Commentary on "A Tale of Two States"

While both California and Texas have experienced declines in teen birth rates over the past three decades, declines in California have been larger, particularly among Hispanic teens. Differences in state policies may have shaped this disparity, as suggested by Tortolero and her colleagues in their article “A Tale of Two States: What We Learn from California and Texas”. Fundamental differences exist between Texas and California in their approaches to sex education, access to family planning services for teens, and public-private partnerships. However, methodological challenges are present when drawing state comparisons, including the limitations of available public health data and the difficulty of disaggregating state characteristics from state policies. Based on their comparison of state data and policies, Tortolero and her colleagues issue sensible recommendations for reducing the teen birth rate in Texas. History suggests that state policies are most effective when political commitment is linked to scientifically effective approaches. Based on our understanding of the scientific literature, the most effective strategies for reducing rates of teen childbearing in Texas would be providing comprehensive school sexuality education and improving teen access to contraceptive services.

Idiographic Self-Monitoring Instruments to Empower Client Participation and Evaluate Outcome in Intensive Family Preservation Services

Intensive Family Preservation Services seek to reflect the values of focusing on client strengths and viewing clients as colleagues. To promote those values, Intensive Family Preservation Programs should include a systematic form of client self monitoring in their packages of outcome measures. This paper presents a model of idiographic self-monitoring used in time series, single system research design developed for Family Partners, a family preservation program of the School for Contemporary Education in Annandale, Virginia. The evaluation model provides a means of empowering client families to utilize their strengths and promote their status as colleague in determining their own goals, participating in the change process, and measuring their own progress.

A study of nurses' judgement of and participation in decision-making for nursing home placement for the elderly

This study investigated the effects of patient variables (physical and cognitive disability, significant others' preference and social support) on nurses' nursing home placement decision-making and explored nurses' participation in the decision-making process.^ The study was conducted in a hospital in Texas. A sample of registered nurses on units that refer patients for nursing home placement were asked to review a series of vignettes describing elderly patients that differed in terms of the study variables and indicate the extent to which they agreed with nursing home placement on a five-point Likert scale. The vignettes were judged to have good content validity by a group of five colleagues (expert consultants) and test-retest reliability based on the Pearson correlation coefficient was satisfactory (average of.75) across all vignettes.^ The study tested the following hypotheses: Nurses have more of a propensity to recommend placement when (1) patients have severe physical disabilities; (2) patients have severe cognitive disabilities; (3) it is the significant others' preference; and (4) patients have no social support nor alternative services. Other hypotheses were that (5) a nurse's characteristics and extent of participation will not have a significant effect on their placement decision; and (6) a patient's social support is the most important, single factor, and the combination of factors of severe physical and cognitive disability, significant others' preference, and no social support nor alternative services will be the most important set of predictors of a nurse's placement decision.^ Analysis of Variance (ANOVA) was used to analyze the relationships implied in the hypothesis. A series of one-way ANOVA (bivariate analyses) of the main effects supported hypotheses one-five.^ Overall, the n-way ANOVA (multivariate analyses) of the main effects confirmed that social support was the most important single factor controlling for other variables. The 4-way interaction model confirmed that the most predictive combination of patient characteristics were severe physical and cognitive disability, no social support and the significant others did not desire placement. These analyses provided an understanding of the importance of the influence of specific patient variables on nurses' recommendations regarding placement. ^

A qualitative assessment of multi-level nutrition strategies for reducing racial and ethnic disparities in diabetes

The purpose of this study is to examine the stages of program realization of the interventions that the Bronx Health REACH program initiated at various levels to improve nutrition as a means for reducing racial and ethnic disparities in diabetes. This study was based on secondary analyses of qualitative data collected through the Bronx Health REACH Nutrition Project, a project conducted under the auspices of the Institute on Urban Family Health, with support from the Centers for Disease Control and Prevention (CDC). Local human subjects' review and approval through the Institute on Urban Family Health was required and obtained in order to conduct the Bronx Health REACH Nutrition Project. ^ The study drew from two theoretical models—Glanz and colleagues' nutrition environments model and Shediac-Rizkallah and Bone's sustainability model. The specific study objectives were two-fold: (1) to categorize each nutrition activity to a specific dimension (i.e. consumer, organizational or community nutrition environment); and (2) to evaluate the stage at which the program has been realized (i.e. development, implementation or sustainability). ^ A case study approach was applied and a constant comparative method was used to analyze the data. Triangulation of data based was also conducted. Qualitative data from this study revealed the following principal findings: (1) communities of color are disproportionately experiencing numerous individual and environmental factors contributing to the disparities in diabetes; (2) multi-level strategies that targeted the individual, organizational and community nutrition environments can appropriately address these contributing factors; (3) the nutrition strategies greatly varied in their ability to appropriately meet criteria for the three program stages; and (4) those nutrition strategies most likely to succeed (a) conveyed consistent and culturally relevant messages, (b) had continued involvement from program staff and partners, (c) were able to adapt over time or setting, (d) had a program champion and a training component, (e) were integrated into partnering organizations, and (f) were perceived to be successful by program staff and partners in their efforts to create individual, organizational and community/policy change. As a result of the criteria-based assessment and qualitative findings, an ecological framework elaborating on Glanz and colleagues model was developed. The qualitative findings and the resulting ecological framework developed from this study will help public health professionals and community leaders to develop and implement sustainable multi-level nutrition strategies for addressing racial and ethnic disparities in diabetes. ^

