Educational Technology-Benefits and Barriers

Statement of Problem: The second background paper for the Medical School Objective Project (MSOP), defined Educational Technology (ET) as the use of information technology to facilitate student’s learning.1 Medical schools as a group have made limited progress in accomplishing the recommended educational technology goals and there had been much greater use of such technology in basic sciences courses than in clinical clerkships. We will explore the positive and negative implications of incorporating ET into the educational experience of TMC schools. [See PDF for complete abstract]

Progenitor cell therapies for traumatic brain injury: barriers and opportunities in translation.

Traumatic brain injury (TBI) directly affects nearly 1.5 million new patients per year in the USA, adding to the almost 6 million cases in patients who are permanently affected by the irreversible physical, cognitive and psychosocial deficits from a prior injury. Adult stem cell therapy has shown preliminary promise as an option for treatment, much of which is limited currently to supportive care. Preclinical research focused on cell therapy has grown significantly over the last decade. One of the challenges in the translation of this burgeoning field is interpretation of the promising experimental results obtained from a variety of cell types, injury models and techniques. Although these variables can become barriers to a collective understanding and to evidence-based translation, they provide crucial information that, when correctly placed, offers the opportunity for discovery. Here, we review the preclinical evidence that is currently guiding the translation of adult stem cell therapy for TBI.

Commentary on "A Needs Assessment Examining Low-Income Fathers’ Barriers to Participation in Parenting Programs"

The article provides insight on issues serving as barriers to low-income fathers' involvement with their children and with parenting programs.

Low-Income Fathers’ Barriers to Participation in Family and Parenting Programs

This exploratory study used semi-structured focus groups to examine: 1) where and from whom fathers obtain information about parenting; 2) the types of parenting services men are aware of, and their attitudes about participating in such services; and 3) fathers’ perceived norms about the acceptability and utility of various parenting practices. Low-income men (N = 17) were recruited from a human services agency in Detroit, Michigan. Four major themes emerged. First was the need for male-focused community resources for fathers. Second was that men were aware of and used positive disciplinary strategies. Third was emphasis on fathers’ positive and effective communication, with male children in particular. Finally, men suggested that constructive and concrete activities, such as engaging with children in activities or mentorship programs with other adult men in the community, were preferable to traditional parenting class such as those offered through Child Protective Services.

Tolerance of allografts across MHC barriers by allochimeric class I MHC proteins

Class I MHC proteins have been shown to induce accelerated rejection or prolong survival of allografts in various experimental models. These immunological effects have been attributed to the highly polymorphic alpha helical regions of the extracellular portions of the class I MHC molecule. The present experiments were designed to elucidate the immunomodulatory effects of these polymorphic regions and delineate the mechanisms involved. Soluble allochimeric class I MHC proteins were produced by substituting the PVG class I MHC RT1.Ac amino acid residues within the a 1 helical region with those of the donor BN ( a 1hn-RT1.Ac), the a 2 helical region of BN ( a 2hn-RT1.Ac), and both the a 1 and a 2 helical regions (RT1.An). The class I MHC proteins were produced in an E. coli protein expression system. The a 2hn-RT1.Ac and RT1.An proteins, when administered subcutaneously into PVG hosts 7 days prior to transplantation, resulted in accelerated rejection of BN cardiac allografts. The a 1hn-RT1.Ac construct did not demonstrate such immunogenic effects. Intra-portal administration of a 1hn-RT1.Ac or RT1.An, in combination with perioperative CsA, induced tolerance to BN cardiac allografts. The a 1hn-RT1.Ac protein was able to induce tolerance in a larger majority of the PVG recipients and at a lower dose of protein when compared to the RT1.An protein. RT1.An administered orally to PVG recipients also induced long term survival of cardiac allografts. In vitro analysis revealed that lymphocytes from tolerant hosts were hyporesponsive to donor splenocytes, but responsive to 3rd party splenocytes. Evaluation of T cell cytokine expression patterns revealed that rejector PVG hosts displayed a Type I T-cell response when re-challenged with donor splenocytes, in contrast to tolerant animals that displayed a Type II T-cell response. FACS analysis of the T cells revealed that the ratio of CD4 to CD8 cells was 3:1 and was consistent in the groups tested suggesting a complex interaction between the subsets of T cells, yielding the observed results. Histologic analysis of the cardiac allografts revealed that tolerant PVG hosts maintained BN cardiac allografts without any evidence of acute or chronic rejection after 300 days post transplant. This body of work has demonstrated that the use of soluble donor/recipient allochimeric class I MHC proteins with a short peri-operative course of CsA resulted in transplant tolerance. This treatment regimen proffers a clinically relevant approach to the induction of tolerance across MHC barriers. ^

