AN EMPIRICAL ESTIMATION OF MEDICAL AND NON-MEDICAL INPUTS IN THE PRODUCTION OF CARDIO-RESPIRATORY PHYSICAL HEALTH STATUS

The purpose of this study was to examine, in the context of an economic model of health production, the relationship between inputs (health influencing activities) and fitness.^ Primary data were collected from 204 employees of a large insurance company at the time of their enrollment in an industrially-based health promotion program. The inputs of production included medical care use, exercise, smoking, drinking, eating, coronary disease history, and obesity. The variables of age, gender and education known to affect the production process were also examined. Two estimates of fitness were used; self-report and a physiologic estimate based on exercise treadmill performance. Ordinary least squares and two-stage least squares regression analyses were used to estimate the fitness production functions.^ In the production of self-reported fitness status the coefficients for the exercise, smoking, eating, and drinking production inputs, and the control variable of gender were statistically significant and possessed theoretically correct signs. In the production of physiologic fitness exercise, smoking and gender were statistically significant. Exercise and gender were theoretically consistent while smoking was not. Results are compared with previous analyses of health production. ^

A PUBLIC HEALTH SURVEILLANCE SYSTEM FOR THE WESTERN CAYO DISTRICT, BELIZE (DISEASE)

A demonstration project entailing disease surveillance was conducted in the western Cayo District, Belize, from November 1981 to March 1982. The purpose was to test and demonstrate the feasibility of community-based surveillance. Interviews were conducted in three hundred twenty households at monthly intervals over a five-month period. Information regarding disease prevalence and medical care utilization relevant to public health practice was analyzed by staff attached to the health center in Benque Viejo. Data collected at the health center were used to validate reported findings.^ Differences between reported and actual study findings regarding clinic visits were small, though in many instances statistically significant. The proportion of underreported clinic visits was greater than the proportion overreported. Overall, reporting accuracy improved with time, particularly from the first to second month. Clinic utilization experience reported for men was as accurate as that reported for females.^ There was agreement between interview and clinic disease findings. In fact, the proportion of conditions defined in the interview and matched to clinic findings was high (malaria, diarrhea, dysentery, skin sores and ulcerations, and problems of nutrition) except for upper respiratory disorders. Finally, some conditions were more likely to be taken to the health center than others, e.g., children with diarrhea or skin sores and ulcerations were less likely to be taken to the health center than if they had malaria. ^

THE EVALUATION OF PUBLIC HEALTH COMPONENTS OF INTERNATIONAL DISASTER RELIEF OPERATIONS: INDOCHINESE REFUGEES IN THAILAND, 1979-1982

Refugee populations suffer poor health status and yet the activities of refugee relief agencies in the public health sector have not been subjected previously to comprehensive evaluation. The purpose of this study was to examine the effectiveness and cost of the major public health service inputs of the international relief operation for Indochinese refugees in Thailand coordinated by the United Nations High Commissioner for Refugees (UNHCR). The investigator collected data from surveillance reports and agency records pertaining to 11 old refugee camps administered by the Government of Thailand Ministry of Interior (MOI) since an earlier refugee influx, and five new Khmer holding centers administered directly by UNHCR, from November, 1979, to March, 1982.^ Generous international funding permitted UNHCR to maintain a higher level of public health service inputs than refugees usually enjoyed in their countries of origin or than Thais around them enjoyed. Annual per capita expenditure for public health inputs averaged approximately US$151. Indochinese refugees in Thailand, for the most part, had access to adequate general food rations, to supplementary feeding programs, and to preventive health measures, and enjoyed high-quality medical services. Old refugee camps administered by MOI consistently received public health inputs of lower quantity and quality compared with new UNHCR-administered holding centers, despite comparable per capita expenditure after both types of camps had stabilized (static phase).^ Mortality and morbidity rates among new Khmer refugees were catastrophic during the emergency and transition phases of camp development. Health status in the refugee population during the static phase, however, was similar to, or better than, health status in the refugees' countries of origin or the Thai communities surrounding the camps. During the static phase, mortality and morbidity generally remained stable at roughly the same low levels in both types of camps.^ Furthermore, the results of multiple regression analyses demonstrated that combined public health inputs accounted for from one to 23 per cent of the variation in refugee mortality and morbidity. The direction of associations between some public health inputs and specific health outcome variables demonstrated no clear pattern. ^

