Healthy policy, healthy babies : the use of the Box-Jenkins ARIMA time series analysis to determine levels of success in Florida's Healthy Start program PDF
Preview Healthy policy, healthy babies : the use of the Box-Jenkins ARIMA time series analysis to determine levels of success in Florida's Healthy Start program
HEALTHYPOLICY,HEALTHYBABIES: THEUSEOFTHEBOX-JENKINSARIMATIMESERIESANALYSISTO DETERMINELEVELSOFSUCCESSINFLORIDA'SHEALTHYSTART PROGRAM By MICHAELW.GARNER ADISSERTATIONPRESENTEDTOTHEGRADUATESCHOOLOFTHE UNIVERSITYOFFLORIDAINPARTIALFULFILLMENTOFTHE REQUIREMENTSFORTHEDEGREEOFDOCTOROFPHILOSOPHY UNIVERSITYOFFLORIDA 1999 ACKNOWLEDGMENTS Iwouldliketoextendmysinceregratitudetoseveralindividualswhohelpedto makethisdissertationareality.First,thenumerousFloridaCountyPublicHealth DepartmentsrepresentativestaughtmehowamajorpublichealtheffortlikeHealthyStart isimplementedatthestreet-level.Thesewonderfulprofessionalstrulycareaboutthe clientstheyserveandhopeforbetterlivesforthechildrentheybringintothisworld. Inaddition,IwouldliketothankRandallRemmel,Ph.D.,formerlywiththe UniversityofSouthFlorida,forhiscontinuedpatiencewithmyrequestsfordatarunsand spreadsheets.WithoutRandy'sassistanceinacquiringthisdata,itwouldhavebeen impossibletocompletethisdissertation. Imustalsoext-ndmygratitudetomyformeremployer,CarolGormley,atthe NorthCentralFloridaHealthPlanningCouncil.Caroltaughtmehowtointeractwith competingagendasinpublicprogramsinawaythatultimatelyledtotheinterestofthe clientpopulationbeingofprimaryconcerntoallinvolvedintheimplementationofthe program.Shedemonstratedamazingdiplomacyinthemostdifficultofsituationsand continuallyshowedhowatrueprofessionalinthepublicpolicyarenashouldconducthim orherself. Ioweatremendousdebtofgratitudetomycurrentemployer,BlueCrossBlue ShieldofFlorida.MelissaRehfus,Ph.D.,andPamelaSmithMartin,Ph.D.,continually supportedthecompletionofthisdissertationthroughbothpersonalencouragementand generosityinthetimetheyallowedmeoverthelastthreeyearstocompletethiswork.I knowthereweremanytimesthattheymusthavewonderedtothemselveswhetherit wouldeverend.Iappreciatetheirpatience. Idonotknowwheretobegintothanktheacademicteamthatledmethroughmy undergraduateandgraduatedegreesattheUniversityofFlorida.Ihavespentsomany yearsinthePoliticalScienceDepartmentthatIfeelathometherelikefewotherplaces. Thankstotheofficestaff(Debbie,Marty,andHazel)foralloftheirhelpwithlong- distanceregistrationandinsightontheupcomingfootballseason.Iwouldalsoliketo thankthewonderfulfacultywhoalwayscreatedastimulatinglearningenvironmentthatis acredittothewholeuniversity. MostimportantlyIwouldliketothankthemembersof mydoctoralcommitteefortheirpatienceandguidanceinthisendeavor.DavidHedge, Ph.D.,andMichaelScicchitano,Ph.D.,trulyearnthemonikersofmentorsandfriends. Theircombinedpushforexcellenceinthisprojectandinmypersonallifehasbeena steadyhandofguidanceinseasthatwereoftenrough.Ionlyhopethatthisworkmeets theirhighexpectationsofqualityandisacontributiontotheacademicfieldworthyofthe