Perceptions of work engagement of nurses in Taiwan

Purpose. The purpose of this study was to determine the perceptions of work engagement of Taiwanese nurses with 3 specific aims: (1) understand Taiwanese nurses' perceptions of work engagement; (2) explore the factors influencing work engagement, and (3) examine how work engagement impacts nursing care for patients. ^ Design. The study used an ethnographic approach with participant observation and semi-structured interviews with RNs. ^ Setting. The study was conducted in the highest and lowest nurse turnover medical surgical units at a regional teaching hospital in southwestern Taiwan. ^ Sample. Purposive sampling resulted in 28 formal interviews with RNs who provided direct patient care, had at least 3 months experience in nursing, and were full-time employees. ^ Methods. Descriptive data were collected through participant observation in each unit. Observations were made while attending meetings, continuing education sessions, and informal conversations with RNs. Field notes and audio recorded semi-structured interviews were analyzed using qualitative thematic analytic techniques. ^ Findings. Findings revealed perceptions of work engagement spanned four domains: patients ("wholehearted care"), work (positive attitude), self (fulfillment and happiness), and others (relationships with colleagues). Providing "wholehearted care" toward patients was the foundation of work engagement for nurses in Taiwan. Engaged nurses felt fulfilled, happy, and found "meaning" through the process of patient care. The study revealed five factors that influenced work engagement: personal, organizational, social, patient, and professional. The impact of work engagement on nurse and patient outcomes are confirmed. ^ Conclusions. Taiwanese nurses connect work engagement with patients, the job, oneself, and colleagues. "Wholehearted patient care" is the core manifestation of work engagement among these nurses. In contrast, studies in western business only focused on work attitudes. Losing interest and "heart" lead to work routines which can lead to individual unhappiness. Findings from this study validate the multiple factors contributing to work engagement of nurses. Job demands and resources can only partially explain what hinders work engagement. Work disengagement and burnout share some commonality but should be measured differently. An understanding of RNs' perceptions of work engagement may provide direction for strategies that improve work engagement leading to decreased RN turnover. ^

FAMILY MEDICINE RESIDENT SURVEY ON HEALTH PROMOTION (PERSONAL EXPECTATIONS, BEHAVIORS, PERCEIVED SELF-EFFICACY, COGNITIVE ASSESSMENT, OUTCOME EXPECTANCY)

This study was designed to test the theoretical predictors of personal efficacy expectations among family medicine resident physicians for helping their patients change thirteen high risk health behaviors. A survey questionnaire was sent to 781 family medicine residents in the six state south central region. The response rate was 60 percent. The hypothesized relationship between lower levels of difficulty and higher personal efficacy expectations was supported by the data. Effort was a significant predictor of perceived self efficacy for health behaviors considered less difficult to change. Situational support did not prove to be a significant predictor for many of the health behaviors. Rate and pattern of success were consistent and significant predictors of perceived self efficacy for helping patients change all thirteen of the health behaviors. Modeling of effective methods by faculty was a significant predictor of efficacy expectations for several but not all of the behaviors. Personal modeling was a significant predictor of perceived efficacy for helping patients change behaviors related to alcohol misuse and exercise. The respondents personally modeled positive health behaviors more consistently than their older colleagues or the general population.^ The results of this study lend substantially to the usefulness of the cognitive-behavioral theory of perceived self efficacy and provide a mechanism for assessing the predictors of personal efficacy expectations of family medicine resident physicians. The findings are expected to have direct implications for faculty to institute systematic programs of interventions designed to increase residents' perceptions of efficacy in facilitating more positive health behaviors among their patients. ^

Practice and attitude differences in physician cigarette use: A study of prevalence, physicians' role, and smoking policy awareness in Dubai, UAE

