Medicaid's role in financing health care for children with behavioral health care needs in the special education system: implications of the Deficit Reduction Act

Background: Recent changes to Medicaid policy may have unintended consequences in the education system. This study estimated the potential financial impact of the Deficit Reduction Act (DRA) on school districts by calculating Medicaid‐reimbursed behavioral health care expenditures for school‐aged children in general and children in special education in particular. Methods: Medicaid claims and special education records of youth ages 6 to 18 years in Philadelphia, PA, were merged for calendar year 2002. Behavioral health care volume, type, and expenditures were compared between Medicaid‐enrolled children receiving and not receiving special education. Results: Significant overlap existed among the 126,533 children who were either Medicaid enrolled (114,257) or received special education (27,620). Medicaid‐reimbursed behavioral health care was used by 21% of children receiving special education (37% of those Medicaid enrolled) and 15% of other Medicaid‐enrolled children. Total expenditures were $197.8 million, 40% of which was spent on the 5728 children in special education and 60% of which was spent on 15,092 other children. Conclusions: Medicaid‐reimbursed behavioral health services disproportionately support special education students, with expenditures equivalent to 4% of Philadelphia’s $2 billion education budget. The results suggest that special education programs depend on Medicaid‐reimbursed services, the financing of which the DRA may jeopardize.     

Which newborns in New York City are at risk for special education placement?

In this study of 162 third graders in New York City public schools, we found that slightly over half of the children in special education were males who had Medicaid coverage at birth and mothers with medical conditions or adverse health habits noted on the birth certificate; two thirds of the children with this combination of characteristics actually were placed in special education. These findings suggest that newborns at risk for later learning disabilities can be targeted to receive preventive interventions.     

湘西少数民族地区城区流动儿童与常住儿童心理健康的比较研究

目的了解湘西少数民族地区流动儿童的心理健康状况,为流动儿童的健康成长提供帮助。方法随机抽取湘西少数民族地区9～12岁流动儿童1600名,城区常住儿童1600名,根据小学生心理健康评定量表的要求,进行心理健康各项指标的调查。结果 9岁流动儿童与城区常住儿童相比,各项指标均无统计学意义。10岁流动儿童与城区常住儿童相比,男性情绪障碍、品德缺陷、学习障碍等差异有统计学意义(P0.05)。在女性儿童中,品德缺陷、学习障碍、不良习惯、社会适应方面等差异有统计学意义(P0.05),其他指标两组均无统计学意义。11岁儿童流动儿童与城区常住儿童相比,男性学习障碍、情绪障碍、社会适应障碍、品德缺陷、行为障碍等方面两组间差异有统计学意义(P0.05)。女性在学习障碍、情绪障碍、行为障碍、社会适应等方面两组间差异有统计学意义(P0.05),其他指标两组均无统计学意义。12岁流动儿童与城区常住儿童相比,男性儿童学习障碍、情绪障碍、行为障碍、社会适应障碍、性格缺陷等方面差异有统计学意义(P0.05),女性儿童在学习障碍、行为障碍等方面两组间差异有统计学意义(P0.05)。其他指标两组间差异均无统计学意义。结论从调查结果总体来看,城区常住儿童的心理健康优于流动儿童,应加强流动儿童的心理健康教育。     

What Girls Won't Do for Love: Human Immunodeficiency Virus/Sexually Transmitted Infections Risk Among Young African-American Women Driven by a Relationship Imperative

