Health outcomes, quality improvement and cost-effectiveness of the Community Diabetes Education (CoDE) program: Results of a randomized controlled trial

The objectives of this dissertation were to evaluate health outcomes, quality improvement measures, and the long-term cost-effectiveness and impact on diabetes-related microvascular and macrovascular complications of a community health worker-led culturally tailored diabetes education and management intervention provided to uninsured Mexican Americans in an urban faith-based clinic. A prospective, randomized controlled repeated measures design was employed to compare the intervention effects between: (1) an intervention group (n=90) that participated in the Community Diabetes Education (CoDE) program along with usual medical care; and (2) a wait-listed comparison group (n=90) that received only usual medical care. Changes in hemoglobin A1c (HbA1c) and secondary outcomes (lipid status, blood pressure and body mass index) were assessed using linear mixed-models and an intention-to-treat approach. The CoDE group experienced greater reduction in HbA1c (-1.6%, p<.001) than the control group (-.9%, p<.001) over the 12 month study period. After adjusting for group-by-time interaction, antidiabetic medication use at baseline, changes made to the antidiabetic regime over the study period, duration of diabetes and baseline HbA1c, a statistically significant intervention effect on HbA1c (-.7%, p=.02) was observed for CoDE participants. Process and outcome quality measures were evaluated using multiple mixed-effects logistic regression models. Assessment of quality indicators revealed that the CoDE intervention group was significantly more likely to have received a dilated retinal examination than the control group, and 53% achieved a HbA1c below 7% compared with 38% of control group subjects. Long-term cost-effectiveness and impact on diabetes-related health outcomes were estimated through simulation modeling using the rigorously validated Archimedes Model. Over a 20 year time horizon, CoDE participants were forecasted to have less proliferative diabetic retinopathy, fewer foot ulcers, and reduced numbers of foot amputations than control group subjects who received usual medical care. An incremental cost-effectiveness ratio of $355 per quality-adjusted life-year gained was estimated for CoDE intervention participants over the same time period. The results from the three areas of program evaluation: impact on short-term health outcomes, quantification of improvement in quality of diabetes care, and projection of long-term cost-effectiveness and impact on diabetes-related health outcomes provide evidence that a community health worker can be a valuable resource to reduce diabetes disparities for uninsured Mexican Americans. This evidence supports formal integration of community health workers as members of the diabetes care team.^

Sexual Health Education from the Perspective of School Staff: Implications for Adoption and Implementation of Effective Programs in Middle School

Introduction: US teens are having sex early; however, the vast majority of schools do not implement evidence-based sexual health education (SHE) programs that could delay sexual behavior and/or reduce risky behavior. This study examines middle school staff’s knowledge, attitudes, barriers, self-efficacy, and perceived support (psychosocial factors known to influence SHE program adoption and implementation). Methods: Professional school staff from 33 southeast Texas middle schools completed an internet or paper-based survey. Prevalence estimates for psychosocial variables were computed for the total sample. Chi-square and t-test analyses examined variation by demographic factors. Results: Almost 70% of participants were female, 37% white, 42% black, 16% Hispanic; 20% administrators, 15% nurses/counselors, 31% non-physical education/non-health teachers, 28% physical education/health teachers; mean age = 42.78 years (SD = 10.9). Over 90% favored middle school SHE, and over 75% reported awareness of available SHE curricula or policies. More than 60% expressed confidence for discussing SHE. Staff perceived varying levels of administrator (28%-56%) support for SHE and varying levels of support for comprehensive sex education from outside stakeholders (e.g., parents, community leaders) (42%-85%). Overall, results were more favorable for physical education/health teachers, nurses/counselors, and administrators (when compared to non-physical education/non-health teachers) and individuals with experience teaching SHE. Few significant differences were observed by other demographic factors. Conclusions: Overall, study results were extremely positive, which may reflect a high level of readiness among school staff for adopting and implementing effective middle school SHE programs. Study results highlight the importance of several key action items for schools.

