Making public health data available to community-level decision makers--goals, issues, and a case report.

Effective community health assessment and planning depends on the availability of appropriate public health data. Web-based technologies have created an unprecedented opportunity for making data available to community-level public health decision makers. An interactive data retrieval system targeted to the community-level user must provide an intuitive and easy-to-learn user interface with functionality and statistical complexity appropriate to the expected users while maintaining confidentiality of personal health information. The authors use the Missouri Information for Community Assessment Web site as an example to discuss goals and issues involved in the development of such systems.

Motor-vehicle occupant injury: strategies for increasing use of child safety seats, increasing use of safety belts, and reducing alcohol-impaired driving.

The Task Force on Community Preventive Services has conducted systematic reviews of interventions designed to increase use of child safety seats, increase use of safety belts, and reduce alcohol-impaired driving. The Task Force strongly recommends the following interventions: laws requiring use of child safety seats, distribution and education programs for child safety seats, laws requiring use of safety belts, both primary and enhanced enforcement of safety belt use laws, laws that lower the legal blood alcohol concentration (BAC) limit for adult drivers to 0.08%, laws that maintain the minimum legal drinking age at 21 years, and use of sobriety checkpoints. The Task Force recommends communitywide information and enforcement campaigns for use of child safety seats, incentive and education programs for use of child safety seats, and a lower legal BAC for young drivers (in the United States, those under the minimum legal drinking age). This report provides additional information regarding these recommendations, briefly describes how the reviews were conducted, and provides information to help apply the interventions locally.

A better way to kill dragons: parody on the experience of building an integrated information system in Missouri.

The Missouri Department of Health has been developing an integrated information system for all state and local public health activities. When the project began, there were more than 60 separate information systems that supported the state and 115 local public health agencies. This parody describes the process of moving from separate data systems (implements of war) to MOHSAIC, a single information system with a common database (scroll). Considerable progress has been made in overcoming the political, financial, and technical challenges to make MOHSAIC a reality.

Evidence-based decision making in public health.

A stronger focus on evidence-based decision making in day-to-day public health practice is needed. This article describes the rationale for this need, including (1) the inter-relationships between evidence-based medicine and evidence-based public health (EBPH); (2) commonly used analytic tools and processes; (3) keys to when public health action is warranted; (4) a strategic, six-step approach to more analytic decision making; and (5) summary barriers and opportunities for widespread implementation of EBPH. The approach outlined is being tested through a series of courses for mid-level managers in the Missouri Department of Health--initial results from a pilot test are encouraging. It is hoped that the greater use of an evidence-based framework in public health will lead to more effective programs.

Building public health goals into the purchasing process: the Missouri Medicaid agency as purchaser.

INTRODUCTION: As managed care radically changes the medical care environment, public health leaders are under increasing pressure to focus more on core public health functions and less on personal health services. As public health re-evaluates its key strategies, it can take advantage of its strategic role in purchasing medical care to forge new partnerships that benefit its constituents. METHODS: Specific roles for public health in medical care purchasing are discussed. The state of Missouri is used as an example of successful strategies for positioning public health as a leader in the managed care environment. Key strategies include increasing influence in contracting; selecting and reporting of key health status indicators; promoting use of population-based data files; taking leadership roles in government-sponsored insurance programs; and assuring stability of critical health conditions during managed care transitions. CONCLUSION: Public health has unprecedented opportunities to develop new methods for improving health status. Public health's well-developed scientific principles and methods, combined with strategic leadership, will position the discipline in the forefront of the dialogue about our nation's health system into the next century.

Missouri's Take a Seat, Please! and program evaluation.

In Missouri, injuries from motor vehicle crashes are the leading cause of death to children aged one to four. In 1984, the state legislature enacted child passenger safety legislation, but by 1992, compliance with the law was still disappointingly low. The Missouri Department of Health implemented a program called Take a Seat, Please! in which concerned citizens reported motorists who transported children under age four in a way not compliant with the state law. Two years later, a telephone survey and a pre- and postobservation study at child care centers did not show that the intervention had any effect. The program was discontinued in September 1995.