PurposeRates of Human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) continue to increase among African-American youth. Adolescents who have a stronger identity in relation to others (relational identity) rather than to themselves (self-identity) may view intimate relationships as imperative to a positive self-concept, which may lead to risky sexual behavior and abuse. Therefore, the present study assessed the associations among a relationship imperative and HIV/STI-related risk factors and behaviors.MethodsParticipants were 715 African-American adolescent females, aged 15 to 21 years. They completed measures that assessed how important a relationship was to them and HIV-related risk factors and behaviors. Participants also provided vaginal swab specimens for STI testing.ResultsMultivariate logistic regression analyses, controlling for covariates, were conducted. Females who endorsed a relationship imperative (29%), compared to those who did not, were more likely to report: unprotected sex, less power in their relationships, perceived inability to refuse sex, anal sex, sex while their partner was high on alcohol/drugs, and partner abuse. Furthermore, participants with less power, recent partner abuse, and a perceived ability to refuse sex were more likely to test STI positive.ConclusionThese results indicate that if African-American adolescent females believe a relationship is imperative, they are more likely to engage in riskier sexual behaviors. Additionally, less perceived power and partner abuse increases their risk for STIs. HIV/STI prevention programs should target males and females and address healthy relationships, sense of self-worth, self-esteem and the gender power imbalance that may persist in the community along with HIV/STI risk.     

The feasibility of recruiting young men in rural areas from community football clubs for STI screening

OBJECTIVE: To investigate the feasibility of recruiting young men from rural football clubs for screening for sexually transmitted infections (STIs). METHODS: Young men aged 16 to 29 were recruited from four football clubs outside of metropolitan areas in Victoria, Australia, and completed a questionnaire about sexual activity, knowledge and history of STIs, and alcohol and drug use, and provided a urine sample for STI testing. RESULTS: One hundred and eight participants completed the questionnaire and 92 (85.2%) also provided a urine sample. More than 90% of eligible players present at the clubs on the night of the study participated. Eighty-seven participants (80.6%) had ever had penetrative sex, with 33 (39.3%) reporting a new sexual partner in the past three months. Among those who had ever had sex, the prevalence of chlamydia was 3.9% (95% Cl 0.8-11.0). While the majority of participants visited their doctor in the past year (78.7%) and were comfortable with the idea of an annual STI screen, few had ever discussed sex or STIs with their doctor or had a previous STI test. CONCLUSION:Young men from rural areas may be at considerable risk of STIs and many have not been previously tested. However, most are willing to participate in screening programs and the high participation rate achieved in this pilot project demonstrates the potential for screening to be successfully extended into non-medical settings such as sporting clubs. IMPLICATIONS: Young people at risk of STIs can be successfully recruited for STI screening from community settings.     

Identifying Syndemics for Sexually Transmitted Infections Among Young Adults in the United States: A Latent Class Analysis

Purpose

Syndemic theory suggests that the convergence of social, environmental, and ecological factors can interact to exacerbate behavioral health problems and are often intensified by social conditions and disparities. This study used latent class analysis (LCA) to determine gender and racial/ethnic specific classes for sexually transmitted infection (STI) risk.

Sexual Orientation Disparities in Sexually Transmitted Infections: Examining the Intersection Between Sexual Identity and Sexual Behavior

The terms MSM (men who have sex with men) and WSW (women who have sex with women) have been used with increasing frequency in the public health literature to examine sexual orientation disparities in sexual health. These categories, however, do not allow researchers to examine potential differences in sexually transmitted infection (STI) risk by sexual orientation identity. Using data from the National Longitudinal Survey of Adolescent Health, this study investigated the relationship between self-reported STIs and both sexual orientation identity and sexual behaviors. Additionally, this study examined the mediating role of victimization and STI risk behaviors on the relationship between sexual orientation and self-reported STIs. STI risk was found to be elevated among heterosexual-WSW and bisexual women, whether they reported same-sex partners or not, whereas gay-identified WSW were less likely to report an STI compared to heterosexual women with opposite sex relationships only. Among males, heterosexual-identified MSM did not have a greater likelihood of reporting an STI diagnosis; rather, STI risk was concentrated among gay and bisexual identified men who reported both male and female sexual partners. STI risk behaviors mediated the STI disparities among both males and females, and victimization partially mediated STI disparities among female participants. These results suggest that relying solely on behavior-based categories, such as MSM and WSW, may mischaracterize STI disparities by sexual orientation.     