'Your Heart Can't Wait'---A worksite program: Increasing the effectiveness of worksite coordinators to implement a community-wide health education program

A worksite health education program called “Your Heart Can't Wait,” was designed by the American Heart Association Gulf Coast Area (AHA). The objectives were to educate individuals about the signs and symptoms of heart attacks and the actions they should take to improve heart attack victims' chances for survival. AHA volunteers agreed to serve as mentors for this program. ^ A study was designed to determine if worksite coordinators who had the assistance of experienced AHA volunteers had higher rates of program adoption and implementation than worksite coordinators without assistance. Ninety-seven companies participated in the study. Twelve AHA volunteers were randomly assigned to work with forty-three of the worksite coordinators. Mentor/mentee contact forms were used to assess the mentoring process during the course of the study. Program adoption forms were used to measure rates of program adoption and follow-up questionnaires were used to measure rates of program implementation after the study was completed. The twelve mentors were interviewed to provide information for improving future mentoring efforts. ^ Thirty-eight companies completed program adoption forms and fifty-one companies reported using YHCW program components. For the most part, the volunteer mentors did not spend a significant amount of time contacting or working with their assigned worksite coordinators. As a result, the planned analysis comparing the implemented programs between worksite coordinators with and without assistance could not be completed. ^ Additional analyses were performed comparing the implemented programs based upon whether the companies had existing health education/health promotion programs and whether the worksite coordinators had experience using AHA Heart At Work program components. ^ Recommendations based on the mentor interviews were made to improve the success of volunteer assistance programs in the future. ^

The association between classroom characteristics and student physical activity in physical education classrooms

Background. With the rapid rise in childhood obesity, physical activity participation among young children has become the subject of much recent attention. Physical education classes have been specifically targeted as a method of providing opportunities for all children to be active. Unfortunately, student participation in moderate-to-vigorous physical activity during these classes still falls far below the current recommendations. While some research to date has reported the levels of activity among elementary-aged children, research is limited on the relationship between these activity levels and the environmental characteristics that exist within the PE classroom. ^ Purpose. The purpose of this study is to examine the association between specific classroom characteristics and contextual characteristics (lesson context, class size, class location, teacher gender, and teacher encouragement for PA) with elementary aged children's moderate-to-vigorous activity during PE class. ^ Methods. A secondary analysis of 211 3rd, 4th and 5th grade physical education classes amongst 39 elementary schools in Harris County, TX and 35 elementary schools in Travis County, TX was conducted using cross-sectional data from the evaluation of a school-based health program. Lesson context and student activity levels were measured using a direct observation measurement tool. Additionally, these variables were further analyzed against a number of classroom characteristics to determine any significant associations. ^ Results. Overall, elementary PE classes are still participating in low levels of moderate-to-vigorous physical activity averaging only 38% of class time. Additionally, close to 25% of class time is spent in classroom management. Male directed classes spent significantly more time in game activities and female directed classes spent more time in fitness, knowledge, and skill activities. Classes that took place outdoors were more active and spent more time in games than those that took place indoors. Significant correlations were demonstrated between class size and time spent in management context. Time spent in management context was also correlated with time spent sitting and standing. Additionally, positive correlations were demonstrated between time very active and teachers that praised students and encouraged physical activity among their classes.^

A summative evaluation of a HIV/AIDS Early Childhood Care, Education and Development Teacher Training Workshop in Mongu, Zambia

Objective. To conduct a summative evaluation of an Early Childhood Care, Education and Development (ECCED) Teacher Training Workshop in Mongu, Zambia by assessing changes in knowledge, attitudes and intent to use the information. ^ Study design. A matched cohort survey design was used with additional qualitative data collected by structured observation of workshop sessions, daily facilitator and participant debriefs and participant interviews. ^ Results. Matching pre and post tests were completed by 27 individuals in addition to daily debriefs, structured workshop observation and participant interviews with 22% of the group. The participant population was predominantly female individuals aged 15-44 years old that had completed high school and additional post-secondary training, been teaching children aged 0 – 8 years for 2-5 years in the Western Province and received other HIV/AIDS and ECCED education. Pre-tests indicated a strong understanding of ECCED principles and misconceptions regarding HIV transmission, prevention and the disease's impact on early childhood development. The workshop was found to significantly increase the participants' knowledge of topics covered by the curriculum (paired t-test, N=27, p = 0.004, 95% CI 1.8, 8.6). Participants began with a more limited understanding of HIV/AIDS than ECCED, but the mean gain was much greater at 7.4 +/- 12.3 points. Significantly more participants believed at post-test that HIV/AIDS education should increase for future educators. The 77.8% of participants that increased their knowledge scores at post-test expressed significantly less fear of having a child with HIV/AIDS in the classroom (Independent Samples t-test, N= 27, p = 0.011). Overall participant fear decreased 15.5%. 92.6% and 88.9% of participants planned at post-test to respectively use and share the taught information in their daily professional lives and reported on innovative strategies to communicate with the community. ^ Conclusions. Teacher training workshops can significantly increase HIV/AIDS awareness and promote positive attitudes in educators working with children affected by HIV/AIDS. Using participant suggested teaching techniques such as poems and songs and translating the materials to the local language could assist future facilitators to both culturally and professionally relate to the workshop audience as well as increase participant capacity to share the information with the local community. ^

