Point-of-sale machines in school cafeterias and parental influence on child food choices

The prevalence of obesity has reached epidemic proportions in the United States. Twenty-five percent of school aged students are overweight. Schools have the opportunity to help slow this epidemic. School cafeterias in the United States feed millions of students every day through the National School Lunch Program.^ Point-of-sale machines are used in most school cafeterias to help streamline the process of purchasing school lunches. The point-of-sale software allows school personnel to place special notes on student's accounts to provide alerts about parental requests. This study investigated what the alerts are used for, who uses the alerts, and if there are any patterns by demographic characteristics. ^ Counts and percentages were used to determine what the alerts were used for and who used them. This study found that students who were white non-Hispanic, paid status, or in elementary school were most likely to have alerts placed on their accounts. Also, the majority of point-of-sale alerts were used as allowances (i.e., allowed to purchase snacks from the balance on the school lunch account), rather than restrictions (i.e., restricted from purchasing high calorie foods or specific food items). Using chi-square analysis, a total of 688 alerts were analyzed. There were significant differences in alert frequencies for intent category by grade level (p=0.000), snack access (p=0.000), and gender (p=0.002). Therefore, the results are significant, and one can conclude there is a significant relationship between gender, grade level, and snack access, and the presence of an alert on the school lunch account.^ Also, school administrators may want to take into consideration possible changes to their program, such as requiring more time to run the software. The results of this study can assist school administrators to better understand that a point-of-sale alert program may help their school lunch programs run more efficiently, while also providing parental influence on students’ food choices at the point-of-sale.^ School food service authorities should consider implementing a structured point-of-sale alert policy to encourage parental input on their children's food choices. When implementing the point-of-sale policy, schools should publicize this policy online, through school lunch menus, and parent communications increase participation throughout the school district.^

Understanding and Characterizing Shared Decision-Making and Behavioral Intent in Medical Uncertainty

Applying Theoretical Constructs to Address Medical Uncertainty Situations involving medical reasoning usually include some level of medical uncertainty. Despite the identification of shared decision-making (SDM) as an effective technique, it has been observed that the likelihood of physicians and patients engaging in shared decision making is lower in those situations where it is most needed; specifically in circumstances of medical uncertainty. Having identified shared decision making as an effective, yet often a neglected approach to resolving a lack of information exchange in situations involving medical uncertainty, the next step is to determine the way(s) in which SDM can be integrated and the supplemental processes that may facilitate its integration. SDM involves unique types of communication and relationships between patients and physicians. Therefore, it is necessary to further understand and incorporate human behavioral elements - in particular, behavioral intent - in order to successfully identify and realize the potential benefits of SDM. This paper discusses the background and potential interaction between the theories of shared decision-making, medical uncertainty, and behavioral intent. Identifying Shared Decision-Making Elements in Medical Encounters Dealing with Uncertainty A recent summary of the state of medical knowledge in the U.S. reported that nearly half (47%) of all treatments were of unknown effectiveness, and an additional 7% involved an uncertain tradeoff between benefits and harms. Shared decision-making (SDM) was identified as an effective technique for managing uncertainty when two or more parties were involved. In order to understand which of the elements of SDM are used most frequently and effectively, it is necessary to identify these key elements, and understand how these elements related to each other and the SDM process. The elements identified through the course of the present research were selected from basic principles of the SDM model and the “Data, Information, Knowledge, Wisdom” (DIKW) Hierarchy. The goal of this ethnographic research was to identify which common elements of shared decision-making patients are most often observed applying in the medical encounter. The results of the present study facilitated the understanding of which elements patients were more likely to exhibit during a primary care medical encounter, as well as determining variables of interest leading to more successful shared decision-making practices between patients and their physicians. Understanding Behavioral Intent to Participate in Shared Decision-Making in Medically Uncertain Situations Objective: This article describes the process undertaken to identify and validate behavioral and normative beliefs and behavioral intent of men between the ages of 45-70 with regard to participating in shared decision-making in medically uncertain situations. This article also discusses the preliminary results of the aforementioned processes and explores potential future uses of this information which may facilitate greater understanding, efficiency and effectiveness of doctor-patient consultations.Design: Qualitative Study using deductive content analysisSetting: Individual semi-structure patient interviews were conducted until data saturation was reached. Researchers read the transcripts and developed a list of codes.Subjects: 25 subjects drawn from the Philadelphia community.Measurements: Qualitative indicators were developed to measure respondents’ experiences and beliefs related to behavioral intent to participate in shared decision-making during medical uncertainty. Subjects were also asked to complete the Krantz Health Opinion Survey as a method of triangulation.Results: Several factors were repeatedly described by respondents as being essential to participate in shared decision-making in medical uncertainty. These factors included past experience with medical uncertainty, an individual’s personality, and the relationship between the patient and his physician.Conclusions: The findings of this study led to the development of a category framework that helped understand an individual’s needs and motivational factors in their intent to participate in shared decision-making. The three main categories include 1) an individual’s representation of medically uncertainty, 2) how the individual copes with medical uncertainty, and 3) the individual’s behavioral intent to seek information and participate in shared decision-making during times of medically uncertain situations.

