Impact of the Health Services Utilization and Improvement Model (HUIM) on self efficacy and satisfaction among a head start population.

Tataw, David B. ; Bazargan-Hejazi, Shahrzad

INTRODUCTION

The powerlessness of low income health services consumers in an ever complex US health care system is self evident. Low income children between the ages of 0 to 5 present unique circumstances due to their distinct provider systems, different epidemiology of illnesses and developmental issues. Their dependence on care-givers to access care (Ferris et. al., 2001), and the limited skills and knowledge of their care-givers calls for a health services model that is separate and different from the adult model (Forrest et. al., 1997) as well as mainstream models.

The Health Services Utilization and Improvement Model (HUIM) is an empowerment and predictive model which was designed to reduce low levels of health services utilization and improve preventive health techniques and disease self-management for Head Start families with the ultimate goal of attaching each child to a medical home (Tataw et. al., 2007). HUIM was implemented through educational and case management strategies that address individual determinants of health services utilization as well as provider accommodation.

The specific aim of this paper is to evaluate and report the impact of HUIM on utilization and satisfaction with care, as well as knowledge regarding prevention, detection, and treatment of asthma, diabetes, tuberculosis, and child injury among low income health services consumers. The rationale, design, and implementation strategies and structures of HUIM have already been covered in a separate paper (Tataw et al., 2007). This report focuses only on the parents' related outcomes including self-efficacy and satisfaction with health services. Self-efficacy refers to the state of competence to perform certain desired tasks or behavior (Baranowski et. al., 2002). Satisfaction with health services refers to the extent to which the patient is comfortable with, or accepts the services of a health provider. We also discuss future research opportunities, and implications for policy and practice.

Satisfaction and Self-efficacy have become important constructs for health services scholars and practitioners. Administrators and researchers have increasingly focused on patients' satisfaction with the health care they receive as an important quality measure because satisfaction has been linked to health status and clinical process outcomes including compliance to medical treatment, prevention interventions, and improvements in health conditions (Cameron, 1996; Hall et al., 1998; Deyo & Diehl, 1986; Winefield, 1995; Redekop et al. 2002; Alazri & Neal, 2003). Studies also tie self efficacy to compliance with therapy regimens and positive coping styles. Non-adherence has been associated with personal factors such as sexual orientation and self-efficacy; physical factors such as loss of appetite; and interpersonal factors such as doctor-patient relationship ( Remien et al. 2007) . Adherence is associated with patients' self-efficacy regarding their medical regimen which, in turn, is associated with their social support (Atkinson et. al., 2008). Also, SoEderlund & Lindberg, (2001), showed that self-efficacy is related to patients' use of different coping styles. Patients with high self-efficacy reported less use of "maladaptive" and passive coping styles than patients with low self-efficacy.

Low-income children and children with special needs have been found to have high levels of unmet needs (Janicke et. al. 2001; Newacheck et. al. 1996; Mel nick, et. al., 2002; Newacheck et. al. , 2002) and experience poorer quality of primary care (Steven& Shi, 2002a; 2002b; 2003). Parent's self-confidence to voice concerns (Janicke & Finney 2003, McCarthy et. al., 2003), Language barriers (Seid et. al., 2003; Weech-Maldonado et al. 2001, 2003), parents' perception of having a regular provider (Stewart et. al. , 1997), and satisfaction with care (Stevens & Shi., 2002a; Christakis et. al., 2002; Baltutis & Morgan, 2002) impact parent's primary care utilization behavior.

CONCEPTUAL FRAMEWORK

The Preventive Health Education and Medical Home Project (PHEMHP)

The Health Utilization Improvement Model (HUIM) is a variation of the Preventive Health Education and Medical Home Project (PHEMHP), which is a minority health services utilization improvement approach designed by faculty in the Department of Pediatrics at Charles R. Drew University in Los Angeles. The PHEMHP calls for coordination and maximum utilization of existing health and medical services within the community for improving the health of a child. This task is accomplished by being an information resource, providing health education, engaging a network of providers and community volunteers, and focusing on establishing a medical home for the child and family. Consumer empowerment and the improvement of the provider's capacity to meet the needs of the low-income family are central to the PHEMHP (Tataw, Bazargan, James, 2009).

