Project Alpha: A culturally appropriate approach to adolescent male sex education

In the United States today, adolescents face unacceptably high rates of mortality and morbidity due to the contraction of HIV/AIDS, sexually transmitted diseases and teenage pregnancy. In view of these rates, there is a need for applied preventive interventions to delay adolescent sexual behavior until adulthood. Project Alpha was a school-adopted, quasi-experimental program for adolescent male students attending Sharpstown High School in Houston, Texas. This intervention used student newsletters to provide specific role-model stories on community and student role models who have changed attitudes or improved efficacy to abstain from sexual behavior until adulthood. It was hypothesized that teenagers exposed to the intervention would show improvements in knowledge, beliefs, avoidance skills, perceived norms, intentions and self-efficacy to delay sexual behavior compared to no-treatment reference teenagers in the same school.^ In total, the Project Alpha program had a significant effect on student knowledge, beliefs (towards abstinence and having sex with multiple partners), perceived risk (HIV/STD testing), self-efficacy (could avoid sex with attractive girl who wants to have sex), perceived social norms (friends believing in sexual abstinence) and sexual intentions. However, no significant intervention effects were found in student's beliefs (that it was OK to have sex with girlfriend), perceived risk of HIV/STD, self-efficacy (to avoid sex with girlfriend) and social norms (friends believe it is OK to have sex with a girlfriend and multiple partners in the same month). ^

Culturally sensitive cancer education: Effect on knowledge, cancer fatalism, and participation in mobile mammography screening among African-American women

Purpose. To evaluate the effectiveness of a culturally sensitive educational intervention that used an African American lay survivor of breast cancer to increase knowledge of breast cancer, decrease cancer fatalism, and increase participation in mobile mammography screening among African American women. ^ Design. Experimental pretest/posttest design. ^ Setting. Two predominantly African American churches in a large southwestern metropolitan city. ^ Sample. Participants included 93 African American women, 40 years of age and older. Participants were randomly assigned to an intervention group (n = 48) or a control group (n = 45). ^ Methods. Pretest and post-test measures included the Breast Cancer Knowledge Test and the Powe Fatalism Inventory. In addition, demographic and breast screening practices were collected by questionnaire. The intervention group received a breast cancer educational testimonial from an African American lay survivor of breast cancer, who answered questions and addressed concerns, while stressing the importance of taking responsibility for one's own health and spreading disease prevention messages throughout the African American community. The control group viewed the American Cancer Society “Keep In Touch” video prepared specifically for African American women. Participants in both groups were given culturally sensitive educational materials designed to increase knowledge about breast cancer, and were instructed on breast self-examination by an African American registered nurse, using ethnically appropriate breast models. In addition, after the post-test, all eligible participants were given an opportunity to have a free mammogram via a mobile mammography unit parked at the church. ^ Findings. Participants in the intervention group had a significant increase (p = .03) in knowledge of breast cancer and a significant decrease (p = .000) in fatalism scores compared to those individuals in the control group. The intervention group had a 61% participation rate in screening, while the control group had a 39% participation rate in screening. However, the difference was not statistically significant at the .05 level (p = .07). ^ Conclusions. Results demonstrate that culturally sensitive breast cancer education is successful in increasing knowledge and decreasing cancer fatalism. While there was a trend toward behavior change in the intervention group, more research needs to be done in this area. ^

CATCH across Texas: Building a model for the diffusion of effective school-based health promotion programs

