标题：Public Health Nursing Case Management for Women Receiving Temporary Assistance for Needy Families: A Randomized Controlled Trial Using Community-Based Participatory Research
摘要：Objectives. We evaluated the effectiveness of a community-based participatory research–grounded intervention among women receiving Temporary Assistance for Needy Families (TANF) with chronic health conditions in increasing (1) health care visits, (2) Medicaid knowledge and skills, and (3) health and functional status. Methods. We used a randomized controlled trial design to assign 432 women to a public health nurse case management plus Medicaid intervention or a wait-control group. We assessed Medicaid outcomes pre- and posttraining; other outcomes were assessed at 3, 6, and 9 months. Results. Medicaid knowledge and skills improved ( P < .001 for both). Intervention group participants were more likely to have a new mental health visit (odds ratio [OR] = 1.92; P = .007), and this likelihood increased in higher-risk subgroups (OR = 2.03 and 2.83; P = .04 and .006, respectively). Depression and functional status improved in the intervention group over time ( P = .016 for both). No differences were found in routine or preventive care, or general health. Conclusions. Health outcomes among women receiving TANF can be improved with public health interventions. Additional strategies are needed to further reduce health disparities in this population. In 1996, welfare reform legislation ushered in a new era of the US welfare system by creating the Temporary Assistance for Needy Families (TANF) program. Major changes in the new program included (1) work requirements and (2) consecutive months and lifetime time limits to benefit receipt. 1 At the time TANF was implemented, the concept of health disparities was just emerging as a focal area for research and gaining recognition as a nationwide problem. 2 Numerous studies had examined earnings and employment after a welfare exit 3 – 7 and the effects of welfare receipt on the health and development of children 8 , 9 ; however, little was known about the health of the women receiving welfare. 10 Given the increased attention on health disparities 11 and findings demonstrating that the majority of women who left welfare for employment remained in poverty, 12 – 14 the new TANF regulations generated a swift increase in research. Notably, these studies began to examine how the health of the TANF population (96% of whom are single mothers and children) may be affected given the clear work mandates, time limits, and high prevalence of health problems in this group. 15 – 17 Early postreform descriptive studies found that 25% to 42% of women receiving TANF had been diagnosed with major depressive disorder compared with 12% of women in the general population, and 9% were suffering from posttraumatic stress disorder. 18 Rates of substance abuse (21%) and domestic violence (14.9%) were also reported to be significantly higher in the TANF population than they were in the general population (13% and 3.4%, respectively), 18 as were rates of poor physical and general health based on the Short Form Health Survey (SF-12). 19 Moreover, 48% of those with a work barrier identified a health problem as the primary limitation to working, 20 and women with health problems that did leave TANF for employment had a 5.4-month shorter job tenure than did those without health problems. 21 Therefore, health-related barriers were threatening—and continue to threaten—the ability of women leaving welfare for work to move toward economic self-sufficiency, and have impeded TANF program progress in meeting this goal. Between 1996 and 2001, more than 5 million persons—predominantly women and children—left TANF (a 57% caseload reduction), 22 with studies indicating that women with health problems 14 and those from racial minority groups 23 were becoming more concentrated in TANF programs. Taken together, these findings suggested that a work-first TANF approach that does not take into account the health needs of this population is unlikely to yield long-term gains in either self-sufficiency or health-related outcomes. Despite this greater concentration, with few recent exceptions 24 – 27 attempts to address health problems among women receiving TANF have relied nearly exclusively on descriptive reports of best practices 16 , 28 , 29 or project evaluations that lack valid and reliable measures, 29 rather than on well-designed intervention studies. Across states, programs to address health needs in this group have largely focused on screening for drug use (64% of states), domestic violence (50%), and mental health problems (45%) 30 ; however, practices vary widely within and across states, and there is a lack of clarity around outcomes. Findings from our preliminary studies indicated that women disliked the health screening process and questionnaires used in an existing Welfare Transition Program (or a WTP, which encompasses the mandatory work-focused activities of TANF), raising questions about the effectiveness of approaches not grounded in their specific needs, perspectives, or life context. 31 This study fills a large gap in the existing intervention-based evidence that is needed to address the health problems among women receiving welfare. Over the past decade, administrators responsible for TANF implementation at the federal, state, and local levels have raised concerns about how to effectively handle the mental and physical health-related needs of the population they serve, 16 but intervention research in this area has not kept pace with the needs. This study was guided by Milio's ecological framework 32 for improving health, which conceptualizes policy factors operating in the macrolevel environment as the most significant determinants of health. As such, it assumes individual or behavioral-focused interventions—although necessary—are insufficient for improving population health. Although we focused on ways to improve women's health through TANF-related system (and policy) enhancements, our research also builds on the literature documenting the effectiveness of public health nursing (PHN) case management with similar populations of low-income, at-risk single mothers, 33 , 34 the importance of tailoring intervention materials to specific groups, 35 , 36 the difficulties low-income patients have in understanding Medicaid benefits, and the application of patient-centered interventions for improving health outcomes. 36 , 37 Specifically, we report the outcomes from a randomized controlled trial that had the following aim: to test the efficacy of a PHN case management and Medicaid knowledge and skills training program for women enrolled in WTPs in (1) increasing rates of health care visits for mental health and chronic health conditions, (2) increasing the ability to navigate the Medicaid system, and (3) improving functional and health status over time among women with chronic health conditions by using a community-based participatory research (CBPR) methodology. To the best of our knowledge, no previous study has tested a similar intervention with this population.