The theoretical concepts of relevance to this study are self-efficacy, social response/conditioning, perceived threat, and perceived barriers. We believe that our intervention will generate enough human and environmental stimuli and reinforcements to overcome barriers to preventive health behavior and health services utilization in the targeted Head Start population. As perceived threats to health are recognized and perceived barriers are overcome, self-efficacy, self-care and positive health prevention, and service utilization outcomes will be realized in the target Head Start population.

Self-efficacy refers to the state that individuals experience as "competence" to perform certain desired tasks or behavior "including confidence in overcoming the barriers to performing that behavior" (Baranowski et al. 2002, p. 173). Self-efficacy is a key concept of the Health Belief Model (HBM) which is one of the most frequently used value-expectancy theories in health behavior applications (McKenzie et. al. 2005). The Health Belief Model posits that health-related action such as self-care, depends on the simultaneous occurrence of three factors: sufficient motivation, perceived threat, and perceived barriers.

Predisposing, enabling, and perceived health factors contribute to self-efficacy and ultimately lead to positive behaviors such as self-advocacy, appropriate utilization of health services, and disease self-management. The HUIM, through education and non-clinical case management, creates enabling, and perceived health factors necessary to generate self-efficacy, self-advocacy, appropriate health utilization patterns, health prevention and disease self-management in the Head Start population.

METHODS AND PROCEDURES

Design

This was a prospective quasi-experimental pretest-posttest intervention study. During the first year, the program focused on four intervention sites. In the second year, four control sites were added to the program.

Site Selection Criteria

The sites were selected based on their geographic location, enrollment numbers and racial/ethnic makeup. The goal was to ensure that selected sites reflect the racial demographic mix of the Head Start population and Head Start's service area.

Participating Parents

During the enrollment of their children to the program, parents were approached for participation in the HUIM program. To be able to enroll in the program, parents/guardians had to meet the following criteria: 1) have a child between the age of 3-5 who was enrolled in the Head Start Program; 2) reside within the geographic area of South Los Angeles; 3) provide written or verbal consent indicating that they were aware of the objectives of the program and are willing to be a part of it; (4) have no definite plans to leave the area in the next year.

Participating Providers

Head Start enrollment databases were used to track each child's compliance with health-related enrollment requirements. Through this database we identified providers with five or more non-compliant enrollees. These were providers who at the time were practicing in any of the following settings: medical offices, medical groups, hospital-based groups, or providers in solo-practice.

Intervention:Health Services Utilization and Improvement Model (HUIM)

The two year HUIM intervention reached 80 community providers, and provided educational services to 250 participating parents representing 600 CDU Head Start children. The average participating Head Start family had 2-3 children. Not every parent who was served participated in the evaluation.

Program Design

HUIM was implemented in two years; during the first year we applied a one group pre and post quasi-experimental design using four intervention sites. For the second year we used a pre and post quasi-experimental design including both intervention and control groups made up of 4 intervention sites and 4 control sites. Therefore, the two year HUIM intervention took place at eight Charles R. Drew University (CDU) Head Start program sites altogether between June 2003 and June 2005. All Head Start sites were located approximately 5 miles from each other (Tataw et al. 2007). Charles Drew University Head Start has 21 state-licensed sites and home-based programs, serving 1,800 children from 0 to 5 years in south central Los Angeles. This is an area which is disproportionately affected by socio-economic and health disparities. The racial makeup of the Drew Head Start Program includes 64% Hispanic, 35% African American and 1% other. The Head Start Program is a university community program serving low income families with semi-autonomous status, supported by federal and state funds and governed by a community policy council.

