Chapter 3

URBAN POPULATIONS:
NEEDS AND DIRECTIONS 

Urban places...a melding of sights, sounds, and rhythms converging from different neighborhoods to a central core that defines the unity of this place or that. America's urbanness reflects this and more the coming together of immigrants from around the globe, some in the past and some more recently; the movement of rural residents to the city; the sharing of opportunity and work; and a vision of the future. Some of America's urban areas are small, others are large. Yet, the problems and challenges are similar, reflecting the hopes and concerns of people, wherever they congregate. 

America's cities are great places of complexity and heterogeneity. Some individuals thrive here, while others despair, searching for promised opportunity. Many families enjoy full access to all that is offered, but other families do not. Health care is one resource that, too often, is not available or affordable for significant numbers of urban residents. These underserved populations thus become vulnerable to poor health as well as the poverty and disarray that already characterize their lives. In some cases, the health care that is offered to individuals is not desired because of prevailing world views or cultural beliefs. These persons, too, will not utilize the services provided and may ultimately suffer disease or illness that could have been prevented or limited. 

America's urban and vulnerable populations, nevertheless, have much to offer to themselves, their communities, and society. Health care strategies that target these populations and involve them in their own health care will benefit not only individuals and families, but also whole communities. Comprehensive approaches that incorporate a community's family, work, and health values, as expressed by the individuals within the community, build on the strengths of these populations. When merged with the technical capabilities of current medicine, these strengths can bring about improved health and quality of life for all individuals and families within the community. 

In this chapter, the panel presents for consideration a review of the state of the science of research on community-based health care strategies for vulnerable and underserved urban populations, identification of research needs and opportunities, and a list of specific recommendations for future research. For context, the panel first presents an overview of the health of urban America. 

Overview: Health in Urban America

The Urban Environment 

The terms urban or city frequently connote large metropolises, now found in all regions of the United States. While urban areas have always been sources of great complexity and diversity, the populations in these metropolises today are chal- lenged by new directions and a range and extent of problems not heretofore seen severe poverty, drug trafficking, substance abuse, high rates of homicide, violence, and homelessness. 

Smaller cities are confronted by many of the same challenges and problems. In fact, as Wright (1993) suggests, these smaller cities may face greater problems because they lack a strong industrial base, have higher proportions of their popula- tions in poverty, and have a less developed welfare system. 

Urban areas are usually distinguished from rural areas by the following characteristics: population size, population density, and geographic space. Compared with rural sections of the country, urban areas in general have larger and more dense populations, combining more and various social and cultural values and norms. 

Populations At Risk

In urban environments, certain populations are vulnerable and underserved. It is these populations that the panel addresses in this chapter. Vulnerability implies a wide range of potential and actual health risks (Aday, 1993). Indeed, individuals and families who are most vulnerable (i.e., suffering the greatest morbidity and mortality from disease and/or the greatest discrepancy between projected needs and available services) are at risk for multiple physical and mental health problems. 

Defining populations at multiple risk is often complicated by a failure to understand the interactions among factors such as poverty, class, race, ethnicity, geography, income, insurance status, education and other indicators of socioeconomic status, and social support systems in contributing to vulnerability or ameliorating against risk (Aday & Andersen, 1983). Cultural beliefs and practices also may influence risk through individuals' perceptions of health and disease as well as their utilization of health care services. 

Populations facing these multiple risks include infants, children and youth, young and middle-aged adults, and elders. As members of vulnerable families and communities in closely bound urban settings, they share in the risks of the larger group. These individuals are challenged by low income and education levels and high rates of infant mortality and chronic disease. They confront infectious diseases, such as tuberculosis, which is reemerging in American cities, and sexually transmitted diseases, including AIDS. In some major metropolitan areas, poverty, drugs, and lifestyle contribute to making AIDS a significant killer of young adults. 

In addition, although illegal drugs and alcohol have for decades been part of the urban scene, the emergence of crack cocaine as a marketable drug in poor urban neighborhoods during the 1980s has elevated drug abuse and trafficking as major health problems among vulnerable U.S. urban populations (Whitehead, Peterson, & Kaljee, 1994). The ready accessibility of crack cocaine, and now heroin, and the economic potential in selling drugs, combined with the decline in other employment opportunities for young men in these populations, have accentuated urban drug problems. A dramatic increase in violence and homicides has accompanied the increased presence of drugs and guns in urban settings. 

These contemporary social problems (drugs, AIDS, violence, as well as unintended pregnancy) are proving particularly harmful to children growing up in the inner cities of America. Children are being recruited into drug trafficking as early as 9 and 10 years of age, and more inner-city children are involved in and are the victims of violence than ever before in American history. 

More children are also having to cope with drug-addicted and/or human immunodeficiency virus (HIV)-infected parents. Hospital maternity wards are tending to babies born addicted to drugs or with HIV. The social, economic, and emotional burden to individuals and society of children addicted to drugs or with AIDS is difficult to estimate. Only now are the costs of special education programs for these children during their school years being realized. One can expect that these children will not become productive adult members of society, but continue to be an economic burden. Already, their care exceeds available community-based resources and they extract a heavy social and emotional toll on families and health care providers. 

Community-Based Strategies in Urban Settings

Well-known community-based health care strategies used in urban settings include early public health approaches, public health departments, categorical programs targeted at particular populations or health problems, community health centers, community nursing centers, and case management services. These different strategies have evolved in response to particular social problems or to fill a gap in health care delivery. Their missions and objectives frequently include varied and differing components of community-based strategies, as conceptualized by the panel. 

Public Health Departments. Originating in the 1800s, public health departments represent a governmental response to environmental problems and infectious diseases. The infrastructure created typically provides preventive services and has been described as contributing significantly to community assessments, health screening and monitoring, and program planning. However, a recent Institute of Medicine study of public health (Institute of Medicine, 1988) calls into question whether clinical services and public health departments are viable and continuing to meet community health needs. 

Categorical Programs. As additional health and social problems were identified, governments and foundations provided funding for an increasing number of categorical programs added to the public health and medical agenda. The proliferation of Federal categorical programs is mirrored at state and local levels. These programs, not all of which are community oriented, include the Title V children's programs, the Ryan White AIDS Care bill, the McKinney Health Care for the Homeless Program, Healthy Start, Breast and Cervical Cancer Outreach and Prevention programs, and numerous mental health and substance abuse programs. 

Programs such as family planning or detection and abatement of lead poisoning, which are supported by public Federal and state funds, and other categorical programs targeted at hypertension, sexually transmitted diseases, prenatal care, and immunization now dominate public health department and community-based intervention programs. Programs designed for, and limited to, specific age groups, such as infants, children, women of reproductive age, or elderly persons, are also often supported publicly. Thus, individuals, families, and communities at multiple risk are often served by a proliferation of categorical programs or by programs that have been pieced together from many categorical funding streams. 

Community Health Centers. One response to meeting the multiple health needs of individuals within small service areas, usually a single neighborhood, is the community health center. First funded in 1965, these centers provide comprehensive primary care (Sardell, 1988) for a geographically defined area. They have had some success in meeting the health needs of medically underserved populations, but have not spread to larger geographic areas for a number of reasons. 

Community Nursing Centers. Nurse-managed community centers provide nursing care that may be categorical or comprehensive. They have provided an institutional base for important nursing contributions to community-based health care (Connolly, 1991; Haas, 1992; Riesch, 1992b). 

Case Management Services. Developed in response to an increasing need to manage the quality and cost of care in the face of limited resources, case management services bridge the gaps in multiple services needed by multirisk individuals. 

Challenges

Community-based strategies for underserved urban populations are faced with the same challenges as those for rural populations. Community members' involvement in these strategies and their utilization of the health care services offered will reflect the degree to which services are available, accessible, affordable, appropriate, adequate, and acceptable to the different groups in the community (Krout, 1986, 1994). For urban settings, comprised of dense populations and great diversity, these challenges are significant and their dimensions will vary for each client group. 

Outcomes

Each strategy can be assessed in terms of outcomes (e.g., impact, efficacy, and effectiveness) based on the literature and experience accumulated thus far. The published literature provides direct and indirect evidence of the benefits of more recent community-based health care strategies. 

Studies published in the early 1970s, for example, show a high quality of care in relationship to standards of care and clinical management protocols (Morehead & Donaldson, 1974; Morehead, Donaldson, & Seravalli, 1971); reduced use of emergency rooms among city children (Hochheiser, Woodward, & Charney, 1971); and reduced morbidity (Gordis, 1973). Compared with other providers, community health centers have been shown to reduce costs to Medicaid when these costs are controlled for patient characteristics and service mix (JRB Associates, 1981, 1982). 

Because of the dearth of more recent studies of community health centers, the Health Resources and Services Administration (HRSA) and Bureau of Primary Health Care adopted an ambitious evaluation strategy in 1992. Within this strategy, these organizations are sponsoring research and evaluation studies to measure case mix, processes and attributes of care, quality of care, patient satisfaction, outcomes of care, health status, and cost of care in community health centers and other federally funded comprehensive primary care systems. 

A major evaluation effort pertaining to community nursing centers is under way. Mandated by the Omnibus Reconciliation Act of 1987, this study addresses community nursing organizations (CNOs) for Medicare members. The CNOs incorporate selected community and ambulatory services, including case management, home health, provision of durable medical equipment, and outpatient therapies, within a nurse-managed, capitated system of care (Lamb, 1995). 

Four CNOs, in Arizona, Illinois, Minnesota, and New York, have enrolled approximately 10,000 participants in this study since early 1994. The evaluation design is longitudinal and experimental. Several quality and cost outcomes will be reported, including health status and health promotion activities of participants, satisfaction with health care, and use and costs of all health services. The four CNOs are using a uniform method for classifying nursing problems and will document frequency and changes in these problems. 

Existing studies of the outcomes of community-based health care strategies in urban settings are deficient in several respects. They lack common conceptual and operational definitions (Bergen, 1992); they are mostly descriptive and offer only limited analysis of outcomes (Riesch, 1992a); and they have focused on small sample sizes and selected populations within noncomparable communities, thus limiting the generalizability of findings. 

These limitations are further complicated by a complex design issue determining which factors influence outcomes. Comparison group, longitudinal designs, or other quasi-experimental designs are needed to clarify the relative importance of a community's context, the model of community health services used, and other factors. The separate or joint effects of community and model characteristics on outcomes have not yet been examined in the literature. 

A Population Focus

In this chapter the panel addresses some of the most vulnerable and underserved populations in American cities, as defined by several key risk factors related to health and health care: income level, ethnicity and race, age, and occupation. The populations addressed are low-income individuals and families (specifically, low-income women and children), ethnic and racial minorities, the elderly, and urban workers. The panel selected these populations as examples of high-risk, vulnerable groups in urban settings; there are many other groups as well. The panel could not specifically address the community health care needs of all these groups, but aimed, through sample populations, to highlight the wide range of health needs and problems faced by all vulnerable urban populations. 

Two populations on which the panel chose not to focus but which are clearly vulnerable urban populations are homeless persons and the mentally ill. Homeless persons are addressed in the literature on community health care and are the target of categorical health care interventions. However, little research has been focused on assessing the clinical services, programs, or health care strategies targeted to this population (Lukomnik, 1993). 

Because of the dearth of documented information assessing health care for homeless persons, the panel was not able to review the community-based health care needs of this population in detail. It should be noted that homeless persons are not a homogeneous population, but include distinct subgroups such as Native Americans, mentally ill persons, and individuals and families marginalized from the larger society for social or economic reasons. For mentally ill persons, a vulnerable population in both urban and rural settings, major research programs are already under way and supported elsewhere. 

The population focus in this chapter also reflects the orientation of studies and programs addressing the health of U.S. urban environments. The published literature largely focuses on categorically defined groups, such as homeless persons, HIV-infected individuals, and pregnant women. Intervention programs, similarly defined by diagnostic categories, focus on, for example, asthma prevention, prenatal care, and hypertension control. Outcomes are generally measured along a single dimension, such as birth outcome. And community-based interventions and programs are often initiated in response to selected health needs of a particular age group or population. 

The characteristics of community-based health care strategies, described in chapter 1, are considered in assessing the state of the science and research needs and opportunities for vulnerable urban populations. Accessibility to available, affordable, appropriate, adequate, and acceptable primary health care across the full continuum of care, including primary, secondary, and tertiary prevention is as relevant to urban settings as to rural areas. 

State of the Science

Low-Income Individuals and Families

Low-income individuals and families represent a large proportion of the vulnerable and underserved populations in urban settings. Low income is a major contributing factor to poor health, affecting men, women, families, and children alike. Low income threatens the self-esteem and self-efficacy of all family members and, in association with violence, AIDS, drugs, incarceration, and low educational achievement, compromises the health of both families and individuals. 

Low-income men and women of all racial and ethnic groups are vulnerable as part of this family unit. Women, especially, are vulnerable as single family providers who also are most often responsible for the care and nurturing of children and youth. In addition, some urban women are faced with an increased number of risk factors associated with low income, including violence, drug abuse, prostitution, and AIDS. 

However families are defined, those with low income are less likely to use formal health care services appropriately or adequately than are families with higher incomes. Financial barriers (affordability) limit their accessibility to services, even when these services are available and acceptable. While Medicare and Medicaid are important programs for these populations, many low-income individuals and families are ineligible for Medicaid and yet do not enjoy employer-sponsored health insurance. 

Without healthy families, one cannot have healthy communities and, if communities are not healthy, they do not survive as an integrating framework for socializing children to become satisfactorily functioning members of society. In this section, the panel specifically addresses low-income women and low-income children and youth as especially vulnerable and underserved urban populations. At the same time, the panel supports the need for community-based health care strategies focused on low-income families, including men as well as women, children, and youth. For this report, the panel considered related reports in family research, but did not conduct an overall, comprehensive review of this extensive body of literature. 