Barriers and facilitators to nurses' acceptance of and implications for injury rates of an IV catheter safety device

This study has the purpose of determining the barriers and facilitators to nurses' acceptance of the Johnson and Johnson Protectiv®* Plus IV catheter safety needle device and implications for needlestick injuries at St. Luke's Episcopal Hospital, Houston, Texas. A one-time cross-sectional survey of 620 responding nurses was conducted by this researcher during December, 2000. The study objectives were to: (1) describe the perceived (a) organizational and individual barriers and facilitators and (b) acceptance of implementation of the IV catheter device; (2) examine the relative importance of these predictors; (3) describe (a) perceived changes in needlestick injuries after implementation of the device; (b) the reported incidence of injuries; and (c) the extent of underreporting by nurses; and (4) examine the relative importance of (a) the preceding predictors and (b) acceptance of the device in predicting perceived changes in needlestick injuries. Safety climate and training were evaluated as organizational factors. Individual factors evaluated were experience with the device, including time using it and frequency of use, and background information, including nursing unit, and length of time as a nurse in this hospital and in total nursing career. The conceptual framework was based upon the safety climate model. Descriptive statistics and multiple and logistic regression were utilized to address the study objectives. ^ The findings showed widespread acceptance of the device and a strong perception that it reduced the number of needlesticks. Acceptance was notably predicted by adequate training, appropriate time between training and device use, solid safety climate, and short length of service, in that order. A barrier to acceptance was nurses' longtime of use of previous needle technologies. Over four-fifths of nurses were compliant in always using the device. Compliance had two facilitators: length of time using device and, to a lesser extent, safety climate. Rates of compliance tended to be lower among nurses in units in which the device was frequently used. ^ High quality training and an atmosphere of caring about nurse safety stand out as primary facilitators that other institutions would need to adopt in order to achieve maximum success in implementing safety programs involving utilization of new safety devices. ^

Depression, interpersonal violence and lack of social support as barriers to cervical cancer screening among recently immigrated Latinas

Background. Various psychosocial factors have been demonstrated to be barriers for cervical cancer screening among Latinas in the United States, but few studies have researched whether depression and interpersonal violence act as psychosocial barriers to cervical cancer screening. ^ Methods. The proposed study assessed whether depression, interpersonal violence, lack of social support and demographic characteristics such as age, income, education and years in the United States acted as barriers to cervical cancer screening among cantineras in Houston, TX. This secondary data analysis utilized data from a previous cross-sectional study called Project GIRASOL- Community Outreach to Prevent Cervical Cancer among Latinas. The data from the baseline survey (sample size 331) was analyzed using Pearson chi-square and multiple logistic regression. ^ Results. Multiple logistic regression indicates that none and low levels of social support from relatives, depression, and total IPV are significant predictors of non-compliance to cervical cancer screening. ^ Conclusions. Future health interventions or physicians that promote cervical cancer screening among cantineras or recently immigrated Latinas with similar socio-demographic characteristics should try to identify whether Latinas are suffering from depression, interpersonal violence or lack of social support and provide proper referrals to alleviate the problems and positively influence screening behavior. ^

Barriers to cross-border research projects: A prelude to improving professional collaborations between the United States and Mexico

Study objective. This was a secondary data analysis of a study designed and executed in two phases in order to investigate several questions: Why aren't more investigators conducting successful cross-border research on human health issues? What are the barriers to conducting this research? What interventions might facilitate cross-border research? ^ Methods. Key informant interviews and focus groups were used in Phase One, and structured questionnaires in Phase Two. A multi-question survey was created based on the findings of focus groups and distributed to a wider circle of researchers and academics for completion. The data was entered and analyzed using SPSS software. ^ Setting. El Paso, TX located on the U.S-Mexico Border. ^ Participants. Individuals from local academic institutions and the State Department of Health. ^ Results. From the transcribed data of the focus groups, eight major themes emerged: Political Barriers, Language/Cultural Barriers, Differing Goals, Geographic Issues, Legal Barriers, Technology/Material Issues, Financial Barriers, and Trust Issues. Using these themes, the questionnaire was created. ^ The response rate for the questionnaires was 47%. The largest obstacles revealed by this study were identifying a funding source for the project (47% agreeing or strongly agreeing), difficulties paying a foreign counterpart (33% agreeing or strongly agreeing) and administrative changes in Mexico (31% agreeing or strongly agreeing). ^ Conclusions. Many U.S. investigators interested in cross-border research have been discouraged in their efforts by varying barriers. The majority of respondents in the survey felt financial issues and changes in Mexican governments were the most significant obstacles. While some of these barriers can be overcome simply by collaboration among motivated groups, other barriers may be more difficult to remove. Although more evaluation of this research question is warranted, the information obtained through this study is sufficient to support creation of a Cross-Border Research Resource Manual to be used by individuals interested in conducting research with Mexico. ^