The impact of health promotion programs is related to both program effectiveness and the extent to which the program is implemented among the target population. The purpose of this dissertation was to describe the development and evaluation of a school-based program diffusion intervention designed to increase the rate of dissemination and adoption of the Child and Adolescent Trial for Cardiovascular Health, or CATCH program (recently renamed the Coordinated Approach to Child Health). ^ The first study described the process by which schools across the state of Texas spontaneously began to adopt the CATCH program after it was tested and proven effective in a multi-site randomized efficacy trial. A survey of teachers and administrator representatives of all schools on record that purchased the CATCH program, but were not involved in the efficacy trial, was used to find out who brought CATCH into the schools, how they garnered support for its adoption, why they decided to adopt the program, and what was involved in deciding to adopt. ^ The second study described how the Intervention Mapping framework guided the planning, development and implementation of a program for the diffusion of CATCH. An iterative process was used to integrate theory, literature, the experience of project staff and data from the target population into a meaningful set of program determinants and performance objectives. Proximal program objectives were specified and translated into both media and interpersonal communication strategies for program diffusion. ^ The third study assessed the effectiveness of the diffusion program in a case-comparison design. Three of the twenty Education Service Center regions in Texas were chosen, selected based on similar demographic criteria, and were followed for adoption of the CATCH curriculum. One of these regions received the full media and interpersonal channel intervention; a second received a reduced media-only intervention, and a third received no intervention. Results suggested the use of the interpersonal channels with media follow-up is an effective means to facilitate program dissemination and adoption. The media-alone condition was not effective in facilitating program adoption. ^

Texas Department of Health organizational structure changes: A reflection of public health policy and agency expansion, September 1, 1946--June 30, 1994

The premise of this study is that changes in the agency's organizational structure reflect changes in government public health policy. Based on this premise, this study tracks the changes in the organizational structure and the overall expansion of the Texas Department of Health to understand the evolution of changing public health priorities in state policy from September 1, 1946 through June 30, 1994, a period of growth and new responsibilities. It includes thirty-seven observations of organizational structure as depicted by organizational charts of the agency and/or adapted from public documents. ^ The major questions answered are, what are the changes in the organizational structure, why did they occur and, what are the policy priorities reflected in these changes in and across the various time periods. ^ The analysis of the study included a thorough review of the organizational structure of the agency for the time-span of the study, the formulation of the criteria to be used in ascertaining the changes, the delineation of the changes in the organizational structure and comparison of the observations sequentially to characterize the change, the discovery of reasons for the structural changes (financial, statutory - federal and state, social and political factors), and the determination of policy priorities for each time period and their relation to the expansion and evolution of the agency. ^ The premise that the organizational structure of the agency and the changes over time reflect government public health policy and agency expansion was found to be true. ^

Zoning and the built environment: A public health analysis of zoning in Austin, Texas

The built environment is part of the physical environment made by people and for people. Because the built environment is such a ubiquitous component of the environment, it acts as an important pathway in determining health outcomes. Zoning, a type of urban planning policy, is one of the most important mechanisms connecting the built environment to public health. This policy analysis research paper explores how zoning regulations in Austin, Texas promote or prohibit the development of a healthy built environment. A systematic literature review was obtained from Active Living Research, which contained literature published about the relationships between the built environment, physical activity, and health. The results of these studies identified the following four components of the built environment that were associated to health: access to recreational facilities, sprawl and residential density, land use mix, and sidewalks and their walkability. A hierarchy analysis was then performed to demonstrate the association between these aspects of the built environment and health outcomes such as obesity, cardiovascular disease, and general health. Once these associations had been established, the components of the built environment were adapted into the evaluation criteria used to conduct a public health analysis of Austin's zoning ordinance. A total of eighty-eight regulations were identified to be related to these components and their varying associations to human health. Eight regulations were projected to have a negative association to health, three would have both a positive and negative association simultaneously, and nine were indeterminable with the information obtained through the literature review. The remaining sixty-eight regulations were projected to be associated in a beneficial manner to human health. Therefore, it was concluded that Austin's zoning ordinance would have an overwhelmingly positive impact on the public's health based on identified associations between the built environment and health outcomes.^

Prevalence of depressive symptoms among Hispanic women attending a public health clinic