In reviewing the state of the science specifically on low-income women and low-income children and youth, the panel notes that the needs of these two groups are often addressed by separate programs. These groups are therefore considered separately below. The panel also recognizes the need, however, for designing community-based programs that link women and their partners with their children. 

Low-Income Women

Low-income women in urban settings face multiple health risks throughout the lifespan (Grisso & Watkins, 1992). Some of these risks are for diseases and conditions common in the U.S. population, which may be exacerbated by urban poverty, and some are for health problems germane to poverty, urban living, and ethnicity. Publicly funded programs have targeted certain problems (e.g., aging, AIDS, pregnancy and prenatal care), but there appear to be no well-designed, comprehensive, community-based strategies for addressing the health of low-income women across a continuum of care. 

It is apparent that accessibility to health care services is a concern, as well as the affordability, appropriateness, adequacy, and acceptability of care. The behavioral and biological factors influencing these issues have yet to be delineated fully and understood. Some success has been shown with educational and focused interventions, involvement of community organizations and members, and use of lay workers. Indications are that low-income urban women would be receptive to, and would benefit from, comprehensive, appropriate, and affordable care. 

Defining the Population. The literature on low-income women focuses predominantly on women in ethnic and racial minority groups (Barbee, 1986; Benjamin & Stewart, 1989; Catchen, 1988; Nyamathi & Flaskerud, 1992) and older women (Arendell & Estes, 1991; Catchen, 1988; Dressel, 1988). Few authors have sought to clarify the bases for classifying women as low income (Gimenez, 1989) or the specific concepts for understanding low income as a designation depicting a vulnerable group (Stevens, Hall, & Meleis, 1992). In the literature, "low income" often is used in association with ethnicity, minority, and single heads of household. 

Health Status. Most of the published studies on the health of low-income women in urban settings are descriptive. Studies of the health risks facing urban low-income women emphasize substance abuse and addiction (Ahijevych & Wewers, 1993; Barnes, Welte, & Dintcheff, 1991; Cotton, 1990; Nyamathi & Flaskerud, 1992; Reiskin & Lindenberg, 1992; Zambrana, Hernandez, Dunkel-Schetter, & Scrimshaw, 1991); sexually transmitted diseases (Abel & von Unwerth, 1988; Coker et al., 1993; Seidman, Mosher, & Aral, 1992); AIDS (Huddleston, 1995; Shayne & Kaplan, 1991; Suffet & Lifshitz, 1991); and battering or violence (Campbell & Parker, 1992). 

Many of the women with these risks are minorities, pregnant, or of childbearing age, factors that further complicate the health problems they face. Isolated studies of diabetes in Mexican-American women (Luyas, 1991) and breast cancer treatment in older women (Drugay, 1992) are also available. 

Factors complicating the health status of urban low-income women include the harsh environment of urban poverty and difficulty in understanding health problems and their treatment because of a low level of education (often less than high school). While some of the risks and complicating factors have been identified and studied, a comprehensive understanding of the health status and diseases or conditions of urban low-income women has not emerged a prerequisite for developing targeted health care strategies. 

Use of Health Care Services. Low-income women in urban settings are at risk for a variety of conditions (mental illness, diabetes, obesity, HIV/AIDS, and cardiovascular disease) but are less likely than women in other income groups to access health promotion and disease prevention services (e.g., prenatal, postpartum, and breast examinations, papanicolaou tests) (Berrier et al., 1991; Burks, 1992; Chavez, Cornelius, & Jones, 1986; Lacey et al., 1989; Makuc, Freid, & Kleinman, 1989; Mandelblatt, Traxler, Lakin, Kanetsky, & Kao, 1992; McCormick, Brooks, Holmes, Wallace, & Heagarty, 1992; Nickens, 1990; Whitman et al., 1991). Nonuse of screening tests is often related to lack of knowledge of the need for the tests or failure to include them in routine primary care. A few studies have examined health beliefs, including traditional beliefs, in relation to the use of these services and recommend incorporation of traditional practices with health education programs (Flaskerud & Rush, 1989; Flaskerud & Thompson, 1991; Frye, 1989-90). 

Studies of the delivery of care to low-income women generally are based on small samples or local service activities and are primarily concerned with prenatal care. These studies show the following: a lower use of reproductive genetic services for women of color compared with Caucasians (Nsiah-Jefferson, 1993); delay in seeking care owing to a lack of understanding that they were pregnant and the absence of risk factors or symptoms associated with pregnancy (e.g., diabetes) (Burks, 1992); and greater use of family planning services offered by public health clinics and private physicians than those offered by voluntary organizations (Handler & Rosenberg, 1992; for rural women, Severy & McKillop, 1990). Other studies document barriers to use of prenatal services (e.g., cultural incongruence between low-income women and providers, inadequate funding for vigorous outreach, lack of community awareness of available services) (Miller, Margolis, Schwethelm, & Smith, 1989) and outreach to homeless women in shelters (Kline & Saperstein, 1992). 

Regarding other concerns, such as use of mental health services in general or disease prevention services by older women, a variety of studies have examined whether physician contact results in screening (pap tests or breast exams) and whether low-income women prefer to access private or public services (Makuc et al., 1989). Findings indicate that Mexican-American women do not use public mental health centers as often as other groups (Palacios & Franco, 1986); Hispanic women use inpatient mental health services less often than do men (Russo, Amaro, & Winter, 1987); use of clinic care (vs. private private) is due most likely to the lack of a regular source of medical care and lack of insurance coverage (Radecki & Bernstein, 1989); and many Black women have coped with life-long adversity and maintain a problem-solving perspective in accessing care (Penn-Nolan, Levy, & Penn, 1986). 

A few studies depict low-income women's management of health. One study shows that African American women successfully use an active psychosocial mastery process in obtaining and managing their care (Edwards, 1993). Another study shows that community low-income women who use public health department clinics for prenatal care are less likely to have preterm, low-birthweight infants than comparable women receiving private physician care (Handler & Rosenberg, 1992). With health care teams that convey acceptable attitudes and have a good multidisciplinary mix, low-income women are receptive, for example, to nurse-provided care in birthing centers (Lyons, Reinke, Sutherland, & Zelenkov, 1992). 

Lia-Hoagberg et al. (1990) make an important point in urging comprehensive, coordinated, and multidisciplinary outreach and services that address psychosocial and structural barriers. In their study of 211 white, Black, and Native American low-income urban women who received adequate, inadequate, or intermediate quality prenatal care, they found that psychosocial, structural, and sociodemographic factors were barriers to care, whereas a mother's beliefs and support from others were motivators for seeking care. Overall, the authors affirm the complexity of achieving low-income women's participation in prenatal care. 

Community-Based Strategies. Community-based programs designed to serve the needs of women and their families are often supported by public funding and limit their services to targeted problems. Low-income women, who are at risk for multiple health problems, are often served by a proliferation of categorical programs or by programs pieced together from many categorical funding streams. 

To facilitate describing community-based health care for low-income women, existing studies have been organized into seven broad topics: development across the life cycle; health promotion and maintenance; health care delivery; reproductive health; physical diseases and health problems; mental health and illness; and economics, ethics, policy, and legislation (McElmurry & Parker, 1993). The number and content of studies under each topic vary, indicating that research on low-income women is broad and unfocused. Few intervention studies, including nursing interventions, are reported. Some policy studies, often related to aging, offer guidance on the policies needed to enable low-income women to access health care. 

Many health care practices are directed to the life cycle development of low-income women, yet low-income women are rarely a focus of research on community-based interventions for these concerns. Mothering, sexuality, families, and relationships are aspects of the life cycle addressed by health care practitioners but relatively unexamined by researchers. Practice and interventions on these and other issues across the life cycle are proceeding without benefit of an extensive base of research knowledge. 

The few studies on community-based health care for low-income women across the life cycle address issues of aging such as menopause attitudes (Standing & Glazer, 1992) and aspects relevant to AIDS such as sexual behavior, sexual decision making and condom use (Fullilove, Fullilove, Haynes, & Gross, 1990; Nyamathi, Bennett, Leake, Lewis, & Flaskerud, 1993; Worth, 1989). 

Positive results have been suggested for health promotion and maintenance interventions designed specifically for low-income women (Reis, Sherman, & Macon, 1989) and for interventions using lay health workers or educators as part of the health care team (McElmurry et al., 1987, 1990; McElmurry, Swider, & Norr, 1991; Sidel, 1991; Sung et al., 1992; Swider & McElmurry, 1990). Some success has been reported in using community organization or mobilization strategies to achieve health education (Braithwaite & Lythcott, 1989; Jefferson & Smith, 1985). 

Some authors note that categorical programs have not been successful in inducing behavioral change (Fehrs, Hill, Kerndt, Rose, & Henneman, 1991) or providing adequate services (Whitman et al., 1991). Others report success with educational interventions (Reis et al., 1989) and expansion of services to achieve a "one-stop-shopping" health experience (Machala & Miner, 1991). 

Much of the literature on reproductive health is concerned with family planning, including prevention of sexually transmitted diseases (McDonald & Johnson, 1995; Woods, 1995); enhancement of pregnancy outcomes for low-income women through prenatal care, outreach, and early identification of low-income pregnant women (Aved, Irwin, Cummings, & Findeisen, 1993; Brooks et al., 1989; Poland, Giblin, Waller, & Hankin, 1992); comparison of clinic, private physician, and nurse midwifery services (Handler & Rosenberg, 1992; Schimmel et al., 1992); stress reduction (Floyd, 1988); and provision of social support during pregnancy (St. Clair & Anderson, 1989). Other studies are focused on the postpartum period: counseling women to achieve success with breastfeeding (Grossman, Harter, Sachs, & Kay, 1990) and assessing women's concerns during this period (Nacion, 1988). 

Most studies are focused on outcomes for infants rather than outcomes and reproductive issues for low-income women. Reproductive health studies of low-income women are limited in both breadth and depth. 

The NINR currently supports a community-based nurse home visitation program to modify the health risks and lifestyle behavior of urban minority young women in relation to their pregnancy outcomes and the childhood development of their infants. This study is replicating a strategy found to be effective among young women in rural areas. Lay health workers have been shown to be effective in accomplishing prenatal outreach among rural women (Meister, Warrick, de Zapien, & Wood, 1992) and may be equally effective in urban settings. 

Few studies of mental health and illness focus on urban low-income women. Areas addressed are depression, including the role of friendship (Poslusny, 1990) and psychosocial factors associated with depression (Tomes, Brown, Semenya, & Simpson, 1990), and relationships between married partners (Vega, Kolody, & Valle, 1986). Two strategies aimed at increasing one's sense of personal mastery were a prevention-oriented stress management training program (Tableman, 1989) and a counseling/vocational approach to improving one's self-concept (Texidor del Portillo, 1987). The environmental and social conditions experienced by low-income women in urban settings can be expected to increase their risk for mental illness. The literature offers a limited and unclear picture of these risks. 

Studies of the economics, ethics, policy, and legislation of health care, which are not specific to urban women, have addressed the economics of women's health (unmet health needs in the areas of prenatal and preventive care), insufficiency of women's retirement pensions, need for essential mental health services, inclusion of women in clinical trials, and use of community-based inventories of homeless and addicted women to identify their health concerns (Golding, 1992; Hewitt, 1990; Hubbell, Waitzkin, Mishra, & Dombrink, 1989; Krauss, 1993; Mastroianni, Faden, & Federman, 1994; Nyamathi & Flaskerud, 1992; Thomas, 1990; Woods, 1988). These policy aspects are important to the health of low-income women in both urban and rural settings. 

Low-Income Children and Youth

Increasing attention is being given to the health care needs of low-income children as the effects of poverty become clearer. Descriptive data are being accumulated and society's concern is stimulating policy discussions and action. Interventions, however, have been focused largely on selected health problems, and only limited attention has been given to determining the impact, efficacy, and cost effectiveness of these interventions. Comprehensive, community-based health care strategies have yet to be initiated or tested, and the combination of factors involved in children's accessibility to, and use of, health care services has not been fully explored. 

As noted in the preceding section on low-income women, a clear definition of "low income" also is lacking. Although not a major impediment to the research needed, use of consistent definitions, and explanation of inconsistent definitions, would advance understanding of the relevance and impact of low income in community health care. A term frequently used is "poverty rate," which is the percentage of people in any group with incomes below the poverty line. 

Defining the Population. The U.S. health care system is among the best in the world for many groups of individuals living in the United States. It is woefully inadequate, however, to meet the needs of many citizens who are children and adolescents who are poor and living in urban areas. The current health care delivery system functions best for individuals who are in middle or higher socioeconomic classes, have access to personal physicians and hospital clinics, have personal health insurance, initiate visits to health care providers, live in stable home environments with strong nurturing family support systems, and belong to the white majority population (Gelberg, Linn, Usatine, & Smith, 1990; Hu, Covell, Morgan, & Arcia, 1989). All or most of these factors do not apply to America's large population of disadvantaged urban children and adolescents. 

Health Status. Low-income children, especially in urban settings, are disproportionately represented among individuals with less-than-optimum health status (National Center for Children in Poverty, 1990). Poor children are more likely than nonpoor children to die young and to suffer from illnesses and handicapping conditions (Starfield, 1992). This excess morbidity and mortality among low-income urban children also imposes significant economic and social costs for society. 

America's disadvantaged urban youth are at greater risk than the rest of the population for a range of health problems that include unintended pregnancy, AIDS and HIV infection, tuberculosis, drug abuse, and injuries associated with violence, as well as chronic illnesses, dental and dermatological problems, mental illness, and speech difficulties (Aday, 1993; Institute of Medicine, 1993; Murata, Patrick, Strehlow, & Shuler, 1992; Roth & Fox, 1990). Violence is a public health problem. 

