Measuring efficiency of community health centers: a multi-model approach considering quality of care and heterogeneous operating environments.

Over 1300 federally-qualified health centers (FQHCs) in the US provide care to vulnerable populations in different contexts, addressing diverse patient health and socioeconomic characteristics. In this study, we use data envelopment analysis (DEA) to measure FQHC performance, applying several techniques to account for both quality of outputs and heterogeneity among FQHC operating environments. To address quality, we examine two formulations, the Two-Model DEA approach of Shimshak and Lenard (denoted S/L), and a variant of the Quality-Adjusted DEA approach of Sherman and Zhou (denoted S/Z). To mitigate the aforementioned heterogeneities, a data science approach utilizing latent class analysis (LCA) is conducted on a set of metrics not included in the DEA, to identify latent typologies of FQHCs. Each DEA quality approach is applied in both an aggregated (including all FQHCs in a single DEA model) and a partitioned case (solving a DEA model for each latent class, such that an FQHC is compared only to its peer group). We find that the efficient frontier for the aggregated S/L approach disproportionately included smaller FQHCs, whereas the aggregated S/Z approach's reference set included many larger FQHCs. The partitioned cases found that both the S/L and S/Z aggregated models disproportionately disfavored (different) members of certain classes with respect to efficiency scores. Based on these results, we provide general insights into the trade-offs of using these two models in conjunction with a clustering approach such as LCA.

Shifting Influences of Pregnancy on Union Formation across Age and Union Stability across Cohabitation Duration.

Nonmarital pregnancy increases the likelihood of entering a marital or cohabiting union. The timing of a pregnancy within the life course of an individual or relationship duration may also impact the likelihood of forming coresidential unions and their stability. This study examines the association between non-marital pregnancy and first union formation and how this varies across age. It also considers whether the influence of pregnancy on the stability of cohabitations shifts across their duration. Using data on young adults in the U.S. (Add Health), competing-risk event-history models examine the time-varying influence of pregnancy on union formation and stability. Findings suggest that pregnancy is more strongly associated with union formation during adolescence, becoming less influential as women age. Within cohabitations, pregnancy had a bigger impact on increasing the likelihood of marriage early within unions, but the longer a couple cohabited the less likely they were to transition to marriage when pregnant.

The adolescent family environment and cohabitation across the transition to adulthood.

This study draws upon a sample of men and women from Waves I and IV of Add Health to examine the linkages between the adolescent family environment and cohabitation behavior across the transition to adulthood. Using event history modeling the current paper considers the association between a variety of family factors and both the timing of first cohabiting unions and their outcomes (marriage, break up, still cohabiting). This paper also considers whether the impact of predictors for cohabitation timing and outcomes varies depending on the age of individuals. Results indicate that exposure during adolescence to family instability, parental cohabitation, lower parental SES, and low family belonging were associated with an elevated likelihood of entering into cohabiting unions, but primarily during adolescence and early adulthood. Family factors, including family belonging and parental relationship history, were also associated with the outcomes of first cohabitations.

My Mother's Husband: Factors Associated with How Adolescents Label their Stepfathers.

Adolescents in stepfamilies use different labels when describing their stepfather, such as "stepfather" or "mother's husband." These labels may reflect youths' sense of family identity or dynamics. The current study uses nationally representative data (Add Health) on a sample of adolescents living with their mothers and a married stepfather (n = 1192) to examine factors that may be associated with how teens describe their stepfather, and changes in this labeling over a year. Findings suggest that closeness with nonresident fathers increases the likelihood that teens avoid the "stepfather" label, while closeness with mothers increases the likelihood that they adopt the label. Closeness with their stepfather was not associated with how they label him. Other characteristics of the stepfamily are also important predictors of stepfather labeling.

Factors associated with positive relationships between stepfathers and adolescent stepchildren.

This study employs nationally representative data on adolescents and their stepfathers (n=2085) from the National Longitudinal Study of Adolescent Health (Add Health) to examine factors associated with positive stepfather-stepchild relationships in married stepfamilies. Results reveal substantial variability in the perceived quality of adolescents' relationships with stepfathers. Structural equation models using Wave I data reveal that close relationships with mothers and close ties between mothers and stepfathers are positively related to the perceived quality of adolescents' relationships with stepfathers. Longitudinal models using Waves I and II do not yield definitive results but suggest that the direction of influence runs in both directions, with the mother-child relationship and the stepfather-stepchild relationship mutually reinforcing one another. We identify a number of other factors that are associated with positive stepfather-stepchild ties, as well as a few factors that may be less consequential than previously thought. Most of the correlates of positive stepfather-stepchild relationships are similar for boys and girls; for Whites, Blacks, and Hispanics; and for stepfamilies of various durations.

