Perspective transformation: Women in long-term recovery from alcohol abuse

Objective. The purpose of this study was to determine the meaning of personal transformation for twenty women in long term, stable recovery from alcohol abuse; to identify themes or patterns of this recovery, and; to determine the extent to which they experienced the phenomenon of perspective transformation. ^ Method. Volunteers were recruited by advertisement, word of mouth, and through a closed circuit web based broadcast. A descriptive, exploratory study, which analyzed perspective transformation from the standpoint of five action phases, was conducted. Data was collected using in-depth personal interviews and questionnaires. Subjects' responses were analyzed by qualitative methods. Triangulation was performed on the grouped data comparing the interviews to the data produced by the questionnaires. Quantitative analysis of questionnaire items explored behavioral changes experienced before and after alcoholism recovery. ^ Results. Five phases of recovery were identified. Phase I which involved recognition that alcohol was a problem and change might be possible took several years during which 3 major transitions occurred: (1) from often being alienated to having relationships with family and friends; (2) from daily upheavals to eventually a more peaceful existence, and; (3) from denial that alcohol was a problem to acceptance and willingness to change. Recovery was often seen in a spiritual context, which also required ongoing support. During Phase II there was an assessment of self, others, and the environment which revealed a pattern of intense unhappiness and negative feelings toward self and others with a disregard for cultural norms. Phase III revealed a period of desperation as life became unmanageable, but gradual willingness to accept support and guidance and a desire to improve self and help others. This led to improvement of existing role performance and the willingness to try out new roles. In Phase IV there was a pattern of personal growth which included: the establishment of boundaries, setting priorities, a willingness to place others' needs above their own, acceptance of responsibility, and learning to cope without alcohol, often with the use of tools learned in AA. During Phase V, many experienced knowledge of frailties but growing respect for self and others, with an improved ability to function in giving relationships. Implications for Prevention and Recovery: Early education concerning addiction and recovery may play a crucial role in prevention and early recovery, as it did for children of women in this study. Recovery requires persistent effort and organized support. ^

Attributing inpatient care to diabetes: The case of Medicare for the elderly in Texas, 1995

Specific aims. This study estimated the accuracy of alternative numerator methods for attributing health care utilization and associated costs to diabetes by comparing findings from those methods with findings from a benchmark denominator method. ^ Methods. Using Medicare's 1995 inpatient and enrollment databases for the elderly in Texas, the researcher developed alternative estimates of costs attributable to diabetes. Among alternative numerator methods were selection of all records having diabetes as a principal or secondary diagnosis, and a complex ICD-9-CM sorting routine as previously developed for study of diabetes costs in Texas. Findings from numerator methods were compared with those from a benchmark denominator method based on attributable risk and adapted from a study of national diabetes costs by the American Diabetes Association. This study applied age, gender and ethnicity specific estimates of diabetes prevalence taken from the 1987–94 National Health Interview Surveys to person-months of Medicare Part A, non-HMO enrollment for Texas in 1995. Outcome measures were number of persons identified as having diabetes using alternative definitions of the disease; and number of hospital stays, patient days, and costs using alternative methods for attributing care and costs to diabetes. Cost estimates were based on Medicare payments plus deductibles, co-pays and third party payments. ^ Findings. Numerator methods for attributing costs to diabetes produced findings quite different than those from the benchmark denominator method. When attribution was based on diabetes as principal or secondary diagnosis, the resulting estimates were significantly higher than those obtained from the denominator method. The more complex sorting routine produced estimates near the lower boundary for the confidence interval associated with estimates from the benchmark method. ^ Conclusions. Numerator methods employed by previous researchers poorly estimate the costs of diabetes. While crude mathematical adjustment can be made to the respective numerator approaches, a more useful strategy would be to refine the complex sorting routine to include more hospitalizations. This report recommends approaches to improving methods previously employed in study of diabetes costs. ^

