The cost of publicly financed dental care in relation to community water fluoridation in Texas

Dental caries lead to children being less ready to learn and results in diminished productivity in the classroom. Tooth decay causes pain and infection, leading to impaired chewing, speech, and facial expression, in addition to a loss in self-esteem. There have been many studies supporting the safety and efficacy of community water fluoridation in reducing dental caries. Water fluoridation has been identified by the Centers for Disease Control and Prevention as one of 10 great public health achievements of the 20th century. The decline in the prevalence and severity of tooth decay in the United States during the past 60 years has been attributed largely to the increased use of fluoride; in particular, the widespread utilization of community water fluoridation. However, in the decades since fluoridation was first introduced, reductions in dental caries have declined, most likely due to the presence of other sources of fluoride. Questions have been raised regarding the need to continue to fluoridate community water supplies in the face of possible excessive exposure to fluoride. Nevertheless, dental caries continue to be a significant public health burden throughout the world, including the United States, especially among low-income and disadvantaged populations. Although many poor children receive their dental care through Medicaid, the percentage of Texas children with untreated dental caries continues to exceed the U.S. average and is well above Healthy People 2010 goals, even as state Medicaid expenditures continue to rise. The objective of this study is to determine the relationship between Medicaid dental expenditures and community water fluoridation levels in Texas counties. By examining this relationship, the cost-effectiveness of community water fluoridation in the Texas pediatric Medicaid beneficiary population, as measured by publicly financed dental care expenditures, may be ascertained.^

Provider perceptions of physical activity counseling: A systematic review

Background: Although the health benefits of physical activity are well-established, the evidence regarding the efficacy of physical activity counseling by primary care providers is inconclusive. Healthy People 2020 recommends that physicians provide counseling on physical activity to their patients; however, few providers adhere to these guidelines. The primary objective of this review is to systematically summarize and evaluate primary care providers' perceptions and attitudes about physical activity counseling. ^ Methods: A systematic literature search of relevant articles was conducted between January and May 2011 using four databases: MEDLINE (1948 to the present), PsycInfo (1806 to the present), CINAHL Plus with Full Text (1981 to the present), and the Cochrane Library. Studies were included if 1) the study population consisted of primary care providers and, 2) the study evaluated providers' attitudes and perceptions pertaining to physical activity counseling. Both quantitative and studies were considered. ^ Results: Most primary care providers agree that physical activity counseling is important and that they have a role in promoting physical activity to their patients. Providers are uncertain about the effectiveness of counseling, feel only marginally comfortable providing more than general advice about physical activity, and cite major barriers to counseling such as lack of time, lack of training, and lack of reimbursement for their counseling efforts. The evidence in this review suggests that beyond these barriers, providers are more likely to counsel their patients about physical activity if they are active themselves, or if they feel that their patients' condition, such as cardiovascular disease or obesity, would strongly benefit from a lifestyle change. ^ Conclusion: While major barriers to physical activity counseling, such as lack of time for counseling and lack of counseling knowledge still exist, primary care providers are receptive to the idea of acting as physical activity promoters in their clinical practices. However, the barriers encountered need to be addressed on multiple levels (e.g. individual, organizational), and additional training is needed in order for providers to effectively promote the physical activity of their patients.^