Children living in poverty are at risk of illness and dying from a wide range of causes. Infant mortality is high because of short gestation periods, low birthweight, and sudden infant death syndrome (National Center for Health Statistics, 1991). These problems are, in turn, related to maternal factors such as low maternal weight gain, obstetrical complications, infections, smoking, drugs, and lack of adequate prenatal care (Institute of Medicine, 1985). 

Children from low-income households have relatively high rates of several health problems. First, infectious diseases such as influenza, meningitis, gastroenteritis, and parasitic diseases are much more prevalent among poor children than among nonpoor children (Egbuonu & Starfield, 1982). The occurrence of measles and other childhood diseases for which vaccines are available may also be high because of low levels of immunization. Second, chronic conditions, including high blood levels of lead (Agency for Toxic Substances and Disease Registry, 1988), also are prevalent among poor urban children, as are intentional and unintentional injuries. 

All these health problems are related to the living conditions of poverty, particularly persistent poverty. Poor persons lack money to buy goods and services that would help them avoid infection, accidents, and injury. They often feel a loss of control over their lives and low levels of self-esteem. Many have unhealthy lifestyles that include smoking and alcohol and drug abuse, and many lack safety precautions such as smoke detectors and seat belts. 

The health problems of poor children have long-range effects on their cognitive, social, and emotional development (Starfield et al., 1991). Low-birthweight children are at risk for developmental delays, particularly if they live in stressful environments. Common and easily treated problems of childhood can create important barriers to development if untreated. Otitis media, for instance, can lead to temporary or permanent hearing loss and delayed language development. Measles and other childhood diseases, for which immunizations are available, can produce permanent damage to sensory organs and neurological functioning. 

Contemporary urban problems and poverty are potentially devastating for children. For example, children are being recruited into drug trafficking as early as 9 and 10 years of age (Whitehead et al., 1994). Inner-city children are both involved in and the victims of violence at higher levels than ever before in American history. In addition, more urban children are coping with parents who are addicted to drugs or infected with HIV. These problems also have far-reaching effects since they may not only dramatically reduce life expectancy rates for children, but also have long-term social effects that can affect every member of society. 

Use of Health Care Services. Poor persons sometimes underuse formal health services primarily because of cost, barriers to access, transportation difficulties, language problems, and inadequate hours of operation (Institute of Medicine, 1985). For many disadvantaged urban youth, the formal health care system and social support structures are simply not able to meet their multiple health and social needs. Comprehensive community-based interventions that involve community residents may be the only realistic solution to the health care crisis in the inner cities (Haas, 1992; Wright, 1993). 

Community-Based Strategies. Policy makers and child health researchers have argued strongly for designing effective interventions to combat the health problems of low-income urban children (Blendon, Aiken, Freeman, & Corey, 1989; Jones, 1992; Mistral, 1991). Yet, disparate funding sources continue to yield community-based interventions and programs initiated in response to selected problems or the health needs of a particular group. These programs are both focused and funded categorically through different agencies and programs. 

Most recent health care initiatives emphasize the need for family-centered primary health care and an integrated approach to community health education and disease prevention programs (Farquhar et al., 1990; Graham, Johnson, Hansen, Flay, & Gee, 1990; Haas, 1992; Hancock, 1993). By expanding community-based interventions to include not only the participation of community members in the design and implementation of interventions, but also the full spectrum of care from primary prevention to secondary and tertiary prevention, strides can be made in improving the health status of high-risk children in urban areas. Given the limited resources available and the wide range of problems to be addressed, interventions must produce the desired outcomes and be cost effective (Becker et al., 1992). 

One of the great advantages of community-based health care strategies is that they enable researchers and practitioners to address the entire context of health care problems. This context includes socioeconomic and cultural factors that may contribute to, or protect against, illness and disease, as well as the interplay among individuals, families, communities, and health care providers. The ability to address this broad context is especially important in treating the health care needs of disadvantaged urban youth which are usually inextricably connected with a host of other factors (Pivnick, Jacobson, Eric, Doll, & Drucker, 1994; Schorr, 1988). 

For example, recent studies show close associations between family environments and health problems from violence and drug abuse and risk of AIDS (Berkowitz, Halfon, & Klee, 1992; Engelke & Engelke, 1992; Pivnick et al., 1994). Other studies related to contextual factors show that community attitudes toward health care professionals and the larger society play an important role in an individual's actions regarding health care (Erkel, 1985a, 1985b; Rowley & Tosteson, 1993). 

Studies of community-based health care strategies for low-income children have focused on categorical programs (e.g., HIV, substance use, Title V, Healthy Start), governmental funding, and the need for restructuring health care delivery systems (Klerman, 1991; Koplin, 1993; Shea, Basch, Lantigua, & Wechsler, 1992; Sundwall & Tavani, 1991). Much of this literature has focused on health service needs, and only limited attention has been given to determining the impact and efficacy of programs (Engelke & Engelke, 1992; Marcenko & Smith, 1992). 

Some of the most exciting recent work, which has applicability to interventions targeted at low-income children as well as other groups, has focused on defining a target community (Assaf, Banspach, Lasater, McKinlay, & Carleton, 1987; Becker et al., 1989; Farquhar et al., 1990; Fisher, Auslander, Sussman, Owens, & Jackson-Thompson, 1992). For example, some studies suggest that the family-centered strategy needs to be supplemented with a larger concept of community that includes extended family and nonfamily groups (Dubowitz, 1994; Fisher et al., 1992). 

Other studies show that collaboration between health care providers and church groups has great promise as a community-based nursing intervention (Levine et al., 1992; McDermott & Burke, 1993; Stillman, Bone, Rand, Levine, & Becker, 1993), as does involvement of a variety of peer groups (Julnes, Konefal, Pindur, & Kim, 1994; Levine et al., 1992; Meister et al., 1992; Quirk, Godkin, & Schwenzfgeier, 1993). In several cases, use of nonprofessional community members has been shown to be effective (Meister et al., 1992; Mittelmark et al., 1986; Quirk et al., 1993; Stillman et al., 1993). 

In addition, several culturally specific programs incorporating the attitudes and practices of ethnic populations seem to show promise in not only educating inner-city youth about health care problems, but also involving them in the solutions to these problems (Campinha-Bacote, 1991; Hong, Kappel, Whitlock, Parks-Thomas, & Freedman, 1994; Hu, Keller, & Fleming, 1989; Julnes et al., 1994; Thomas & Quinn, 1993). The culturally specific programs are addressing both specific health care needs and the contextual and social problems encompassing them. 

The NINR currently supports several promising community-based interventions targeted to urban youth. Three studies are addressing health promotion among adolescents and the influence of violence. Another study is testing risk behavior interventions to prevent AIDS. 

Ethnic and Racial Minorities

Ethnicity and race are additional risk factors that add complexity to the profile of urban underserved and vulnerable populations, a profile that includes low income, low education levels, and low economic opportunity. For ethnic and racial minorities, this profile is complicated by the strengths that these populations offer in their family, health, and work values which may be important, positive factors in their health care factors that, too often, are overlooked if one focuses only on socioeconomic factors (Hayes-Bautista, 1992). 

Addressed below is the state of the science of community-based health care strategies for three vulnerable and underserved ethnic and racial minority groups: African Americans, Asian and Pacific Islander Americans, and Latinos. Within these broad population classifications are many diverse, heterogeneous subpopulations that continue to enrich the American landscape. As these minorities become an increasing part of the U.S. population, their health care needs and contributions deserve closer attention. 

Minority groups in the United States experience many of the same diseases affecting all Americans and may have special needs or conditions related to particular sociocultural or environmental factors. Their risk for certain diseases is often disproportionately higher than the white population, reflecting socioeconomic and/or cultural factors that influence their use of health care services. Accessibility to health care services is a common problem, relating to geography and socio- economic status, and affordability (i.e., availability of insurance) is a problem for many. 

Although culturally relevant health care seems imperative, few investigators have examined the appropriateness, adequacy, or acceptability of care among these populations. Similarly, the need for and use of a continuum of services, from preventive to restorative care, have received little attention. 

In the sections below, the panel describes, for each of the three major groups, population data, major health problems, use of health care services, and community-based health care strategies. The information presented is not intended to be exhaustive, but to characterize the state of the science in each area. 

African Americans

Defining the Population. Although African Americans are often perceived as a homogeneous group, the population is very diverse. Notable differences are based on country of origin, religion, socioeconomic status (income and education levels and occupation), area of residence, and regional origin. 

Most African Americans are native-born Americans of African ancestry. However, in recent years, there has been significant immigration from several Caribbean and African countries to major U.S. metropolitan areas. Some researchers suggest that, regardless of country of origin, both native and foreign-born African Americans tend to share common beliefs, attitudes, and values (Dixon, 1994; Randall-Davis, 1989; U.S. Department of Health and Human Services, 1985) and that the experience of being black in America has produced sentiments that have evolved into a sense of "peoplehood" among most African Americans (Dixon, 1994; Hatch, Moss, Saran, Presley-Cantrell, & Mallory, 1993; Randall-Davis, 1989; U.S. Department of Health and Human Services, 1985). 

African Americans reside in all regions of the United States, with a majority living in the southernmost regions of the country (Dixon, 1994; Randall-Davis, 1989; U.S. Department of Health and Human Services, 1985). About 23 percent live within small metropolitan areas, 19 percent live in rural settings, and nearly 59 percent live in central cities where they are often challenged by significant environmental hazards, including pollution, substandard and overcrowded housing, crime, violence, and generally high levels of stress (Dixon, 1994; Randall-Davis, 1989; U.S. Department of Health and Human Services, 1985). 

African Americans are represented in every socioeconomic group; however, they are more likely than the majority population to be unemployed and unskilled and to live within a household with an earned income below the Federal poverty line. National data show that one in three African Americans lives in a family whose income falls below the Federal poverty level, compared with one in every eight Americans overall (Mosbacher, 1991; U.S. Public Health Service, 1990). African Americans in the workforce are highly concentrated in blue collar and service-related occupations and are consistently underrepresented in management and professional occupations (U.S. Department of Health and Human Services, 1985). 

Health Status. Despite the many strides made in the capacity to diagnose, cure, and control disease, the health condition of African Americans lags far behind that of the total population. African Americans have a higher risk of disease and premature death than any other group living in the United States (Abraham, 1993; Dixon, 1994; U.S. Department of Health and Human Services, 1985; U.S. Public Health Service, 1990). 

The disparities suffered by African Americans were described by the Secretary's Task Force on Black and Minority Health in the mid-1980s as persistent, distressing, and excessive (Bowles & Robinson, 1989; U.S. Department of Health and Human Services, 1985). Data indicate that the leading causes of death among African Americans are the same as for the total population, but African Americans suffer disproportionately from cancer, cardiovascular disease and stroke, chemical dependency, diabetes, homicide and unintentional injuries, infant mortality and low birthweight, and HIV infection (Dixon, 1994; Hildreth & Saunders, 1991; National Center for Health Statistics, 1993; U.S. Department of Health and Human Services, 1985; U.S. Public Health Service, 1990). 

The life expectancy of African Americans also lags behind that of the overall population. For African Americans, their life expectancy is currently 69.4 years and falling, compared with 75 years for the overall population (Abraham, 1993; Dixon, 1994; National Center for Health Statistics, 1993; U.S. Department of Health and Human Services, 1985; U.S. Public Health Service, 1990). 

The disparities in health and longevity among African Americans are said to result from a number of factors, including lifestyle preferences, habits and behaviors, many social- and economically related risk factors, diagnostic limitations, and treatment limitations (Abraham, 1993; Dixon, 1994; Snow, 1993; U.S. Department of Health and Human Services, 1985; U.S. Public Health Service, 1990). The combined effect of economic disadvantage, medical disadvantage, and indigenous cultural factors often impedes access to many health care services and resources (Abraham, 1993; Dixon, 1994; U.S. Department of Health and Human Services, 1985; U.S. Public Health Service, 1990).

Use of Health Care Services. Statistics demonstrate with sharp clarity that African Americans do not receive enough early, routine, and preventive health care. They often reside in areas not near formal medical services, are unable to pay for care in largely fee-for-service medical systems, are frustrated by recurring incidents of discrimination and abuse, and lack sufficient insurance to cover health care costs. In relation to these factors, African Americans are often described, in comparison with others, as having become more tolerant of illness and disease; less reliant on Western medicine; and less likely to utilize ambulatory, inpatient, and extended care facilities for emergent care or other health-related conditions (Abraham, 1993; Bailey, 1989; Dixon, 1994; Lewin-Epstein, 1991; Snow, 1993). 

Health care services research data confirm that, compared with other populations, African Americans often have no usual source of medical care and reportedly make fewer annual visits to a physician. As a result, hospital emergency rooms or hospital clinics tend to be their most common source of medical care (Abraham, 1993; Bailey, 1989; Dixon, 1994; National Center for Health Statistics, 1993; U.S. Public Health Service, 1990). 

Given current knowledge of disease prevention, health promotion, risk reduction, early detection, and treatment, the health status and longevity of Africans Americans could be significantly enhanced in spite of these disparities (U.S. Depart- ment of Health and Human Services, 1985; U.S. Public Health Service, 1990). If health care were made more available, affordable, acceptable, and accessible, many diseases could be prevented and many deaths could be avoided (U.S. Department of Health and Human Services, 1985; U.S Public Health Service, 1990). 

Community-Based Strategies. National health care efforts have failed to reduce the health care burden of African Americans. However, an increasing body of research suggests that community-based health care strategies can be effective in promoting health and wellness among this population (National Center for Health Statistics, 1993; U.S. Department of Health and Human Services, 1985; U.S Public Health Service, 1990). 

