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Maternal Outcomes of a Randomized Controlled Trial of a Community-Based Support Program for Families of Children With Chronic Illnesses
Henry T. Ireys, PhD;
Robin Chernoff, MD;
Katherine A. DeVet, PhD;
Young Kim, PhD
Arch Pediatr Adolesc Med. 2001;155:771-777.
ABSTRACT
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Background Parents of children with chronic illnesses are at high risk for secondary
mental health problems, such as anxiety and depression.
Objective To evaluate maternal outcomes of a support intervention for families
of children with selected chronic illnesses.
Design A randomized controlled clinical trial design with repeated measures
1 year apart.
Setting A community-based family support intervention linked to subspecialty
and general pediatric clinics and practices in a metropolitan area.
Participants A population-based sample of 193 mothers of children aged 7 to 11 years;
the children were diagnosed as having diabetes, sickle cell anemia, cystic
fibrosis, or moderate to severe asthma. About 15% of the persons contacted
refused to participate in the research, and 14% of the families were lost
to follow-up.
Intervention The 15-month intervention, the Family-to-Family Network, was designed
to enhance mothers' mental health by linking mothers of school-aged children
with selected chronic illnesses with mothers of older children with the same
condition. The program included telephone contacts, face-to-face visits, and
special family events.
Main Outcome Measures Beck Depression Inventory score and the Psychiatric Symptom Index.
Results Maternal anxiety scores for participants in the experimental group decreased
during the intervention period for all diagnostic groups and for the total
group; scores for the control group increased (F = 5.07, P = .03). In multiple regression analyses, the intervention group was
a significant predictor of posttest anxiety scores (P
= .03). Effects were greater for mothers with high baseline anxiety (P<.001) and for those who were themselves in poor health
(P<.01).
Conclusions A family support intervention can have beneficial effects on the mental
health status of mothers of children with chronic illnesses. This type of
intervention can be implemented in diverse pediatric settings.
INTRODUCTION
BETWEEN 10 and 13 million children in the United States have a chronic
health condition.1, 2 Three decades
of epidemiological and clinic-based studies3, 4, 5
indicate that their primary guardians, still largely their mothers, are at
risk for secondary mental health problems. For clinicians, parental mental
health can be critical in managing the child's medical treatment.
Despite extensive documentation of heightened mental health risk for
caregivers, few theory-driven interventions to reduce this risk have been
implemented and evaluated with methodologically strong designs.6
In this report, we present parent outcomes of a randomized, controlled, clinical
trial of a 15-month family support intervention for school-aged children with
1 of 4 chronic illnesses (diabetes, sickle cell anemia, cystic fibrosis, or
moderate to severe asthma) and their mothers. Although we focused on 4 conditions,
the support intervention was conceptualized and structured so that it can
be provided to families of children who have any chronic condition. The evaluation,
however, was designed deliberately to be generic; the same mental health measures
were used for all mothers and children, regardless of diagnosis. This design
feature (a disease-specific intervention with a generic evaluation) allowed
us to assess the effects of a program that could be implemented feasibly within
pediatric subspecialty clinics and to do so with a sample size that would
permit a robust test of the treatment. This report describes key attributes
of the program and its evaluation.6, 7, 8
THE PROGRAM AND ITS THEORETICAL FRAMEWORK
Our program, the Family-to-Family Network, was designed to enhance (a) mothers' perceived availability of social support by
linking mothers of school-aged children with selected chronic illnesses with
"veteran" or "experienced" mothers whose similarly affected child has become
a young adult and (b) the children's self-esteem.
(Specific intervention variables and outcomes for the child are reported elsewhere.)
(R.C., H.T.I., K.A.D., Y.K., unpublished data, 2000) The program integrated
2 complementary mutually reinforcing components under a standard intervention
protocol. One component involved the experienced mothers, who referred to
themselves as "Network Mothers" (NMs). The other component involved a child
life specialist (CLS) who met and talked primarily with the child. Thus, each
family in the Family-to-Family Network had a 2-person intervention team assigned
for the 15-month duration of the program.
In developing the program, we incorporated design elements from previous
work4, 9, 10, 11
and added new elements based on clinical and conceptual considerations.12 We focused on enhancing social support because of
evidence linking availability of support for parents to their general well-being.13, 14, 15 Social support, defined as information leading people to believe that
they are esteemed and valued and that they belong to a network of mutual obligations,16 can be provided by grafting a strategically selected
veteran into a mother's existing support network.17
This person can communicate support based on similarity in experience, self-disclosure,
and a sense of optimism.18 In turn, this support
can help families to address practical problems and manage stressors associated
with raising a child with a chronic illness.