Evaluation of racial and ethnic disparities of glycemic control in the Health and Retirement Study. 2003 Diabetes Survey

Objective. To examine and evaluate racial and ethnic disparities in glycemic control among HRS respondents with diabetes aged 55-94 years. ^ Methods. The HRS Diabetes 2003 database provides data on blood-drawn glycemic control and self-reported demographics, socioeconomic status, clinical, health access and self-care characteristics. 1,141 non-Hispanic White, non-Hispanic Black, and Hispanic respondents were included in multiple logistic regression of glycemic control. ^ Results. The rate of poor control was significantly higher among Blacks (61.5%, 105/171) and Hispanics (65.3% 72/110) than among Whites (45.0% 387/860) (p < 0.01). After controlling for influential covariates and interactions, Blacks and Hispanics had a three-fold increased risk for poor control compared to Whites when duration was five years or less. ^ Conclusions. Clinical and self-perception variables, like duration, medication, and self-rated poor diabetes control affected glycemic control independent of race and ethnicity, but there remains unexplained racial and ethnic disparities for newly-diagnosed individuals. This is the first study to find an interaction between duration and race and ethnicity on glycemic control. Future research should incorporate cultural beliefs and attitudes about diabetes control that may explain the racial and ethnic disparity. ^

Defining barriers in caring for seriously-ill children in a resource-limited setting: An observational study of 2 children's hospitals in Haiti

Background. According to the WHO 2007 country report, Haiti lags behind the Millennium Development Goal of reducing child mortality and maintains the highest under-5 mortality rate in the Western hemisphere. 3 Overall, few studies exist that seek to better grasp barriers in caring for a seriously ill child in a resource-limited setting and only a handful propose sustainable, effective interventions. ^ Objectives. The objectives of this study are to describe the prevalence of serious illnesses among children hospitalized at 2 children's hospitals in Port au Prince, to determine the barriers faced when caring for seriously ill children, and to report hospital outcomes of children admitted with serious illnesses. ^ Methods. Data were gathered from 2 major children's hospitals in Port au Prince, Haiti (Grace Children's Hospital [GCH] and Hopital d l'Universite d'Etat d'Haiti [HUEH]) using a triangulated approach of focus group discussions, physician questionnaires, and retrospective chart review. 23 pediatric physicians participated in focus group discussions and completed a self-administered questionnaire evaluating healthcare provider knowledge, self-efficacy, and perceived barriers relating to the care of seriously ill children in a resource-limited setting. A sample of 240 patient charts meeting eligibility criteria was abstracted for pertinent elements including sociodemographics, documentation, treatment strategies, and outcomes. Factors associated with mortality were analyzed using χ2 test and Fisher exact test [Minitab v.15]. ^ Results. The most common primary diagnoses at admission were gastroenteritis with moderate dehydration (35.5%), severe malnutrition (25.8%), and pneumonia (19.3%) for GCH, and severe malnutrition (32.6%), sepsis (24.7%), and severe respiratory distress (18%) for HUEH. Overall, 12.9% and 27% of seriously ill patients presented with shock to GCH and HUEH, respectively. ^ Shortage of necessary materials and equipment represented the most commonly reported limitation (18/23 respondents). According to chart data, 9.4% of children presenting with shock did not receive a fluid bolus, and only 8% of patients presenting with altered mental status or seizures received a glucose check. 65% of patients with meningitis did not receive a lumbar puncture due to lack of materials. ^ Hospital mortality rates did not differ by gender or by institution. Children who died were more likely to have a history of prematurity (OR 4.97 [95% CI 1.32-18.80]), an incomplete vaccination record (OR 4.05 [95% CI 1.68-9.74]), or a weight for age ≤3rd percentile (OR 6.1 [95% CI 2.49-14.93]. Case-fatality rates were significantly higher among those who presented with signs of shock compared with those who did not (23.1% vs. 10.7%, RR=2.16, p=0.03). Caregivers did not achieve shock reversal in 21% of patients and did not document shock reversal in 50% of patients. ^ Conclusions. Many challenges face those who seek to optimize care for seriously ill children in resource-limited settings. Specifically, in Haiti, qualitative and quantitative data suggest major issues with lack of supplies, pre-hospital factors, including malnutrition as a comorbidity, and early recognition and management of shock. A tailored intervention designed to address these issues is needed in order to prospectively evaluate improvements in child mortality in a high-risk population.^