The use of tobacco products ruins the health of millions of people around the world. On average, tobacco users die nearly seven years earlier than non-tobacco users. n1 Cigarette smoking is a particular concern in the developing countries of the Middle East and Gulf Cooperation Council (GCC) region where smoking prevalence is expected to increase. This is due to the tobacco industry's vigorous commercial and marketing activities. n3 Smoking prevalence among physicians is considered to be an effective indicator of a society's readiness to identify the smoking epidemic and its related health diseases. n4 There is a lack of detailed data on the smoking prevalence among healthcare professionals, particularly physicians, in the United Arab Emirates (UAE). This cross sectional study is the first to address smoking practices among physicians working at the Department of Health and Medical Services (DOHMS); in Dubai, UAE. ^ This study describes the cigarette smoking prevalence among DOHMS Physicians, physician attitudes towards tobacco use and tobacco bans; physician attitudes towards smoking cessation techniques (among smokers and non-smokers); and physician awareness of official anti-smoking policies. Data for the study was collected through the use of an adapted WHO standardized questionnaire, the Global Health Professionals Survey. The questionnaire was administered by the researcher to physicians (n=288) at their work place. Date was analyzed using the SPSS analytic software program. ^ Twelve percent of DOHMS physicians smoked cigarettes. Regardless of smoking status, the majority supported a tobacco ban in hospitals and public places, and a ban on tobacco advertising. There is a significant relationship between physician smoking status and discussing risks of tobacco use (p < 0.05). Non-smoking physicians reported spending more time with patients discussing hazards of smoking (p < 0.01). Non-smokers reported providing more counseling than their smoking colleagues. The majority of DOHMS physicians (63%) reported a lack of knowledge about 5As/ 5Rs. The majority of physicians also reported they are aware of hospital smoking policies that restrict smoking. Regardless of physician smoking status, DOHMS physicians are not very actively involved in smoking cessation activities. This cross sectional study is the first to address smoking programs, policies, and practices among physicians in Dubai, UAE. Findings support the need for increased physical smoking cessation training as well as the development of smoking cessation programs for tobacco control, and programs with a focus on physician participation in reducing tobacco and cigarette use among the general population.^

Comparative Disciplinary Rates as a Tool for Reducing Exclusionary Discipline and Eliminating the School to Prison Pipeline

Invited Commentary on "Comparing Campus Discipline Rates: A Multivariate Approach for Identifying Schools with Significantly Different than Expected Exclusionary Discipline Rates" by Eric Booth and colleagues.

Formalizing a Conceptual Framework of Work Domain Knowledge

Background: The failure rate of health information systems is high, partially due to fragmented, incomplete, or incorrect identification and description of specific and critical domain requirements. In order to systematically transform the requirements of work into real information system, an explicit conceptual framework is essential to summarize the work requirements and guide system design. Recently, Butler, Zhang, and colleagues proposed a conceptual framework called Work Domain Ontology (WDO) to formally represent users’ work. This WDO approach has been successfully demonstrated in a real world design project on aircraft scheduling. However, as a top level conceptual framework, this WDO has not defined an explicit and well specified schema (WDOS) , and it does not have a generalizable and operationalized procedure that can be easily applied to develop WDO. Moreover, WDO has not been developed for any concrete healthcare domain. These limitations hinder the utility of WDO in real world information system in general and in health information system in particular. Objective: The objective of this research is to formalize the WDOS, operationalize a procedure to develop WDO, and evaluate WDO approach using Self-Nutrition Management (SNM) work domain. Method: Concept analysis was implemented to formalize WDOS. Focus group interview was conducted to capture concepts in SNM work domain. Ontology engineering methods were adopted to model SNM WDO. Part of the concepts under the primary goal “staying healthy” for SNM were selected and transformed into a semi-structured survey to evaluate the acceptance, explicitness, completeness, consistency, experience dependency of SNM WDO. Result: Four concepts, “goal, operation, object and constraint”, were identified and formally modeled in WDOS with definitions and attributes. 72 SNM WDO concepts under primary goal were selected and transformed into semi-structured survey questions. The evaluation indicated that the major concepts of SNM WDO were accepted by 41 overweight subjects. SNM WDO is generally independent of user domain experience but partially dependent on SNM application experience. 23 of 41 paired concepts had significant correlations. Two concepts were identified as ambiguous concepts. 8 extra concepts were recommended towards the completeness of SNM WDO. Conclusion: The preliminary WDOS is ready with an operationalized procedure. SNM WDO has been developed to guide future SNM application design. This research is an essential step towards Work-Centered Design (WCD).