Program Components

The educational component had two subcomponents, parent education and provider orientation. Non-clinical case management included assessment/screening, individualized action plans, attachment to existing payer sources, referral to existing health resources, monitoring and third party advocacy as participants navigated the health care system.

All consented Head Start participants for selected sites were screened using California and American Academy of Pediatrics well-child care standards and provided utilization activation tools. Utilization activation tools included a brochure listing patient rights, existing resources, how to qualify for health insurance, well-child guidelines, what questions to ask a child's provider, and common provider mistakes on Head Start health forms. Based on the outcome of the initial screening, enrollees were referred to any needed services and mentored. Health educational workshops were provided to parents during routine Head Start parent educational sessions. Enrolled participants also filled out a 30-40 minute structured questionnaire. Both English and Spanish versions of the questionnaires were available and were used based on the participant's preferences. Follow-up assessments were carried out; a pretest and 3-month post intervention assessment using only one group (i.e. intervention group). A pretest and 6-months post intervention assessment, again using only one group (i.e. intervention group), and a pre and 6 month post intervention using both intervention and control group.

After completion of baseline assessments in the intervention sites and when applicable in control sites, enrollees in both intervention and control sites received five health educational/training workshops covering areas related to prevention, identification, and treatment of diabetes, asthma, obesity, tuberculosis, and child injury. In addition to educational workshops, enrollees in the intervention sites received structured case management delivered by bilingual English and Spanish Community Health Workers who were trained for this purpose.

Thirty minute, on site, in-service, information sessions were scheduled with all consented providers to share and exchange information about the unique needs of Head Start families. Information sessions were delivered by the program trained staff and included information regarding how to complete Head Start forms, billing practices, class and cultural issues that handicap self-expression by Head Start families.

Detailed intervention components are outlined below and include the following:

Parental education: Parental education was composed of health systems education and preventive health techniques workshops. The topics were chosen based on the results of our baseline survey, children health status review at enrollment into the Head Start Program, community public health data, and parent preferences obtained through the advisory committee.

Health systems education: There was one health system module delivered in 3 one-hour workshops. The topics covered included types of payer programs, process of obtaining coverage, eligibility, enrollment process, who/where to enroll, types of providers, what makes a good provider, what to look for when selecting a provider, knowledge of local providers, free to low-cost primary care facilities and sub-specialty services for low-income families, what is a medical home, and what is an appropriate medical home. One hundred fifty parents took part, covering 400 children. There was an average of 2-3 children per Head Start family.

Preventive health education techniques: There were 12 preventive health education modules covering the most common diseases in the community. Parents received 41 thirty-minute workshops. Conditions covered were obesity, hypertension/blood pressure, diabetes, asthma, child safety, asbestos/lead poisoning, immunizations, tuberculosis, head lice, oral hygiene, child abuse prevention and mandatory reporting, and hand washing as a universal precaution. Class sizes ranged from 30 to 50. Two hundred fifty parents took part covering 600 children.

Provider orientation workshops: In the first year, 30 community providers participated in two round tables and one grand round. Topics covered included medical homes for Head Start children, billing strategies, and the special health services needs of Head Start children. Based on the feedback from participants in the provider orientations and the fact that less than 15 Head Start providers took part in the orientations in the first year, provider orientations in the second year, were transformed to targeted on-site in-service sessions. In the second year, 30-minute workshops based on one module were delivered to 50 community providers. Topics covered included how to complete Head Start forms, billing practices, class and cultural issues that handicap self-expression by Head Start families, the unique health needs of the Head Start population, and Head Start health-related enrollment requirements.

Non-clinical case management: Non-clinical case management for parents was implemented by community health workers. Community health workers were drawn from the same community as the participants, and had an average educational level of an associate degree. They had no formal clinical training, but received training on specific disease conditions and in case-management techniques. Since community health workers were from the same ethnic and socio-economic background as the target population, they could easily establish rapport and trust with participants. HUIM's case management was made up of assessment/screenings, referrals, service coordination, individualized planning, coaching, monitoring, and third party advocacy for the purpose of maintaining a continuum and a regular source of care. This is distinct from clinical case management which includes treatment plans and implementation and are usually physician driven and nurse implemented (Huber 2000, Birmingham & Colon, 2005).