Clostridium difficile infection (CDI) in HIV-positive patients

The main aim of this study was to look at the association of Clostridium difficile infection (CDI) and HIV. A secondary goal was to look at the trend of CDI-related deaths in Texas from 1999-2011. To evaluate the coinfection of CDI and HIV, we looked at 2 datasets provided by CHS-TDSHS, for 13 years of study period from 1999-2011: 1) Texas death certificate data and 2) Texas hospital discharge data. An ancillary source of data was national level death data from CDC. We did a secondary data analysis and reported the age-adjusted death rates (mortality) and hospital discharge frequencies (morbidity) for CDI, HIV and for CDI+HIV coinfection.^ Since the turn of the century, CDI has reemerged as an important public health challenge due to the emergence of hypervirulent epidemic strains. From 1999-2011, there has been a significant upward trend in CDI-related death rates; in the state of Texas alone, CDI mortality rate has increased 8.7 fold in this time period at the rate of 0.2 deaths per year per 100,000 individuals. On the contrary, mortality due to HIV has decreased by 46% and has been trending down. The demographic groups in Texas with the highest CDI mortality rates were elderly aged 65+, males, whites and hospital inpatients. The epidemiology of C. difficile has changed in such a way that it is not only staying confined to these traditional high-risk groups, but is also being increasingly reported in low-risk populations such as healthy people in the community (community acquired C. difficile), and most recently immunocompromised patients. Among the latter, HIV can worsen the adverse health outcomes of CDI and vice versa. In patients with CDI and HIV coinfection, higher mortality and morbidity was found in young & middle-aged adults, blacks and males, the same demographic population that is at higher risk for HIV. As with typical CDI, the coinfection was concentrated in the hospital inpatients. Of all the CDI-related deaths in USA from 1999-2010, in the 25-44 year age group, 13% had HIV infection. Of all CDI-related inpatient hospital discharges in Texas from 1999-2011, in patients 44 years and younger, 17% had concomitant HIV infection. Therefore, HIV is a possible novel emerging risk factor for CDI.^

Second, do less harm: The state of states' medical error reporting programs

Statement of the problem and public health significance. Hospitals were designed to be a safe haven and respite from disease and illness. However, a large body of evidence points to preventable errors in hospitals as the eighth leading cause of death among Americans. Twelve percent of Americans, or over 33.8 million people, are hospitalized each year. This population represents a significant portion of at risk citizens exposed to hospital medical errors. Since the number of annual deaths due to hospital medical errors is estimated to exceed 44,000, the magnitude of this tragedy makes it a significant public health problem. ^ Specific aims. The specific aims of this study were threefold. First, this study aimed to analyze the state of the states' mandatory hospital medical error reporting six years after the release of the influential IOM report, "To Err is Human." The second aim was to identify barriers to reporting of medical errors by hospital personnel. The third aim was to identify hospital safety measures implemented to reduce medical errors and enhance patient safety. ^ Methods. A descriptive, longitudinal, retrospective design was used to address the first stated objective. The study data came from the twenty-one states with mandatory hospital reporting programs which report aggregate hospital error data that is accessible to the public by way of states' websites. The data analysis included calculations of expected number of medical errors for each state according to IOM rates. Where possible, a comparison was made between state reported data and the calculated IOM expected number of errors. A literature review was performed to achieve the second study aim, identifying barriers to reporting medical errors. The final aim was accomplished by telephone interviews of principal patient safety/quality officers from five Texas hospitals with more than 700 beds. ^ Results. The state medical error data suggests vast underreporting of hospital medical errors to the states. The telephone interviews suggest that hospitals are working at reducing medical errors and creating safer environments for patients. The literature review suggests the underreporting of medical errors at the state level stems from underreporting of errors at the delivery level. ^

Development and formative evaluation of an obesity prevention intervention for the pediatric primary care setting: Helping HAND (Healthy Activity and Nutrition Directions)

As the obesity epidemic continues to increase, the pediatric primary care office setting remains a relatively unexplored arena to offer obesity prevention interventions for children. The increased risk for adult obesity among 10 to 14 year-old children who are overweight, suggests obesity prevention programs should be introduced just before this age or early in this age period. Research is also accumulating on the importance of targeting parents along with children, since parents are in charge of the home environment for children. Therefore, the aim of this project was to develop an obesity prevention program called Helping HAND (Healthy Activity and Nutrition Directions) based on Social Cognitive Theory and authoritative parenting techniques for the pediatric primary care setting and conduct one-on-one interviews with parents as the initial formative evaluation of the intervention material for the obesity prevention intervention. A secondary aim of the project was to determine the feasibility of identifying appropriate subjects for the intervention, and conducting qualitative evaluations of the materials through recruitment through pediatric primary care settings. ^

Prenatal care programs in a clinic based center in El Paso, Texas: Evaluating outcomes among Hispanic women