Examining Time to Treatment and the Role of School‐Based Health Centers in a School‐Based Sexually Transmitted Infection Program

BACKGROUND

Barriers to health care service utilization contribute to the spread of sexually transmitted infections (STIs) among teens. School‐based STI screening programs reach adolescents outside of the clinic‐based health care model and schools with school‐based health centers (SBHCs) may expedite treatment because of their proximity to the population. This study examined whether students who tested positive for STIs in a school‐based screening program had differing times to treatment based on treatment location.

METHODS

All positive cases of chlamydia and gonorrhea from the 2012‐2013 school year in a Chicago Department of Public Health (CDPH) and Chicago Public Schools school‐based STI screening program were reviewed. Median time to treatment was compared for those treated at an SBHC versus those treated elsewhere (CDPH STI clinic, community health center, private physician).

RESULTS

Overall, 540 students had positive results. The median age was 17 years, 427 had chlamydia (79.1%), 59 had gonorrhea (10.9%), and 54 had dual infections (10.0%); 144 were tested in a school with a SBHC on site (26.7%). Of the 483 students who received treatment (89.4%), those treated at a SBHC had a faster time to treatment compared to CDPH STI clinics (median 17 days versus 28 days, respectively, p < .001).

CONCLUSIONS

For students testing positive in the Chicago school‐based STI program, time to treatment is accelerated in locations with SBHCs.

     

Chlamydia and Gonorrhea Prevalence and Treatment in Detained Youths: Strategies for Improvement

PurposeAdolescents and young adults have the highest prevalence of sexually transmitted infections (STIs), accounting for more than 50% of all reported infections. An especially high-risk group includes adolescents in juvenile or correctional facilities.MethodsThis retrospective analysis was conducted at the only juvenile detention facility in the State of Hawai'i from 2014 to 2017. Adolescents aged 12–17 years were offered STI screening and/or presumptive treatment at the time of medical evaluation.ResultsOf 2,208 adolescents offered voluntary testing, 461 males and 372 females agreed to be tested for Chlamydia trachomatis and Neisseria Gonorrhea. Acceptance did not vary by age; females chose testing more often than males (67.4% vs. 27.8%; p < .0001). Females were also more likely to accept presumptive treatment (22.8% vs. 8.8%; p < .0001). In tested youth, STIs were prevalent in 24% of females and 10% of males. Before leaving the detention facility, only half the STIs in females and only 39% of male STI infections had been treated.ConclusionsThere was a high prevalence of STIs in both males and females admitted to this juvenile detention facility, with fewer than half the documented infections being treated before discharge. This indicates a need for universal and timely testing to allow the treatment of those infected. If for whatever reason rapid testing cannot be obtained, presumptive treatment offers a pragmatic approach to treatment and infection control.     

Prevalence of Sexually Transmitted Infection/Human Immunodeficiency Virus Counseling Services Received by Teen Males, 1995–2002

PurposeTo examine whether improvements have been made in the delivery of sexually transmitted infection and/or human immunodeficiency virus (STI/HIV) counseling services to teen males.MethodsAnalysis was performed using the 1995 National Survey of Adolescent Males (N = 1,729, response rate = 75%) and the 2002 National Survey of Family Growth (N = 1,121, response rate = 78%), which are two nationally representative surveys of 15–19-year-old males. Main outcome measure included discussion about STIs/HIV with a doctor/nurse. Weighted bivariate and multivariate Poisson regression analyses examined the association of outcome measures and survey year among males engaging in various types of sexual behaviors (e.g., varying partner numbers, higher risk sex) unadjusted and adjusted for sociodemographic and health care access factors.ResultsIn 2002, STI/HIV counseling receipt in the past year was reported by one-third of males who reported three or more female partners, anal sex with female partners, or oral/anal sex with male partners. Only 26% of males reporting high-risk sex (e.g., sex with prostitute, person with HIV or often/always high with sex) reported STI/HIV counseling receipt. Overall, no improvements were found between 1995 and 2002 in STI/HIV counseling, even after controlling for sociodemographic and health care access factors.ConclusionsMechanisms are needed to raise the importance of STI/HIV counseling services among sexually active male teens as well as to improve health care providers' delivery of these services.     