timetheyhavegivenmeovertheyears. Finally,Iwouldliketothankmypartner,mybestfriend,andmylove,Lisa.You havebeenaconstantsourceofcaringandsupportthroughthisprocess,andyourown accomplishmentsinacademiaservedasaninspirationwhenIneededitmost. Tomy children,BritandKaren,Iamsorryforthetimethatthisworkhastakenawayfromyou. Icanonlyhopethatyouwillseethisworkassomethingthatmademeabetterpersonand helpedyourmotherandmetogiveyouthetypeoflifeyouhavehadgrowingup.Ialso hopethisdemonstratesthateducationisalifetimecommitmentforallofus. TABLEOFCONTENTS page ACKNOWLEDGMENTS ii LISTOFTABLES vi LISTOFFIGURES vii ABSTRACT ix CHAPTER1:INTRODUCTION 1 CHAPTER2:REVIEWOFLITERATURE 4 PolicyEvaluationasanAdministrativeandPoliticalTool 4 PolicyInnovationintheStates 6 StatesandHealthPolicy 15 StatesandHealthPolicyAnalysis/Evaluation 19 IssuesinPolicyImplementation 21 SummaryofPolicyLiterature 34 PublicPolicyProblem:LowBirthweightBirths 34 LowBirthweightBirths:Incidence,CausesandImpacts 36 MedicalandPsychosocialInterventions 61 ThePerinatalParadox 69 ProgramstoReduceLBW:NationalandState 71 MInatteerrvneanltiaonndPIrnofgarntamHseatlotRhePdoluiccey:LSBtaWteiInnFiltioartiidvaes 9937 Florida'sApproachtoMaternalandInfantHealthPrograms 100 CentralHypothesis 112 CHAPTER3:METHODSANDRESULTS-STATE-LEVELANALYSIS 114 Hypothesis 114 DependentVariable 125 Procedure 126 Results 127 ARIMA:IdentificationProcess 130 ARIMA:EstimationandDiagnosis 134 ARIMA:InterventionComponent 138 ResultsSummary:State-LevelAnalysis 144 CHAPTER4:METHODSANDRESULTS-SUBSTATESURVEYAND ANALYSIS 145 SurveyofHealthyStartExperts 145 Participants 146 SurveyResults 147 DescriptionofSurveyRespondents 147 ImplementationDifferencesintheSurveyedCoalitions 150 Decision-makerResultsSummary 158 MethodsandResults:SubstateARIMAAnalysis 158 Hypothesis 158 DependentVariable 159 Procedure 159 ResultsofSubstateARIMAAnalysis 160 DatasetValidity 160 ARIMA:IdentificationProcess 163 ARIMA:EstimationandDiagnosis 164 ARIMA:InterventionComponent 164 CHAPTER5:DISCUSSIONANDCONCLUSIONS 166 SummaryofResearchFindings 166 PossibleReasonsforPolicyFailure 168 AdditionalAreasofPossibleResearch 171 APPENDIXA:HEALTHYSTARTEXPERTSURVEY 172 APPENDIXB:SUBSTATESCATTERGRAMS 179 APPENDIXC:SUBSTATEARIMAANALYSES 185 REFERENCES 205 BIOGRAPHICALSKETCH 221 . LISTOFTABLES Table page 1. FederalHealthyStartprogramsbystate:1998 87 2. Maternalandinfantcareprogramsbystate 94 3 FloridaHealthyStartcoalitionsandtheirrespectivecounties 102 4. PROCPRINToutputofHealthyStartdataset 128 5. Descriptionofsurveyedcounties 148 . LISTOFFIGURES Figure E5ge 1. PregnanciesandtheiroutcomesintheUnitedStates:1980-1992 38 2. InfantmortalityratesintheUnitedStates:1985-1996 38 3. Infantmortalityratesbyageofmother,UnitedStates:1996 40 4. Infantmortalityratesbyeducationalattainmentofmother,US 41 5. Infantmortalityratesbysmokingstatusofmother,US:1996 43 6. Infantmortalityratesbytrimesterwhenprenatalcarebegan 44 7. Percentageoflivebirthswithlateornoprenatalcare,US 45 8. Infantmortalityratesbysexofinfant,US:1996 46 9. Infantmortalityratesbyperiodofgestation,US:1996 47 