Friends of the library groups in health sciences libraries.

The Houston Academy of Medicine--Texas Medical Center (HAM--TMC) Library collected data on friends of the library groups from 103 health sciences libraries, using a mail questionnaire. Sixteen of the responding libraries had independent friends groups; seven had friends groups that were subordinate to a university group. The sixteen independent groups gave as their major purposes (1) to raise money for their associated library and (2) to develop support for their library. These groups contributed an average of $4,870 a year to their libraries, the money being used primarily to purchase rare books and working-collection books and to sponsor social events. The subordinate groups contributed relatively little money to the health sciences libraries responding to the survey.

Physiologic and psychosocial stage-based differences for dietary fat consumption in women with type 2 diabetes

Purpose. This cross-sectional, observational study explored differences among groups staged for intent to decrease dietary fat intake in women with type 2 diabetes in relation to demographic, weight concern, physiological, and psychosocial variables. ^ Methods. A sample of 100 community-dwelling, English-speaking women, who were over age 30 and had type 2 diabetes for at least a year, was accessed through a culturally diverse endocrinology clinic. Subjects completed 7 self-report instruments: demographic sheet, with 11-point weight satisfaction scale; staging algorithm; fat intake (MEDFICTS); depression (CES-D); diabetes-specific dietary knowledge (ADKnowl), social support and self-efficacy scales (SE-Type 2). Physiological variables were abstracted from the medical record (HbA 1c, blood pressure, serum cholesterol and triglycerides). ^ Results. The women's average age was 57.69 years ( SD = 3.07); 50% were married. Subjects were well-educated ( M = 14 years; SD = 3.33), with average diabetes duration of 10.57 years (SD = 9.11), high body mass index (M = 35.72; SD = 8.36), low diabetes-specific dietary knowledge, low weight satisfaction, but in good diabetes control. Racial/ethnic composition was 44% non-Hispanic-White-American, 18% Hispanic-White-American, 15% non-Hispanic-African-American, 16% Hispanic-African-American and 5% other. Fat intake was low and differed by racial/ethnic demographics. The highest fat intake scores were for non-Hispanic-African-Americans (M = 53), followed by Hispanic-White-Americans (M = 51), non-Hispanic-White-Americans (M = 45), and Hispanic-African-Americans (M = 32), who had the lowest fat intake scores. ^ MANOVA analyses revealed no significant differences between stages of behavior change in relation to psychosocial or weight concern variables, age, education, HbA1c, or cholesterol levels. Single women were more likely to be in the three preaction stages (precontemplation, contemplation, and preparation); married women were equally distributed across stages (the preaction stages plus action and maintenance). African-American women (Hispanic and non-Hispanic) were more likely in contemplation and preparation. Triglycerides were higher in women in the action stage than contemplation or preparation. Systolic blood pressure was higher in action than preparation; diastolic blood pressure was higher in action than preaction. ^ Conclusions. Healthcare professionals should consider race, ethnicity, and marital status in client interactions. Dietary intake can vary according to both race and ethnicity; collapsing racial/ethnic groups can alter means and distributions, generating faulty conclusions. Further research is warranted to explore relationships between dietary self-care and marital status, race, ethnicity, and physiological variables. ^

A process evaluation of a health literacy intervention targeting pediatric providers' communication skills at the Texas Children's Health Plan