Assessment/screening: These involved one-on-one meetings in which the community health workers were able to assess the specific needs of the individual family. Needs usually included enrollment to a payer source and switching from a provider or insurance plan (usually due to dissatisfaction with provider and/or transportation challenges based on provider's location). The HUIM staff was then able to make recommendations that met the family's needs.

Self-advocacy tools: All parents were provided voice activation tools, including well-child guidelines, common provider mistakes on Head Start forms, and what questions to ask a child's provider. Additional tools included a brochure listing local health resources, patient rights, and how to get insurance.

Individualized action plan: This involved opening a file/folder for the family with various tracking forms, which were used to monitor the goals planned for participants and also involved discussions on individualized solutions and goal-setting. Each family was identified a short- or long-term plan based on services needed. Progress notes were kept at every stage and at the completion of each goal.

Linkages: Staff facilitated access to a new provider, enrolling the child or another family member in the house to a payer source, and identified and directed the family to local free or low-cost community health facilities.

Monitoring and advocacy: This involved service coordination, coaching, and third-party advocacy so that the child had a regular source of care. Staff assisted the family in obtaining appropriate services, ensuring that the provider sees them on time and that the child's required school health forms are filled out completely and accurately. HUIM staff also facilitated the provision of an absent permit from work to allow a parent/guardian to take time off to attend their scheduled appointment for insurance enrollment or medical service.

Families were weaned out of case management activity once HUIM staff was assured that the family was maximally utilizing their medical home and existing insurance programs. This usually took about 6-12 months. After 2-3 visits, most families were able to assure HUIM staff of their satisfaction with the provider's services.

Instructional Materials, Methods, and Tools

Instructional materials: All preventive education workshops on health conditions such as asthma, diabetes, or obesity, relied on validated and widely-used curriculum developed by experts in the discipline or professional organizations. The health systems education and provider education curriculum were developed in-house by HUIM staff.

Group teaching: All workshops were face-to-face and team-delivered in groups of 2 to 3 HUIM staff. A translator was included as needed and instruction was usually in English and Spanish. There was usually a lecture and smaller group or individual discussions for specific questions to be addressed. All parent educational sessions took place at the Head Start sites during required parent educational sessions. Provider education took place at provider sites and at the provider's convenience.

Tools: Tools used included posters, displays, flipcharts, and bulletin boards. Videotapes, overhead transparencies, and printed materials were also used. In topics in which the HUIM staff did not have expertise, they relied on community resources for guest lecturers.

Study Measures

This study was approved by Charles Drew University IRB. Study questionnaire items covering parent outcomes included items related to predisposing and enabling factors, perceived health status, knowledge of health services, self-efficacy in disease prevention and health services utilization, disease identification, prevention, and self-management skills, and health services utilization. The following socio-demographic variables were also included in the questionnaire: marital status, relation to child, person making decisions, length of time living at current address, regular source of care, if the child has health insurance, access to regular source of health care, child's health status, and location of regular care. Same study survey was used for follow-up assessment, although a few intervention specific items were added for evaluative purpose. Main outcome variables include: participants' self-efficacy in disease prevention and health services utilization as well as their satisfaction with the medical encounter. A comprehensive parent survey instrument administered at baseline, 3 months (first year), and at 6 months (second year) follow-up was the main instrument used to measure predisposing factors, enabling factors, perceived health status factors, knowledge of health services, self-efficacy in disease prevention and health services utilization, disease identification, prevention, and self-management skills, and health services utilization.

Predisposing characteristics: included marital status of the parents/guardians and the number of years lived in current address.