Drawing on as many aspects of community life as possible, community-based health care strategies have proven to be successful in bridging gaps within the health care system. By carefully designing culturally sensitive programs that emphasize health promotion, risk reduction, early detection, and early treatment of disease primary, secondary, and tertiary prevention in a supportive community environment, the health, health behaviors, and health outcomes of African Americans can be positively influenced (Braithwaite, Murphy, Lythcott, & Blumenthal, 1989; Brooks, Smith, & Anderson, 1991; Kipke, Montgomery, & MacKenzie, 1993; Molbert, Boyer, & Shafer, 1993; U.S. Public Health Service, 1990). 

The challenge faced by health care professions has been to design health care strategies that maximize effectively the potential for community participation in health-related initiatives (Kipke, Montgomery, et al., 1993; Schneider, Greenberg, & Choi, 1993; U.S. Public Health Service, 1990). The literature contains numerous reports by nurses and other professionals describing strategies of care developed to address many of the health care needs of African Americans and other underserved populations. 

Most notable among these reports are strategies to reduce the health disparities of African Americans by implementing interventions focused specifically on reducing infant mortality and low birthweight; prevention and early detection of cancer; promotion of physical activities; AIDS education, prevention, and risk reduction; reducing substance abuse; prevention of coronary heart disease; and, coordination of health care services and resources (Baranowski et al., 1990; Eng, 1993; Holland, Foster, & Louria, 1993; Holman, Jenkins, Gayle, Duncan, & Lindsey, 1991; Kipke, Boyer, & Hein, 1993; Kipke, Montgomery, et al., 1993; Lacey, 1993; Lacey et al., 1989, 1993; Lacey, Tukes, Manfredi, & Warnecke, 1991; Mitchell & Daniels, 1989; Molbert et al., 1993; Nyamathi & Flaskerud, 1992; Pearson, Jenkins, & Thomas, 1991; Rubin & Black, 1992; Smith, 1989; Suarez, Nichols, & Brady, 1993; U.S. Public Health Service, 1990). 

Many of these strategies targeted to the African American community have attempted to engage health-oriented institutions peripheral to the community in developing community-based health care systems (Bowles & Robinson, 1989; Fletcher & Himburg, 1991; Kang & Bloom, 1993; Mitchell & Daniels, 1989; Rudolph, Kahan, & Bordeu, 1993). Other community-based health care strategies utilize community settings that are more engaged in the community's social structure, such as religious institutions, housing units, community centers, and civic centers, as points of access to this population (Baranowski et al., 1990; Eng, 1993; Holman et al., 1991; Kipke, Boyer, et al., 1993; Kipke, Montgomery, et al., 1993; Lacey, 1993; Lacey et al., 1989, 1991, 1993; Mitchell & Daniels, 1989; Molbert et al., 1993; Nyamathi & Flaskerud, 1992; Pearson et al., 1991; Rubin & Black, 1992; Smith, 1989; Thomas, Quinn, Billingsley, & Caldwell, 1994). 

Reports highlighting the impact of these two types of strategies demonstrate that involving institutions perceived as being outside the community often fails to achieve optimal involvement and that far greater participation is gained by involving settings that are frequented by large numbers of persons in the community and that play a strong role in community life (Bowles & Robinson, 1989; Fletcher & Himburg, 1991; Kang & Bloom, 1993; Lacey, 1993; Lacey et al., 1991, 1993; Mitchell & Daniels, 1989; Rudolph et al., 1993; Smith, 1989). However, little comparative research has been reported on the impact of these strategies across various points of access. 

Also highlighted in the literature are community-based health care strategies that have addressed the health needs of African American communities through incorporation of natural helpers, peer role models, lay health educators, informants, and other persons indigenous to the community into the health care team (Dignan et al., 1990; Eng, 1993; Lacey et al., 1991; Rubin & Black, 1992; Suarez et al., 1993). The increased familiarity of these individuals with African American lifestyles, values, and beliefs has been suggested as making them uniquely qualified to serve in this capacity. 

Research suggests that involvement of persons indigenous to the community in community outreach, health promotion, and health education facilitates the organization, motivation, and mobilization of clients within the African American community (Bowles & Robinson, 1989; Fletcher & Himburg, 1991; Kang & Bloom, 1993; Lacey, 1993; Lacey et al., 1991, 1993; Mitchell & Daniels, 1989; Rudolph et al., 1993; Smith, 1989). Their use of techniques and strategies that "model" behaviors familiar to persons within the community has been shown to be consoling for those struggling with serious life problems (Dignan et al., 1990; Eng, 1993; Lacey et al., 1991; Rubin & Black, 1992; Suarez et al., 1993). 

However, the ability of these individuals to encourage sustained participation and to improve health, health care, and health outcomes substantially has yet to be demonstrated. Similarly, methods for measuring the effectiveness of community-based interventions are inadequate, and data on effectiveness, including cost effectiveness, are lacking. 

Asian and Pacific Islander Americans 

Defining the Population. Asian and Pacific Islander Americans (APIAs) are a diverse, heterogeneous group of individuals who speak different languages and have different cultures. Residents of the United States, they or their parents or grand- parents come from Asia and the Pacific Islands, which include countries in the Indian subcontinent (e.g., India, Pakistan, Bangladesh, Sri Lanka), Southeast Asia (e.g., Vietnam, Laos, Cambodia, Malaysia, Thailand, Singapore, Philippines, Indone- sia), East Asia (e.g., Japan, China, Korea), and the Pacific Islands (e.g., Fiji, Micronesia, Tonga, Samoa, Hawaii). 

Although specific projections differ, APIAs are considered one of the fastest growing minority groups in the United States. The APIA population in the United States is projected to reach between 17.9 and 20.2 million by 2020 (Ong & Hee, 1993). The Bureau of the Census (1992) expects APIAs to reach 10.7 percent of the U.S. population by 2050. 

Health Status. The health issues confronting APIAs have not been defined adequately. Neither the Healthy People 2000 policy guidelines (U.S. Public Health Service, 1990) nor the Federal report on Health Status of Minorities and Low-Income Groups (U.S. Department of Health and Human Services, 1991) provides satisfactory data on APIA health issues, particularly if one views health as a multidimensional concept in which physical, social, mental, environmental, and economic aspects are important. Errors and inconsistencies in identifying APIAs add to the problem (Yu & Liu, 1992). Despite the limited data available, some important findings have emerged. 

Lin-Fu (1993) summarizes existing literature on APIA health problems. Two infectious diseases are of grave importance: hepatitis B and tuberculosis. Hepatitis B is of particular concern in new immigrants from Southeast Asia where the problem is widespread. Infants born to mothers infected with the hepatitis B virus (HBV) are at high risk of acquiring HBV infection and of remaining chronically infected (Arevalo & Washington, 1988; Centers for Disease Control, 1988; both cited by Lin-Fu, 1993). As noted by Lin-Fu (1993), chronic infection with HBV contributes to primary hepatoma and cirrhosis. 

Tuberculosis also occurs with greater frequency among Southeast Asian refugees (Centers for Disease Control, 1991; Powell, Brown, & Farer, 1983; both cited by Lin-Fu, 1993). Unfortunately, many APIAs are infected with drug-resistant tuberculosis strains. 

Important genetic problems are alpha- and beta-thalassemia and hemoglobin E (an abnormal hemoglobin). According to Choi and Necheles (1983, cited in Lin-Fu, 1993), about 5 percent of Chinese Americans in Boston are carriers of alpha- and beta-thalassemia. Hemoglobin E is found in 30 million people, mostly Southeast Asians, a large number of whom have immigrated to the United States, greatly increasing U.S. incidence (Ferguson & O'Reilly, 1985). Crocker (1985, cited in Lin-Fu, 1993) states that 28 percent of Laotians and 26 percent of Cambodians are carriers of hemoglobin E. Rowley, Loader, Sutera, and Walden (1987, cited in Lin-Fu, 1993) report that 14 percent of Southeast Asians in Rochester, New York, are carriers of hemoglobinopathy. Lactase deficiency also is common among APIAs (Lin-Fu, 1993). 

Cancer is a serious problem among native Hawaiians, who have the highest incidence of cancer of the stomach, breast, corpus uteri, and ovaries and the second highest incidence of lung cancer in the United States. Stomach cancer also is high among Japanese Americans, whereas liver cancer is high among Chinese Americans (U.S. Department of Health and Human Services, 1986, as cited by Lin-Fu, 1993). Other notable health problems include nocturnal death (sudden death) in seemingly healthy young people, particularly Hmong and Laotians (Lin-Fu, 1987); cardiovascular disease (Chen, 1993b); and smoking (Centers for Disease Control, 1992). 

Use of Health Care Services. Data on APIA use of health care services and the factors involved in their use of these services are very limited. Affordability is a major problem. Since 1990, more than 60 percent of the APIA population in the United States comprises foreign-born immigrants, many of whom are on welfare (Ong & Hee, 1993). More than 25 percent of APIAs have no health insurance (National Center for Health Statistics, 1991). These conditions pose barriers to health care services use. Information is lacking on the use of health care services by uninsured APIAs. 

Accessibility is another problem. Hafner-Eaton (1993) reports that Asians have considerably less access to the American health care system than other groups, even when controlling for insurance and health and income status. In addition to lack of funds, other barriers to receiving timely care are language problems, location of services, and psychological barriers (True, 1985). Common psychological barriers among APIA groups are fear of hospitalization, fear of intrusive procedures, and preference for traditional medicine and healers (Lasky & Martz, 1993). 

APIAs also commonly underutilize mental health services (Matsuoka, 1990), a finding that does not necessarily correlate with less severe conditions. As with general health care, proper utilization of mental health services is influenced by location, availability, and cultural and linguistic appropriateness of services (Sue, 1993). 

The diversity among APIA cultures makes it difficult to generalize about primary, secondary, and tertiary prevention practices across APIA groups. Lasky and Martz (1993) explain that although traditional APIAs engage in health practices to prevent illness, they may do so in non-Western ways. In the case of traditional Pilipinos, for example, prevention practices may include maintaining a balance of spirit, morals, body elements, and diet (Baysa, Cabrera, Camilon, & Torres, 1980). That is, rapid shifts from hot to cold are avoided. Air imbalances, such as allowing wind to blow on the body, are avoided to prevent illnesses such as colds, fever, and pneumonia. Being a morally good person is desirable so that one deserves to have good things happen. Emotional stress can cause disequilibrium and, subsequently, greater susceptibility to illness. 

Pilipinos, following their traditional prevention practices, also underutilize health care services (Baysa et al., 1980). They may suppress signs of suffering in front of strangers, are more expressive within the family, and may not seek treatment or accept hospitalization in a timely manner (Lasky & Martz, 1993). 

Community-Based Strategies. Not knowing the extent of the potential or real health problems of APIAs makes it difficult to design community-based health care strategies that address the physical and mental health care needs of APIAs (Guillermo, 1993; Sue, 1993). Also, many health care providers do not understand the important role of culture in the lifestyles and health behaviors of these groups (Andrews, 1992; Lin-Fu, 1993). In addition, health providers may not recognize disease or illness conditions in this population. For example, Pilipinos with mental illness may seek treatment for headaches, insomnia, dizziness, or fatigue (Lasky & Martz, 1993). 

Few studies have assessed or tested health-related intervention programs for APIAs (Chen, 1993a) or community-based health care strategies for APIAs. Chen (1993a) explains that current data are insufficient to assess the extent to which objective 8.11 of the Healthy People 2000 document has been met for the APIA population (U.S. Public Health Service, 1990). This objective addresses the need for a 50 percent increase in the proportion of counties with culturally and linguistically appropriate health promotion programs for racial and ethnic minority populations (e.g., APIAs). 

Recent national health surveys shed some light on the availability of community-based programs for APIAs. The Asian American Health Forum conducted a national survey of health promotion and disease prevention programs available through APIA community-based organizations or public entities (Guillermo, 1993). The survey revealed that 62 percent of the organizations had some health programs for APIAs. Most of these programs targeted HIV/AIDS; other programs focused on infectious diseases, mental health, nutrition, and substance abuse. Health education was the most frequent type of service delivered, followed by screening, counseling, research, and primary care (Guillermo, 1993). 

A survey of the Association of State and Territorial Health Officials (1992) in the United States revealed that only 26 percent of respondents felt that linguistically appropriate service delivery is of high priority. The respondents also reported that bilingual/bicultural services were not offered uniformly across service programs. Those that were offered dealt with sexually transmitted diseases, HIV/AIDS, immunization, tuberculosis, and maternal and child health programs. In summary, national data indicate that current community-based programs for APIAs are inadequate for the health care needs of these groups (Guillermo, 1993). 

The NINR is currently supporting several community-based interventions aimed at controlling the reemergence of tuberculosis, preventing transmission of the disease, and promoting adherence to treatment. These studies include intervention strategies for ethnic and racial minorities infected with tuberculosis. 

Latinos 

Defining the Population. The Latino population is the fastest growing minority group in the United States. Between 1981 and 1991, the U.S. Latino population increased at a rate of 4.1 percent per year, reaching 23,350,000 in 1991. As a percentage of the national population, persons of Latino origin increased from 6.8 to 9.3 percent during the decade (Bureau of the Census, 1993). It is projected that, by 2010, Latinos are expected to total 39 million or 12.9 percent of the U.S. population (Exter, 1992) and will be one of the fastest growing minority groups. In the next 20 years, the number of Latinos between the ages of 45 and 54 will more than double and the number of women older than 75 will triple (Biafora & Longino, 1990; Exter, 1992). 

The Latino population in the United States includes four main groups: Mexicans (63 percent of the U.S. Latino population), Puerto Ricans (12 percent), Cubans (5 percent), South and Central Americans (10 percent), and other Latinos (8 percent) (National Coalition of Hispanic Health and Human Services Organizations, 1988). Participation in the U.S. health care system differs among Latinos based on group of origin and/or identification, duration of residency in the United States, and income. 