Early prenatal care has been found to improve pregnancy and birth outcomes by reducing the risk of low birth weight and preterm births. Statistics point to lower utilization rates of prenatal care in El Paso, Texas and increasing rates of low birth weight. This study was a secondary data analysis, which explored the perceived benefits and barriers known to influence the utilization of prenatal care, and the birth outcomes among participating subjects attending three different prenatal care programs offered at the Centro San Vincent Clinic during the period of December 2006 to February 2008. A survey was used to collect data on demographics and assess perceived benefits and barriers regarding early prenatal care and self-efficacy of the participants. Post-partum birth records were used to gather data about the participant's newborns to include birth weight, gestational age, and the type of delivery (i.e. vaginal versus Cesarean birth). Chi square analysis was conducted to test for significant differences and associations. The sample of women in the study had high risk factors for inadequate utilization of prenatal care. In spite of high demographic risk factors, these women had higher perceived benefits, lower perceived barriers and high self-efficacy associated with prenatal care utilization. The perceived benefits and barriers to prenatal care were associated with place of birth and language preferred, with women from Mexico and who preferred Spanish having higher perceived benefits and lower barriers. There was no significant difference in birth outcomes among the women in different prenatal care programs. The findings of this study suggest that of all participants in the study, those born in Mexico demonstrated higher rates of perceived benefits of early prenatal care. The analysis also suggested that healthy birth outcomes were evenly distributed among women participating in one of the three prenatal care programs. ^

The relationship between food preparation time, time spent grocery shopping, and BMI

Recent data have shown that the percentage of time spent preparing food has decreased during the past few years, and little information is know about how much time people spend grocery shopping. Food that is pre-prepared is often higher in calories and fat compared to foods prepared at home from scratch. It has been suggested that, because of the higher energy and total fat levels, increased consumption of pre-prepared foods compared to home-cooked meals can lead to weight gain, which in turn can lead to obesity. Nevertheless, to date no study has examined this relationship. The purpose of this study is to determine (i) the association between adult body mass index (BMI) and the time spent preparing meals, and (ii) the association between adult BMI and time spent shopping for food. Data on food habits and body size were collected with a self-report survey of ethnically diverse adults between the ages of 17 and 70 at a large university. The survey was used to recruit people to participate in nutrition or appetite studies. Among other data, the survey collected demographic data (gender, race/ethnicity), minutes per week spent in preparing meals and minutes per week spent grocery shopping. Height and weight were self-reported and used to calculate BMI. The study population consisted of 689 subjects, of which 276 were male and 413 were female. The mean age was 23.5 years, with a median age of 21 years. The fraction of subjects with BMI less than 24.9 was 65%, between 25 and 29.9 was 26%, and 30 or greater was 9%. Analysis of variation was used to examine associations between food preparation time and BMI. ^ The results of the study showed that there were no significant statistical association between adult healthy weight, overweight and obesity with either food preparation time and grocery shopping time. Of those in the sample who reported preparing food, the mean food preparation time per week for the healthy weight, overweight, and obese groups were 12.8 minutes, 12.3 minutes, and 11.6 minutes respectively. Similarly, the mean weekly grocery shopping for healthy, overweight, and obese groups were 60.3 minutes per week (8.6min./day), 61.4 minutes (8.8min./day), and 57.3 minutes (8.2min./day), respectively. Since this study was conducted through a University campus, it is assumed that most of the sample was students, and a percentage might have been utilizing meal plans on campus, and thus, would have reported little meal preparation or grocery shopping time. Further research should examine the relationships between meal preparation time and time spent shopping for food in a sample that is more representative of the general public. In addition, most people spent very little time preparing food, and thus, health promotion programs for this population need to focus on strategies for preparing quick meals or eating in restaurants/cafeterias. ^

Has implementation of integrated mental health services in primary care programs positively impacted health outcomes among the mentally ill in developing countries?