Safer sex choices among African-American college women

The purpose of this dissertation was to explore and describe the factors that influence the safer sex choices of African-American college women. The pandemic of HIV and the prevalence of other sexually transmitted diseases has disproportionately affected African-American females. As young women enter college they are faced with a myriad of choices. Unprotected sexual exploration is one choice that can lead to deadly consequences. This dissertation explores, through in-depth interviews, the factors associated with the decision to practice or not practice safe sex. ^ The first study describes the factors associated with increased sexual risk taking among African-American college women. Sexual risk taking or sex without a condom was found to be more likely when issues of self or partner pleasure were raised. Participants were also likely to have sexual intercourse without a condom if they desired a long term relationship with their partner. ^ The second study examined safe sex decision making processes among a group of African-American college women. Women were found to employ both emotional and philosophical strategies to determine their safe sex behavior. These strategies range from assessing a partner's physical capabilities and appearance to length of the dating relationship. ^ The third study explores the association between knowledge and risk perception as predictors for safer sex behaviors. Knowledge of HIV/AIDS and other STDs was not found to be a determinant of safer sex behavior. Perception of personal risk was also not highly correlated with consistent safer sex behavior. ^ These studies demonstrate the need for risk-based safer sex education and intervention programs. The current climate of knowledge-based program development insures that women will continue to predicate their decision to practice safer sex on their limited perception and understanding of the risks associated with unprotected sexual behavior. Further study into the emotional and philosophical determinants of sexual behavior is necessary for the realistic design of applicable and meaningful interventions. ^

Multilevel analysis for a longitudinal clinical trial

This study applies the multilevel analysis technique to longitudinal data of a large clinical trial. The technique accounts for the correlation at different levels when modeling repeated blood pressure measurements taken throughout the trial. This modeling allows for closer inspection of the remaining correlation and non-homogeneity of variance in the data. Three methods of modeling the correlation were compared. ^

Analysis of recurrent failure times: A time-dependent Yule process approach

Analysis of recurrent events has been widely discussed in medical, health services, insurance, and engineering areas in recent years. This research proposes to use a nonhomogeneous Yule process with the proportional intensity assumption to model the hazard function on recurrent events data and the associated risk factors. This method assumes that repeated events occur for each individual, with given covariates, according to a nonhomogeneous Yule process with intensity function λx(t) = λ 0(t) · exp( x′β). One of the advantages of using a non-homogeneous Yule process for recurrent events is that it assumes that the recurrent rate is proportional to the number of events that occur up to time t. Maximum likelihood estimation is used to provide estimates of the parameters in the model, and a generalized scoring iterative procedure is applied in numerical computation. ^ Model comparisons between the proposed method and other existing recurrent models are addressed by simulation. One example concerning recurrent myocardial infarction events compared between two distinct populations, Mexican-American and Non-Hispanic Whites in the Corpus Christi Heart Project is examined. ^

Forecasting cost based on a stochastic utilization plan and a fixed cost function

The application of Markov processes is very useful to health-care problems. The objective of this study is to provide a structured methodology of forecasting cost based upon combining a stochastic model of utilization (Markov Chain) and deterministic cost function. The perspective of the cost in this study is the reimbursement for the services rendered. The data to be used is the OneCare database of claim records of their enrollees over a two-year period of January 1, 1996–December 31, 1997. The model combines a Markov Chain that describes the utilization pattern and its variability where the use of resources by risk groups (age, gender, and diagnosis) will be considered in the process and a cost function determined from a fixed schedule based on real costs or charges for those in the OneCare claims database. The cost function is a secondary application to the model. Goodness-of-fit will be used checked for the model against the traditional method of cost forecasting. ^

Physician adoption of a practice guideline: Effect on the cost of medical care for adult patients with diabetes