Health Status. The prevalence of certain diseases varies among Latino groups (Mendoza et al., 1991). Compared with whites, Latinos are more likely to have diabetes, hypertension, AIDS, alcoholism, specific cancers, and violent deaths (Council on Scientific Affairs, 1991). In a nationally representative sample of Mexican, Cuban, and Puerto Rican Americans (National Center for Health Statistics, 1985), Latinos of Mexican descent were at highest risk for hypertension and cardiovascular disease (Pappas, Gergen, & Carroll, 1990). 

Risk factors among Latinos include excessive alcohol intake, obesity, use of processed food, and stress (Bray & Edwards, 1991). Yet, despite the high incidence of cardiovascular disease, especially among Mexicans, mortality from this condition is reported to be low. Culture may serve as a buffer for individuals at risk for heart attacks (Chrisman & Kleinman, 1983). 

Still, mortality from heart attacks is expected to increase among Latinos, especially for those with untreated hypertension. This expected increase is mostly due to the lack of cultural value Latinos have for Western preventive health care practices and certain treatment regimens for diseases such as hypertension and obesity (Chrisman, 1984). The fact is that clinical symptoms of hypertension can go undetected for a long period of time, and adherence to treatment is an issue among all patient populations. 

For inner-city, underrepresented populations, these problems are compounded by poverty, low education, inability to read or speak English or functional illiteracy in English, inability to follow a prescribed regimen, and, for economic or cultural reasons, inability to seek health care (Francis, 1991). It also has been reported that Latinos are less likely to be willing to be hospitalized for their illnesses (Welch, Comer, & Steinman, 1973). If preventive health care behaviors and adherence to hypertension treatment regimens are not valued by Latinos as they are by the majority white population, the chances for severe cardiovascular complications are more likely to increase. 

Among Latinos, Puerto Ricans have the highest incidence of diabetes and are twice as likely to have used cocaine (National Center for Health Statistics, 1985). Puerto Rican women also are more likely to smoke cigarettes, increasing their risk for pulmonary and other related diseases (National Center for Health Statistics, 1985). 

Use of Health Care Services. Latinos tend to delay seeking medical care. Reasons include underinsurance or no insurance (Lieu, Newacheck, & McManus, 1993) and social or cultural factors such as language barriers, health beliefs and practices, perceived health care needs, and use of home remedies and traditional healers (Andersen, Giachello, & Aday, 1986; Lukomnik, 1993). 

Analysis of a study conducted by the National Access Survey between 1982 and 1986 revealed that twice as many Latinos as whites have no regular source of health care (Weisfeld, 1987). Of the three major Latino groups in the United States, Mexicans are least likely to have routine physical examinations or to see a physician regularly (Warner, 1991). Elderly Latinos rely on extended family members for support and care (Ailinger, Dear, & Holley-Wilcox, 1993). 

Although lack of access to health care services is not a problem unique to Latinos, they are less likely in comparison with other minority groups, such as African Americans, to use these services (Trevi¤o & Moss, 1984). Lack of access and inability to qualify for health services are posing major problems for medical institutions, which are reporting increased use of hospital emergency rooms by Latinos as a way of receiving health care. 

This phenomena can be attributed to several factors: (1) lack of resources available in the community to assist Latinos in becoming socialized with the culture of health and to assist providers in becoming socialized to Latinos' culture of health; (2) lack of value for preventive health care; (3) inability to pay for health services; and (4) lack of homogeneous sociocultural knowledge about this group. 

A mutual understanding of concepts relating to the health values, beliefs, and culture of the majority and Latino populations is pivotal to the success of health services. Examination and testing of the adequacy and acceptability of health care practices delivered to Latinos also are imperative. For example, a group of Puerto Rican parents who had children with cancer reported feeling more comfortable talking to a nurse about their concerns and fears about childhood cancer than to a psychologist. Psychologists were believed to be necessary only when people were "mentally ill" by this group of parents (Munet-Vilar¢, 1984). Existing scientific data about health values and the utilization of these data in delivering services to Latinos are random, anecdotal, and limited. 

Community-Based Strategies. For Latinos, as for other populations, social constructs and cultural beliefs influence their health behaviors and health-seeking practices. These beliefs and practices, which may protect or impede health, must be considered when devising community-based health care strategies. 

For example, differing from the majority white U.S. population, Latinos place extreme importance on "la familia" (the family), highly value "respeto" (respect) for authority figures, prefer to develop interpersonal relationships based on trust and "personalismo" (personalism), and believe that every individual has a life mission (fate) that cannot be altered (Perez-Stable, 1987; Sabogal, Marin, Otero-Sabogal, Marin, & Perez-Stable, 1987). Some of these characteristics may explain why Latinos tend to delay seeking formal medical care when needed. 

The authors of one study comparing the beliefs and attitudes of Anglos and Latinos reported that Latinos believed that bruises from being hit, sugar substitutes, microwave ovens, breastfeeding, spicy foods, and antibiotics could cause cancer (Perez-Stable, Sabogal, Otero-Sabogal, Hiatt, & McPhee, 1992). The Latinos in this study were also more likely to believe that cancer is a death sentence and to prefer not to know that they have it. 

In addition, use of traditional healers for specific illnesses, especially those caused by "bad spirits" are still part of the care-seeking health behaviors of some Latinos. Some Mexicans use "curanderos" and folk healers; some Puerto Ricans seek care from "espiritistas" (Giachello, 1985). While these services are sought primarily by new immigrants who believe that Western medicine is not effective, many Latinos use home remedies such as herbal teas and baths along with conventional Western medical treatment such as chemotherapy for cancer (Munet-Vilar¢, 1984). These practices may be conducted without the knowledge of nurses and doctors because the persons fear being ridiculed. 

Data on the impact, efficacy, and cost effectiveness of established or innovative health care services for Latinos are limited. Community-based interventions have been shown to be successful among Latinos and may eventually decrease the cost of care when a partnership with the community to be served includes members of the community as well as culturally sensitive health professionals (Mahon, McFarlane, & Golden, 1991; Milburn, 1993). 

For example, in an Arizona suburban community of Latino migrant workers, lay health workers were trained and used in a community-based prenatal intervention project (Meister et al., 1992). Incorporating sociocultural factors, the program included use of Spanish, community lay workers as "promotoras" (health promoters), the indigenous system for delivering health education, and a support network of health care professionals. The use of lay workers as a community resource proved to be one of the most successful strategies in this cost-effective program. Information from this study can be extrapolated to other Latino communities. 

Community-based health care for Latinos can work if culturally appropriate strategies are used. A cancer detection and prevention program designed to reach underserved and poor Latino and black communities in Dade County, Florida, was successful due to the strategies used (Zavertnik, 1993). For example, Spanish newspapers and Latino radio stations were used to reach the public, informing them about cancer prevention services such as mammograms. Listeners also were able to call with questions during an interview program offered by the radio stations. 

Other successful strategies in this program included informal talks and networking at elderly meal sites in senior citizen centers, presentations to church groups and organizations, and puppet presentations at Head Start Sites. A signifi- cant change in in situ and local stage of disease was observed among the group that was screened, in comparison with the un- screened group. Financial savings also were reported to be significant when compared with the costs of cancer treatment. 

Urban Elderly

Elderly persons offer a rich resource of experience and knowledge on which society can draw. Many continue to live with vigor well into their 80s or beyond, yet others suffer illness and disability. Constituting a growing segment of the American population, elders utilize a significant percentage of the country's health care resources. Comprehensive, community-based programs have much to offer elderly persons at risk, especially low-income frail elderly. Creative solutions that capitalize on existing resources in both rural and urban areas are sorely needed. 

Ensuring that health care is available, accessible, affordable, appropriate, adequate, and acceptable to all elderly persons, including the frail elderly, requires community-based health care strategies that include codetermination of health care intervention strategies among consumers, nurses, physicians, and other health care professionals. Careful attention also must be given to including elders in decision making about their health care to ensure that their concerns about their quality of life are incorporated into the strategies adopted. 

Defining the Population. Persons aged 65 and older represent about 12 percent of the U.S. population (U.S. Senate Special Committee on Aging, 1991). This proportion is expected to increase to between 18 and 20 percent by 2030 (Board of Trustees, 1994). 

Health Status. Aggregate data on the health status and costs associated with health care for elderly Americans are startling. Although elderly persons comprise about 12 percent of the U.S. population, they account for 31 percent of all hospital discharges, 42 percent of all short-stay hospital days, and more than 34 percent of the country's total health care expenditures (U.S. Senate Special Committee on Aging, 1991). The projected increase in the proportion of elders over the next 40 years is likely to be accompanied by substantial increases in total health spending. 

The average annual number of days of restricted activities due to acute and chronic conditions for persons aged 65 and older in 1990 was 31.4 (i.e., 1 month out of every year is lost to illness and frailty), of which 2 weeks, on average, are spent confined to bed (National Center for Health Statistics, 1992). Further, nearly 32 percent of persons aged 75 years and older report their health as "fair" or "poor" (National Center for Health Statistics, 1992). 

The health needs and costs for elderly persons are influenced by a myriad of social issues, including housing, transportation, and fixed incomes. Older persons have substantially less cash income than those under 65, and the old-old (85 years of age and older) have significantly lower money incomes than the young-old (65 to 74 years of age) (U.S. Senate Special Committee on Aging, 1988). Further, the median income of elderly women is slightly more than half (56 percent) the median income of elderly men (U.S. Senate Special Committee on Aging, 1988). 

Elderly persons living in urban areas face special challenges. Although urban areas have greater numbers and types of health care services and more rapid introduction of new technologies than rural areas, urban elderly face different access problems, including those related to transportation and sociodemographic factors (Prospective Payment Assessment Commission, 1993, 1994). 

Use of Health Care Services. Elderly Americans today consume a disproportionate share of the nation's health care resources in part due to the availability of Medicare and supplemental insurance and the acute and highly technical services required to care for exacerbations of multiple chronic conditions. Currently, 96 percent of adults 65 or older are enrolled in Medicare (Prospective Payment Assessment Commission, 1994). Per capita health care expenditures for people in this age group are almost double those for 45- to 64-year-olds and almost 4 times the average for individuals aged 18 to 44 (Prospective Payment Assessment Commission, 1994). 

However, as a consequence of health insurance coverage lagging behind use patterns and the inflation of medical care prices, out-of-pocket health care expenses by elderly persons now comprise the same proportion of their incomes as prior to the enactment of Medicare and Medicaid (U.S. Senate Special Committee on Aging, 1988). More than 26 percent of persons age 85 years and older have only Medicare for their health insurance coverage (National Center for Health Statistics, 1992). 

Many elderly persons have special needs for social support associated with loss of spouse and friends, reduced physical capacity to engage in usual social activities, lower cognitive function, and clinical depression which is often a reaction to frailty, chronic disease, and other losses. These social support needs cannot be overlooked: Only about 5 percent of elderly persons live in nursing homes at any given time; relatives represent 84 percent of all caregivers and provide 89 percent of all days of care for disabled elderly men living in the community (U.S. Senate Special Committee on Aging, 1988). 

Community-Based Strategies. A variety of community-based intervention strategies have been used to prevent disease, promote health, and provide supportive and restorative health care among elderly persons residing in urban settings. Examples of these interventions are given below to highlight the state of the science and to point to research needs and opportunities. Many of them may be applicable to rural areas and diverse population groups. 

Primary and Secondary Prevention

Many diseases of older adults cancer, cardiovascular disease, pulmonary diseases, stroke/cerebrovascular disease, and unintentional injuries stem from long-term habits that undermine health inactivity, alcohol abuse, physical abuse, psychological abuse, high-fat/low-fiber diets, and poor compliance with recommended prevention and disease-screening protocols (Berg & Cassells, 1990; Sattin, 1992; Surgeon General, 1993; Tinetti, Speechley, & Ginter, 1988). These diseases and habits are common to both urban and rural older adults. 

Primary and secondary prevention strategies, when placed within a comprehensive health care outreach and service delivery system, offer ways of reducing the risks and effects of these diseases through health promotion, disease prevention and screening, and early diagnosis and treatment. Through health promotion one aspect of primary prevention it is possible to modify elderly persons' high-risk behaviors such as smoking, excessive alcohol intake, and lack of physical activity. An increase in "protective" activities, such as exercise and making environmental changes for safety, is also possible. Immunizations another aspect of primary prevention can reduce elderly persons' risk for upper respiratory infections, such as influenza and pneumonia. Screening for cancer or other serious diseases secondary prevention can identify early signs of diseases that increase with age. 

For these and other primary and secondary prevention services, community-based strategies offer an appropriate public health context that can have major benefit for elderly persons throughout the United States. Such strategies include health fairs that offer a wide range of screening programs; educational forums; public service announcements on television and radio; dissemination of prevention tip sheets and workbooks; "one-stop-shopping" centers for meals, health screening, and social support; technical assistance to public agencies and private organizations serving older persons; and neighborhood watch programs. Experience has been gained in using these and other community-appropriate intervention strategies to increase positive health outcomes for a growing segment of American society. 

Exercise and Functional Dependence. As an increasing number of persons survive well into their 70s and 80s, greater societal, public health, and clinical attention is being focused on the prevalence and etiology of functional dependence and associated deterioration in quality of life so that interventions can be developed to reverse or prevent this dependence (Boult, Kane, Louis, Boult, & McCaffrey, 1994; Kaplan, 1992; Kiel et al., 1989; Mor et al., 1989; Rowe & Kahn, 1987). Most of the research in this area has been conducted among urban elderly, largely because urban residents are more accessible to researchers. The studies do not distinguish between urban and rural elderly or different population groups. 