Study of rural leadership and implications for community participation and development in the health and family planning programs in Bangladesh

The vast majority of Bangladesh are poor and are unable even to provide for the most basic human needs. These are the landless and marginal farmers of Bangladesh. They constitute 70% of the rural population, which in turn constitute about 90% of the country's population.^ Effective development of Bangladesh would largely mean the development of the landless and marginal farmers. Past efforts of development in this section of the population, including that of the government, have not succeeded. One of the development goals of the government of Bangladesh is to improve the quality of life of the rural population through health and population control measures. Overpopulation, malnutrition and diarrhea are the major impediments to socioeconomic development in Bangladesh.^ The current study was designed to identify whether there is effective opinion leadership among the marginal and landless peasants affecting decisions on acceptance or nonacceptance of family planning methods and oral rehydration therapy (ORT) in the selected rural areas of Bangladesh. The study was conducted in eight randomly selected villages with funding from the Ministry of Health and Family Planning, government of Bangladesh. One hundred twenty-five opinion leaders were interviewed after they were identified by 408 rural couples owning land less than 2 acres and wives' age below 50. The study was conducted in two phases; couples' interview preceded that of the leaders.^ Findings of the study reveal that the opinion leaders influencing adoption of health and family planning among the landless and marginal farmers belong to the same class. Theses opinion leaders own land much less than the rich farmers and the formal leaders in the rural areas. Majority of these of opinion leaders are friends, neighbors and relatives, some are other persons who are businessmen and professionals like doctors, while the rest few are the field workers of health and family planning. Source of influence as a factor contribute most in differentiating use and non-use of family planning and ORT among both couples and leaders. The most frequent sources of influence referred by the couples and the leaders are the field workers of health and family planning, followed by the peer opinion leaders (friends, neighbors, relatives) and spouse.^ The opinion leaders do not differ much from the poor couples on land holding, a strong indicator of economic status, they however differ considerably on social factors such as family planning practice, education, and exposure to mass media.^ The study suggests that future development efforts in Bangladesh have to ensure community participation by the landless and marginal farmers and opinion leaders belonging to their class. ^

Understanding mental illness in Nigeria: Bringing culture and traditional medicine into mental health policy

One of the major challenges in treating mental illness in Nigeria is that the health care facilities and mental health care professionals are not enough in number or well equipped to handle the burden of mental illness. There are several barriers to treatment for individual Nigerians which include the following: such as the lack of understanding of the root causes of mental illness, lack of financial support to get mental treatment, lack of social support (family, friends, neighbors), the fear of stigmatization concerning being labeled as mentally ill or being in association with the mentally ill, and the consultation of traditional native healers who may be unknowingly prolonging illness, rather than addressing and treating them due to lack of formal education and standardization of their treatments. Another barrier is the non-health nature of the mental health services in Nigeria. Traditional healers are essentially the mental health system. The elderly, women, and children are the most vulnerable groups in times of strife and hardships. Their mental well-being must be taken into account as well as their special needs in times of personal or societal crisis. ^ Nigerian mental health policy is geared toward forming a mental health system, but in actuality only a mental illness care system is the observed result of the policy. The government of Nigeria has drafted a mental health policy, yet its actual implementation into the Nigerian health infrastructure and society waits to be materialized. The limited health legislation or policy implementations tend to favor those who have access to these urban areas and the facilities' health services. Nigerians living in rural areas are at a disadvantage; many of them may not even be aware of services available to help them understand and treat mental illness. Perhaps, government driven health interventions geared toward mental illness in rural areas would reach an underserved Nigerians and Africans in general. Issues with political instability and limited infrastructure often hinder crucial financial resources and legislation from reaching the people that are truly in need of governmental leadership in regards to mental health policy.^ Traditional healers are a severely untapped resource in the treatment of mental illness within the Nigerian population. They are abundant within Nigerian communities and are meeting a real need for the mentally ill. However, much can be done to remove the barriers that prevent the integration of traditional healers within the mental health system and improve the quality of care they administer within the population. Mental illness is almost exclusively coped with through traditional medicine practices. Mobilization and education from each strata of Nigerian society and government as well as input from the medical community can improve how traditional medicine is utilized as a treatment for clinical illness and help alleviate the heavy burden of mental illness in Nigeria. Currently, there is no existing policy making structure for a working mental health system in Nigeria, and traditional healers are not taken into account in any formulation of mental health policy. Advocacy for mental illness is severely inadequate due to fear of stigmatization, with no formally recognized national of regional mental health association.^