Background. Estimates of perinatal depression have ranged from 5% to more than 25% of women (Gavin et al. 2005). Although Hispanics have one of the highest birthrates, few studies have looked at the prevalence of depression among this population. This study aims to describe the prevalence of depressive symptoms among a sample of Hispanic women. Methods. A convenience sample of 439 Hispanic women were screened for depression using the Center for Epidemiologic Studies Depression Scale. Sociodemographic data relating to pregnancy were also collected. Results. Although bivariate analysis found several variables to be significant, multivariate analysis found only marital and pregnancy status to be significant in predicting depression. Conclusions. While marital and pregnancy status proved to the strongest predictors for depression, future research would benefit from collecting information on timing of pregnancy and postpartum to further explore the role of pregnancy status and depressive symptoms. ^

A model for use by local public health departments to evaluate pandemic influenza plans

The events of the 1990's and early 2000's demonstrated the need for effective planning and response to natural and man-made disasters. One of those potential natural disasters is pandemic flu. Once defined, the CDC stated that program, or plan, effectiveness is improved through the process of program evaluation. (Centers for Disease Control and Prevention, 1999) Program evaluation should be accomplished not only periodically, but in the course of routine administration of the program. (Centers for Disease Control and Prevention, 1999) Accomplishing this task for a "rare, but significant event" is challenging. (Herbold, John R., PhD., 2008) To address this challenge, the RAND Corporation (under contract to the CDC) developed the "Facilitated Look-Backs" approach that was tested and validated at the state level. (Aledort et al., 2006).^ Nevertheless, no comprehensive and generally applicable pandemic influenza program evaluation tool or model is readily found for use at the local public health department level. This project developed such a model based on the "Facilitated Look-Backs" approach developed by RAND Corporation. (Aledort et al., 2006) Modifications to the RAND model included stakeholder additions, inclusion of all six CDC program evaluation steps, and suggestions for incorporating pandemic flu response plans in seasonal flu management implementation. Feedback on the model was then obtained from three LPHD's—one rural, one suburban, and one urban. These recommendations were incorporated into the final model. Feedback from the sites also supported the assumption that this model promotes the effective and efficient evaluation of both pandemic flu and seasonal flu response by reducing redundant evaluations of pandemic flu plans, seasonal flu plans, and funding requirement accountability. Site feedback also demonstrated that the model is comprehensive and flexible, so it can be adapted and applied to different LPHD needs and settings. It also stimulates evaluation of the major issues associated with pandemic flu planning. ^ The next phase in evaluating this model should be to apply it in a program evaluation of one or more LPHD's seasonal flu response that incorporates pandemic flu response plans.^

Racial disparities in CD4 counts at initial HIV-1 diagnosis: Analysis of the Adult Spectrum of HIV disease dataset and public health implications

Introduction. The HIV/AIDS disease burden disproportionately affects minority populations, specifically African Americans. While sexual risk behaviors play a role in the observed HIV burden, other factors including gender, age, socioeconomics, and barriers to healthcare access may also be contributory. The goal of this study was to determine how far down the HIV/AIDS disease process people of different ethnicities first present for healthcare. The study specifically analyzed the differences in CD4 cell counts at the initial HIV-1 diagnosis with respect to ethnicity. The study also analyzed racial differences in HIV/AIDS risk factors. ^ Methods. This is a retrospective study using data from the Adult Spectrum of HIV Disease (ASD), collected by the City of Houston Department of Health. The ASD database contains information on newly reported HIV cases in the Harris County District Hospitals between 1989 and 2000. Each patient had an initial and a follow-up report. The extracted variables of interest from the ASD data set were CD4 counts at the initial HIV diagnosis, race, gender, age at HIV diagnosis and behavioral risk factors. One-way ANOVA was used to examine differences in baseline CD4 counts at HIV diagnosis between racial/ethnic groups. Chi square was used to analyze racial differences in risk factors. ^ Results. The analyzed study sample was 4767. The study population was 47% Black, 37% White and 16% Hispanic [p<0.05]. The mean and median CD4 counts at diagnosis were 254 and 193 cells per ml, respectively. At the initial HIV diagnosis Blacks had the highest average CD4 counts (285), followed by Whites (233) and Hispanics (212) [p<0.001 ]. These statistical differences, however, were only observed with CD4 counts above 350 [p<0.001], even when adjusted for age at diagnosis and gender [p<0.05]. Looking at risk factors, Blacks were mostly affected by intravenous drug use (IVDU) and heterosexuality, whereas Whites and Hispanics were more affected by male homosexuality [ p<0.05]. ^ Conclusion. (1) There were statistical differences in CD4 counts with respect to ethnicity, but these differences only existed for CD4 counts above 350. These differences however do not appear to have clinical significance. Antithetically, Blacks had the highest CD4 counts followed by Whites and Hispanics. (2) 50% of this study group clinically had AIDS at their initial HIV diagnosis (median=193), irrespective of ethnicity. It was not clear from data analysis if these observations were due to failure of early HIV surveillance, HIV testing policies or healthcare access. More studies need to be done to address this question. (3) Homosexuality and bisexuality were the biggest risk factors for Whites and Hispanics, whereas for Blacks were mostly affected by heterosexuality and IVDU, implying a need for different public health intervention strategies for these racial groups. ^