In addition to demographic factors (age, gender, race, income, and education) and behaviors (smoking and excessive alcohol consumption), factors frequently identified as independent predictors of functional decline include arthritis (Guralnik & Kaplan, 1989; Mor et al., 1989); lack of regular exercise (Kiel et al., 1989; Mor et al., 1989; Wagner, LaCroix, Buchner, & Larson, 1992); falls within the past year, particularly injurious falls (Dunn, Rudberg, Furner, & Cassell, 1992; Kiel, O'Sullivan, Teno, & Mor, 1991; Mor et al., 1989); and obesity (Kiel et al., 1989). In a cognitively intact population, inactivity and other high-risk behaviors are amenable to prevention efforts. 

Recent epidemiological research continues to confirm the benefit of physical activity for positive health outcomes in later life (Wagner et al., 1992). Older persons who engage in leisure-time physical activity have reduced risks of morbidity and mortality as well as improved functioning (Wagner et al., 1992). Moreover, changes in physical activity levels over time are associated with changes in health status even for persons 75 and older, supporting the value of exercise-based interventions (Kaplan, 1992). 

Sustained, regular physical exercise has been hypothesized to improve health and well-being through mechanisms such as improved self-efficacy, expanded social networks, attention effects, and direct physiological responses. Sorock et al. (1988) found in one investigation that walking more than 1 mile at least 3 times per week was protective against suffering a fall injury even after controlling for important health-related confounders. 

Until recently, however, prevention-oriented exercise interventions were not conducted in older populations, which are assumed to be uninterested in or unable to adopt new lifestyles (Gatz, Popkin, Pino, & VandenBos, 1985). These myths are now being challenged by recent studies showing that older persons can be successfully recruited and retained in community-based exercise programs (Stevens, Hornbrook, Wingfield, Hollis, & Greenlick, 1991). 

A growing body of scientific evidence also indicates the feasibility of obtaining high levels of physical activity adherence among older persons (Blumenthal et al., 1989; Emery, Hauck, & Blumenthal, 1992) and of methods for achieving adequate long-term adherence (Dishman, 1988; Sallis & Hovell, 1990). Studies of physical activity in middle-aged and older-aged adults show that adherence rates of 70 percent or higher are feasible in group- or class-based programs (Wood et al., 1983, 1988) and in properly supervised home-based programs (King & Fredericksen, 1984; King, Haskell, Taylor, Kraemer, & DeBusk, 1991; King, Taylor, Haskell, & DeBusk, 1988; King, Young, Oka, & Haskell, 1992) using appropriate techniques such as regular telephone and mail contact supplemented with periodic face-to-face encounters. 

These studies underscore the utility of a regularly delivered package of behavioral strategies for enhancing long-term adherence to exercise regimens among older adults. The strategies include behavioral contracts, ongoing monitoring, regular feedback, engaging of a person's support networks, and consistent staff support. Such efforts and strategies are natural components of a comprehensive community-based health promotion program targeted to elderly persons. 

Smoking Cessation. Smoking continues to be a major health risk for most populations, including lower income and older persons. Nearly 15 percent of males and 12 percent of females age 65 and older smoked cigarettes in 1990 (National Center for Health Statistics, 1992). Although this reflects a significant drop in smoking by elderly males, from about 29 percent in 1965, older women still smoke at higher rates than their 10 percent rate in 1965. These numbers do not reflect total lifetime exposure to cigarette smoke. Currently, nearly 30 percent of males age 45 to 64 years smoke (National Center for Health Statistics, 1992). 

Smoking compounds other health risks among the elderly as well. Among Americans aged 65 to 74, 70 percent have hypertension, 34 percent have borderline high serum cholesterol, and 33 percent are overweight (National Center for Health Statistics, 1992). The six leading causes of death in the United States in 1989 were, in order: heart disease, malignant neoplasms, cerebrovascular diseases, accidents and adverse effects, chronic obstructive pulmonary disease, and pneumonia and influenza (National Center for Health Statistics, 1992). All of these diseases and injuries have some link to smoking. 

Through research, increasingly sophisticated intervention techniques have been developed to promote smoking cessation, including intensive group behavioral programs, nicotine replacement therapy, brief cognitive interventions, public media campaigns, workplace smoking cessation policies, and restrictions on smoking in public facilities. Further, health care professionals can have a powerful impact on patients' smoking behaviors (Hollis et al., 1994; Hollis, Lichtenstein, Mount, Vogt, & Stevens, 1991; Hollis, Lichtenstein, Vogt, Stevens, & Biglan, 1993). These techniques and opportunities can be combined to effect positive change in smoking habits among elderly persons. 

Research shows that intensive group-intervention efforts, coupled with medical and nursing support, can be highly effective in reducing high-risk behaviors, such as smoking, among persons amenable to change (Hollis et al., 1991, 1993, 1994). Low-intensity, brief, personalized interventions for smoking cessation, although not nearly as effective as group approaches, can also be highly cost effective (Hornbrook et al., 1995). Interventions that combine physician advice with nurse counseling in primary care settings, if widely disseminated, appear to offer substantial promise for reducing national prevalence rates for smoking, including prevalence rates among elderly persons. 

Disease Prevention and Screening. Adherence to physician recommendations and use of available preventive measures are two factors that positively influence health status and yet are often overlooked by elderly persons. The reasons for elderly persons' poor adherence to and underutilization of preventive measures are not documented, and techniques to improve adherence and utilization have not been rigorously tested. 

Hypothesized reasons relate, for example, to the lack of transportation, poor health, reduced cognitive function, lack of education about efficacy of prevention, and financial barriers to access (low income and lack of Medicare coverage of preventive services). Older populations, for example, often demonstrate poor adherence to immunizations recommended by their physicians and health plans, even when insurance covers these services (Mullooly et al., 1994). For individuals without health insurance coverage for vaccinations, the cost (affordability) of this important prevention measure may be a barrier to its use. 

However, even among persons with coverage (e.g., individuals subscribing to health maintenance organizations offering these services), adherence in terms of the recommendations of the U.S. Preventive Services Task Force is low (Mullooly et al., 1993; U.S. Preventive Services Task Force, 1989). Techniques to influence elderly persons' approach to immunizations (e.g., ignorance of, resistance to, lack of belief in efficacy of) have not been thoroughly tested, although research has shown that influenza immunizations can be a cost-saving measure for community-based health care systems (Mullooly et al., 1994). 

Underutilization is demonstrated by elderly persons' use of mammography. This procedure has been shown to be an effective, including cost-effective, screening service for elderly women (Shapiro, Venet, Strax, & Venet, 1988; Tab r, Faberberg, Day, & Holmberg, 1987) and, as a result, is now covered by Medicare. However, removal of financial barriers to this service has not produced desired screening levels among older women (Zapka, Stoddard, Costanza, & Greene, 1989). Other factors that may be involved have not been delineated. 

Breast cancer rates continue to be highest among unscreened women of all ages, indicating that high priority should be placed on the screening of populations that lack access to screening services, particularly low-income, nonwhite, elderly women living alone (Sobel et al., 1989). That is, the risk factors for underservice in urban areas correlate strongly with underuse of cancer screening services. 

Tertiary Prevention

Supportive and restorative services for older adults have been offered as part of comprehensive integrated health care programs or as separate and distinct intervention activities. Most commonly, these services (such as home health, case management, homemaker services, personal care, companion services, adult day care, transportation, home and centralized meal programs, and respite for caregivers) have been viewed as lower-cost alternatives to expensive hospital and nursing home stays. 

Comprehensive, Integrated Strategies. Over the past two decades, several comprehensive strategies of supportive and restorative services for older adults have been implemented and evaluated in projects funded under Medicare and Medicaid waivers and by private foundations. Many of these strategies have been implemented in urban settings and have targeted specific aspects of community-based care, most commonly, accessibility, appropriateness, and adequacy of services. There has been limited examination of differences in implementation and outcomes of these comprehensive strategies between urban and rural settings and limited attention given to the acceptability of comprehensive community services to urban elderly. 

Community care demonstrations funded through Medicare and Medicaid waivers in the 1970s and 1980s offered case management and an expanded package of community services to reduce nursing home placement of community dwelling older adults (Kemper, 1988; Weissert, 1985). These demonstrations, in aggregate, showed that although caregiver satisfaction improved, the small savings gained in reduced nursing home days did not offset the increased cost of providing expanded community packages. 

Analyses also indicated that, in several programs, participants were not screened adequately to identify those at highest risk of nursing home placement and, thus, the programs had expanded services to many individuals less likely to use expensive nursing home days (Kemper, 1988; Kemper, Applebaum, & Harrigan, 1987; Weissert, 1985). Programs that used specific nursing home screens as sampling criteria, such as the South Carolina Community Long-Term Care Program, were more likely to show a savings in cost (Kemper et al., 1987). 

In 1985, the Social Health Maintenance Organizations (Social/HMO) demonstration, funded by the Health Care Financing Administration, was implemented to examine the impact of an integrated acute and chronic health care continuum on the quality and costs of care for Medicare beneficiaries (Greenlick, Nonnenkamp, Gruenberg, Leutz, & Lamb, 1988; Leutz, Greenlick, Ervin, Feldman, & Malone, 1991). Each of the four Social/HMO sites is located in an urban setting. In addition to traditional Medicare-covered services, the Social/HMO demonstration sites offer expanded community care and nursing home services (Leutz, Abrahams, & Capitman, 1993; Leutz, Abrahams, Greenlick, Kane, & Prottas, 1988). 

As in the previously cited demonstrations, the Social/HMO demonstrations rely on case management to monitor and coordinate services for high-risk individuals and to address issues of appropriateness and adequacy of care (Abrahams, Macko, & Grais, 1992). However, the results of recent studies of decision making among case managers suggest that there may be considerable variation between case managers in decisions related to allocation of services, thus affecting older adults' access to adequate and appropriate services (Abrahams, Capitman, Leutz, & Macko, 1989). In addition, initial enrollment in the Social/HMO demonstrations was very slow, suggesting that clients had concerns relating to the acceptability and perceived affordability of the more comprehensive package of community services (Greenlick et al., 1988). 

The Supportive Services Program for Older Persons, funded by the Robert Wood Johnson Foundation, more directly addressed the acceptability of a variety of community services to older adults. Eleven participating home health agencies used consumer-driven marketing research approaches to determine which community services would be acceptable and affordable for older adults and their caregivers (Hereford, 1989). The intent of this study was to build home health agencies' capacity to offer new services that would become self-supporting. Services in greatest demand by older adults and their caregivers were home maintenance, housekeeping, and yard and chore support. Case management was not in as high demand as anticipated. The results indicate a need for nontraditional community services and a willingness of older adults to pay for selected services even when their incomes are limited (Hereford, 1989). 

These and other studies of comprehensive strategies for supportive and restorative community services demonstrate both a demand and unmet need for these community services. To date, federally subsidized strategies have not shown consistent quality or cost outcomes in either urban or rural settings. Most of the studies have emphasized issues and outcomes related to the potential cost savings of home-based and community care in comparison with institutional care. However, it is important to note that the interventions tested in these studies may have influenced directly and/or indirectly some or all of the components of community-based care, including the availability, accessibility, affordability, appropriateness, adequacy, and acceptability of services. The results of these studies should be examined for information about strategies that enhance or diminish the effectiveness of community-based care for older adults. 

Nursing-Centered, Focused Interventions. In contrast to comprehensive, integrated strategies of supportive and restorative services, some community programs have focused on specific needs or sets of needs of vulnerable older adults. These needs include transitional care between health care settings (Naylor, 1990), long-term monitoring of chronic illness (Lamb, 1992; Lundeen, 1993), assistance with personal care and activities of daily living (Jamieson, 1990), respite care (Jamieson, 1990), and support for caregivers (Archbold, Stewart, Greenlick, & Valanis, 1993). 

An example of work currently supported by the NINR is a study to examine the effects of a short-term, standardized nursing intervention. In this study, the investigators are examining the quality of life and outcomes for postsurgery cancer patients 60 years and older and family caregivers' perceived burden. 

In these strategies of care, nurses increasingly play pivotal roles as administrators, decision makers on resource use, and evaluators of the quality and cost effectiveness of care. These strategies typically also are based on comprehensive community assessments and active consumer participation (Jamieson, 1990; Lundeen, 1993). 

Riesch (1992a) identifies three categories of nursing-centered models: (1) community health or outreach models, which may include hospital and university-affiliated clinics (Culbert-Hinthorn, Fiscella, & Shortridge, 1985; Lundeen, 1993), parish nurse programs (McDermott & Burke, 1993), or block nursing programs (Jamieson, Campbell, & Clarke, 1989); (2) wellness and health promotion models; and (3) independent practice models. Each of these nursing models contains numerous examples of supportive and restorative programs for elderly persons. Most have been implemented in urban settings. 

Research examining these models is extremely limited. As noted by Riesch (1992a, p. 22): 

We know the clients and patients are satisfied with the care. We know how many and [what] types of persons avail themselves of the services. However, we know very little about the scientific adequacy of practice in these centers, the cost of care, and the outcomes. 

Available studies provide helpful information about the use and acceptability of services in nurse-centered community strategies. However, there is little information on: (1) the nonmedical factors that place elders at risk of departing from the community, (2) predictors of the type and amount of supportive and restorative services needed by frail urban elderly and their caregivers, or even (3) descriptors of skilled community nursing care (Lang, Kraegel, Rantz, & Krejci, 1990; Lundeen, 1993). Little is known about how nurse-centered community strategies influence access, adequacy, or appropriateness of services for older adults in urban areas. 

Urban Workers

Workplaces can be viewed as communities of workers having a variety of health care needs. Occupational health services have been developed in response to these needs, meeting the demand for health promotion, disease and injury prevention, as well as case management to minimize the effects of disease and disability associated with occupational health problems. As the American workplace changes, so will these services. 