Burden of invasive pneumococcal disease in Harris County, Texas (2003--2010) and the implication for enhanced public health surveillance of isolates

Invasive pneumococcal disease (IPD) causes significant health burden in the US, is responsible for the majority of bacterial meningitis, and causes more deaths than any other vaccine preventable bacterial disease in the US. The estimated National IPD rate is 14.3 cases per 100,000 population with a case-fatality rate of 1.5 cases per 100,000 population. Although cases of IPD are routinely reported to the local health department in Harris County Texas, the incidence (IR) and case-fatality (CFR) rates have not been reported. Additionally, it is important to know which serotypes of S. pneumoniae are circulating in Harris County Texas and to determine if ‘replacement disease’ is occurring. ^ This study reported incidence and case-fatality rates from 2003 to 2009, and described the trends in IPD, including the IPD serotypes circulating in Harris County Texas during the study period, particularly in 2008 and 2010. Annual incidence rates were calculated and reported for 2003 to 2009, using complete surveillance-year data. ^ Geographic information system (GIS) software was used to create a series of maps of the data reported during the study period. Cluster and outlier analysis and hot spot analysis were conducted using both case counts by census tract and disease rate by census tract. ^ IPD age- and race-adjusted IR for Harris County Texas and their 95% confidence intervals (CIs) were 1.40 (95% CI 1.0, 1.8), 1.71 (95% CI 1.24, 2.17), 3.13 (95% CI 2.48, 3.78), 3.08 (95% CI 2.43, 3.74), 5.61 (95% CI 4.79, 6.43), 8.11 (95% CI 7.11, 9.1), and 7.65 (95% CI 6.69, 8.61) for the years 2003 to 2009, respectively (rates were age- and race-adjusted to each year's midyear US population estimates). A Poisson regression model demonstrated a statistically significant increasing trend of about 32 percent per year in the IPD rates over the course of the study period. IPD age- and race-adjusted case-fatality rates (CFR) for Harris County Texas were also calculated and reported. A Poisson regression model demonstrated a statistically significant increasing trend of about 26 percent per year in the IPD case-fatality rates from 2003 through 2009. A logistic regression model associated the risk of dying from IPD to alcohol abuse (OR 4.69, 95% CI 2.57, 8.56) and to meningitis (OR 2.42, 95% CI 1.46, 4.03). ^ The prevalence of non-vaccine serotypes (NVT) among IPD cases with serotyped isolates was 98.2 percent. In 2008, the year with the sample more geographically representative of all areas of Harris County Texas, the prevalence was 96 percent. Given these findings, it is reasonable to conclude that ‘replacement disease’ is occurring in Harris County Texas, meaning that, the majority of IPD is caused by serotypes not included in the PCV7 vaccine. Also in conclusion, IPD rates increased during the study period in Harris County Texas.^