Objective. The World Health Organization (WHO) estimates that nearly 450 million people suffer from a mental disorder in the world. Developing countries do not have the health system structure in place to support the demand of mental health services. This study will conduct a review of mental health integration in primary care research that is carried out in low-income countries identified as such from the World Bank economic analysis. The research follows the standard of care that WHO has labeled appropriate in treatment of mental health populations. Methods. This study will use the WHO 10 principles of mental health integration into primary care as the global health standard of care for mental health. Low-income countries that used these principles in their national programs will be analyzed for effectiveness of mental health integration in primary care. Results. This study showed that mental health service integration in primary care did have an effect on health outcomes of low-income countries. However, information did not lead to significant quantitative results that determined how positive the effect was. Conclusion. More ethnographic research is needed in low-income countries to truly assess how effective the program is in integrating with the health system currently in place.^ ^

Community diagnosis: A working tool for developing culturally appropriate diarrhea intervention programs

Most studies related to diarrhea have been focused narrowly on the etiological and pathophysiological factors involved in inducing the disease. Such studies have often failed to consider other facets contributing to and possibly prolonging the problem, namely: socio-economic conditions, educational opportunities and attainments, cultural characteristics and beliefs, and the political administration and its commitment towards fulfilling its moral and ethical obligations in responding to and fostering human development.^ This study utilized the diagnostic approach of the PRECEDE model. The acronym stands for the predisposing reinforcing, and enabling constructs in educational diagnosis and evaluation. The constituents of this model were identified by utilizing participant observation field methods, traditionally applied by ethnographers to collect data describing the multiple facets of a culture, and linguistic anthropology used to capture and define characteristic semantics and viewpoints. The household study sample was randomly selected from a defined list of households known to have at least one child less than five years of age. An open-ended questionnaire format was used to interview the 115 mothers in the selected households sample.^ Kalama, the study community, is characteristically an agricultural village, situated in the Governorate of Kaliobia and located approximately 25 Km (about 15.5 miles) from the capital, Cairo, Egypt. The 1986 census indicates a population size of 13,328 people in 4,818 households. There were 65 deaths occurring among children less than five years in 1986. The causes of death were primarily related to diarrhea, followed by upper respiratory infections, congenital anomalies and birth injuries.^ This study outlines (a) practices related to the management of diarrhea, including the administration of foods and drinks during such episodes; (b) influences of governmental policies; and (c) recommended strategies for overcoming barriers and promoting effective diarrhea intervention programs. ^

Community health workers: The critical link to sustainable, healthy societies in low-resource settings---A model for the Baylor Shoulder to Shoulder Foundation

Community health workers (CHWs) can serve as a bridge between healthcare providers and communities to positively impact social determinants of health and, thus, the overall health of the population. The potential to effect lasting change is particularly significant within resource-poor settings with limited access to formally trained health care providers such as the small, rural village of Santa Ana Intibucá, Honduras and surrounding areas—located on the geographically and politically isolated border of Honduras and El Salvador. The Baylor Shoulder to Shoulder Foundation (BSTS) works in conjunction with Santa Ana's volunteer health committee to bring a health brigade that has provided health care and public health projects to the area at least twice a year since 2001. They have also hired a full-time Honduran physician, a Honduran in-country administrative director, and built a clinic; yet, no community health worker program exists. This CHW program model is the response to a clear need for a CHW program within the area served by BSTS and presents a CHW program model specific to Santa Ana Intibucá and surrounding areas to be implemented by BSTS. Methods used to develop this model include reviewing the literature for recommendations from leading authorities as well as successfully implemented CHW programs in comparable regions. This information was incorporated into existing knowledge and materials currently being used in the area. Using the CHW model proposed here, each brigade, in conjunction with the communities served, can help develop new modules to respond to the specific health priorities of the region at that time, incorporating consistent modes of contact with the local physician and the CHWs to provide refresher courses, training in new topics of interest, and to be reminded of the importance of community health workers' role as the critical link to healthy societies. With cooperation, effort, and support, the brigade can continue to help integrate a sustainable CHW system in which communities may be able to maximize the care they receive while also learning to care for their own health and the future of their communities.^

Effects of a health advocacy program to promote physical activity and nutrition behaviors among adolescents: An evaluation of the Young Leaders for Healthy Change program