Background. Health literacy is an important determinant for quality health care, and affects communication between patients and physicians. Poor communication may result in negative effects in health. Improved communication between patients and physicians could positively affect health outcomes. Communication skills are teachable.^ Objectives. (1) to evaluate the process involved in the design and implementation of a health literacy intervention targeting pediatric providers’ communication skills at the Texas Children’s Health Plan in Houston, Texas; and (2) to describe lessons learned from this process that may be used in future attempts to address the issue of health literacy and health communication. ^ Design/methods. The process evaluation of the implementation of a health literacy strategy at the Texas Children’s Health Plan (TCHP) consisted of a critical analysis of all documents and minutes from meetings of the team of investigators. It also involved a secondary analysis of data collected between December 2006 and June 2007. Descriptive statistics, paired t-test and Wilcoxon-signed-rank test were employed in analyzing the data. This information was complemented with a limited review of existing literature on communication skills training programs. ^ Results. The design of the educational intervention followed recommendations from experts in the field of health literacy. The delivery of the intervention was possible and benefited from existing resources and logistics within the TCHP. Very few targeted providers participated in two offerings of the workshop (6.6% and 1.7% respectively). After the educational intervention, providers showed increased knowledge of health literacy facts and its effects in health (p=0.001); increased awareness of the low health literacy problem (p=0.003); increased expectations for change in practice (p=0.002), and intent to use health literacy strategies for communication immediately following the intervention (p=0.001). Low participation indicated the need for further investigation of barriers to, and means for successful implementation of programs aimed to improving health communication. ^ Conclusions. A short, focused intervention utilizing health literacy strategies for communication appeared effective in increasing knowledge and intentions for change in a small group of pediatric providers. ^

Exploring a model of skillful engagement in nursing practice

Prominent challenges facing nurse leaders are the growing shortage of nurses and the increasingly complex care required by acutely ill patients. In organizations that shortage is exacerbated by turnover and intent to leave. Unsatisfactory working conditions are cited by nurses when they leave their current jobs. Disengagement from the job leads to plateaued performance, decreased organizational commitment, and increased turnover. Solutions to these challenges include methods both to retain and to increase the effectiveness of each nurse. ^ The specific aim of this study was to examine the relationships among organizational structures thought to foster the clinical development of the nurse, with indicators of the development of clinical expertise, resulting in outcomes of positive job attitudes and effectiveness. Causal loop modeling is incorporated as a systems tool to examine developmental cycles both for an organization and for an individual nurse to look beyond singular events and investigate deeper patterns that emerge over time. ^ The setting is an academic specialty-care institution, and the sample in this cross-sectional study consists of paired data from 225 RNs and their nurse managers. Two panels of survey instruments were created based on the model's theoretical variables, one completed by RNs and the other by their Nurse Managers. The RN survey panel examined the variables of structural empowerment, magnet essentials, knowledge as identified by the Benner developmental stage, psychological empowerment, job stage, engagement, intent to leave, job satisfaction and the early recognition of patient complications. The nurse manager survey panel examined the Benner developmental stage, job stage, and overall level of nursing performance. ^ Four regression models were created based on the outcome variables. Each model identified significant organizational and individual characteristics that predicted higher job satisfaction, decreased intent to leave, more effectiveness as measured by early recognition and acting upon subtle patient complications, and better job performance. ^ Implications for improving job attitudes and effectiveness focus on ways that nursing leaders can foster a more empowering and healthy work environment. ^

Follow-up care after a health fair screening in three Houston neighborhoods in 2008