The program protocol specified that, during the program period, each
NM would (a) make 7 visits of 60 to 90 minutes to
each assigned family, either alone or with the CLS, either in the family's
home or, if the mother so requested, at nearby coffee shops; (b) have biweekly telephone contacts of at least 5 minutes to build
and maintain support, follow up on issues discussed previously, or plan future
meetings; and (c) participate in 3 special events,
such as bowling parties or small-group lunches, that would allow program parents
to meet each other in a nonstressful venue. The intervention was provided
to 2 separate but overlapping cohorts from May 4, 1996, to January 31, 1999.
The NMs were recruited by asking directors and staff of specialty clinics
to nominate potentially suitable mothers whose affected child was aged 18
years or older. A total of 106 women were nominated. Of these, 39 joined our
30-hour training program, for which they were paid at an hourly rate. This
training focused on enhancing skills in listening, reflecting, and "story
swapping." Role plays, videotaped interviews, and in-class practice interviews
were used. We invited successful "graduates" of the training program to participate
in the Family-to-Family Network as NMs. These persons then underwent an additional
20 hours of training along with the CLS to reinforce the team aspects of the
program and to review operational procedures. Overall, 18 women worked as
NMs for the Family-to-Family Network. Each NM had from 1 to 7 assigned families
and was paid hourly for all program-related efforts. Three CLSs were employed
in half-time positions.
Team assignments to enrolled parents were made based on diagnosis (parents
with children who had the same condition were linked) and, to the extent possible,
geographic proximity. After assignments were made, the NMs contacted the parents
and the program began. The NMs and CLSs all met together weekly with a pediatrician
(R.C.) and a social worker to ensure that the intervention was being delivered
as planned to the greatest extent possible. These meetings served to coordinate
efforts within and across teams, address ongoing problems, and review issues
related to recent or upcoming contacts or special events. The NMs and the
CLSs coordinated their efforts with each family and were in regular telephone
contact to exchange information from individual visits and telephone calls.
Additional program details can be found in a manual available from one of
us (H.T.I.).
The objective of the intervention was to decrease maternal risk for
symptoms of anxiety and depression. The NMs were trained to provide 3 specific
types of support.19, 20, 21
Informational support was provided by linking families with existing health
and community resources and by sharing information among mothers about child
behavior, parenting, and coping; this type of support was enhanced when the
NM acted as a link to put mothers in contact with existing services (eg, housing
or educational assistance). The NM provided affirmational support by enhancing
a mother's confidence in parenting and by reassuring her that her concerns
and issues were appropriate. Specifically, the NM identified the mother's
special competencies and provided feedback about those skills that contribute
to positive self-evaluation. The NM also provided emotional support by being
available to listen to a parent's concerns, demonstrating a continued interest
in the mother's viewpoints and experiences, and effectively communicating
an understanding of the mother's feelings and concerns. Throughout the intervention,
the NM aimed to (1) identify naturally occurring sources of support, (2) point
out examples of effective parenting by the mother, and (3) discuss opportunities
for strengthening these sources of support and existing parenting skills.
All parent-related program activities were guided by concepts drawn from 4
areas (social support concepts, theories of reactions to offers of aid, concepts
of empowerment, and social comparison processes) and by specific assumptions
about phases in relationships between the NMs and their assigned parents (introduction,
rapport building, maintaining contact, and termination). Our manual provides
additional information about the program's conceptual framework.
CONTROL GROUP PROGRAM
The program offered to the control group was designed to reflect a common
clinical practice in many subspecialty clinics, where the physician gives
a mother the name of another parent to call should she need support or information.
The mothers randomly assigned to our control group were given a telephone
number through which they could reach an experienced parent if they so wanted.
This experienced parent did not go through any training and did not initiate
telephone calls. Conceptually, this procedure yields a low-dose control group.
Less than 3% of mothers (n = 2) assigned to the control group called this
number.