Background. This study was designed to evaluate the effects of the Young Leaders for Healthy Change program, an internet-delivered program in the school setting that emphasized health advocacy skills-development, on nutrition and physical activity behaviors among older adolescents (13–18 years). The program consisted of online curricular modules, training modules, social media, peer and parental support, and a community service project. Module content was developed based on Social Cognitive Theory and known determinants of behavior for older adolescents. ^ Methods. Of the 283 students who participated in the fall 2011 YL program, 38 students participated in at least ten of the 12 weeks and were eligible for this study. This study used a single group-only pretest/posttest evaluation design. Participants were 68% female, 58% white/Caucasian, 74% 10th or 11th graders, and 89% mostly A and/or B students. The primary behavioral outcomes for this analysis were participation in 60-minutes of physical activity per day, 20-minutes of vigorous- or moderate- intensity physical activity (MVPA) participation per day, television and computer time, fruit and vegetable (FV) intake, sugar-sweetened beverage intake, and consumption of breakfast, home-cooked meals, and fast food. Other outcomes included knowledge, beliefs, and attitudes related to healthy eating, physical activity, and advocacy skills. ^ Findings. Among the 38 participants, no significant changes in any variables were observed. However, among those who did not previously meet behavioral goals there was an 89% increase in students who participated in more than 20 minutes of MVPA per day and a 58% increase in students who ate home-cooked meals 5–7 days per week. The majority of participants met program goals related to knowledge, beliefs, and attitudes prior to the start of the program. Participants reported either maintaining or improving to the goal at posttest for all items except FV intake knowledge, taste and affordability of healthy foods, interest in teaching others about being healthy, and ease of finding ways to advocate in the community. ^ Conclusions. The results of this evaluation indicated that promoting healthy behaviors requires different strategies than maintaining healthy behaviors among high school students. In the school setting, programs need to target the promotion and maintenance of health behaviors to engage all students who participate in the program as part of a class or club activity. Tailoring the program using screening and modifying strategies to meet the needs of all students may increase the potential reach of the program. The Transtheoretical Model may provide information on how to develop a tailored program. Additional research on how to utilize the constructs of TTM effectively among high school students needs to be conducted. Further evaluation studies should employ a more expansive evaluation to assess the long-term effectiveness of health advocacy programming.^

Comparison of health behaviors of Mexican American and non -Hispanic White females: Implications for health promotion programs

Hispanics form the second-largest minority group in the United States totaling 22 million people. Health data on this population are sparse and inconsistent. This study seeks to determine use of preventative services and risk factor behaviors of Mexican American and non-Hispanic White females residing in South Texas.^ Baseline data from female respondents in household surveys in six South Texas counties (Ramirez and McAlister, 1988; McAlister et al., 1992) were analyzed to test the following hypotheses: (1) Mexican American and Non-Hispanic White females exhibit different patterns of health behaviors; (2) Mexican American females will exhibit different health behaviors regardless of age; and (3) the differences between Mexican American women and non-Hispanic White females are due to education and acculturation factors.^ Over the past decade, the traditional behaviors of Mexican American females have begun to change due to education, acculturation, and their participation in the labor force. The results from this study identify some of the changes that will require immediate attention from health care providers. Results revealed that regardless of ethnicity, age, education, and language preference, non-Hispanic White females were significantly more likely to participate in preventive screening practices than were Mexican American females. Risk factor analysis revealed a different pattern with Mexican American females significantly more likely to be non-smokers, non-alcoholic drinkers, and to have good fat avoidance practices compared to non-Hispanic White females. However, compared to those who are less-educated or Spanish-speaking, Mexican American females with higher levels of education and preference for speaking English only showed positive and negative health behaviors that were more similar to the non-Hispanic White females. The positive health behaviors that come with acculturation, e.g., more participation in preventive care and more physical activity, are welcome changes. But this study has implications for global health development and reinforces a need for "primordial" prevention strategies to deter the unwanted concomitants of economic development and acculturation. Smoking and drinking behaviors among Mexican American females need to be kept at low levels to prevent increased morbidity and premature deaths in this population. ^