Sexually active older Australian's knowledge of sexually transmitted infections and safer sexual practices

Objective: Rates of sexually transmitted infections (STIs) are rising among older Australians. We conducted a large survey of older people's knowledge of STIs and safer sexual practices. Methods: A total of 2,137 Australians aged 60 years and older completed the survey, which included 15 questions assessing knowledge of STIs and safer sexual practices. We examined both levels of knowledge and factors associated with an overall knowledge score. Results: In total, 1,652 respondents reported having sex in the past five years and answered all knowledge questions. This group had good general knowledge but poorer knowledge in areas such as the protection offered by condoms and potential transmission modes for specific STIs. Women had better knowledge than men. Men in their 60s, men with higher education levels, and men who thought they were at risk of STIs reported better knowledge than other men. Knowledge was also better among men and women who had been tested for STIs or reported ‘other’ sources of knowledge on STIs. Conclusions: Many older Australians lack knowledge of STIs and safer sexual practices. Implications for public health: To reverse current trends toward increasing STI diagnoses in this population, policies and education campaigns aimed at improving knowledge levels may need to be considered.     

Sexual behaviour and related knowledge among a representative sample of secondary school students between 1997 and 2008

Objective: This paper reports on the sexual health knowledge and risk behaviours of year 10 and 12 students between 1997 and 2008. Method: Data were from nationally representative cross‐sectional stratified cluster samples of year 10 and 12 students in the Australian secondary school system collected at three intervals — 1997, 2002 and 2008. A number of methods were used to analyse students' sexual health knowledge and behavioural data over time. Results: Student knowledge of HIV/AIDS has stabilised since the 2002 survey and remains high. Between 1997 and 2008 there has been an increase in student knowledge with respect to STIs and hepatitis. Although the proportion of students reporting ever having had sexual intercourse has increased over time, the increases between 2002 and 2008 were not significant. There has been a significant increase in the number of sexual partnerships reported by students over a year, particularly for those in year 12. Conclusion: Student knowledge of HIV/AIDS remains high and there has been some improvement in STI and hepatitis knowledge, although knowledge in these domains is still moderate. Sexually active students were more likely to report having sex with multiple partners compared to previous surveys. Consistency of condom use has not increased since 1997. Implications: Although consistent condom use remains moderately high, it is of some concern that condom use has not increased since 1997 despite related increases in sexual activity among adolescents who have experienced sexual intercourse and increased rates of STIs among this group.     

Infecciones de transmisión sexual en hombres internos en prisión: riesgo de desarrollo de nuevas infecciones

ObjectiveTo measure incidence and main risk factors related to sexually transmitted infections (STIs) in Daroca Prison (Zaragoza, Spain).MethodA retrospective cohort study (2005-2013) to measure the incidence of STI and a cross-sectional study to measure risk factors.ResultsOf the 203 inmates, 79 developed an STI, 37 had a previous STI, 55.2% lacked knowledge on STI prevention, and 28.9% showed behaviours unfavourable for STI prevention. The incidence rate was 6.5 STIs per 1,000 inmates-year. The most frequent STIs were hepatitis B (39.7%), Ureaplasma urealyticum (19.1%), herpes simplex (16.2%) and HIV (8.8%). The risk (hazard ratio, HR) of acquiring a new STI was significantly higher in inmates with a history of previous STI (HR = 2.61; 95%CI: 1.01 to 6.69), and was at the limit of significance for non-preventive behaviour (HR = 2.10; 95%CI: 0.98 to 4.53), but not in knowledge related to STIs (HR = 1.33; 95%CI: 0.58 to 3.07).ConclusionThe most important risk factors in prison are behaviours related to STIs and previous history of STIs. Other factors are being a repeat offender, injecting drug use, or being in a methadone programme. Health personnel and peer education can facilitate prevention and control.     