Evaluation of a pilot diabetes educational intervention using the American Diabetes Association's Risk Assessment form with the patrons of The Health Museum, Houston Texas

Diabetes Mellitus is not a disease, but a group of diseases. Common to all types of diabetes is high levels of blood glucose produced from a variety of causes. In 2006, the American Diabetes Association ranked diabetes as the fifth leading cause of death in the United States. The complications and consequences are serious and include nephropathy, retinopathy, neuropathy, heart disease, amputations, pregnancy complications, sexual dysfunction, biochemical imbalances, susceptibility and sensitivity to many other diseases and in some cases death. ^ The serious nature of diabetes mellitus and its complications has compelled researchers to devise new strategies to reach population segments at high risk. Various avenues of outreach have been attempted. This pilot program is not unique in using a health museum as a point of outreach. However health museums have not been a major source of interventions, either. Little information was available regarding health museum visitor demographics, visitation patterns, companion status and museum trust levels prior to this pilot intervention. This visitor information will improve planning for further interventions and studies. ^ This thesis also examined prevalence data in a temporal context, the populations at risk for diabetes, the collecting agencies, and other relevant collected data. The prevalence of diabetes has been rapidly increasing. The increase is partially explained by refinement of the definition of diabetes as the etiology has become better understood. Increasing obesity and sedentary lifestyles have contributed to the increase, as well as the burdensome increase on minority populations. ^ Treatment options are complex and have had limited effectiveness. This would lead one to conclude that prevention and early diagnosis are preferable. However, the general public has insufficient awareness and education regarding diabetes symptoms and the serious risks and complications the disease can cause. Reaching high risk, high prevalence, populations is challenging for any intervention. During its “free family Thursdays” The Health Museum (Houston, Texas) has attracted a variety of ethnic patrons; similar to the Houston and Harris County demographics. This research project explored the effectiveness of a pilot diabetes educational intervention in a health museum setting where people chose to visit. ^

An analysis of Texas's school based HPV vaccine mandate: A public health risk communication failure: HPVETO!

Genital human papillomavirus (HPV) is of public health concern because persistent infection with certain HPV types can cause cervical cancer. In response to a nationwide push for cervical cancer legislation, Texas Governor Rick Perry bypassed the traditional legislative process and issued an executive order mandating compulsory HPV vaccinations for all female public school students prior to their entrance in the sixth grade. By bypassing the legislative process Governor Perry did not effectively mitigate the risk perception issues that arose around the need for and usefulness of the vaccine mandate. This policy paper uses a social policy paradigm to identify perception as the key intervening factor on how the public responds to risk information. To demonstrate how the HPV mandate failed, it analyzes four factors, economics, politics, knowledge and culture, that shape perception and influence the public's response. By understanding the factors that influence the public's perception, public health practitioners and policy makers can more effectively create preventive health policy at the state level. ^