Comprehensive, community-based approaches are as valid for workers as for other communities. Faced with a myriad of different and changing job hazards, workers can benefit greatly from integrated primary, secondary, and tertiary prevention services. In addition, the workplace offers an important arena for health promotion activities directed at modifying behaviors or risk factors associated with diseases and conditions common among the U.S. population and for addressing the health care needs of vulnerable and otherwise underserved populations. 

Defining the Population. Today's occupational health care is frequently characterized as uncoordinated, fragmented, and inadequate to meet the health needs of employees. The workplace has recently been described as "America's forgotten environment" (Department of Occupational Safety and Health, AFL-CIO, 1993). Workplace injuries, illnesses, and fatalities impose tremendous costs on workers, employers, and society. 

Employers are placing greater concern on the health needs of elderly persons, ethnic minorities, women, adolescents, and the physically challenged. Ethnic minorities, particularly African Americans, Asians, and Latinos, will influence the composition of the workforce in coming decades. Between 1980 and 1987, the number of African Americans in the U.S. workforce increased by 13 percent and the number of Latinos by 34 percent, soaring above the 7 percent increase for whites (Aguirre-Molina & Molina, 1990). Substantial increases in the number of Asian Americans in the U.S. workforce also are projected. Johnson and Packer (1987) note, "Only 15 percent of the new entrants to the labor force over the next 13 years will be native white males, compared to 47 percent entrants in that category today." 

These changes will influence the types of health services needed and the types of worksites in which they will be offered. For example, given current patterns, ethnic minorities are more likely to be employed in semiskilled or nonprofessional occupations, will more often hold jobs that do not offer access to health care programs, and will have larger families with a high rate of households headed by single females (Aguirre-Molina & Molina, 1990). Physically challenged workers also will require a different array and form of health services. 

Health Status. Changes in the workplace have increased the need for occupational health and safety services. Premature death, diseases, injuries, and other unhealthful conditions resulting from occupational exposures pose important national health problems (U.S. Public Health Service, 1990). During 1987, permanent impairments on the job increased from 60,000 to 70,000, and totally disabling injuries numbered 1.8 million (U.S. Public Health Service, 1990). 

Nearly 10,000 workers are killed on the job each year by traumatic injuries, and almost two-thirds of these (6,900) are workers in urban settings such as construction, manufacturing, transportation, public utilities, service industries, and government (National Safety Council, 1992, p. 38). Six million individuals are injured, and more than 300,000 are made ill each year by workplace hazards (Bureau of Labor Statistics, 1992). As many as 100,000 workers die each year from the long-term effects of occupational diseases (Department of Occupational Safety and Health, AFL-CIO, 1993). 

As noted by Peck, Goldbeck, and Myers (1987), (a) new technologies, including computers, robotics, lasers, etc., that have the potential to displace workers can pose new health threats in the workplace, including stress from forced unemploy- ment or the fear of unemployment, which can be linked to health problems; (b) hazardous substances have potential for negative effects on both workers and communities; (c) certain types of worksettings (e.g., hospitals, construction sites) are more hazardous than others; (d) growth in small businesses and service industries has increased the number of employees without health benefits; (e) violence has increased in the workplace; and (f) worker demographics are changing, with more minorities, women, adolescents, and elderly in the workforce. Among low-income individuals working, for example, in construction and service jobs, injuries and illness may be associated with, or aggravated by, low literacy and/or poor English-communication skills. 

Use of Health Care Services. Corporations have limited control over the quality and increasing costs of health care. Yet they pay for this care for 150 million Americans; in 1990, companies spent more than $3,000 per employee for health care benefits (Health Insurance Association of America, 1990). Corporations will have increasing difficulty absorbing annual increases in health care costs of 20 to 30 percent, an amount representing more than one-half of American companies' pre-tax profits (Herzlinger & Schwartz, 1985). 

The current debate over different strategies for health care reform leaves the future scope of occupational health services unclear. Some believe there will be an expansion of better coordinated primary health care services provided at or near worksites (Bryant, 1991; Burgel, 1992); others believe the future lies in health promotion services and reduced primary care services at worksites (Scofield, 1990). In the 1960s and 1970s, interest in occupational safety and health focused on work-related injury and illness and employers' responsibility for identifying and controlling workplace hazards. In contrast, the 1980s were characterized by a focus on work-related health problems for which primary responsibility was placed on individual workers with emphasis on behavioral change and self-management techniques. These two approaches coexist in most workplaces today independent of each other, resulting in a piecemeal, uncoordinated approach to managing workplace health issues (DeJoy & Southern, 1993). 

Community-Based Strategies. The literature indicates that the companies providing most of the health services at worksites have 50 or more employees and that the larger the company, the greater amount of services offered (U.S. Department of Health and Human Services, 1993). To control direct and indirect health care costs, larger companies are providing onsite primary care for employees and their dependents. The workplace not only offers convenience and accessibility for primary health care delivery, but also provides an opportunity for monitoring outcomes of care (Burgel, 1992). Within these settings, occupational health nurses provide a wide array of comprehensive health and safety services for workers and their families (American Association of Occupational Health Nurses, 1993). 

Current Worksite Strategies

In a study to document the current complex role of occupational health nurses, Lusk, Disch, and Barkauskas (1988) surveyed 173 Fortune 500 companies and found that most of them employed nurses 90 percent employed registered nurses, 61 percent employed safety engineers, 61 percent employed physicians, and 45 percent employed industrial hygienists. The survey described the four most common occupational health nursing activities as (1) supervising the provision of nursing care for job-related emergency and minor illness episodes (90 percent of companies); (2) counseling employees regarding health risks (88 percent); (3) providing case management for employees with workers' compensation claims (67 percent); and (4) performing periodic health assessments (63 percent). 

In this same study, Lusk and colleagues assessed employers' desires regarding future roles of occupational health nurses. Employers' expectations placed greater emphasis on analysis of trends in health promotion and risk education, development of special health programs to meet the needs of corporations, and analysis of health and cost outcomes. 

In a recent statement, the American Association of Occupational Health Nurses (1993) emphasizes that the primary focus of an occupational health nurse is on preventing illnesses and injuries. Worksite nurses are responsible for delivering primary care, ensuring compliance with health and safety regulations, assessing worksite hazards, developing surveillance programs, conducting health promotion and injury prevention programs, and managing workers' compensation claims. 

These worksite-based services have been categorized in the literature as primary, secondary, and tertiary prevention activities (Burgel, 1992; Dalton & Harris, 1991; DeJoy & Southern, 1993; Hoffman, 1993). Using the same definitions for primary, secondary, and tertiary prevention adopted earlier in this report, Hoffman (1993) describes as follows the types of interventions conducted in the workplace. 

Primary prevention interventions include worksite analysis to address potentially hazardous work conditions; health promotion and disease prevention and health education to reduce risk factors; assurance of compliance with local, state, and Federal health and safety regulations, including mandatory Occupational and Safety Health Administration (OSHA) programs for monitoring worksites and providing surveillance; and preplacement evaluations (job matching) designed to place workers in jobs based on physical capabilities. 

Secondary prevention interventions include health surveillance or screening programs to identify real and potential health problems; direct care services or assessment, minor treatment, referral, and coordination of services to injured or ill employees (employer maintains control of care for work-related injuries or illnesses); and employee assistance programs such as crisis-oriented counseling to respond to changes in work performance or for conflict and stress management. 

Tertiary prevention interventions include case management, early intervention, rehabilitation, facilitating return to work, and monitoring of quality and cost of care by the right provider in the right setting. The American Disabilities Act requires reasonable accommodations by the employer so that an otherwise qualified employee can perform the job. 

Outcomes. Efforts have been made to determine health and cost outcomes of occupational health care services. In the area of primary prevention, considerable evidence demonstrates that worksite health promotion programs yield positive changes in employee behavior and health status (Katz & Showstack, 1990). Improved health status is specifically cited in relation to hypertension control, cholesterol reduction, smoking cessation, and increased physical fitness (Fielding, 1984). 

A recent comprehensive review assessing the impact of worksite health promotion programs concluded that such programs can reduce annual health care costs per employee by as much as $865 (Opatz, Chenoweth, & Kaman, 1990). It is therefore not surprising that 81 percent of private worksites with 50 or more employees now offer some form of health promotion. Nor is it surprising that self-insured worksites are more likely to offer onsite wellness programs than are worksites insured through an insurance company (U.S. Department of Health and Human Services, 1993). 

Other attempts have been made to determine the costs and cost effectiveness of worksite health promotion programs. However, in examining 289 articles addressing the economic implications of worksite health promotion programs, Warner, Wickizer, Wolfe, Schildroth, and Samuelson (1988) concluded that (a) much of the literature published through early 1986 provided only anecdotal evidence and (b) the results frequently are suspect due to flawed assumptions and methodology. 

In another study of worksite health promotion programs, researchers found that white employees were 2.47 times more likely to participate in a program than nonwhites (Strange et al., 1991). One of the few minority studies available suggests that one factor contributing to the seemingly low participation of African Americans and Latinos in worksite health promotion programs is the absence of cultural relevance due to the monocultural approaches in many of the current programs (Aguirre-Molina & Molina, 1990). 

In the area of secondary prevention, Conway, Simmons, and Terry (1993) established, through a nationwide survey of occupational health medical surveillance programs, that the likelihood of an industry's having a medical surveillance program increased directly with the size of the company (i.e., the larger the company, the more likely they were to have a surveillance program). The most common component of the medical surveillance programs was a general physical examination before employment and periodic surveillance of employees with existing conditions. Nevertheless, most of the firms surveyed had no systematic methods or procedures for assessing the costs or effectiveness of their medical surveillance programs. 

Another widespread secondary prevention activity is employee assistance programs. The goal of these programs is to provide short-term counseling services to employees who encounter personal problems that might affect their work performance. In a national survey conducted in 1992, nearly all worksites had a formal policy concerning the use of alcohol and other drugs. Forty percent of the worksites surveyed offered an employee assistance program, either directly or indirectly through an outside contractor. One-fourth (26 percent) of the worksites had an employee drug testing program for all their employees, and 14 percent had one for some of their employees (U.S. Department of Health and Human Services, 1993). 

In the area of tertiary prevention, several studies document that an integrated approach to disability prevention, including accident prevention, case management, and return-to-work policies, is most effective in reducing medical claims and wage-loss claims for work-related illnesses and injuries (Dalton & Harris, 1991; DeJoy & Southern, 1993; Scofield & Martin, 1990). 

Most of the research on primary, secondary, and tertiary prevention in the workplace is descriptive and focuses on individual programs rather than integrative or comprehensive approaches linking primary, secondary, and tertiary prevention services. A few examples of systems having demonstrated linkages across the care continuum have been documented (Dalton & Harris, 1991; Scofield & Martin, 1990). In most instances, however, health service programs are fragmented and uncoordinated organizationally, with responsibilities distributed among a company's health service and human resources and safety and hygiene units. 

Given these fragmented individual programs, measuring long-term health care and cost outcomes is difficult if not impossible. Some authors (e.g., Katz & Showstack, 1990) suggest, however, that comprehensive, broad-based program efforts are more likely to be effective in reducing health care costs than single-issue programs in occupational health services. 

Strategies for the Future

Significant changes are occurring in the American workforce. The principal shift is away from a manufacturing-based economy to an economy based on the provision of services. Hazards to exposures in heavy industry, such as those faced by coal workers, may be less important in the future, while hazards associated with office work, such as exposure to video display terminals, or with new synthetic materials and solvents, such as those used in the electronics industry, may become more important. 

In urban areas, the increase in service jobs which often involve more part time and shift work conducted indoors present specific environmental problems, including indoor air pollution, inadequately designed workspaces, and high levels of stress. Specific service jobs which are often filled by ethnic minorities, women, adolescents, elders, and low-income individuals present additional hazards, including violence in the workplace. Some of the hazards associated with service jobs have been documented, but few specific data are available. 

For example, homicide, often occurring among service workers, is the leading cause of occupational death from injury for women and the third leading cause of occupational death among all workers (American Association of Occupational Health Nurses, 1993). Other hazards associated with service jobs include back injuries and exposure to infectious diseases, bloodborne pathogens (e.g., HIV, hepatitis B and C), and needle sticks. 

Most recent empirical work on occupational health care services focuses, first, on health promotion or disease and injury prevention activities; second, on health surveillance and direct care services; and, third, on case management and monitoring of work-related disability effects. An untested but promising approach is suggested by Burgel (1992) who proposes use of nurse-managed primary health care delivery models at or near worksites. She proposes five models to meet the needs of small and large employers in geographically dispersed communities: 

Model #1, with a single nurse onsite, may be the best choice for employers with limited resources, a small workforce, or few workplace hazards. The nurse acts as the inhouse expert on health-related issues and develops a network of quality, community-based referrals for services not provided inhouse. 

Model #2, a multiple-nurse unit onsite, is ideal for employers with a medium-to-large workforce. Essential services are offered onsite in a nurse-managed care center. The focus is on primary care as well as work-related illnesses and injuries. 

Model #3, the consortium, enables groups of employers with a small number of workers to provide services in a centralized, nurse-managed, free-standing clinic. Essential services are provided onsite with expanded hours of service, and a local hospital provides services during off hours through a preferred provider arrangement. 

Model #4, with onsite services (as in model #2) accommodates a large workforce and provides services to neighboring small businesses through contractual arrangement. 

Model #5 offers the services of an occupational health nurse, acting as consultant, to small businesses in geographically scattered locations. This nurse consultant is onsite at each location periodically, providing some direct services and coordinating other services through a local hospital and nearby specialty providers. 