Better together: Addressing maternal and child health outcomes through community health worker continuing education curricula

Background. The incidence of birth defects is a significant public health issue in the United States, adversely affecting the quality of life for parents as well as children born with these defects. Minority populations face a greater burden of birth defects and associated health problems. Prenatal practices can have a large impact on infant health outcomes. Several behaviors during pregnancy, including the intake of folic acid, can greatly influence the likelihood of a child being born with a birth defect. Community Health Workers have been shown to be effective agents at improving prenatal practices, especially when they facilitate support groups that feature pregnant women. ^ Methods. A continuing education curriculum has been created for Community Health Workers that provides content in the area of Maternal and Child Health. Content was selected after conducting a review of relevant literature and theory. Materials for conducting a training for Community Health Workers have been created in addition to materials that were designed for the population with whom the CHWs work. ^ Results. A description of each "key point" of the curriculum and a justification how it relates to the literature of the prevention of birth defects is given here. Additionally, the process of creating the curriculum using the platform delineated in the methods is described. ^ Discussion. Insights for future curriculum development are discussed along with next steps in the process of certifying the curriculum at the state level. A framework for future evaluation of the curriculum is given.^

Sudden Infant Death disparities: A systematic review on health education and policy recommendations for decreasing Sudden Infant Death in the African-American community

Objective: To perform a systematic review of the literature on SIDS and SUID deaths concentrated in the African-American community, describe health education and policy recommendations and recommend a new approach that may aid in decreasing the disparity of infant mortality in the African-American community. ^ Methods: The PubMed database was systematically searched to identify relevant articles for final review and analysis. Using the CASP 2006 system to critique literature, twelve articles were found that met inclusion and exclusion criteria. ^ Results: Evidence in the literature confirmed there was a current disparity among African Americans' infant mortality rates in comparison to other US ethnic groups. The underlying reasons for these disparities included the following maternal and infant characteristics: mothers younger than eighteen, having more than one live infant, having a high school education or less, never been married, and have infants born preterm or with low birth weight. Maternal smoking, substance abuse, and breastfeeding did not have a significant impact on infant sleep environments among African Americans. ^ Conclusion: Tailored health education programs at the community level, better access to pre-pregnancy and prenatal care, and increased maternal perception of risk that is relevant to the infants sleeping environment are all possible solutions that may decrease African American infant mortality rates.^

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. ^

Using service-learning to encourage community health advocacy among high school students

The project outlined throughout this program management plan aims to develop a health-focused student advocacy group in the San Antonio Independent School District (SAISD). At its core, this project will be an opportunity for SAISD students to engage in service-learning, through which they will learn and develop by designing, organizing and participating in meaningful public health service experiences. ^ This program management plan addresses the genuine need for public health community education by using the service-learning model as a framework to engage students to effect change. The plan delineates the process by which the student advocacy group is to be assembled, selection of service-learning project, project objectives, technical objectives, and communication requirements. Ideally, the plan should help to facilitate project coordination, communication, and planning, and to support the direction of resources. The appendices that follow also provide useful tools with which to follow through with project implementation. ^ The plan is about more than providing a tool to educate students about the health issues in their community. It is about providing a way to teach health advocacy and self-interest and encourage civic engagement via public health. Students have the potential to positively effect lasting change among their peers, in their schools and in the community.^

A promotora de salud CVD intervention: Participant responses after Su Corazon, Su Vida education