Identifying and removing barriers to cycling as a viable means of transportation in Houston, Texas

The citizens of Houston, Texas, spend much time commuting. It has repeatedly been named among the “Fattest Cities” by Men’s Fitness Magazine (The fittest and fattest cities in America – Men’s Fitness. ). Obesity is one of its major public health problems as Houstonians often do not engage in enough physical activity to help them maintain their ideal weights. The use of bicycles provides a healthy and ecological alternative to commuting by driving. However, because urban cyclists must often share the roads with motorized vehicles, cyclists are often exposed to high levels of emissions. As vulnerable users of the roadways, urban cyclists also face the threat of injury. Nevertheless, there are some programs that encourage the use of bicycles. Laws and ordinances not only reveal public policy relating to bicycling but are a means to develop policy which can encourage bicycling. ^

Latino perceptions of and barriers to preventive healthcare maintenance in the southwest United States

Between the 1990 and 2000 Censuses, the Latino population accounted for 40% of the increase in the nation’s total population. The growing population of Latinos underscores the importance for understanding factors that influence whether and how Latinos take care of their health. According to the U.S. Department of Human Health Service’s Office of Minority Health (OMH), Latinos are at greater risk for health disparities (2003). Factors such as lack of health insurance and access to preventive care play a major role in limiting Latino use of primary health care (Institute of Medicine, 2005). Other significant barriers to preventive health care maintenance behaviors have been identified in current literature such as primary care physician interaction, self-perceived health status, and socio-cultural beliefs and traditions (Rojas-Guyler, King, Montieth and 2008; Meir, Medina, and Ory, 2007; Black, 1999). Despite these studies, there remains less information regarding interpersonal perceptions, environmental dynamics and individual and cultural attitudes relevant to utilization of healthcare (Rojas-Guyler, King, Montieth and 2008; Aguirre-Molina, Molina and Zambrana, 2001). Understanding the perceptions of Latinos and the barriers to health care could directly affect healthcare delivery. Improved healthcare utilization among Latinos could reduce the long term health consequences of many preventable and manageable diseases. The purpose of this study was to explore Latino perceptions of U.S. health care and desired changes by Latinos in the U.S. healthcare system. The study had several objectives, including to explore perceived barriers to healthcare utilization and the resulting effects on health among Latinos, to describe culturally influenced attitudes about health care and use of health care services among Latinos, and to make recommendations for reducing disparities by improving healthcare and its utilization. The current study utilized data that were collected as part of a larger study to examine multidimensional, cross-cultural issues relevant to interactions between healthcare consumers and providers. Qualitative methods were used to analyze four Spanish-language focus group transcripts to interpret cultural influences on perceptions and beliefs among Latinos. Direct coding of transcript content was carried out by two reviewers, who conducted independent reviews of each transcript. Team members developed and refined thematic categories, positive and negative cases, and example text segments for each theme and sub-theme. Incongruities of interpretations were resolved through extensive discussion. Study participants included 44 self-identified Latino adults (16 male, 28 female) between age 18 and 64 years. Thirty seven (84.1%) of the participants were immigrants. The study population comprised eight ethnic subgroups. While 31% of the participants reported being employed on a full-time basis, only 18.4% had medical insurance that was private or employee sponsored. Five major themes regarding the perceptions and healthcare utilization behaviors of Latinos were consistent across all focus groups and were identified during the analysis. These were: (1) healthcare utilization, experience, and access; (2) organizational and institutional systems; (3) communication and interpersonal interactions between healthcare provider, staff, and patient; (4) Latinos’ perception of their own health status; (5) cultural influences on healthcare utilization, which included an innovation termed culturally-bound locus of control. Healthcare utilization was directly influenced by healthcare experience, access, current health status, and cultural factors and indirectly influenced by organizational systems. There was a strong interdependence among the main themes. The ability to communicate and interact effectively with healthcare providers and navigate healthcare systems (organizational and institutional access) significantly influenced the participant’s health care experience, most often (indirectly) impacting utilization negatively. ^ Research such as this can help to identify those perceptions and attitudes held by Latinos concerning utilization or underutilization of healthcare systems. These data suggest that for healthcare utilization to improve among Latinos, healthcare systems must create more culturally competent environments by providing better language services at the organizational level and more culturally sensitive providers at the interpersonal level. Better understanding of the complex interactions between these impediments can aid intervention developments, and help health providers and researchers in determining appropriate, adequate, and effective measurers of care to better increase overall health of Latinos.^