Sexual, Behavioral, and Social Characteristics of Female Sex Workers and Their Risk of Sexually Transmitted Infections: In South Korea

This study calculated the sexually transmitted infection (STI) prevalence rates among female sex workers (FSWs) in South Korea and elucidated the social and behavioral risk factors that affect FSW??s infection with STIs. FSWs were recruited using a multistage cluster probability sampling method (N?=?1,073). STI prevalence rates were 9.8?% for Treponema pallidum, 2.6?% for gonorrhea, and 12.5?% for Chlamydia. The risk probability of STI infection was higher for participants with fewer social relationships (OR?=?0.99), more suicide attempt experiences (OR?=?1.36), lower frequency of condom use (OR?=?0.81), lower self-efficacy (OR?=?0.78), and more irregular STI examination experiences (OR?=?0.69). The STI prevalence rates of FSWs in South Korea were lower than those of FSWs in other Southeast Asian nations. While the direct factors for STI prevalence among this population were related to safe sex, indirect factors such as social support were also significant. Because this affects the self-efficacy of isolated individuals among sex workers, preventive interventions in STIs among FSWs must be expanded to the promotion of social support and mental health programs.     

Passive smoking in babies: The BIBE study (Brief Intervention in babies. Effectiveness)

Background

Although number of sexually transmitted infections (STIs) reported in STI surveillance increased rapidly for women in Japan during the 1990s, the sexual behavior of women potentially at risk of STI infection remains unknown.

Methods

In order to determine the demographic and behavioral characteristics of non-sex worker (SW) females attending STI clinics, female attendees (n = 145), excluding SW, from nine clinics across Japan and female controls from the general population (n = 956), both aged 18-50 years, were compared using two data sets of nationwide sexual behavior surveys conducted in 1999.

Results

Although the occupation-type and education level were unrelated to STI clinic attendance in multivariate analysis, non-SW females attending STI clinics were younger (adjusted odds ratios [AOR] = 0.94, 95%CI: 0.89, 0.99), and more likely to be unmarried (AOR = 4.11, 95% CI: 1.73, 9.77) than the controls from the general population. In the previous year, STI clinic attendees were more likely to have had multiple partnerships (AOR = 3.09, 95% CI: 1.42, 6.71) and unprotected vaginal sex with regular partners (AOR = 3.59, 95% CI: 1.49, 8.64), and tended to have had their first sexual intercourse at a younger age (AOR = 1.77, 95%CI: 0.89, 3.54) and more unprotected vaginal and/or oral sex with casual partners (AOR = 2.08, 95%CI: 0.75, 5.71). Identical sexual behavior patterns were observed between the female attendees with a current diagnosis of STI (n = 72) and those before diagnosis (n = 73) and between those with a past history of STI (n = 66) and those without (n = 79).

Conclusion

These results indicate that not only multiple partnerships or unprotected sex with casual partners, but also unprotected vaginal sex within a regular partnership is prevalent among non-SW female STI clinic attendees. The identical sexual behavior patterns observed between female attendees with a current STI diagnosis and those without, and between those attendees with a past history of STI diagnosis and those without, indicate that the result are unlikely confounded with the cases of non-STI infection. This sexual behavior pattern may be predictive of STI infection among young Japanese women and could have contributed to the STI epidemic in women in Japan during the 1990s.     

Emergency department reliance among rural children in Medicaid in New York State

Abstract Purpose: This study examines variation in emergency department reliance (EDR) between rural and metro pediatric Medicaid patients in New York State for noninjury, nonpoisoning primary diagnoses and seeks to determine the relationship between receipt of preventive care and the likelihood of EDR. Methods: Rural/urban designations were based on Urban Influence Codes established by the United States Department of Agriculture (USDA). Healthcare Effectiveness Data and Information Set (HEDIS^®) well‐visit measures were calculated using 2008 Medicaid claims and encounter data. Well‐child numerator status and location of residence variables were then entered as independent variables in multivariate logistic regression models. Models controlled for the effects of Medicaid financing system (fee‐for‐service vs managed care), Medicaid aid type, race/ethnicity, gender, and 2008 clinical risk group category. Findings: The likelihood of EDR was higher in all age categories for rural compared to metro residing Medicaid children in New York State. Meeting HEDIS well‐child criteria was protective against emergency department (ED) reliance in the adolescence age group (OR = 0.84). Conclusion: ED reliance is associated with rural residence. Increased access to primary and specialty care in rural settings could help reduce EDR, particularly among rural adolescents.     