10. Infantmortalityratesbyperiodofgestation>26weeks 47 11 Infantmortalityratesbyleadingcausesofdeath,US:1996 49 12. Infantmortalityratesbybirthweight,US:1996 49 13. Infantmortalityratesbybirthweights>2,000grams 50 14. LowbirthweightbirthratesintheUnitedStates:1970-1995 52 15. LowbirthweightbirthratesinFlorida:1986-1996 99 16. InfantmortalityratesinFlorida;1991-1996 100 17. HealthyStartprenatalscreeningrates:1992-1997 107 18. HealthyStartinfant(postnatal)screeningrates:1992-1997 109 19. PROCGPLOToutputofNWLBWRbySASDATE 130 20. PROCARIMAoutputfortheHealthyStartdataset 131 21. PROCARIMAoutputoftheHealthyStartdatasetwithestimates 135 22. PROCARIMAoutputwithinterventioncomponents 139 23. Meansforsurveyedcoalitiondatasets 161 AbstractofDissertationPresentedtotheGraduateSchool OftheUniversityofFloridainPartialFulfillmentof RequirementsfortheDegreeofDoctorofPhilosophy HEALTHYPOLICY,HEALTHYBABIES: THEUSEOFTHEBOX-JENKINSARIMATIMESERIESANLAYSISTO DETERMINELEVELSOFSUCCESSINFLORIDA'SHEALTHYSTART PROGRAM By MichaelW.Garner December1999 Chairman:DavidM.Hedge,Ph.D MajorDepartment:PoliticalScience Withinthestudyofpublicpolicyimplementationaretheprinciplesthatthesuccess orfailureofapolicyisneveragivenandthatitisdifficult,ifnotimpossible,tocausally linktheactionsofvariousactorsintheprocessofimplementationtoaparticularoutcome. ThisresearchexaminestheFloridaHealthyStartprograminordertodetermineif theprogrammadeasignificantimpactonitsoutcomeobjectives.Thestudyuseda combinationofBox-Jenkinsautoregressiveintegratedmovingaverage(ARIMA)time seriesanalysisofmonthlylowbirthweightratesinFloridabetweenJanuary1988through December1996,andaqualitativetelephonesurveyofexpertsintheHealthyStart program.TheresultsoftheARIMAtime-seriesanalysisindicatethatanintervention impactresultingfromtheimplementationoftheHealthyStartprogramin1992couldnot bedetermined,apparentlyindicatingthattheprogramhasnothadanimpactonlow birthweightbirthratesinFlorida. Inaddition,thestudiesfoundthatalthoughthe coalitionsareacombinationofruralandurbancountiesacrossthestate,the implementationoftheHealthyStartprogramhasbeenverysimilaracrosscoalitions. In conclusion,themethodologyallowsresearcherstodirectlyexamineifapublichealth programhastheabilitytoimpactatargetpopulation,beyondthelargertrendofchange thatwouldotherwisebepresent.Thesefindingsaddtothepolicyinnovation,policy implementation,andmedicalliteratureinseveralways. AdditionalresearchinthisareamightcomparetheimpactofFlorida'smaternal andinfantcareprogramstothatofotherstateprograms,orsimilarprogramsadministered atthefederallevel. Researchmayalso,andshould,beconductedonthecausebehindthe consistentseasonalpatternoflowbirthweightbirthsinnonwhitewomeninFlorida.This researchshoulddetermineiftheseasonalpatternisuniquetoFlorida'snonwhite population;whetherthepatternisconsistentoveralargerspanofyears;andwhetherthe causeoftheseasonalityisbiological,environmental,oraresultofthepredominantuseof thepublichealthcaresysteminFloridabynonwhitewomenforaccessingperinatalhealth care.
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