Enabling characteristics: were measured using the following indices:

The first index, difficulty in accessing medical care, used a 7-item measure on a Likert scale (1 = extremely difficult to 5 = not difficult at all), which included the following questions: Overall, how difficult would it be for you to get the following services for every child in the family (1) routine physical exam; (2) routine eye exam; and, (3) see a health specialist.

The second index included difficulty to (1) get an appointment to see a health care provider; and (2) to get an appointment to see a specialist.

The third index included difficulty (1) to get/travel to the health care provider ; (2) to get/travel to a medical specialist.

Perceived health status factors: were measured through need-for-care characteristics. The need-for-care characteristic index was measured by health status including three variables:

Number of self-reported physical health, mental health, vision, and dental-related needs which were perceived by the parent/guardian needing medical advice or treatment during the past 12 months (8 items; 1 = yes, 0 = no).

Parent/guardian's self-report of the child's Well-Child Visits which were measured by 11 items asking questions regarding immunization schedule. The questions were based on the criteria set for Pediatric Health Examination by the American Academy of Family

Physicians (2003).

Perceived self-rated health status of the child was measured by asking the question, "Would you say your child's health, in general, is poor, fair, good, or excellent?" Response categories ranging from (1 = poor to 5 = excellent).

Knowledge of existing health services: was measured by knowledge of health care service locations, based on 7 (1= yes or 0= no) questions on knowledge of location of the following: immunization /routine physical check-up, medical advice or treatment, emergency care, dental care, eye care, hospital care, and specialty care.

Self-efficacy in disease prevention and health services utilization: was measured through availability of health related information and voice.

Availability of health related information: was assessed by three sub-domains. A Likert scale (1 = don't know at all, to 5 = excellent) was used to assess the following sub-domains: Overall, how would you rate your knowledge on a) identifying, b) preventing, c) taking care of 1) asthma, 2) diabetes, 3) tuberculosis using 3-item questions for each health condition.

Voice: refers to parent's ability to voice their concerns and therefore ask questions from their health care provider regarding the health of their child. Parent/guardian's "voice" was assessed by asking respondents to report in a Likert scale "strongly disagree" (= 1) to "strongly agree" (= 5) if they can ask and/or talk about the following matters with their child's regular health care provider : how to prevent child asthma; how to prevent child obesity; ask a child's health care provider to explain the child's health care plan in a way the parent/guardian could understand; be very honest and open with the child's health care provider and express concern if the parent/guardian has a problem with the health care provider's advice.

Disease identification, prevention, and self management skills: were measured on a Likert scale (1 = don't know at all, 2 = poor, 3 = good, 4 = very good, 5 = excellent) of 11 self-report questions on identifying, preventing, and taking care of asthma, diabetes, tuberculosis, injury, and violence at home.

Health services utilization factors: were measured by the following variables: health services utilization, affordability of medical care, regular source of care, parent's satisfaction with their child's regular health care provider, and satisfaction with health care utilization. Health services utilization was measured by 7 items. All of them tap formal services received during the past 12 months. Items included the following: did you take your child/children to a health care provider for the following reasons: 1) immunization or routine checkup, 2) medical advice or treatment, 3) emergency care, 4) dental care, 5) eye care, 6) hospitalization, and/or 7) specialty care (1 = yes, 0 = no).

Affordability of medical care: was assessed by asking whether during the past 12 months the participants had difficulty acquiring medical coverage, eye coverage, dental coverage, or purchasing prescribed medication because "you had to pay out of your pocket".

Regular sources of care: were assessed with one item asking the participant whether there is "a place you usually take your child/children when they are sick or need medical advice about health." (1 = yes, 0 = no).