SPECIFIC HYPOTHESES
We hypothesized that, controlling for baseline status and other key
factors (eg, maternal health status), parents in the experimental group would
report at the end of the intervention fewer psychological symptoms compared
with parents in the control group. To determine whether the intervention had
differential effects on particular subgroups, we tested hypotheses that the
intervention would have particularly positive effects for mothers with elevated
baseline levels of anxiety, depression, or stressful life events. We examined
stressful life events because a previous project had found this factor to
be an important effect moderator for a similar intervention.4
PARTICIPANTS AND METHODS
SAMPLE IDENTIFICATION
Potential participants were identified by 11 specialty clinics and 5
general pediatric clinics in the Baltimore, Md, area. An effort was made to
recruit every potentially eligible family on clinic or practice rosters. Participants
were eligible if they lived within an 80-km radius of Baltimore, they had
a telephone, a woman was the primary caregiver and the child lived with her,
the child was aged 7 to 11 years, the child did not have mental retardation,
the diagnosis was made at least 6 months before recruitment, and the family
spoke English. In addition, to enroll only children with moderate to severe
asthma, the following criteria for eligibility were used: (1) daily medication,
(2) wheezing 2 to 3 times per week, or (3) at least 1 hospital or emergency
department visit in the past 6 months.22
RECRUITMENT AND DATA COLLECTION PROCEDURES
After potential participants were identified, a letter was sent by the
clinic director or pediatrician to the families describing longitudinal research
involving families of children with chronic illness, inviting them to participate
if they wanted, and noting that someone would call them to explain the project
in detail. The letter stressed that participation was voluntary.
If families agreed to participate during the follow-up telephone call,
appointments were made for interviewers to come to the family's home (or to
meet at the clinic if the parent so desired) for the interviews. Data were
collected by 45- to 90-minute, face-to-face, structured interviews at baseline
and at 12 months postbaseline and by 15- to 20-minute telephone interviews
at 4, 8, and 16 months postbaseline. At each face-to-face interview, mothers
were paid $20 for their time. Mothers received $15 after completing the set
of telephone interviews. Interviews were completed by paid interviewers who
had undergone extensive training and were blind to group assignment. Posttest
questions pertaining to group assignment (eg, questions about the relationship
with the NM) were asked only after all other parts of the interview were complete.
Each completed interview was reviewed by one of us (H.T.I. or K.A.D.) to identify
interviewer error or need for follow-up. Informed consent statements pertaining
to the research project were signed at the initial interview. All procedures
were approved by relevant institutional review boards.
ASSIGNMENT-TO-GROUP PROCEDURES
In the recruitment letter and follow-up telephone call, participants
were invited to join a longitudinal research study examining the lives of
families raising children with chronic illnesses. No mention was made of intervention
programs until the end of the baseline interview, at which time the interviewer
described the experimental and control programs. The interviewer explained
that the mother had the opportunity to put her name "in a hat" and that families
would be drawn by chance and assigned to one of the programs. The interviewer
emphasized that the mother could still participate in the research interviews
regardless of whether the mother decided to put her name in the hat. This
design allowed us to identify characteristics of program nonparticipants or
"nonjoiners" (those who would participate in the research but not in the intervention).
These families continued to be followed up for research interviews. Conceptually,
this is an important group to follow up because in almost every community-based
program there will be some eligible individuals who will not want to participate;
it is helpful to know whether this subgroup is psychologically better, worse,
or no different from those who do participate. Our design sheds light on this
question.23
Families who agreed to be randomized (who put their names in the hat)
were randomly assigned by a project investigator (K.A.D.) to experimental
or control groups within clinics using blocks of 4 cells (eg, experimental-control-control-experimental
or control-experimental-control-experimental). This method ensured that an
approximately equal number of families from each clinic would be assigned
to the experimental and control conditions. Mothers were sent letters informing
them of their group assignment and, if appropriate, the name of their NM and
CLS. Network Mother-CLS teams were informed of assignments at their weekly
meetings.
RECRUITMENT OUTCOMES AND THE FINAL STUDY SAMPLE
As Figure 1 illustrates, 565
letters were sent to patients, inviting them to participate in the study.
One hundred seventy-four (31%) were unable to be contacted and 115 (20%) were
ineligible (outside the geographic area, mental retardation, language difficulties,
or asthma severity criteria). Fifty-seven (10%) refused to participate and
26 (5%) were unable to be scheduled for an interview within the interview
period. One hundred ninety-three interviews were completed.
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Figure 1. Study design. T1 indicates baseline;
T2, 12 months postbaseline.