Race and Place Matter: Inequity in Prenatal Care for Reservation-Dwelling American Indian People.

Early initiation and consistent use of prenatal care is linked with improved health outcomes. American Indian birthing people have higher rates of inadequate prenatal care (IPNC), but limited research has examined IPNC among people living on American Indian reservations. The current study uses birth certificate data from the state of Montana (n = 57,006) to examine predictors of IPNC. Data on the community context is integrated to examine the role of community health in mediating the associations between reservation status and IPNC. Results suggest that reservation-dwelling birthers are more likely to have IPNC, an association partially mediated by community health. Odds of IPNC are higher for reservation-dwelling American Indian people compared to reservation-dwelling White birthers, highlighting intersecting inequalities of race and place.

American Indians travel great distances for obstetrical care: Examining rural and racial disparities.

Rural, American Indian/Alaska Native (AI/AN) people, a population at elevated risk for complex pregnancies, have limited access to risk-appropriate obstetric care. Obstetrical bypassing, seeking care at a non-local obstetric unit, is an important feature of perinatal regionalization that can alleviate some challenges faced by this rural population, at the cost of increased travel to give birth. Data from five years (2014-2018) of birth certificates from Montana, along with the 2018 annual survey of the American Hospital Association (AHA) were used in logistic regression models to identify predictors of bypassing, with ordinary least squares regression models used to predict factors associated with the distance (in miles) birthing people drove beyond their local obstetric unit to give birth. Logit analyses focused on hospital-based births to Montana residents delivered during this time period (n = 54,146 births). Distance analyses focused on births to individuals who bypassed their local obstetric unit to deliver (n = 5,991 births). Individual-level predictors included maternal sociodemographic characteristics, location, perinatal health characteristics, and health care utilization. Facility-related measures included level of obstetric care of the closest and delivery hospitals, and distance to the closest hospital-based obstetric unit. Findings suggest that birthing people living in rural areas and on American Indian reservations were more likely to bypass to give birth, with bypassing likelihood depending on health risk, insurance, and rurality. AI/AN and reservation-dwelling birthing people traveled significantly farther when bypassing. Findings highlight that distance traveled was even farther for AI/AN people facing pregnancy health risks (23.8 miles farther than White people with pregnancy risks) or when delivering at facilities offering complex care (14-44 miles farther than White people). While bypassing may connect rural birthing people to more risk-appropriate care, rural and racial inequities in access persist, with rural, reservation-dwelling AI/AN birthing people experiencing greater likelihood of bypassing and traveling greater distances when bypassing.

Evaluating disparities in access to obstetric services for American Indian women across Montana.

PURPOSE: Pregnant women across the rural United States have increasingly limited access to obstetric care, especially specialty care for high-risk women and infants. Limited research focuses on access for rural American Indian/Alaskan Native (AIAN) women, a population warranting attention given persistent inequalities in birth outcomes. METHODS: Using Montana birth certificate data (2014-2018), we examined variation in travel time to give birth and access to different levels of obstetric care (i.e., the proportion of individuals living within 1- and 2-h drives to facilities), by rurality (Rural-Urban Continuum Code) and race (White and AIAN people). FINDINGS: Results point to limited obstetric care access in remote rural areas in Montana, especially higher-level specialty care, compared to urban or urban-adjacent rural areas. AIAN women traveled significantly farther than White women to access care (24.2 min farther on average), even compared to White women from similarly rural areas (5-13 min farther, after controlling for sociodemographic characteristics, risk factors, and health care utilization). AIAN women were 20 times more likely to give birth at a hospital without obstetric services and had less access to complex obstetric care. Poor access was particularly pronounced among reservation-dwelling AIAN women. CONCLUSIONS: It is imperative to consider racial disparities and health inequities underlying poor access to obstetric services across rural America. Current federal policies aim to reduce maternity care professional shortages. Our findings suggest that racial disparities in access to complex obstetric care will persist in Montana unless facility-level infrastructure is also expanded to reach areas serving AIAN women.