Parents' satisfaction with their child's regular health care provider: was assessed by asking respondent to report in a Likert scale if they strongly disagree (= 1), to strongly agree (= 5) with the statements regarding their child's health care provider including; a) health care provider being friendly and easy to talk to; 2) health care provider respecting me and answering all my questions; 3) health care provider speaks my language; 4) health care provider spent enough time with me and my child; 5) health care provider gave me child injury preventive advice; 6) my child's health care provider cares about us; 7) I can trust my child's health care provider

Satisfaction with health care utilization: as the outcome measure was assessed by 6 items asking parents/guardians to rate on a scale of 1 (strongly disagree) to 5 (strongly agree) where they stand in their opinion regarding getting a "good caring services from the doctor" when they used various health care services for their child/children in the past 12 months. The list of health services included obtaining routine/regular check-ups, medical advice or treatment, emergency care, dental care, eye care, and hospitalization. Detailed descriptions of the study measures have already been covered in a separate paper (Tataw et al., 2007).

DATA ANALYSIS

The data analysis evaluated whether the intervention (HUIM) has improved participants' utilization and satisfaction with care, as well as their knowledge of prevention, detection, and treatment of asthma, diabetes, tuberculosis, and child injury. We conducted the following three step analyses: In the first step, we compared the baseline scores of the first year participants (n= 64) with their subsequent follow-up scores (n= 25). In other words, conducting one group pre and 3 months post intervention evaluation. In the second step, using paired sample t-test, again, we compared baseline scores of the second year participants in the intervention (n = 179) with their respective follow-up scores (n = 84). This time conducting a one group pre and 6 month post intervention evaluation. In the third step, using an independent sample t-test we compared follow-up scores of the second year participants in the intervention group (n = 84) with the follow-up scores of the participants in the control group (n = 27). In other words, conducting a two group pre and post intervention evaluation.

These tests allow us to say whether there were any detectable differences between the means of the groups, and if the differences were statistically significant. All analysis were performed using the Statistical Package for Social Science (SPSS version 12.0, 2004), A p-value = <0.05 was considered statistically significant.

RESULTS

Step 1: One Group Pre and 3-Month Post Intervention Evaluation (Table 1).

Sixty four Head Start parents/ guardians were consented, enrolled, and received intervention during the first year of the study. Most participants were mothers of the index child (92.0%), and majority reported being separated/divorced/living with companion, or never married (69%). Fifty six percent reported living in the United States [less than or equal to] 5.

Comparing the health related variables in the baseline and follow-up (Table 1), we observed nearly 13% increase in the percentage of respondents who reported "extremely/very satisfied (P [less than or equal to] .05) with the ability to be honest and open with providers (from 48.3% to 61.6%). Regarding the knowledge items, while during the pretest 13% of the respondents reported having "very good/excellent" knowledge regarding diabetes identification, post results indicate that 27% of these respondents reported such answers (increase of 14%), (P [less than or equal to] .05). The percentage of parents who reported having "good/excellent" knowledge regarding prevention of diabetes increased from 15% in baseline to 20% in the follow-up (increase of 5%), (P [less than or equal to] .05). The percentage of parents who reported having "good/excellent" knowledge regarding taking care of diabetes increased from 14.5% in the baseline to 31% in the follow-up (increase of 15%), (P [less than or equal to] .05).

We also detected positive trends from baseline to follow- up , though not statistically significant, in the following items: parents' knowledge regarding, identification, detection, and treatments for asthma; respondents who reported not having a regular source of medical care for their children; the number of respondents who were unable to get medical care for their child/children due to not knowing where to go or who to talk to; and knowledge regarding preventing child injury. (Data not reported in Table 1).

Step 2: One Group Pre and 6-month Post Intervention Evaluation (Table 2).