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Of the 193 mothers who were eligible for randomization at baseline,
32 (17%) refused to be randomized. These mothers, compared with their counterparts
who agreed to participate in one of the programs, reported more confidence,
more support, and less depression.23 Other
differences between the refused randomization group and the experimental and
the control groups are described in detail elsewhere.23
For this report, we excluded data from mothers who refused to be randomized.
These data were excluded because we undertook an intent-to-treat analysis
of program effects. There was no intention to treat this subgroup because
they declined the opportunity to be randomized to either program; thus, they
represent a subgroup of persons who would not be exposed to the intervention
by their own choice. Excluding this subgroup accomplishes 2 purposes. First,
the remaining sample approximates more accurately the population that would
participate in the program if it were implemented widely. Second, it allows
for a fairer test of intervention effects because these effects will not be
diluted by persons disinterested in participating.
Of the remaining 161 families, 86 were randomly assigned to the experimental
group and 75 to the control group. No differences on demographic, condition-related,
or mental health variables were found between the experimental and the control
groups at baseline. A total of 22 families were lost to follow-up, with no
difference in attrition between experimental (13 families [15%]) and control
(9 families [12%]) groups. Compared with families who completed interviews
12 months postbaseline, families lost to follow-up were more likely to be
on welfare; no other statistically significant differences were found.
For evaluating program effects, we used data from 139 mothers. Diagnostic
and selected demographic characteristics of this sample are shown in Table 1.
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Table 1. Selected Diagnostic and Demographic Characteristics of the
Study Sample
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MEASURES
The structured questionnaire included items used in previous studies4, 9, 10 to collect demographic
data and information related to the child's diagnosis, health status, and
functioning. Maternal physical health was assessed with the following item:
"Compared to other people your age, would you say that your health is excellent,
very good, good, fair, or poor?" For some analyses, we dichotomized this variable
to define 2 groups: those who said that their health was excellent or very
good and those who said that their health was good, fair, or poor.
Maternal anxiety was measured by the 11-item anxiety subscale of the
Psychiatric Symptom Index (PSI).24 The PSI
has been used in several similar studies.4, 9, 10
One of its subscales pertains to anxiety.  Coefficients for the 11-item
anxiety subscale have ranged from .85 to .91.9, 24
Psychiatric Symptom Index subscale scores are standardized; their possible
range is from 0 to 100.
Maternal depression was assessed by the 21-item Beck Depression Inventory.25 Each item describes a specific behavioral manifestation
of depression and consists of a graded series of evaluative statements ranked
from neutral to maximum severity. Studies26
have yielded split-half reliability coefficients of 0.86 and validity estimates
ranging from 0.59 to 0.68.
Stressful life events were assessed with items from the Psychiatric
Epidemiology Research Interview Life Events Scale.27
The list of events was developed from surveys of events actually experienced
by diverse populations, and represents stressors in various domains such as
school, work, and family. This scale has been used in evaluating a similar
intervention that was found to be relatively more effective for parents reporting
many negative life events.4
We measured "dose" of intervention in 2 ways: number of contact minutes
between families and their intervention team and overall ratings by the CLSs
of the extent to which families were involved in the program.
ANALYTIC PLAN
First, using t tests, we examined whether the
experimental and control groups were comparable at baseline to check the results
of randomization. Second, using analyses of variance, we examined whether
maternal mental health outcomes varied by intervention group and baseline
maternal characteristics (eg, baseline anxiety level or their own physical
health status). Third, we assessed the effect of the intervention on anxiety
and depression using multiple regression models. We used stepwise multivariate
analyses, first with selected covariates measured at baseline (including baseline
anxiety scores) and then with selected interactions.
RESULTS
Table 2 shows baseline and
postintervention mean scores on the PSI anxiety subscale for the experimental
and control groups by diagnosis and for the total sample. These data indicate
that participants in the experimental group reported lower levels of anxiety
postintervention compared with baseline scores; mean anxiety scores decreased
in each diagnostic group. In contrast, participants in the control group reported
higher levels of anxiety 1 year after baseline; increases occurred across
all diagnostic groups. Analyses of variance indicated that the intervention
had a significant main effect (F = 5.07, P = .03).