In the demanding environment of healthcare reform, reduction of unwanted physician practice variation is promoted, often through evidence-based guidelines. Guidelines represent innovations that direct change(s) in physician practice; however, compliance has been disappointing. Numerous studies have analyzed guideline development and dissemination, while few have evaluated the consequences of guideline adoption. The primary purpose of this study was to explore and analyze the relationship between physician adoption of the glycated hemoglobin test guideline for management of adult patients with diabetes, and the cost of medical care. The study also examined six personal and organizational characteristics of physicians and their association with innovativeness, or adoption of the guideline. ^ Cost was represented by approved charges from a managed care claims database. Total cost, and diabetes and related complications cost, first were compared for all patients of adopter physicians with those of non-adopter physicians. Then, data were analyzed controlling for disease severity based on insulin dependency, and for high cost cases. There was no statistically significant difference in any of eight cost categories analyzed. This study represented a twelve-month period, and did not reflect cost associated with future complications known to result from inadequate management of glycemia. Guideline compliance did not increase annual cost, which, combined with the future benefit of glycemic control, lends support to the cost effectiveness of the guideline in the long term. Physician adoption of the guideline was recommended to reduce the future personal and economic burden of this chronic disease. ^ Only half of physicians studied had adopted the glycated hemoglobin test guideline for at least 75% of their diabetic patients. No statistically significant relationship was found between any physician characteristic and guideline adoption. Instead, it was likely that the innovation-decision process and guideline dissemination methods were most influential. ^ A multidisciplinary, multi-faceted approach, including interventions for each stage of the innovation-decision process, was proposed to diffuse practice guidelines more effectively. Further, it was recommended that Organized Delivery Systems expand existing administrative databases to include clinical information, decision support systems, and reminder mechanisms, to promote and support physician compliance with this and other evidence-based guidelines. ^

Reactions of African immigrants living in Houston, Texas, to the American media and legislation regarding female circumcision

Female circumcision was almost unheard of in the United States a few years ago. The recent influx of African immigrants has increased media attention to the subject, leading to laws criminalizing female circumcision. This study examines the reactions of African immigrants living in Houston, Texas, to media portrayal and legislation regarding female circumcision in an attempt to understand the effectiveness of U.S. laws, and media messages in deterring the practice. ^ Through literature reviews the study looks at how female circumcision is portrayed in the Houston Chronicle, and gives detailed discussion of laws regarding it. Attitudes, beliefs, experiences and reactions of African immigrants towards the practice and American's perceptions of female circumcision is examined via a series of case studies. ^ Data show that media and laws portray female circumcision negatively and make little attempt to understand the cultural practice, generating outrage among Africans who would like to see changes in the practice. ^

An analysis of two methods for the classification of stage of readiness to obtain repeat mammography screening

Background and purpose: Breast cancer continues to be a health problem for women, representing 28 percent of all female cancers and remaining one of the leading causes of death for women. Breast cancer incidence rates become substantial before the age of 50. After menopause, breast cancer incidence rates continue to increase with age creating a long-lasting source of concern (Harris et al., 1992). Mammography, a technique for the detection of breast tumors in their nonpalpable stage when they are most curable, has taken on considerable importance as a public health measure. The lifetime risk of breast cancer is approximately 1 in 9 and occurs over many decades. Recommendations are that screening be periodic in order to detect cancer at early stages. These recommendations, largely, are not followed. Not only are most women not getting regular mammograms, but this circumstance is particularly the case among older women where regular mammography has been proven to reduce mortality by approximately 30 percent. The purpose of this project was to increase our understanding of factors that are associated with stage of readiness to obtain subsequent mammograms. A secondary purpose of this research was to suggest further conceptual considerations toward the extension of the Transtheoretical Model (TTM) of behavior change to repeat screening mammography. ^ Methods. A sample (n = 1,222) of women 50 years and older in a large multi-specialty clinic in Houston, Texas was surveyed by mail questionnaire regarding their previous screening experience and stage of readiness to obtain repeat screening. A computerized database, maintained on all women who undergo mammography at the clinic, was used to identify women who are eligible for the project. The major statistical technique employed to select the significant variables and to examine the man and interaction effects of independent variables on dependent variables was polychotomous stepwise, logistic regression. A prediction model for each stage of readiness definition was estimated. The expected probabilities for stage of readiness were calculated to assess the magnitude and direction of significant predictors. ^ Results. Analysis showed that both ways of defining stage of readiness for obtaining a screening mammogram were associated with specific constructs, including decisional balance and processes of the change. ^ Conclusions. The results of the present study demonstrate that the TTM appears to translate to repeat mammography screening. Findings in the current study also support finding of previous studies that suggest that stage of readiness is associated with respondent decisional balance and the processes of change. ^