Missouri's emergency department E-code data reporting: a new level of data resource for injury prevention and control.

This article describes the results of the first statewide external cause of injury (E-code) reporting system that includes emergency department (ED) visits. The results indicate that for every injury-related death, there are 20 hospitalizations and 174 ED visits. Although firearms and motor vehicle crashes were the leading causes of injury-related deaths, falls and motor vehicle crashes were the leading causes of ED visits. An analysis of injuries in one metropolitan statistical area in the state demonstrates similarities and differences from the statewide results. The statewide reporting of cause of injury information in ED visits provides valuable information for injury control efforts.

Developing an integrated public health information system for Missouri.

The Missouri Department of Health realized it had a problem with 67 different information systems that ran on different platforms and could not communicate with one another. A new, integrated information system, the Missouri Health Strategic Architectures and Information Cooperative (MOHSAIC) is being developed based on information engineering (IE). This article describes IE, the process of developing MOHSAIC, and some key lessons learned in developing the system. Some of the lessons learned include the importance of executive sponsorship, tension between efficiency and program accountability, importance of confidentiality, and difficulties of funding an integrated system. The article stresses how integrated information systems will be important for the viability of public health under health care reform.

Smoking and pregnancy outcome: trends among black teenage mothers in Missouri.

OBJECTIVES: The purpose of this study is to analyze the smoking changes that have occurred among pregnant Black teenagers in Missouri. The study also examines changes in Black teenage pregnancy outcomes in relation to smoking behavior changes. METHODS: This analysis used computerized data files from the 1978 to 1990 Missouri birth certificates to acquire information on smoking during pregnancy for 41,544 Black teenagers and 105,170 White teenagers. All Missouri births with smoking history were included in the study. RESULTS: During the study period, the rate for Blacks who smoked during pregnancy decreased from 37% in 1978 to less than 22% in 1990. A large part of this reduction is attributable to Black teenagers, whose smoking-during-pregnancy rate declined from 35.8% to 7.2%. Additionally, the Black teenage-specific low-birthweight rate decreased by 13.6% over the study period, possibly influenced by the decrease in smoking. CONCLUSIONS: The results indicate that a major norm has changed in smoking status among pregnant Black teenagers. Understanding the reasons behind this change could assist smoking cessation and other health promotion efforts.

Changes in characteristics of women who smoke during pregnancy: Missouri, 1978-88.

The Missouri birth certificate has had a question, "cigarettes smoked per day?" since 1978; the current data base contains more than 800,000 records. A comparison of the Missouri data for married mothers with the National Natality Survey (NNS) data shows mainly consistent findings between the two data sets. The Missouri data, however, also provided information on the smoking status during pregnancy of unmarried women that is not available from the NNS. The Missouri data show a substantial difference in the smoking rates of married (23.2 percent) and unmarried (40.9 percent) women. The highest smoking rates during pregnancy are found among unmarried women, ages 20-24, with less than a high-school education, and those with a fourth or higher order child. There has been a relatively small overall drop in the smoking rate from 1978-80 to 1986-88 (31.1 percent versus 27.5 percent). However, blacks and teenagers have had very substantial drops in smoking rates. There has been only a slight decrease for other high-risk groups such as white unmarried women, women with less than a high-school education, and those having a fourth or higher order birth. Missouri started using the new national standard birth certificate in 1989 with a differently worded smoking question. The percentage of women smoking and those smoking less than one pack per day in 1989 went down more than would be expected from the trend data. It appears that the new birth certificate question will provide a lower estimate of the percentage of mothers who smoke cigarettes than was acquired from the previous version on the Missouri certificate. The births in Missouri for which mothers' rate of smoking was unknown increased nearly fourfold to 0.9 percent.

Differentiating the barriers to adequate prenatal care in Missouri, 1987-88.