Operational efficiency, patient composition and regional context of U.S. health centers: Associations with access to early prenatal care and low birth weight.

Community health centers (CHCs) provide comprehensive medical services to medically under-served Americans, helping to reduce health disparities. This study aimed to identify the unique compositions and contexts of CHCs to better understand variation in access to early prenatal care and rates of low birth weights (LBW). Data include CHC-level data from the Uniform Data System, and regional-level data from the US Census American Community Survey and Behavioral Risk Factor Surveillance System. First, latent class analysis was conducted to identify unobserved subgroups of CHCs. Second, data envelopment analysis was performed to evaluate the operational efficiency of CHCs. Third, we used generalized linear models to examine the associations between the CHC subgroups, efficiency, and perinatal outcomes. Seven classes of CHCs were identified, including two rural classes, one suburban, one with large centers serving poor minorities in low poverty areas, and three urban classes. Many of these classes were characterized by the racial compositions of their patients. Findings indicate that CHCs serving white patients in rural areas have greater access to early prenatal care. Health centers with greater efficiency have lower rates of LBW, as do those who serve largely white patient populations in rural areas. CHCs serving poor racial minorities living in low-poverty areas had particularly low levels of access to early prenatal care and high rates of LBW. Findings highlight that significant diversity exists in the sociodemographic composition and regional context of US health centers, in ways that are associated with their operations, delivery of care, and health outcomes. Results from this study highlight that while the provision of early prenatal care and the efficiency with which a health center operates may improve the health of the women served by CHCs and their babies, the underlying social and economic conditions facing patients ultimately have a larger association with their health.

A Latent Class Analysis of Behavioral and Psychosocial Dimensions of Adolescent Sexuality: Exploring Race Differences.

Adolescent sexuality is a multidimensional concept involving sexual behavior as well as aspects of youth's sexual self-concept and sexual socialization. The current study used latent class analysis (LCA) to examine patterns of adolescent sexuality, with data from a nationally representative sample of youth (Add Health; n = 13,447), incorporating information on behavioral and psychosocial dimensions of adolescent sexual experiences. LCA results highlighted that youth may exhibit similar sexual behaviors but vary on psychosocial dimensions, including sexual self-efficacy, knowledge, and views about sex. Sociodemographic characteristics, family factors, mental health, and substance use emerged as predictors of membership into different latent classes of sexuality. Given persistent racial differences in sexual outcomes and sexually transmitted infection (STI) rates, the current study also examined how adolescent patterns of sexuality may help mediate racial differences in sexual outcomes by young adulthood. Results suggested that racial differences in adolescent patterns of sexuality help mediate racial differences in the number of sexual partners by young adulthood but not differences in STI diagnosis. Findings highlight the need for research on multiple aspects of adolescent sexuality to understand linkages with later outcomes and group differences.

Parent-Child Relationships in Stepfather Families and Adolescent Adjustment: A Latent Class Analysis.

In the current study the authors drew on Waves I and III from Add Health to examine the closeness of parent-adolescent relationships in married mother-stepfather families (N = 1,934). They used latent class analysis to identify family constellations defined by adolescents' relationships with all of their parents: mothers, stepfathers, and biological nonresident fathers. In particular, the authors (a) identified the most common underlying patterns of adolescent-parent relationships in stepfamilies; (b) determined the background characteristics that predict membership in these groups; and (c) examined how adolescents in these groups fare with respect to depressive symptoms, delinquency, and substance use. The results indicate that adolescents' relationships can be represented with 4 latent classes. Adolescents in these classes differ on measures of adjustment, and many of these differences persist into the early adult years.

Adolescents' Perceptions of Family Belonging in Stepfamilies.

Prior research has established that adolescents' perceptions of family belonging are associated with a range of well-being indicators and that adolescents in stepfamilies report lower levels of family belonging than adolescents in two-biological-parent families. Yet, we know little regarding what factors are associated with adolescents' perceptions of family belonging in stepfamilies. Guided by family systems theory, the authors addressed this issue by using nationally representative data (Add Health) to examine the associations between family characteristics and adolescents' perceptions of family belonging in stepfather families (N = 2,085). Results from structural equation models revealed that both the perceived quality of the stepfather-adolescent relationship, and in particular the perceived quality of the mother-adolescent relationship, were the factors most strongly associated with feelings of family belonging.