The intervention group (n= 179) pretest scores were compared with their subsequent 6-month follow-up (n=84) post test scores. On average, during the follow-up, they reported a lesser degree of difficulty to travel to a child's provider or specialty [(M = 4.51, SE = .096) vs. (M = 8.98, SE = .208), P [less than or equal to] 0.001]; greater knowledge regarding identification, prevention, and treatment of asthma during the follow-up [(M = 8.20, SE = 394) vs. (M = 6.47, SE = .0508), P [less than or equal to] 0.000]; greater knowledge regarding identification, prevention, and treatment of diabetes during follow-up (M = 7.63, SE = .428) vs. (M = 5.68, SE = .552), P [less than or equal to]0.002]; and greater knowledge regarding identification, prevention, and treatment of tuberculosis during follow-up (M = 7.66, SE = .432) vs. (M = . 5.27, SE = .4197), P [less than or equal to]].001

Step 3: Two Group Pre and 6-month Post Intervention Evaluation

Table 3 reveals a statistically significant difference between the mean scores of the intervention group and control group at 6-month follow-up assessment. On average, participants in the intervention group reported greater satisfaction with the child's regular doctor during the follow-up (M = 26.1, SE = .608), than their counterpart control group (M = 22.8, SE = 1.45) P [less than or equal to] 0.016. In comparison to the control group, participants in the intervention group also reported being more able to voice their concerns and therefore ask questions from their doctors regarding the health of their child [(M = 26.0, SE = .681) vs. (M = 22.7, SE = 1.520), P [less than or equal to] 0.031].

Furthermore, the follow-up results in Table 3, show that in comparison to the control group, participants in the intervention group reported greater knowledge regarding identification, prevention, and treatment of asthma [(M = 8.36, SE = .370) vs. (M = , 6.66, SE = .708) P [less than or equal to] 0.029], diabetes [(M = 7.93, SE = .398)] vs. [(M = 5.84, SE = .696) P [less than or equal to] 0.010], and Tuberculosis(TB) [(M = 7.95, SE = .402) vs. (M = 5.79, SE = .714) P [less than or equal to] 0.009].

Like in step 1 above, in step 2 and 3, the data showed a positive , though not statistically significant trend in the following areas: a) higher mean score on knowledge regarding accessing (i.e. where and how to get) various health care services; b) less difficulty to access care such as regular care, vision care, and specialty care; c) less difficulty to get appointment to see a primary care doctor or specialty care. (Data not reported in Tables 2 and 3.

CONCLUSION AND RECOMMENDATIONS FOR RESEARCH, POLICY, AND PRACTICE

Conclusion.

Many scholars have documented and advocated for the role of educational and ecological interventions in determining health prospects (Green and Kreuter, 1999; Mckenzie et al., 2005). Empowerment has been advanced as both a means and an end in enhancing and promoting health (Wallerstein 1988, 1992; Braithwaite et. al., 1994; Labonte 1994; Perkins & Zimmerman, 1995, Tataw et al. 2007; Tataw, Bazargan, James, 2009). HUIM outcomes data shows that the coupling of parental education and ecological factors (service linkage and provider orientation) impacts the health services utilization experience of low income consumers evidenced by improved self-efficacy ( knowledge and voice), and satisfaction with care from a child's regular provider. Participation in HUIM activities also improved the low income consumer's knowledge of disease identification, self care and prevention.

Future Research Opportunities

One shortcoming of the HUIM evaluation is the length of time between intervention and follow-up assessment. While the baseline was usually based on one year of experience, the follow-up data was based on a much shorter time frame. Three months for the first year and 6 months for the second year. Future research should provide a minimum of one year for follow-up assessment to take place. That would give more time for utilizations experiences to be fully demonstrated. Also, a longitudinal study that follows the participants for about 5 years or more will provide stronger data to inform research and practice. Furthermore, HUIM provider data is still descriptive. Future intervention research efforts should focus on more rigorous methods in measuring provider outcomes including sensitivity to the needs of their vulnerable clients as well as behaviors in the provider domain that might positively impact client experiences during a medical care contact. In addition, future HUIM interventions should include other at-risk populations which might be less diverse than our study population such as Native American populations, low income rural white populations, and people with disabilities. Finally, investigations which measure the impact of HUIM on behavioral and health outcomes of Head Start and other at-risk populations will move HUIM research closer to its optimum.