In this study we sought to identify and understand feelings, benefits and barriers to making heart healthy behavioral changes by reviewing and analyzing participant responses to a follow-up telephone survey conducted as part of the HEART project (Health Education Awareness Research Team). Individuals who participated in HEART attended classes and received “Su Corazon, Su Vida” education. The HEART follow-up telephone survey was conducted only on those participants who were part of the experimental group. A total of 93 individuals from this group were successfully contacted for participation in the telephone survey after the classes ended. Quantitative data regarding ‘feelings’ and ‘difficulty making heart healthy behavioral changes’ were analyzed by calculating frequencies of each category of response for post-intervention weeks 9, 13, and 15. In addition, Wilcoxon rank-sum tests were conducted for post-intervention at weeks 9, 13, and 15 to measure associations between feelings and difficulties making heart healthy behavioral changes. Changes in responses over time for feelings and difficulties making heart healthy behavioral changes were looked at by counting differences in responses between pairs of follow up weeks. Qualitative responses to the survey were analyzed by categorizing content of responses under themes in order to identify factors related to feelings and difficulties making heart healthy behavioral changes. Telephone survey participants showed positive attitudes towards making nutritional and physical activity changes. Out of the 93 telephone survey respondents, 53 (57%) reported some type of physical activity change during the follow-up period while 46 (49%) reported specific changes in nutrition. Data from the “difficulty to making changes” responses were categorized under constructs from the Health Belief Model, perceived benefits and barriers. Overall, the barriers for physical activity were health issues, individual habits and time. Barriers to eating healthy were family support, individual habits, and knowledge. This study suggests that with respect to nutritional knowledge barriers, educational programs should explore other ways of teaching and familiarizing individuals with information sources that may be more appropriate for those populations not accustomed to them. For example, nutrition labels, portions, recipes, and use of photonovelas. Our findings of the barriers to changes in food preparation due to lack of family support may also suggest the need for the development of programs where influential partners or relatives are involved in order to create a more supportive environment which may provide more opportunity for change toward healthier lifestyle behaviors. Finally, the physical activity barriers found suggest that it may be beneficial to recommend appropriate exercises for those with specific health problems or those with time restrictions due to work or travel so that physical activity is not completely avoided.^

Development and evaluation of a nutrition education program designed to increase fruit and vegetable consumption in girls, ages 9--12

The purpose of this study is to evaluate the theory-based Eat 5 nutrition badge. It is designed to increase fruit and vegetable (F&V) intake in 4th-6th grade junior Girl Scouts. Twenty-two troops were recruited and randomized by grade level (4th, 5th, 6th, or mixed) into either the intervention or control conditions. The leaders in the intervention condition received a brief training and the materials and conducted the program with their troops during four meetings. The Girl Scouts in the intervention condition completed 1-day Food Frequency Questionnaires and Nutrition Questionnaires both before and after completing the Eat 5 badge, and a third measurement of F&V intake three months after the posttest. Girl Scouts in the control condition were only evaluated at the three time periods.^ The primary hypotheses were that the Girl Scouts in the intervention condition would increase their daily intake of fruits and vegetables at both the posttest and three months later, compared to the Girl Scouts in the control condition. Other study questions investigated the impact of the Eat 5 program on intervening variables such as knowledge, self-efficacy, barriers, norms, F&V preference, and F&V selection and preparation skills.^ A nested ANOVA, with troop as the unit of analysis nested within condition, was used to assess the effects of the program. Pretest F&V intake and grade level were used as covariates. Pretest mean F&V intake for the total sample of 210 girls was 2.50 servings per day; 3.0 for the intervention group (n = 101). Significant increases in F&V intake (to 3.4 servings per day), knowledge, and fruit and vegetable preference were found for the intervention condition troops compared to the troops in the control condition. Three months later, the mean F&V intake had returned to pretest levels.^ This study indicates that social groups such as Girl Scouts can provide a channel for nutrition education. Long term effects were not sustained by the intervention; a possible cause was the lack of change in self-efficacy. Therefore, additional interventions are recommended such as booster lessons to maintain increased F&V intake by Girl Scouts. ^

A practice-based culminating experience: Writing a HRSA grant application with Texas Organ Sharing Alliance for public education efforts to increase solid organ donation