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Table 2. Mean T1 and T2 PSI Scores for Anxiety by Diagnosis and Intervention
Group*
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Bivariate analyses suggested that the intervention's effect was especially
pronounced for mothers who were highly anxious at baseline. Figure 2 illustrates this finding. We compared the decrease in anxiety
scores between experimental group and control group mothers whose anxiety
scores were above the overall group mean at baseline (which is equivalent
to the mean anxiety score plus 1 SD in the normative sample).24
Mean anxiety scores for the highly anxious experimental group mothers decreased
from 33.3 at baseline to 26.4 at 12 months postbaseline; mean scores for the
highly anxious control group mothers remained unchanged during this period
(31.9 vs 31.6). Mean anxiety scores for the low-anxiety experimental group
mothers increased slightly from 10.5 at baseline to 11.1 at 12 months postbaseline;
in contrast, mean scores for the low-anxiety control group mothers increased
substantially from 9.9 to 14.1 during this period. This pattern cannot be
explained by overall regression to the mean because of the differential effects
across the groups.
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Figure 2. Effects of the intervention on
posttest anxiety by maternal baseline anxiety (A) and physical health status
(B). PSI indicates Psychiatric Symptom Index; E, experimental; T1, baseline;
and C, control.
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Maternal physical health at baseline also was an important factor in
determining effects of the intervention, as Figure 2 illustrates. The mean anxiety score for experimental group
mothers who reported that they were in good, fair, or poor health at baseline
decreased from 26.4 to 23.9 during the intervention period; in contrast, the
mean anxiety score for the control group mothers who reported being in good,
fair, or poor health at baseline increased from 24.8 (baseline) to 26.5 (12
months postbaseline). Experimental group mothers who said that they were in
very good or excellent health also showed a decrease in anxiety (from 13.4
to 11.5); in contrast, control group mothers in very good or excellent health
reported an increase in anxiety during this period (from 15.2 to 17.9).
Results of multivariate analyses of these main and interaction effects
on PSI anxiety scores are shown in Table
3. In step 1, we introduced only the intervention group variable
and found that its effect on anxiety scores was marginally significant. After
controlling for baseline anxiety, however, the effect of the intervention
group became significant, as indicated in step 2. This result suggests that
the intervention was successful in reducing anxiety in those who were assigned
to the experimental group. We also examined the effects of the interactions
illustrated in Figure 2, as shown
in the third step of our multivariate analysis. Both interactions have significant
effects. In these analyses, baseline anxiety was entered as a continuous variable.
Maternal health also has a main effect, indicating that mothers who reported
that they were in good, fair, or poor health benefited particularly from the
intervention.
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Table 3. Standardized ß Coefficients From Hierarchical Regression
Predicting the Posttest PSI Anxiety Score*
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The intervention had no demonstrable effect on symptoms of depression,
as reported on the Beck Depression Inventory, possibly because mothers in
the sample reported unexpectedly low levels of depressive symptoms compared
with other studies of this population using the same or similar instruments.
It is unclear why depressive symptoms are low in this sample.
We found no support for differential effects depending on the number
of stressful life events as reported by the mother and no support for a dose-response
relationship.
COMMENT
Our results demonstrate the effectiveness of a family support intervention
in reducing symptoms of anxiety in mothers of children with selected chronic
health conditions. The intervention had a similar effect across diagnostic
groups, suggesting that it could be effective for mothers of children with
other chronic illnesses. The intervention may be especially salient for mothers
who are anxious or who themselves are in poor health.
Several features of this study enhance confidence in its results. First,
the randomized trial design is a rigorous method for program evaluation. Second,
excluding nonjoiners from an intent-to-treat analysis avoids dilution of program
effects. Third, the program was implemented in a disease-specific manner while
the evaluation was conducted at a generic level, thus increasing the power
to detect true differences without diminishing clinical relevance. Fourth,
the control group was designed to reflect practices in many sites. Finally,
we randomized within recruitment site to avoid potential site-specific biases.
Our findings are consistent with other evaluations of similar interventions
for mothers of children with chronic illnesses. In a sample of 343 inner-city
mothers of children with a wider range of chronic illnesses, Silver and colleagues4 reported a decrease in experimental group PSI anxiety
scores from 21.4 to 19.4; the control group showed no change (scores decreased
from 17.6 to 17.3). In a sample of 42 mothers of children with arthritis,
Ireys and colleagues9 reported a decrease in
experimental group PSI anxiety scores from 16.9 to 11.6; the control group
showed no change (scores increased from 15.3 to 15.6). In neither study were
the changes statistically significant. However, these 2 studies combined with
the study reported herein provide compelling evidence that family support
interventions do have positive effects on maternal anxiety.