An investigation into the relationship between screen time, consumption of advertised foods, and physical activity among Texas 4th grade elementary school children

Background. The high prevalence of obesity among children has spurred creation of a list of possible causative factors, including the advertising of foods of minimal nutritional value, a decrease in physical activity, and increased media use. Few studies show prevalence rates of these factors among large cohorts of children. ^ Methods. Using data from the 2004-2005 School Physical Activity and Nutrition project (SPAN), a secondary analysis of 7907 4th-grade children (mean age 9.74 years) was conducted. In addition, a comic-book–based intervention that addressed advertised food consumption, physical activity, and media use was developed and evaluated using a pre-post test design among 4th-grade children in an urban school district. ^ Results. Among a cohort of 4th-grade children across the state of Texas, children who had more than 2 hours of video game or computer time the previous day were more than twice as likely to drink soda and eat candy or pastries. In addition, children who watched more than 2 hours of TV the previous day were more than three times as likely to consume chips, punch, soda, candy, frozen desserts, or pastries (AOR 3.41, 95% CI: 1.58, 7.37). A comic-book based intervention held great promise and acceptance among 4th-grade children. Outcome evaluation showed that while results moved in a positive direction, they were not statistically significant. ^ Conclusion. Statistically significant associations were found between screen time and eating various types of advertised food. The comic book intervention was widely accepted by the children exposed to it, and pre-post surveys indicated they moved constructs in a positive direction. Further research is needed to look at more specific ways in which children are exposed to TV, and the relationship of the TV viewing time with their consumption of advertised foods. In addition, researchers should look at comic book interventions more closely and attempt to utilize them in more in studies with a longer follow-up time. ^

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. ^

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. ^

Perspectives on the public health implications of global climate change and the epidemiology of vector-borne disease

Global climate change is becoming an increasing concern among the public health community. Some researchers believe the earth is rapidly undergoing changes in temperature, sea level, population movement, and extreme weather phenomenon. With these geographic, meteorological, and social changes come increased threats to human health. One of these threats is the spread of vector-borne infectious diseases. The changes mentioned above are believed to contribute to increased arthropod survival, transmission, and habitation. These changes, in turn, lead to increased incidence among neighboring human populations. It is also argued that human action may play more of a role than climate change. This systematic review served to determine whether or not climate change poses a significant risk to human exposure and increased incidence of vector-borne disease. ^

Validation of an instrument for assessing the medicolegal death investigation system: A public health approach

Background. This study validated the content of an instrument designed to assess the performance of the medicolegal death investigation system. The instrument was modified from Version 2.0 of the Local Public Health System Performance Assessment Instrument (CDC) and is based on the 10 Essential Public Health Services. ^ Aims. The aims were to employ a cognitive testing process to interview a randomized sample of medicolegal death investigation office leaders, qualitatively describe the results, and revise the instrument accordingly. ^ Methods. A cognitive testing process was used to validate the survey instrument's content in terms of the how well participants could respond to and interpret the questions. Twelve randomly selected medicolegal death investigation chiefs (or equivalent) that represented the seven types of medicolegal death investigation systems and six different state mandates were interviewed by telephone. The respondents also were representative of the educational diversity within medicolegal death investigation leadership. Based on respondent comments, themes were identified that permitted improvement of the instrument toward collecting valid and reliable information when ultimately used in a field survey format. ^ Results. Responses were coded and classified, which permitted the identification of themes related to Comprehension/Interpretation, Retrieval, Estimate/Judgment, and Response. The majority of respondent comments related to Comprehension/Interpretation of the questions. Respondents identified 67 questions and 6 section explanations that merited rephrasing, adding, or deleting examples or words. In addition, five questions were added based on respondent comments. ^ Conclusion. The content of the instrument was validated by cognitive testing method design. The respondents agreed that the instrument would be a useful and relevant tool for assessing system performance. ^