Funding the utilization of community health workers in Texas

Community health workers (CHWs) are volunteers or paid members of communities that perform outreach, patient assistance, health education, and assist in navigation of healthcare system amongst other duties. The utilization of CHWs in hospital and community setting provides health benefits to their communities while reducing cost to the overall healthcare system. ^ The general population of Texas lacks adequate access to primary care. An important indicator of such a crisis is excessive usage of emergency department services in Texas, especially by the large minority population within the state. Also, unmanaged chronic diseases have been shown to be correlated with the excessive usage of emergency services. According to a recent survey of 25 Houston metropolitan area hospitals, almost 54% of the ER visits could have been resolved in primary care settings. A Galveston based study also indicated that the ER usage was higher amongst African-Americans and Latinos. Meanwhile, 28.5% of the total ER visits were made by Latinos from the surrounding areas (Begley et al., 2007). There is substantial evidence present which indicates enormous cost-savings that CHWs have produced in Texas and nationwide through reduction in unnecessary ER visits along with better management of chronic diseases (Fedder et al, 2003). ^ This paper provides an analysis regarding the need and importance for sustainable and stable sources of funding for Community health workers (CHWs) in Texas utilizing Kingdon's model of Agenda Setting as framework. The policy analysis is also aimed at reporting on the policy process and actions taken by Children at Risk to address this critical issue. Children at Risk, a Houston based advocacy organization, has created a legislative proposal that calls on the Texas Health and Human Commission to apply for a Medicaid §§1115 waiver to provide sustainable sources of funding for CHWs, Rep. John Zerwas sponsored HB 2244 bill and it was filed on March 3, 2011. The bill would affect the use of CHWs in Texas in two ways: 1) through the establishment and operation of a program designed to train and educate CHWs 2) by creating a statewide training and certification advisory committee. The advisory committee is required in the bill to submit recommendations for providing sustainable funding and employment for CHWs. The HB 2244 failed to move out of the House Public Health committee. However, HB2244 was amended into HB 2610 introduced by Representative Guillen. The House Bill 2610 is geared towards establishing a community-based navigator program in order to assist individuals applying for public assistance through the Internet. The House Bill 2610 was signed by the Governor and will be effective September 1, 2011.^

Water to Thrive health needs assessment for Robit, Ethiopia

Developing countries suffer from an array of diseases, of which the developed world is unfamiliar. In order to facilitate the development of community interventions and streamline NGO partnership, needs assessments in targeted areas are conducted. The purpose of this assessment was to attain baseline descriptive data to further understand the needs of the village of Robit, Ethiopia. A trained team collected data from Austin based non-profit Water to Thrive (W2T) on June 1st and 2nd, 2011 through focus groups, key informant interviews, and individual surveys. Qualitative and quantitative data were paired to affirm the results of one another through triangulation. The results identified an apparent need for health intervention and education. Malaria, water-borne disease, respiratory issues (asthma, Upper respiratory tract infections), and maternal and child health were among the evident problems in Robit. There was a clear need for midwife training as well as water sanitation, latrine building, and general illness treatment. Poor road conditions and annual flooding of Robit plays an important role in the poor health and lack of food security of the village. While some evidence of social desirability and recall bias was found in the interview and survey data, the triangulation of findings provided important insights and validity to the needs assessment. ^

Systematic review of current trends of cardiovascular disease (CVD) and association between health insurance coverage and CVD mortality among women aged 60--65 in Texas in 2000--2011

Cardiovascular disease (CVD) is highly preventable, yet it is a leading cause of death among women in Texas. The primary goals of this research were to examine past and current trends of CVD, as well as identify whether there is an association between the insurance coverage and mortality from CVD among women aged 60–65 in Texas between 2000 and 2011. ^ The systematic review of the research is based on the guidelines and recommendations set by the Centre for Reviews and Dissemination for conducting reviews in health care. Over 47 citations of peer-reviewed articles from Ovid MEDLINE and PubMed databases and five websites were identified, of which 7 studies met inclusion criteria for the first systematic review to examine the trends of CVD in Texas. Ten citations of peer-reviewed articles from Ovid MEDLINE and PubMed databases and five web sites were reviewed for the second systematic review (to study the association between insurance coverage and cardiovascular health among Texas women 60–64 years of age), of which 3 studies met inclusion criteria and were included in the research. The results of the study highlighted key gaps in the existing literature and important areas for the further research, as well as determined directions for future public health CVD prevention programs in Texas. ^ Based on the conducted research, the major determinants of premature mortality among women attributed to cardiovascular disease are based on individual level characteristics, more specifically sex, age, race/ethnicity, and education. The results indicate that African American and non-Hispanic white women are more likely to have higher CVD mortality rates than Hispanic women due to higher prevalence of cardiac risk factors. The data also shows higher levels of mortality from CVD in the southeastern United States, with Texas ranking as the third state with the highest prevalence of CVD among women. According to the Texas Department of State Health Services, there are approximately 56,000 deaths caused by CVD annually in Texas, which represents about one death every ten minutes. Coronary artery disease and stroke were the causes of 31.2 percent of all female deaths in Texas in 2009, meaning that approximately 68 women die from any form of cardiac disease in Texas each day. ^ The data of the reviewed studies indicate that women' lack of health insurance was significantly associated with a higher prevalence of cardiovascular disease. The uninsured women were more likely to be unaware of their risk factors and more likely to have undiagnosed diabetes—a co-morbidity factor of CVD. One of the studies also reports strong correlation between state rates of uninsured and lower rates of preventive care. Given these strong correlations, those who were chronically uninsured were at a higher risk of mortality than the insured, due to prolonged periods of time without basic access to preventive and medical care. ^ Suggested recommendations to decrease CVD mortality rates in Texas are consistent with the existing literature and include state policy development that addresses elimination of health disparities, consideration of potential benefits of universal health coverage by the legislative policymakers, and maintenance of solid partnerships between public health agencies and hospitals to educate on, diagnose, and treat CVD among the female population in Texas. ^