Each model incorporates five criteria essential for providing quality in a cost-conscious environment: (1) quality-provider availability; (2) consumer involvement, with emphasis on prevention and prudent purchase of health care services; (3) use of practice guidelines to assure quality of care; (4) accountability assumed by the providers for the quality of care and costs; and (5) use of a case management system. The development of nurse-managed primary health care delivery strategies at or near the worksite is critical to meeting the health care needs of today's urban worker. These strategies could deliver accessible, quality care to employees and their dependents at a reasonable cost. 

Research Needs and Opportunities 

The agenda for nursing research on community-based health care strategies for urban populations must focus on developing, demonstrating, and assessing innovative nursing-based approaches to preventing disease and functional impairment and to delivering care to multirisk, vulnerable underserved populations. Community-based health care strategies in which nurses and nurse researchers play a leadership role hold promise for reorienting the health care system's traditional focus on acute and curative care to emphasis on the promotion of health and primary, secondary, and tertiary prevention of disease. 

Presented below are research needs and opportunities for research on community-based interventions addressing the health care needs of all urban underserved populations. These populations include low-income individuals and families, ethnic and racial minorities, urban elderly, and urban workers. 

Five general areas of research needs and opportunities are described: descriptive data collection; prevention activities; factors affecting care; comprehensive community-based strategies; and assessing effectiveness. Nurse researchers have an opportunity to play a leadership role in each area, working in tandem with other health care professionals in designing, implementing, and assessing community-based strategies for vulnerable and underserved urban populations. 

Descriptive Data Collection

Defining Populations. A critical issue in defining populations is the ability to identify all members of a defined group, including timely identification of changes in the membership of this group (e.g., births, death, adoptions, marriages, divorces, emigration, immigration, health insurance). Related to this is the need to identify characteristics of individuals in sufficient detail and specificity for determining disease risk, appropriate health care interventions, and care outcomes. 

Representative sample surveys are conducted regularly by the Federal and state governments. However, the design and implementation of these surveys do not always enable researchers to identify basic health status information by appropriate ethnic, age, and other characteristics that can be important identifiers of potential risk. 

Similarly, individual researchers may fail to use up-to-date, culturally sensitive categories in gathering information about these basic identifying characteristics. To make progress in understanding the relative contribution of individual and community or contextual factors to the success of various interventions in urban settings, basic descriptive data are needed on the identifying characteristics of individuals. 

Determining Health Status. The health status, problems, and needs of many urban underserved populations have not been clearly delineated. Descriptive data are needed for many populations before appropriate and effective health care inter- ventions can be designed. Related to this is the need to identify known and potential risk factors for poor health and dysfunction in specific populations, including disease-specific markers of illness severity and progression. These data should reflect the complexity and diversity of urban living for low-income individuals and families, ethnic and racial minorities, elderly persons, and workers. Information also is needed on the outcomes of illnesses and their treatment in order to assess the effectiveness of care. 

In order to conduct appropriate and effective community-based strategies, the knowable risk profile of all members of a target population should be available on a timely basis to the primary health care team charged with designing, conducting, and assessing a primary, secondary, and/or tertiary prevention program for this population. 

Refining Measurement Tools. New measures of ethnic identity, socioeconomic status, and assimilation have been developed but need to be more widely and consistently applied in describing urban populations. In particular, measures of ethnic identity are available which allow researchers to discriminate individuals who identify with more than one group and/or are members of an ethnic subgroup not differentiated separately from a larger category. New measures of socioeconomic status incorporate the realization that, in some racial and ethnic groups, income may not be as important a determinant of status as other variables. 

Prevention Activities

Primary Prevention. Nurse researchers can play an especially important role in primary prevention in urban settings by fostering, guiding, and assessing health education efforts to reduce risk factors associated with disability and death (e.g., violence and substance abuse), health promotion activities (e.g., related to exercise and nutrition), and disease prevention (e.g., immunizations). In these efforts, they can participate in expanding existing programs or developing new intervention programs aimed at modifying health-compromising behaviors of urban underserved populations, including urban racial and ethnic groups and populations in relapse (e.g., drug abusers, smokers), as well as low-income women and children, elderly persons, and workers. 

Cost-effective interventions are especially needed to modify lifelong habits undermining health, such as inactivity, alcohol abuse, physical and psychological abuse, and poor diet. Nurse researchers, in coordination with other health care professionals, can develop comprehensive counseling and education programs to inform clients about long-term health risks. While the medical care system has focused on treatment of advanced, complex disease processes facilitated by a payment system biased toward diagnosed conditions low priority has been placed on disease prevention and health promotion efforts. Nurse researchers can promote attention to these efforts long emphasized by the nursing profession. 

Secondary Prevention. Another promising area of research in urban settings is community-based strategies focused on secondary prevention (early detection of disease and intervention before symptoms appear). Existing programs need to be assessed in terms of their impact, efficacy, and cost effectiveness, and new programs need to be designed and tested. In particular, nurse researchers can bring their unique perspective to the design and evaluation of health surveillance and screening programs targeted to ethnic and racial minorities, low-income women and children, urban elderly, and urban workers. 

Tertiary Prevention. Community-based tertiary prevention strategies for urban populations have received little focus in comparison with primary or secondary prevention. Yet, the need for these strategies, particularly among elderly populations and disabled workers, suggests many opportunities for nursing research. 

With the aim of minimizing the effects of disease or disability and reducing complications or premature deterioration, nurse researchers should seek active roles in designing comprehensive, community-based programs of transition care management, rehabilitation, and care management across the full range of health services. The needs, and the resources available for meeting these needs, will vary across settings and populations. Research is particularly needed to define and test nurse-managed, coordinated strategies for different underserved urban populations. 

Factors Affecting Care

The emphasis in clinical services and research supporting these services has been on actual services delivered and/or the quality of services received. In developing and testing new community-based strategies, attention needs to be given to key factors affecting the care provided and received. 

Availability/Accessibility/Affordability. Three critical factors in the demand for and use of prevention services by urban underserved populations are the availability, accessibility, and costs of these services. Additional research is needed to clarify the dimensions of these factors for vulnerable urban populations, especially racial and ethnic minorities, low-income women and children, and urban elderly. Insurance coverage and awareness of available services are two dimensions noted thus far. New interventions should incorporate the knowledge gained from this research. 

Appropriateness/Adequacy/Acceptability. Use of health care services is also a reflection of whether the services offered are appropriate, adequate, and acceptable to the population(s) for which they are designed. The dimensions of these factors have not been explored sufficiently in specific urban underserved populations. Given nurses' access to these populations through school- and community-based clinics, nurse researchers have an opportunity to shed light on these particular dimensions and to involve community members in their explanation. Two related issues are contextual effects and cultural factors, noted below. 

Contextual Effects. Most interventions in urban settings have been developed to meet unmet needs under specific local conditions with specific vulnerable populations. As these interventions are studied more intensively and/or in different populations, measuring and analyzing relevant contextual effects will be important. The effects of family structure and function, community environment, and available resources are particularly important in both designing and assessing the effectiveness of community-based strategies. 

Cultural Factors. Language barriers, culture-specific beliefs and health practices, the cultural knowledge of professional and lay care providers, and other cultural aspects of community organization reflect the broad diversity of urban environments and influence the assumptions and actions that affect individuals' health status directly or indirectly. Cultural factors have been included in the design and/or analysis of numerous individual studies of urban populations, particularly innovative interventions tested within the U.S. health care system. 

The challenge in expanding research on community-based nursing strategies is to identify and measure cultural factors at all research stages from assessing community needs to planning and designing an intervention, implementing the inter- vention, analyzing and interpreting data, and determining outcomes. Culture is far more than language, and the complexity of understanding culture's contribution to effective care is demonstrated by studies that show that data provided by respondents may differ based on the language of the interview and the cultural similarities of the interviewer and respondent. 

Research is particularly needed on the factors involved in fostering and maintaining a community's "ownership" of the health care services offered. Identifying needs and services for particular populations is no longer sufficient, given the new paradigm of health care adopted by this panel. Increased research to understand communities' endorsement and participation in health-promoting interventions is now required. 

Comprehensive Community-Based Strategies

Community-based studies are needed to further describe the health status, health behavior, and barriers to health care among vulnerable and underserved urban populations; to establish culturally specific health promotion, disease prevention, and treatment strategies in community settings; and to demonstrate new ways of recruiting and sustaining the involvement of underserved populations in community-based health promotion activities. Such studies will also be useful in identifying criteria for selecting organizations with which nurse researchers can collaborate on prevention activities. 

Defining a Community. As suggested in this chapter, an urban underserved community may consist of a particular ethnic or racial population or subgroup, a group or subset of low-income women and/or children, urban elderly residing in a given area or participating in a senior-citizen center or day-care facility, or workers in a company or at a worksite. The variables defining a community need to be explored and the findings applied in the design and evaluation of community-based strategies. As noted previously, for example, the target community for strategies for low-income children in some population groups may extend beyond the children's immediate family to include extended families or nonfamily members. 

Involving the Community. Special efforts are needed to uncover innovative ways to encourage community members' involvement and participation in assessing the health care needs of their community and in designing programs to address these needs. For urban settings, these efforts must necessarily take into account socioeconomic, cultural, and related contextual factors influencing members' involvement and participation. The extent to which this involvement actually occurs also needs to be evaluated. 

Integrating Services. Comprehensive community-based strategies offer potential for integrating primary, secondary, and tertiary prevention services and providing a continuum of care for urban underserved populations. This integration of services across a spectrum of care promises great benefit in improving the health awareness and health status of these populations. Strategies could include public-private partnerships among managed care organizations, state and local health departments, and public and private health programs focused on disease prevention, health promotion, and management of chronic illness. In constructing these strategies for urban populations, special attention must be given to the multiple health risks, including environmental risks, faced by urban underserved populations; the mix of behavioral and biological factors contributing to these health risks; and the need for an interdisciplinary approach incorporating the experience, skills, and techniques of all the health care professionals involved. 

Assessing Effectiveness

Community-based systems bring health care out of the hospitals into the communities served by these hospitals. A variety of approaches are used in urban settings, including community health centers, nurse-managed clinics, home visitation, and educational and other outreach programs. The benefits to individual users suggest promising results (McElmurry et al., 1991; Olds, Henderson, Tatelbaum, & Chamberlin, 1988). 

Equally important are the benefits to professional health care providers who can engage the participants in community-based programs as research partners for identifying the health care problems, and possible solutions to these problems, for urban underserved populations. In addition, the ensuing dialogue between urban communities and health care providers has been credited with fostering a sense of community empowerment (e.g., through collective decision making) that can be focused on numerous problems other than simply health care (McElmurry et al., 1990, 1991). 

Reports highlighting the impact of community-based health care strategies demonstrate the benefit of working within community-based settings and within settings that play a strong role in the life of a community. However, health disparities and barriers to accessing health care continue to persist even for populations (e.g., African Americans) whose health status and health dilemmas have been well described and for which successful strategies of care have been documented (Brooks et al., 1991). 

Few researchers have attempted to describe the characteristics of community-based health care settings deemed to be essential to developing successful community-based health care strategies (Hatch et al., 1993; Michielutte & Beal, 1990). Identification of these critical indicators, however, is important for the populations in need and for professionals attempting to identify and select organizations or settings for collaboration in delivering community-based health promotion, disease prevention, and treatment services. 

In addition, few reports compare the impact of community-based health care strategies across various points of access, and few studies compare the effectiveness and efficiency of specific community-based strategies targeted to different popu- lations (Lewin-Epstein, 1991; McBride, 1993; Sullivan, 1992). Similarly, the degree to which community-based strategies help reduce society's health care burden and improve the health of different populations has not been determined. 

Research is particularly needed to establish the impact, efficacy, and cost effectiveness of culturally specific health promotion, disease prevention, and treatment strategies in community settings. Systematic comparative studies are needed to assess existing community-based strategies, including both focused and comprehensive interventions, to define the characteristics of successful interventions. 

Such studies should include measurement of the influence of community involvement on changes in the health status of community members. Methods need to be developed for monitoring the actual extent to which community members are fully invested and involved in defining health needs, developing interventions, and assessing their effectiveness. All these variables and methods then need to be incorporated into the design and evaluation of new interventions. 

Recommendations

Based on the foregoing assessment of the state of the science and research needs and opportunities for community-based health care strategies in urban settings, the panel offers the following recommendations for future research. The overall goal of these recommendations is to identify and test models for improving the health of target populations. The recommendations may apply to rural settings as well. 

Develop and test innovative community-based strategies for health care, including public-private partnerships among managed care organizations, state and local health departments, and public and private health programs that focus on disease prevention and health promotion and management of chronic illness in vulnerable and underserved urban popula- tions. 

Develop and test screening tools for identifying urban populations that are vulnerable to health problems requiring intervention and health status monitoring. 

Determine the impact of various care management strategies, including managed care, on outcomes and costs for at-risk individuals, families, and defined populations across various types of urban community settings. 

Develop culturally relevant measures of individual, family, and community functioning which are appropriate for community-based studies. 

Develop and test culturally relevant measures of clinical and cost outcomes of community-based interventions. Examine the impact of cultural factors on use and outcomes of community-based programs. 

Develop and test community-based strategies that actively seek and have consumer participation in the design, conduct, and evaluation of health services. Develop and test measures of the extent and effect of community representation on meeting the goals and objectives of community models being evaluated. 

Design studies of community-based health care strategies, including managed care, that are of sufficiently large enough scale to enable analysis of the relative contribution of individual, family, and community characteristics and of intervention(s) to clinical and cost outcomes. 

Describe factors associated with successful outcomes of community-based care strategies targeted to vulnerable and underserved urban populations. 

Develop and test classification systems for health problems and interventions that are sensitive to cultural differences. 

Develop and test strategies, such as disease registries, within communities as a basis for implementing and testing "safety net" programs in secondary and tertiary prevention. 

Develop and test alternative primary care strategies that integrate delivery of acute, ambulatory, and long-term care for vulnerable populations such as frail elderly. 

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