Knowledge,perceived stigma,and care-seeking experiences for sexually transmitted infections: a qualitative study from the perspective of public clinic attendees in Rio de Janeiro,Brazil

Background  

An estimated 12 million sexually transmitted infections (STIs) are documented in Brazil per year. Given the scope of this public health challenge and the importance of prompt treatment and follow-up counseling to reduce future STI/HIV-related risk behavior, we sought to qualitatively explore STI clinic experiences among individuals diagnosed with STIs via public clinics in Rio de Janeiro, Brazil. The study focused on eliciting the perspective of clinic users with regard to those factors influencing their STI care-seeking decisions and the health education and counseling which they received during their clinic visit.     

Epidemiology of STIs: UK

The epidemiology of STIs in the UK has undergone marked changes over the last century. After two major peaks in syphilis and gonorrhoea coinciding with the two World Wars, the incidence of these STIs decreased dramatically after World War II, with the advent of penicillin. The 1960s and 1970s saw a resurgence of gonorrhoea and syphilis, and the male:female ratio of reported syphilis cases increased, suggesting that transmission among men who have sex with men (MSM) was increasing. STI incidence again declined in the 1980s with the advent of the HIV/AIDS epidemic, suggesting that widespread changes in sexual risk behaviour patterns were occurring. These decreases were not sustained, however, and during the mid-to-late 1990s both viral and bacterial acute STIs increased substantially. This trend has been most marked in young people and MSM. Numbers of reported gonococcal infections more than doubled to between 1995 and 2003, to 24,157 cases in England, Wales and Northern Ireland; syphilis increased more than tenfold to 1580 cases as a consequence of localised outbreaks, particularly in MSM. Data from 2003 compared with 2002 indicate stabilization or slowing of some STIs, including gonorrhoea and genital herpes, numbers of which decreased by 4% and 3% respectively. Rates of genital warts, chlamydial infection and syphilis continued to increase. Delivery of appropriate, effective STI preventive interventions targeted to those at highest risk, including young people and MSM, continues to be a public health priority.     

The effect of maternal smoking during pregnancy on intellectual disabilities among 8-year-old children

Prenatal tobacco smoke exposure has been implicated as a risk factor for cognitive deficits in children. The purpose of this study is to examine the association between prenatal tobacco smoke exposure and diagnosis of intellectual disabilities (ID) among 8-year-old children living in Arkansas, Georgia, North Carolina and Utah. In 2002 and 2004, 965 ID case children were identified through a surveillance network and compared with the population of children born in the surveillance region during the same period ( n  = 104 607). Prenatal tobacco smoke exposure was determined from birth certificates. We estimated the effect of prenatal tobacco smoke exposure (none, <10, 10–19 and ≥20 cigarettes per day) on ID using logistic regression.
Generally, the risk of ID was mildly elevated among children whose mothers smoked ≥20 cigarettes per day during pregnancy [RR 1.34; 95% (confidence interval) CI 0.96, 1.87] after adjustment for maternal education, maternal race, maternal age, marital status, child sex, birth year and study site. However, the effect of exposure to ≥20 cigarettes per day significantly differed for males [RR 1.77, 95% CI 1.20, 2.62] compared with females [RR 0.81, 95% CI 0.44, 1.50]. Supplemental analyses reveal substantial confounding of this relationship by socio-economic indicators. A differential effect of tobacco smoke exposure on the risk of ID is suggested for males and females and deserves further investigation; however, the interpretation is tempered by the potential for residual confounding.