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.^

The response of Texas public health agencies and workers to the emergency preparedness initiatives after 9/11

The purpose of this research was to better understand the impact of the terrorist attacks in 2001 on public health, particularly for Texas public health. This study employed mixed methods to examine changes to public health culture within Texas local public health agencies, important attitudes of public health workers toward responding to a disaster, and the funding policies that might ensure our investment in public health emergency preparedness is protected. ^ A qualitative analysis of interviews conducted with a large sample of public health officials in Texas found that all the constituent parts of a peculiar culture for public health preparedness existed that spanned the state's local health departments regardless of size, or funding level. The new preparedness culture in Texas had the hallmarks necessary for a robust public health preparedness and emergency response system. ^ The willingness of public health workers, necessary to make these kinds of changes and mount a disaster response was examined in one of Texas' most experienced disaster response teams—the public health workers for the City of Houston. A hypothesized latent variable model showed that willingness mediated all other factors in the model (self-efficacy, knowledge, barriers, and risk perception) for self-reported likelihood of reporting to work for a disaster. The RMSEA for the final model was 0.042 with a confidence interval of 0.036—0.049 and the chi-squared difference test was P=0.08, indicating a well-fitted model that suggests willingness is an important factor for consideration by preparedness planners and researchers alike. ^ Finally, with disasters on the rise and federal funding for preparedness dwindling, a review of states' policies for the distribution of these funds and their advantages and disadvantages were examined through a review of current literature and public documents, and a survey of state-level public health officials, emergency management professionals and researchers. Although the base plus per-capita method is the most common, it is not necessarily perceived to be the most effective. No clear "optimal" method emerged from the study, but recommendations for a strategic combination of three methods were made that has the potential to maximize the benefits of each method, while minimizing the weaknesses.^

