis (p<.001). Treating a greater proportion of clients in the community rather than hospitalizing them did not increase the risk of subsequent hospitalization. Those most likely to be hospitalized were young, homeless, and experiencing acute problems; they were referred by psychiatric hospitals, the legal system, or other treatment facilities; they showed signs of substance abuse, had no income, and were severely mentally disabled. CONCLUSIONS: Results indicate that community-based mobile crisis services resulted in a lower rate of hospitalization than hospital-based interventions. Consumer characteristics were also associated with the risk of hospitalization.

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Despite a general awareness that screening for substance abuse is an important component of primary care, many clinicians are reluctant to screen for such issues. This study examines the utility of an interactive telephone technology for screening for substance abuse in primary care settings. The study was conducted at two primary care medical practices in Cleveland, Ohio. The project was implemented in two phases. The first phase examines the general reaction to the new screening methodology of 305 patients and 40 practitioners in two general medical practices. The second phase examines the concordance of patient responses given to the telecomputer screening system as compared to responses given to a research nurse in the practice. Results indicate that both patients and practitioners have generally positive reactions to this mode of screening and results may be comparable to clinician-administered screening.

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Women's health status is investigated in the context of stratification in the world-system. We investigate three alternative conceptualizations of the world-system for their effects on women's health status, using country-level data. The models investigate the effects of world-system position, military expenditures, and health resources on women's health status. Comparison of the alternative conceptualizations of world-system position indicate that a continuous model is only negligibly better than three- or five-block models at explaining women's health status. Regardless of how it is measured, world-system position has dramatic effects on women's health.

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OBJECTIVES: The authors describe computer services designed to make patients better informed and more motivated to participate in treatment. Patients use these services through their touch-tone telephone; access to a home computer or a modem is not needed. METHODS: The authors tested the impact of these computer services on the management of 179 pregnant women who had used cocaine during pregnancy or 1 month before pregnancy (as reported by the woman). Patients were randomly assigned to control and experimental groups; only the experimental group had access to the computer services. Patients were enrolled during the prenatal period and followed for 6 months after the birth of a live child. Self-reported data on the subjects' participation in drug treatment programs, health status (using the SF-36), and addiction severity (using the addiction severity index) were collected. The computer collected data on the frequency of the use of the service. The dependent variables were participation in formal treatment during the course of the project, and drug and alcohol use at exit interview. Multiple and logistic regressions were used to identify the effects of the intervention after controlling for demographic and baseline variables. RESULTS: Data showed that poor, pregnant, undereducated clients who use drugs and lived in multiple residences could use the services; about one-third of clients used the services more than three times a week. Access to the service did not lead to significant change in patients' health status, drug use, or utilization of services. Use of the services did lead to significant changes in participation in drug treatment: subjects who used the service more than three times a week were 1.5 times more likely to participate in formal drug treatment than subjects who used the service less often. Participation in formal drug treatment, however, was not effective in reducing the drug or the alcohol use. CONCLUSIONS: Almost all patients used the computer services to some extent, but there seems to be a threshold after which the use of the services had a more positive impact.

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OBJECTIVES: The authors analyzed the impact of home health education by studying the impact of a computer service called Community Health Rap. When patients call this service, the computer records their questions and alerts an expert who records a response. Subsequently, the computer alerts the patient that the question has been addressed. METHODS: Subjects included a group of 82 pregnant women who had used cocaine during or 1 month before pregnancy (as reported by the woman) and a group of residents of zip code areas with the lowest income in Cleveland. From the drug-using pregnant women, we collected data regarding satisfaction with Community Health Rap, usage of Community Health Rap per month, self-reported health status (using the General Health Survey), and the extent of drug use (using the Addiction Severity Index). Trained coders also classified the nature of questions posed to the Community Health Rap by either the pregnant women who abuse drugs or the members of target households. Among the pregnant women who abuse drugs, we compared the differences between those who used the service and those who did not. To control for baseline differences between the two groups, analysis of co-variance was used with exit values as the dependent variables, the baseline values as the co-variates, and participation in the Community Health Rap as the independent variable. RESULTS: Almost half (45%) of poor, undereducated subjects who lived in inner urban areas used the computer service. Content analysis of Community Health Rap messages revealed that subjects had many questions that were of a social nature (regarding sex, relationships, etc), in addition to medical questions. Analysis showed that poor health status, more frequent drug use, lower education, and age did not affect regular use of Community Health Rap service. No health outcomes or utilization of treatment were associated with regular use of Community Health Rap. One exception, however, was that regular users of Community Health Rap reported slower improvement of their pain than those who did not use Community Health Rap. CONCLUSIONS: These data suggest that expansion of information services to households will not leave the poor and the undereducated population groups "behind." They will use computer services, though such services may not have an impact on their health status or cost of care.

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The health status of women is examined within the context of a global political economy. The authors present a beginning attempt to model some key macrolevel processes linked to the health of women. In particular, a structural modeling technique known as LVPLS (or "soft modeling") is used to empirically test one recent formulation of world-system theory. The findings give added emphasis to the importance of the larger economic forces that affect women's health.

PIP: This study examined the impact of macroeconomic and political structural processes on the health status of women within the framework of world systems theory. The research questioned whether or not the world system position (WSP) of nations affects the health status of women and whether or not country stratification into core, strong, weak periphery, and periphery is valid. WSP and economic and social development were expected to be positively associated with women's health status. Analysis was based on 64 countries included in Ruth Sivard's 1982-83 data set on 142 countries, which is available from the Inter-University Consortium for Political and Social Research. WSP was determined according to the Nehmeth and Smith framework for 86 nations. Level of economic development was determined by per capita gross national product and energy consumption. Health status was measured by female infant and child mortality, mortality of women aged 15-45 years, and life expectancy of women at birth. Latent variable path analysis with partial least squares was used to express relationships. Multicollinearity effects were not taken into account, and latent variable path coefficients were understood to be rough estimates reflecting the theoretical ordering imposed by the model. 63% of the variance of each latent variable was explained by other variables in the model. When the WSP variable was excluded, the explained variance increased to 74%. The R2 of each latent variable was 0.60 for economic development, 0.65 for military expenditures, 0.39 for military expenditures per soldier, 0.76 for health expenditures, 0.94 for health services, and 0.79 for women's health status. The communality coefficient of 0.78 indicates a good measurement model. The average correlation between all the error terms of the manifest variables and the error terms of the latent variables is 0.06, which means a good overall fit. The model takes into account that the international stratification system of each country determines that country's world position. 60% of the variation in economic development is accounted for by WSP, which does not have independent effects on health-related latent variables including women's health status. The level of economic development plays a key role in women's health status.

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