Inadequate prenatal care has previously been identified as a significant risk factor for women who have low birth weight infants and infants who die during the neonatal period. Postpartum interviews with 1,484 primarily low-income women were conducted during 1987-88 in three areas of Missouri with the highest rates of inadequate prenatal care. The purpose of the study was to identify barriers to prenatal care and to determine which barriers differentiated between women receiving adequate and those receiving inadequate prenatal care. Women who received inadequate prenatal care were more likely to be black, unmarried, higher parity, and have less education than those who received adequate care. These women were also more likely to be poor, Medicaid-eligible, to have had an unwanted pregnancy, more stress and problems during pregnancy, and less social support. In the multivariate analysis, race and marital status lost their importance. The strongest predictor of inadequate prenatal care was women not knowing that they were pregnant in the first 4 months of pregnancy (adjusted odds ratio 9.28). To improve the rate of adequate prenatal care, society must address the issues of poverty and wantedness of pregnancy.

Maternal smoking during pregnancy: no association with congenital malformations in Missouri 1980-83.

Using a multisource birth defects registry developed by the Missouri Center for Health Statistics for the years 1980-83, we examined the relation between maternal smoking during pregnancy and the occurrence of congenital malformations. There were 288,067 live singleton births in this data set of which 10,223 had one or more congenital malformations. When adjusted for potential confounders the odds ratio for congenital malformations in the infants of women who smoked during pregnancy was not increased (odds ratio = 0.98, 95% confidence interval = 0.94 - 1.03). We examined the relation between smoking and groups of malformations using the International Classification of Diseases, 9th Revision, as well as analyzing for certain specific malformations within each group and found no increased risk for infants of smokers.

The association of maternal smoking with age and cause of infant death.

Linked birth certificate and infant death certificate data from Missouri for 1979-1983 were used to explore the association of maternal smoking with age and cause of infant death. The data included 305,730 singleton white livebirths, of which 2,720 resulted in infant deaths. Using multiple logistic regression to control for the confounding effects of maternal age, parity, marital status, and education, the authors found that smoking was associated with both neonatal and post-neonatal mortality and with each cause of death except congenital anomalies. The adjusted odds ratio for smoking was higher for postneonatal deaths than neonatal deaths and was particularly high for two causes: respiratory disease (odds ratio = 3.4) and sudden infant death syndrome (odds ratio = 1.9). A moderate odds ratio (about 1.4) was found for causes attributed to the International Classification of Diseases, 9th Revision Perinatal Conditions Chapter. Although the associations for neonatal deaths and perinatal conditions were partially attributable to the effect of maternal smoking in lowering birth weight, virtually none of the excess respiratory mortality and sudden infant death syndrome mortality among the offspring of smokers was attributable to birth weight differences between the infants of smokers and nonsmokers. This suggests that respiratory deaths and sudden infant death syndrome deaths may be related to the effect of passive exposure of the infant to smoke after birth.

The effects of maternal smoking on fetal and infant mortality.

Although maternal cigarette smoking has been shown to reduce the birth weight of an infant, previous findings on the relation between smoking and fetal and infant mortality have been inconsistent. This study used the largest data base ever available (360,000 birth, 2,500 fetal death, and 3,800 infant death certificates for Missouri residents during 1979-1983) to assess the impact of smoking on fetal and infant mortality. Multiple logistic regression was used to estimate the joint effects of maternal smoking, age, parity, education, marital status, and race on total mortality (infant plus fetal deaths). Compared with nonsmoking women having their first birth, women who smoked less than one pack of cigarettes per day had a 25% greater risk of mortality, and those who smoked one or more packs per day had a 56% greater risk. Among women having their second or higher birth, smokers experienced 30% greater mortality than nonsmokers, but there was no difference by amount smoked. The prevalence of smoking in this population was 30%. It was estimated that if all pregnant women stopped smoking, the number of fetal and infant deaths would be reduced by approximately 10%. The higher rate of mortality among blacks compared with whites could not be attributed to differences in smoking or the other four maternal characteristics studied. In fact, the black-white difference was greater among low-risk women (e.g., married multiparas aged 20 and over with high education) than among high-risk women (e.g., unmarried teenagers with low education).