Does a mean change of 2 to 3 points on the PSI anxiety subscale have
clinical significance? In effect, this change means that most mothers in the
experimental group reported some reduction in frequency of feelings related
to anxiety. The normative score for the anxiety subscale, as reported by Ilfeld,24 is 7. Although these normative data are somewhat
old, they suggest that most mothers in our sample and in similar samples from
prior studies have more frequent feelings of anxiety than do the population
as a whole. However, no clinical cut points have been established for the
PSI and none of the mothers reported that they had been diagnosed as having
an anxiety disorder. It is our clinical impression that mothers of children
with chronic conditions spend a great deal of time worrying about their children's
health and the quality of their children's health care services. It is quite
plausible that this worry translates into more than occasional feelings of
"having an upset stomach," "feeling tense or keyed up," or "feeling nervous
or shaky inside," all of which are items included on the PSI. If our intervention
has reduced the frequency of these feelings for most of the mothers in our
high-risk but not clinically diagnosable sample, then we believe the intervention
has had meaningful effects.
We anticipated that the intervention would decrease symptoms of maternal
depression, but found no evidence for this effect. One reason for this result
may be the relatively low baseline level of depressive symptoms reported by
this sample of mothers, which would have been difficult to reduce further
with any kind of support program. In addition, our sample may not have included
mothers with elevated levels of depressive symptoms if these mothers selectively
excluded themselves from the study. The possibility of selection bias in trials
of community-based interventions with high-risk families should be explored
more fully in future studies.
The study has several limitations. Despite extensive recruitment efforts,
our sample may not be representative of the broader population of families
of children with chronic health problems. Resources unfortunately precluded
assessment of the mental health of fathers, an important dimension for inclusion
in future studies. We also are unable to determine mechanisms of effects.
For example, measurement of available resources (eg, social support) was limited
to a few items; as a result, we may have missed measuring critical pathways
by which the intervention had its effect. Finally, in the medical world of
the early 21st century, success is often measured by reduction in use or cost
of services. Using this metric, our intervention remains untested.
This study underscores the value of family support programs for parents
of children with special health care needs. In the more than 10 million American
families who have a child with a chronic health condition, there are many
parents who are worried about their children's well-being.5, 28, 29
Most parents of these children are well aware of the profound effects that
chronic and disabling conditions can have on quality of life. As a result,
many of these parents bring their worries to the attention of their physicians.
The availability of a well-designed family-to-family support program offers
physicians and other clinicians a referral that promises to have important
psychological benefits for mothers.
AUTHOR INFORMATION
What This Study Adds
Epidemiological and clinic-based studies indicate that mothers of children
with chronic illnesses are at risk for secondary mental health problems. Despite
this finding, few theory-driven interventions to reduce this risk have been
implemented and evaluated with methodologically strong designs.
In this report, we present parent outcomes of a randomized controlled
clinical trial of a 15-month, community-based, family support intervention
for school-aged children with 1 of 4 chronic illnesses (diabetes, sickle cell
anemia, cystic fibrosis, or moderate to severe asthma) and their mothers.
Our results demonstrate that the intervention reduced mothers' symptoms of
anxiety. The availability of a well-designed family-to-family support program
offers pediatricians a referral that promises to have important psychological
benefits for mothers.
Accepted for publication January 22, 2001.
This study was supported by grant MCJ-240804 from the Maternal and Child
Health Bureau, US Department of Health and Human Services, Rockville, Md.
We thank the pediatricians, project interviewers, and families who graciously
participated in this effort; Miye Schakne, Beverly B. Walsh, PhD, Ruth E.
K. Stein, MD, Susan Radius, PhD, Laurie Bauman, PhD, and the program's 3 child
life specialists, Erin Munn, Marcy Widener, and Gina Fortunato, who are pioneers
in their field; and the Network Mothers for their commitment, caring, and
enthusiasm, which made the program work.
From the Department of Population and Family Health Sciences, School
of Hygiene and Public Health (Drs Ireys, DeVet, and Kim), and the Department
of Pediatrics, School of Medicine (Dr Chernoff), The Johns Hopkins University,
Baltimore, Md. Dr Ireys is now with Mathematica Policy Research, Inc, Washington,
DC.
Corresponding author and reprints: Henry T. Ireys, PhD, Mathematica
Policy Research, Inc, 600 Maryland Ave SW, Suite 550, Washington, DC 20024-2512
(e-mail: hlreys{at}mathematica-mpr.com).
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