The role of youth sports in public health

Study 1: Schools provide a range of opportunities for youth to be active, however, over the past decade, these opportunities have been declining. Sports teams are a promising venue to promote physical activity yet limited research has examined the gender an ethnic differences in sport participation. The purpose of this study is to examine trends in sport participation from 1991-2009 among US high school students. Secondly, we examined the association between gender and ethnicity with sports over time. This serial cross-sectional study used surveillance data from the Youth Risk Behavior Survey, a probability based sample weighted to represent gender and race/ethnic subpopulations of US high school students. The findings of this paper reveal persistent gender and ethnic disparities for sports participation among US youth. Since sports teams may provide a substantial source of physical activity, greater efforts should be undertaken to increase the participation of girls, especially minorities, in sports teams. ^ Study 2: Sports team participation is congruent with teaching and supporting healthy eating, yet limited research has examined the association between sports participation and dietary behaviors. This study aims to determine the association between youth sports participation and dietary behaviors among elementary-aged children. Significant dose-response associations were observed between number of sports teams and consumption of most fruits and vegetables. The likelihood of eating fruit for boys increased with the number of sports teams (1 team: OR=1.89; 3 teams: OR=3.44, p<0.001) and the likelihood of consuming green vegetables for girls was higher with the number of sports teams (1 team: OR=1.50; 3 teams: OR=2.39; p<0.001). For boys, the odds of consuming fruit-flavored drinks was higher ( p=0.019) and the odds of drinking soda was lower (p=0.018) with participation in increasing number of sports teams whereas for girls, sports participation was positively associated with diet soda consumption (p=0.006). ^ Study 3: Parents and peers have been shown to have a strong influence over the physical activity, dietary, and sedentary behaviors of youth. Youth sports teams have the potential to offer physical activity, displace sedentary behaviors, and promote a healthy diet. The purpose of this study is to assess how peer and parental support for physical activity and healthy eating, coupled with sport participation, is associated obesity related risk factors including diet and sedentary behaviors. A secondary analysis of data from the School Physical Activity and Nutrition study, a state-representative survey, was conducted. Eighth (n=3,931) and 11th (n=2,785) grade students were categorized into four groups based upon the level of peer and parental support derived from a three item scale and their participation in sports (sports/high support, sports/low support, no sports/high support, no sports/low support). Linear models were conducted to determine the difference in means between these groups for the following outcome variables: previous day fruit and vegetable intake, scores for an unhealthy and healthy food index, and hours spent watching television, playing video games, and working on a computer. Eighth graders had significantly greater levels of parental support for healthy eating and physical activity compared to 11th grade. Both 8 th and 11th graders in the sport/high support for healthy eating from peers and parents scored significantly higher on the healthy food index than other groups. Eighth and 11th graders in the sport/high support for physical activity from peers participated in fewer hours of sedentary behaviors than any other group (p ≤ 0.032). Although it is thought that sport participation may offer opportunities to support a healthy diet and displace sedentary time by offering providing physical activity, our study found that parental and peer support for activity and healthy eating may further attenuate this association. Parents and peer support should be an important target when developing strategies to improve healthy diets and reduce sedentary time among youth, especially in the context of youth sports. (Abstract shortened by UMI.)^

The SanaViz: Human Centered Geovisualization to facilitate visual exploration of Public Health data

These three manuscripts are presented as a PhD dissertation for the study of using GeoVis application to evaluate telehealth programs. The primary reason of this research was to understand how the GeoVis applications can be designed and developed using combined approaches of HC approach and cognitive fit theory and in terms utilized to evaluate telehealth program in Brazil. First manuscript The first manuscript in this dissertation presented a background about the use of GeoVisualization to facilitate visual exploration of public health data. The manuscript covered the existing challenges that were associated with an adoption of existing GeoVis applications. The manuscript combines the principles of Human Centered approach and Cognitive Fit Theory and a framework using a combination of these approaches is developed that lays the foundation of this research. The framework is then utilized to propose the design, development and evaluation of “the SanaViz” to evaluate telehealth data in Brazil, as a proof of concept. Second manuscript The second manuscript is a methods paper that describes the approaches that can be employed to design and develop “the SanaViz” based on the proposed framework. By defining the various elements of the HC approach and CFT, a mixed methods approach is utilized for the card sorting and sketching techniques. A representative sample of 20 study participants currently involved in the telehealth program at the NUTES telehealth center at UFPE, Recife, Brazil was enrolled. The findings of this manuscript helped us understand the needs of the diverse group of telehealth users, the tasks that they perform and helped us determine the essential features that might be necessary to be included in the proposed GeoVis application “the SanaViz”. Third manuscript The third manuscript involved mix- methods approach to compare the effectiveness and usefulness of the HC GeoVis application “the SanaViz” against a conventional GeoVis application “Instant Atlas”. The same group of 20 study participants who had earlier participated during Aim 2 was enrolled and a combination of quantitative and qualitative assessments was done. Effectiveness was gauged by the time that the participants took to complete the tasks using both the GeoVis applications, the ease with which they completed the tasks and the number of attempts that were taken to complete each task. Usefulness was assessed by System Usability Scale (SUS), a validated questionnaire tested in prior studies. In-depth interviews were conducted to gather opinions about both the GeoVis applications. This manuscript helped us in the demonstration of the usefulness and effectiveness of HC GeoVis applications to facilitate visual exploration of telehealth data, as a proof of concept. Together, these three manuscripts represent challenges of combining principles of Human Centered approach, Cognitive Fit Theory to design and develop GeoVis applications as a method to evaluate Telehealth data. To our knowledge, this is the first study to explore the usefulness and effectiveness of GeoVis to facilitate visual exploration of telehealth data. The results of the research enabled us to develop a framework for the design and development of GeoVis applications related to the areas of public health and especially telehealth. The results of our study showed that the varied users were involved with the telehealth program and the tasks that they performed. Further it enabled us to identify the components that might be essential to be included in these GeoVis applications. The results of our research answered the following questions; (a) Telehealth users vary in their level of understanding about GeoVis (b) Interaction features such as zooming, sorting, and linking and multiple views and representation features such as bar chart and choropleth maps were considered the most essential features of the GeoVis applications. (c) Comparing and sorting were two important tasks that the telehealth users would perform for exploratory data analysis. (d) A HC GeoVis prototype application is more effective and useful for exploration of telehealth data than a conventional GeoVis application. Future studies should be done to incorporate the proposed HC GeoVis framework to enable comprehensive assessment of the users and the tasks they perform to identify the features that might be necessary to be a part of the GeoVis applications. The results of this study demonstrate a novel approach to comprehensively and systematically enhance the evaluation of telehealth programs using the proposed GeoVis Framework.