In November 2010, nearly 110,000 people in the United States were waiting for organs for transplantation. Despite the fact that the organ donor registration rate has doubled in the last year, Texas has the lowest registration rate in the nation. Due to the need for improved registration rates in Texas, this practice-based culminating experience was to write an application for federal funding for the central Texas organ procurement organization, Texas Organ Sharing Alliance. The culminating experience has two levels of significance for public health – (1) to engage in an activity to promote organ donation registration, and (2) to provide professional experience in grant writing. ^ The process began with a literature review. The review was to identify successful intervention activities in motivating organ donation registration that could be used in intervention design for the grant application. Conclusions derived from the literature review included (1) the need to specifically encourage family discussions, (2) religious and community leaders can be leveraged to facilitate organ donation conversations in families, (3) communication content must be culturally sensitive and (4) ethnic disparities in transplantation must be acknowledged and discussed.^ Post the literature review; the experience followed a five step process of developing the grant application. The steps included securing permission to proceed, assembling a project team, creation of a project plan and timeline, writing each element of the grant application including the design of proposed intervention activities, and completion of the federal grant application. ^ After the grant application was written, an evaluation of the grant writing process was conducted. Opportunities for improvement were identified. The first opportunity was the need for better timeline management to allow for review of the application by an independent party, iterative development of the budget proposal, and development of collaborative partnerships. Another improvement opportunity was the management of conflict regarding the design of the intervention that stemmed from marketing versus evidence-based approaches. The most important improvement opportunity was the need to develop a more exhaustive evaluation plan.^ Eight supplementary files are attached to appendices: Feasibility Discussion in Appendix 1, Grant Guidance and Workshop Notes in Appendix 2, Presentation to Texas Organ Sharing Alliance in Appendix 3, Team Recruitment Presentation in Appendix 5, Grant Project Narrative in Appendix 7, Federal Application Form in Appendix 8, and Budget Workbook with Budget Narrative in Appendix 9.^

Factors influencing participation in individuals with disability: A secondary data analysis

Individuals with disabilities face numerous barriers to participation due to biological and physical characteristics of the disability as well as social and environmental factors. Participation can be impacted on all levels from societal, to activities of daily living, exercise, education, and interpersonal relationships. This study evaluated the impact of pain, mood, depression, quality of life and fatigue on participation for individuals with mobility impairments. This cross sectional study derives from self-report data collected from a wheelchair using sample. Bivariate correlational and multivariate analysis were employed to examine the relationship between pain, quality of life, positive and negative mood, fatigue, and depression with participation while controlling for relevant socio-demographic variables (sex, age, time with disability, race, and education). Results from the 122 respondents with mobility impairments demonstrated that after controlling for socio-demographic characteristics in the full model, 20% of the variance in participation scores were accounted for by pain, quality of life, positive and negative mood, and depression. Notably, quality of life emerged as being the single variable that was significantly related to participation in the full model. Contrary to other studies, pain did not appear to significantly impact participation outcomes for wheelchair users in this sample. Participation is an emerging area of interest among rehabilitation and disability researchers, and results of this study provide compelling evidence that several psychosocial factors are related to participation. This area of inquiry warrants further study, as many of the psychosocial variables identified in this study (mood, depression, quality of life) may be amenable to intervention, which may also positively influence participation.^

It's your game, keep it real. Sexual education study

Purpose: This study translated and adapted the It's Your Game, Keep It Real study currently being implemented with middle school youth in Southeast Texas for a middle school population in rural western Honduras. The study tested the effects of a sexual health education program focused on human immunodeficiency virus, sexually transmitted infections, and pregnancy prevention. We hypothesized that the number of adolescents in the intervention group who initiate sexual activity will reduce in comparison to the control group and there will be an increase consistent condom use in sexually active adolescents in the intervention group. ^ Methods: The target population included Spanish-speaking Hispanic middle school students from a small, semi-urban city in western Honduras. One school was randomly selected to receive the intervention and one to the comparison condition. The intervention curriculum consisted of 10 seventh-grade lessons that included individual and group classroom-based activities and personal journaling. Follow-up surveys were completed three months after the last lesson with 146 students (79.3% of the defined cohort). ^ Results: In the comparison condition, 21.4% of students initiated sex by the post-test follow-up three months after the intervention compared to 7.8% in the intervention condition. ^ Conclusions: A multi-component, curriculum-based program that is theory driven and culturally relevant can increase knowledge about STIs and HIV, increase self-confidence amongst middle school students, and develop communication skills amongst friends and partners. Further research must be conducted to assess delay in sexual initiation and the generalizability of these results.^