Prenatal care: A survey of African American women in Houston

The focus of the study was to identify variables that African American women who delivered at a teaching hospital in Houston, Harris County, Texas, between January 12, 1998 and April 24, 1998 perceived to prevent them from receiving adequate prenatal care. The research was based on Aday and Andersen's Framework for the Study of Access to Medical Care. A self-administered questionnaire, using realized and potential access indicators, was developed and administered to 161 African American patients at the study hospital. ^ The objectives of the study were (1) to describe the demographic characteristics of African American women who delivered at a large urban teaching hospital between January 12, 1998 and April 24, 1998; and to determine the relationships between (2) predisposing factors such as age, race, educational level, marital status, family structure, social support and attitude toward prenatal care and prenatal care utilization; (3) enabling factors such as income, employment, insurance status, transportation, appointment, and regular source of care; (4) need factors such as perceived health status, number of past pregnancies, pregnancy occurrence; and (5) the relative importance of predisposing, enabling and need factors as predictors of utilization of prenatal care. The indicators of prenatal care utilization examined included the trimester in which the women initiated prenatal care, number of visits, and numbers and types of services received during pregnancy. Barriers cited included low income and inadequate insurance coverage, problems of transportation and child care, unawareness of pregnancy, delays in the scheduling of appointments, and having too many other problems. ^ The results of the study have implications for well-defined public health promotion campaigns, social support system enhancement, and appointment scheduling reform with an emphasis on prenatal care. ^

Effects of exercise with oxygen prebreathe for decompression risk reduction

Astronauts performing extravehicular activities (EVA) are at risk for occupational hazards due to a hypobaric environment, in particular Decompression Sickness (DCS). DCS results from nitrogen gas bubble formation in body tissues and venous blood. Denitrogenation achieved through lengthy staged decompression protocols has been the mainstay of prevention of DCS in space. Due to the greater number and duration of EVAs scheduled for construction and maintenance of the International Space Station, more efficient alternatives to accomplish missions without compromising astronaut safety are desirable. ^ This multi-center, multi-phase study (NASA-Prebreathe Reduction Protocol study, or PRP) was designed to identify a shorter denitrogenation protocol that can be implemented before an EVA, based on the combination of adynamia and exercise enhanced oxygen prebreathe. Human volunteers recruited at three sites (Texas, North Carolina and Canada) underwent three different combinations (“PRP phases”) of intense and light exercise prior to decompression in an altitude chamber. The outcome variables were detection of venous gas embolism (VGE) by precordial Doppler ultrasound, and clinical manifestations of DCS. Independent variables included age, gender, body mass index, oxygen consumption peak, peak heart rate, and PRP phase. Data analysis was performed both by pooling results from all study sites, and by examining each site separately. ^ Ten percent of the subjects developed DCS and 20% showed evidence of high grade VGE. No cases of DCS occurred in one particular PRP phase with use of the combination of dual-cycle ergometry (10 minutes at 75% of VO2 peak) plus 24 minutes of light EVA exercise (p = 0.04). No significant effects were found for the remaining independent variables on the occurrence of DCS. High grade VGE showed a strong correlation with subsequent development of DCS (sensitivity, 88.2%; specificity, 87.2%). In the presence of high grade VGE, the relative risk for DCS ranged from 7.52 to 35.0. ^ In summary, a good safety level can be achieved with exercise-enhanced oxygen denitrogenation that can be generalized to the astronaut population. Exercise is beneficial in preventing DCS if a specific schedule is followed, with an individualized VO2 prescription that provides a safety level that can then be applied to space operations. Furthermore, VGE Doppler detection is a useful clinical tool for prediction of altitude DCS. Because of the small number of high grade VGE episodes, the identification of a high probability DCS situation based on the presence of high grade VGE seems justified in astronauts. ^