Self-reported participation and perceived barriers to exercise in South Texas Hispanic adults

National data show that Hispanics report low levels of physical activity. Limited information on barriers to exercise in this population exists in the literature. Surveys were administered to 398 Hispanic participants from two colonias in South Texas to investigate self-reported levels of and perceived barriers to exercise. Results show that 67.6% of respondents did not meet physical activity recommendations of at least 150 minutes per week, as compared to 55.6% nationally. Overall, the most frequently reported barriers included “lack of time”, “very tired” and “lack of self-discipline” to exercise. An exploratory factor analysis of the barriers reported by participants not meeting physical activity recommendations resulted in a three-factor structure. A unidimensional scale was found for participants meeting recommendations. Findings suggest that future interventions should be specific to gender and exercise level to address the high prevalence of inactivity in this population. ^

Industrial benzene emissions in Houston: Legal barriers to reducing a public health threat

Decades of research show that environmental exposure to the chemical benzene is associated with severe carcinogenic, hematoxic and genotoxic effects on the human body. As such, the Environmental Protection Agency (EPA) has designated the chemical as a Hazardous Air Pollutant and prescribed benzene air concentration guidelines that provide cities with an ideal ambient level to protect human health. However, in Houston, Texas, a city home to the top industrial benzene emitters in the US who undoubtedly contribute greatly to the potentially unsafe levels of ambient benzene, regulations beyond the EPA’s unenforceable guidelines are critical to protecting public health. Despite this, the EPA has failed to establish National Ambient Air Quality Standards (NAAQS) for benzene. States are thus left to regulate air benzene levels on their own; in the case of Texas, the Texas Commission on Environmental Quality (TCEQ) and state legislature have failed to proactively develop legally enforceable policies to reduce major source benzene emissions. This inaction continues to exacerbate a public health problem, which may only be solved through a legal framework that restricts preventable benzene emissions to protect human health and holds industrial companies accountable for violations of such regulations and standards. This analysis explores legal barriers that the City of Houston and other relevant agencies currently face in their attempt to demand and bring about such change. ^

Comparing barriers and predictors for colorectal cancer screening between African Americans and Whites

Colorectal cancer (CRC) has been one of the leading causes of cancer death in the United States. Although incidence and mortality rates of colorectal cancer in the United States have decreased in recent years, the disparity in CRC incidence and mortality between African Americans and Whites remain. Disparity in CRC screening rates is believed to be one of the causes that contribute to the disparity in CRC incidence and mortality between these two races. Finding the differences in CRC screening barriers and predictors between these two groups can help us to design more effective intervention programs to improve CRC screening rates for African Americans. However, most of the previous studies have investigated different types of CRC screening barriers for African Americans and/or Whites, but no studies have compared the same CRC screening barriers between African Americans and Whites. The purpose of this study is to describe and compare the same CRC screening barriers between these two races. Using chi-square analysis, significant differences between African Americans and Whites were found for marital status, income and education. Compared to Whites, African Americans were less aware of CRC screening procedures and lacked CRC knowledge. Significant differences were found between African Americans and Whites in the awareness of sigmoidoscopy, colonoscopy and barium enema. After adjusting for sex, education, marital status, and household income, six out of thirteen CRC screening barriers and two out of nine CRC screening predictors remained to be statistically significantly different between African Americans and Whites. The results of this study indicated that different CRC screening barriers and predictors had different impact on African Americans, and African Americans had more CRC barriers to overcome than Whites.^