Policy and Practice Implications

The positive outcomes in our two year implementation of the HUIM raise significant questions about the dominant Health Access Policy model in the US, which focuses almost exclusively on insurance or financial factors. Should this trend hold with larger samples, the results will represent a strong basis for rethinking the current Health Access Policy Paradigm? Potentially, education and service linkage activities similar to those offered in the HUIM could become part of required and reimbursable activities in Health Access Public and Private Programs serving low income populations. Also, the outcomes data in this study underscores the need to integrate health systems education in health education designs for low income children and their families. Finally, the outcomes data suggest that service linkage or non-clinical case management should be a standard part of practice for pediatric providers in low income populations which are similar to our head start population.

Acknowledgement

The Implementation and Evaluation of the Health Services Utilization Improvement Model was supported by a Grant from the California Endowment.

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DAVID B. TATAW

Indiana University, Kokomo

SHAHRZAD BAZARGAN-HEJAZI

Charles R. Drew University

Table 1
One Group Pre and 3-Month Post Intervention Evaluation

Variable                          Baseline           Follow-up
                                  Based on last 12   Based on last
                                  months             12 months
                                  (n-64). N/%        (N-25) N/%
Satisfaction with ability to be
honest, open with provider.
  * Extremely
    satisfied/very
    satisfied/satisfied           54/ 93.1           26/ 100
  * A little satisfied/not
    satisfied                     4/ 5.9             0/00

Knowledge regarding
identifying diabetes                                 --
  * Very poor                     5/ 8.1             --
  * Poor                          10/ 16.1           12/ 46.2
  * Fair                          19/ 30.6           5/ 19.2
  * Good                          9/ 14.5            5/ 19.2
  * Very good                     3/ 4.8             2/ 7.7
  * Excellent                     5/ 8.1             2/ 7.7
  * Don't know                    11/ 17.7

Knowledge regarding taking
care of diabetes                                     --
  * Very poor                     2/ 3.2             1/ 3.8
  * Poor                          5/ 8.1             9/ 34.6
  * Fair                          19/ 30.6           6/ 23.1
  * Good                          11/17.7            4/ 15.4
  * Very good                     3/ 4.8             4/ 15.4
  * Excellent                     6/ 9.7             2/ 3.1
  * Don't know                    16/ 25.8

Sources used to find a medical
provider for one's children
  * Health professional           35/ 72.9           24/ 92.3
  * Internet                      11/ 27.5           12/ 46.2
  * Head Start staff/HUIM         29/ 63.0           20/ 76.9
    community workers

** S = Significant (p < .05)

Table 2
One Group Pre and 6-month Post Intervention Evaluation.

Variables        Intervention Intervention
                 at baseline  at follow-up
                  (n= 1 79)     (n= 84)

                Mean   SE     Mean   SE    t (df), p

Difficulty      8.98   0.208  4.51   .096  25(81), 0.001
to travel for
care

Knowledge       6.47   .0508  8.20   .394  -3.19(66),
(asthma)                                   0.002

Knowledge       5.68   .552   7.66   .432  -3.17(64),
(diabetes)                                 0.002

Knowledge       5.27   .4197  4.51   .096  -4.44(64),
(TB)                                       0.001

** S = Significant (p < .05)

Table 3 Independent t-test for Two Group Pre and 6-Month Post
Intervention Evaluation

Variables       Intervention     Control
                  (n= 84)        (n= 27)

               Mean   SE       Mean    SE      t (df), p

Satisfaction   26.1   .608     22.8    1.45    2.45
with the                                       (109),
child's                                        0.016
regular
doctor

Voice          26.0   .681     22.7    1.52    2.19
                                               (108),
                                               0.031

Knowledge      8.36   .370     6.66    .708    2.22
(asthma)                                       (95),
                                               0.029

Knowledge      7.93   .398     5.84    .696    2.63
(diabetes)                                     (96),
                                               0.01

Knowledge      7.95   .402     5.79    .714    2.66
(TB)                                           (95),
                                               0.009

** S = Significant (p < .05)