Predictors of weight stability in women and men: The aerobic center longitudinal study, 1987--1995

It is estimated that more than half the U.S. adult population is overweight or obese as classified by a body mass index of 25.0–29.9 or ≥30 kg/m 2, respectively. Since the current treatment approaches for long-term maintenance of weight loss are lacking, the National Institutes of Health state that an effective approach may be to focus on weight gain prevention. There is a limited body of literature describing how adults maintain a stable weight as they age. It is hypothesized that weight stability is the result of a balance between energy consumption and energy expenditure as influenced by diet, lifestyle, behavior, genetics and environment. The purpose of this research was to examine the dietary intake and behaviors, lifestyle habits, and risk factors for weight change that predict weight stability in a cohort of 2101 men and 389 women aged 20 to 8 7 years in the Aerobic Center Longitudinal Study regardless of body weight at baseline. At baseline, participants completed a maximal exercise treadmill test to determine cardiorespiratory fitness, a medical history questionnaire, which included self-reported measures of weight, dietary behaviors, lifestyle habits, and risk factors for weight change, a three-day diet record, and a mail-back version of the medical history questionnaire in 1990 or 1995. All analyses were performed separately for men and women. Results from multivariate regression analyses indicated that the strongest predictor of follow-up weight for men and women was previous weight, accounting for 87.0% and 81.9% of the variance, respectively. Age, length of follow-up and eating habits were also significant predictors of follow-up weight in men, though these variables only explained 3% of the variance. For women, length of follow-up and currently being on a diet were significantly associated with follow-up weight but these variables explained only an additional 2% of the variance. Understanding the factors that influence weight change has tremendous public health importance for developing effective methods to prevent weight gain. Since current weight was the strongest predictor of previous weight, preventing initial weight gain by maintaining a stable weight may be the most effective method to combat the increasing prevalence of overweight and obesity. ^

Environmental and behavioral risk factors for moderate or severe rotavirus diarrhea in children less than 24 months

On a global basis rotaviruses are the most important agents involved in childhood diarrhea. In developing countries they account for 6% of all diarrheas and 20% of all diarrhea related deaths of children under 5 years of age, with over 1 billion episodes and over 4 million deaths annually. Given the disease burden, there is a need for better understanding the risk factors involved in rotavirus disease, to identify areas of intervention. In order to provide this information, two areas were developed: a review of the literature, examining the causal evidence for rotavirus diarrhea and a case comparison study. The case comparison study analyzed two areas: identifying climate factors and, identifying environmental and behavioral risk factors. The literature review showed that few analytical studies have identified specific risk factors such as home environment, and a winter seasonal trend for temperate areas, but in key areas evidence is contradictory. The case comparison study for climate factors demonstrated that seasonality occurs in a tropical country like Venezuela and that a complex interplay between weather conditions contribute to the seasonal pattern. A positive association between rain fall (OR 4.1); dew point (OR 2.3) and temperature differential during the day (OR 1.4) and, an inverse association with temperature (OR 0.5) and relative humidity (OR 0.8) was found. This information is useful in understanding the seasonal pattern of rotavirus and for planning health care needs. The second analysis demonstrated that environmental variables such as crowding (OR 14.3), contact with someone with an infectious disease (OR 4.9) and animal ownership (OR 2.3) were important. Restricting the analysis to animal owners demonstrated that living In a rural settling (OR 13.8), defecating in inappropriate places (OR 7.2), crowding(4.2) and indoor animals (4.0) are of importance. Behavioral variables identified were: lack of breast feeding (OR 4.0) and visiting when someone was sick (OR 3.4). Biological and demographic variables of importance were: age, with a dose response relationship; undernurishment (OR 11.3) and household per capita monthly income less than US $ 16.30 (OR 8.5). Using a diarrhea compeer group we found that, although some of the previous variables were of importance, no major differences were found. These findings are important in identifying paths for prevention and further research. ^