Patenting genes and gene sequences: Analysis of public health implications and the law

At issue is whether or not isolated DNA is patent eligible under the U.S. Patent Law and the implications of that determination on public health. The U.S. Patent and Trademark Office has issued patents on DNA since the 1980s, and scientists and researchers have proceeded under that milieu since that time. Today, genetic research and testing related to the human breast cancer genes BRCA1 and BRCA2 is conducted within the framework of seven patents that were issued to Myriad Genetics and the University of Utah Research Foundation between 1997 and 2000. In 2009, suit was filed on behalf of multiple researchers, professional associations and others to invalidate fifteen of the claims underlying those patents. The Court of Appeals for the Federal Circuit, which hears patent cases, has invalidated claims for analyzing and comparing isolated DNA but has upheld claims to isolated DNA. The specific issue of whether isolated DNA is patent eligible is now before the Supreme Court, which is expected to decide the case by year's end. In this work, a systematic review was performed to determine the effects of DNA patents on various stakeholders and, ultimately, on public health; and to provide a legal analysis of the patent eligibility of isolated DNA and the likely outcome of the Supreme Court's decision. ^ A literature review was conducted to: first, identify principle stakeholders with an interest in patent eligibility of the isolated DNA sequences BRCA1 and BRCA2; and second, determine the effect of the case on those stakeholders. Published reports that addressed gene patents, the Myriad litigation, and implications of gene patents on stakeholders were included. Next, an in-depth legal analysis of the patent eligibility of isolated DNA and methods for analyzing it was performed pursuant to accepted methods of legal research and analysis based on legal briefs, federal law and jurisprudence, scholarly works and standard practice legal analysis. ^ Biotechnology, biomedical and clinical research, access to health care, and personalized medicine were identified as the principle stakeholders and interests herein. Many experts believe that the patent eligibility of isolated DNA will not greatly affect the biotechnology industry insofar as genetic testing is concerned; unlike for therapeutics, genetic testing does not require tremendous resources or lead time. The actual impact on biomedical researchers is uncertain, with greater impact expected for researchers whose work is intended for commercial purposes (versus basic science). The impact on access to health care has been surprisingly difficult to assess; while invalidating gene patents might be expected to decrease the cost of genetic testing and improve access to more laboratories and physicians' offices that provide the test, a 2010 study on the actual impact was inconclusive. As for personalized medicine, many experts believe that the availability of personalized medicine is ultimately a public policy issue for Congress, not the courts. ^ Based on the legal analysis performed in this work, this writer believes the Supreme Court is likely to invalidate patents on isolated DNA whose sequences are found in nature, because these gene sequences are a basic tool of scientific and technologic work and patents on isolated DNA would unduly inhibit their future use. Patents on complementary DNA (cDNA) are expected to stand, however, based on the human intervention required to craft cDNA and the product's distinction from the DNA found in nature. ^ In the end, the solution as to how to address gene patents may lie not in jurisprudence but in a fundamental change in business practices to provide expanded licenses to better address the interests of the several stakeholders. ^