Primary lung cancer after breast cancer: The role of radiation therapy and cigarette smoking

The magnitude of the interaction between cigarette smoking, radiation therapy, and primary lung cancer after breast cancer remains unresolved. This case control study further examines the main and joint effects of cigarette smoking and radiation therapy (XRT) among breast cancer patients who subsequently developed primary lung cancer, at The University of Texas M. D. Anderson Cancer Center (MDACC) in Houston, Texas. Cases (n = 280) were women diagnosed with primary lung cancer between 1955 and 1970, between 30–89 years of age, who had a prior history of breast cancer, and were U.S. residents. Controls (n = 300) were randomly selected from 37,000 breast cancer patients at MDACC and frequency matched to cases on age at diagnosis (in 5-year strata), ethnicity, year of breast cancer diagnosis (in 5-year strata), and had survived at least as long as the time interval for lung cancer diagnosis in the cases. Stratified analysis and unconditional logistic regression modeling were used to calculate the main and joint effects of cigarette smoking and radiation treatment on lung cancer risk. Medical record review yielded smoking information on 93% of cases and 84% of controls, and among cases 45% received XRT versus 44% of controls. Smoking increased the odds of lung cancer in women who did not receive XRT (OR = 6.0, 95%CI, 3.5–10.1) whereas XRT was not associated with increased odds (OR = 0.5, 95%CI, 0.2–1.1) in women who did not smoke. Overall the odds ratio for both XRT and smoking together compared with neither exposure was 9.00 (9 5% CI, 5.1–15.9). Similarly, when stratifying on laterality of the lung cancer in relation to the breast cancer, and when the time interval between breast and lung cancers was >10 years, there was an increased odds for both smoking and XRT together for lung cancers on the same side as the breast cancer (ipsilateral) (OR = 11.5, 95% CI, 4.9–27.8) and lung cancers on the opposite side of the breast cancer (contralateral) (OR= 9.6, 95% CI, 2.9–0.9). After 20 years the odds for the ipsilateral lung were even more pronounced (OR = 19.2, 95% CI, 4.2–88.4) compared to the contralateral lung (OR = 2.6, 95% CI, 0.2–2.1). In conclusion, smoking was a significant independent risk factor for lung cancer after breast cancer. Moreover, a greater than multiplicative effect was observed with smoking and XRT combined being especially evident after 10 years for both the ipsilateral and contralateral lung and after 20 years for the ipsilateral lung. ^

Intendedness of pregnancy among active duty women in the U.S. Army

Objective. The objective of this study was to determine the prevalence of unintended pregnancy and the association between social and demographic factors among a population of active duty women in the U.S. Army giving birth to viable infants at a U.S. Army hospital at Fort Hood, Texas. Prevalence of unintended pregnancy in this group was 50.9% (95% CI 44.0 to 57.9) with 36.3% being mistimed (95% CI 29.8 to 33.2) and 14.6% being unwanted (95% CI 10.2 to 20.1). A further 14.2% of the women experienced ambivalence (95% CI 9.8 to 19.6). ^ The study population was a cross-sectional group of active duty pregnant women who represent the target population of all female soldiers that deliver viable infants in the Army. Using a survey based on previous studies, intendedness of pregnancy at conception was retrospectively determined. Unintended births are further characterized as mistimed or unwanted. Demographic and other exposures were described bivariately. Associations were evaluated using measures of relative risk and chi-square analysis. ^ The results of the research indicate that in the study population, race/ethnicity is not associated with unintended pregnancy and non-commissioned officers had a lower rate of unintended pregnancy than other rank groupings. ^