Background. Each year thousands of people participate in mass health screenings for diabetes and hypertension, but little is known about whether or not those who receive higher than normal screening results obtain the recommended follow-up medical care, or what barriers they perceive to doing so. ^ Methods. Study participants were recruited from attendees at three health fairs in low-income neighborhoods in Houston, Texas Potential participants had higher than normal blood pressure (> 90/140 mgHg) or blood glucose readings (100 mm/dL fasting or 140 mm/dL random). Study participants were called at one, two, and three months and asked if they had obtained follow-up medical care; those who had not yet obtained follow-up care were asked to identify barriers. Using a modified Aday-Andersen model of health service access, the independent variables were individual and community characteristics and self-perceived need. The dependent variable was obtaining follow-up care, with barriers to care a secondary outcome. ^ Results. Eighty-two study participants completed the initial questionnaire and 59 participants completed the study protocol. Forty-eight participants (59% under an intent to treat analysis, 81% of those completing the study protocol) obtained follow-up care. Those who completed the initial questionnaire and who reported a regular source of care were significantly more likely to obtain follow-up care. For those who completed the study protocol the relationship between having a regular source of care and obtaining follow-up care approached but did not reach significance. For those who completed the initial questionnaire, self-described health status, when examined as a binary variable (good, very good, excellent, or poor, fair, not sure) was associated with obtaining follow-up care for those who rated their health as poor, fair, or not sure. While the group who completed the study protocol did not reach statistical significance, the same relationship between self-described health status of poor, fair, or not sure and obtaining follow-up care was present. The participants who completed the study protocol and described their blood pressure as OK or a little high were statistically more likely to get follow-up care than those who described it as high or very high. All those on oral medications for hypertension (12/12) and diabetes (4/4) who were told to obtain follow-up care did so; however, the small sample size allows this correlation to be of statistical significance only for those treating hypertension. ^ The variables significantly associated with obtaining follow-up care were having a regular source of care, self-described health status of poor, fair, or not sure, self-described blood pressure of OK or a little high, and taking medication for blood pressure. ^ At the follow-up telephone calls, 34 participants identified barriers to care; cost was a significant barrier reported by 16 participants, and 10 reported that they didn’t have time because they were working long hours after Hurricane Ike. ^ The study included the offer of access assistance: information about nearby safety-net providers, a visit to or information from the Health Information Center at their Neighborhood Center location, or information from Project Safety Net (a searchable web site for safety net providers). Access assistance was offered at the health fairs and then again at follow-up telephone calls to those who had not yet obtained follow-up care. Of the 48 participants who reported obtaining follow-up care, 26 said they had made use of the access assistance to do so. The use of access assistance was associated with being Hispanic, not having health insurance or a regular source of care, and speaking Spanish. It was also associated with being worried about blood glucose. ^ Conclusion. Access assistance, as a community enabling characteristic, may be useful in aiding low-income people in obtaining medical care. ^

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. ^

Secondary analysis of effectivness of tinidazole-containing-quadruple eradication therapy in asymptomatic H. pylori infected children in El Paso

Helicobacter pylori infection is frequently acquired during childhood. This microorganism is known to cause gastritis, and duodenal ulcer in pediatric patients, however most children remain completely asymptomatic to the infection. Currently there is no consensus in favor of treatment of H. pylori infection in asymptomatic children. The firstline of treatment for this population is triple medication therapy including two antibacterial agents and one proton pump inhibitor for a 2 week duration course. Decreased eradication rate of less than 75% has been documented with the use of this first-line therapy but novel tinidazole-containing quadruple sequential therapies seem worth investigating. None of the previous studies on such therapy has been done in the United States of America. As part of an iron deficiency anemia study in asymptomatic H. pylori infected children of El Paso, Texas, we conducted a secondary data analysis of study data collected in this trial to assess the effectiveness of this tinidazole-containing sequential quadruple therapy compared to placebo on clearing the infection. Subjects were selected from a group of asymptomatic children identified through household visits to 11,365 randomly selected dwelling units. After obtaining parental consent and child assent a total of 1,821 children 3-10 years of age were screened and 235 were positive to a novel urine immunoglobulin class G antibodies test for H. pylori infection and confirmed as infected using a 13C urea breath test, using a hydrolysis urea rate >10 μg/min as cut-off value. Out of those, 119 study subjects had a complete physical exam and baseline blood work and were randomly allocated to four groups, two of which received active H. pylori eradication medication alone or in combination with iron, while the other two received iron only or placebo only. Follow up visits to their houses were done to assess compliance and occurrence of adverse events and at 45+ days post-treatment, a second urea breath test was performed to assess their infection status. The effectiveness was primarily assessed on intent to treat basis (i.e., according to their treatment allocation), and the proportion of those who cleared their infection using a cut-off value >10 μg/min of for urea hydrolysis rate, was the primary outcome. Also we conducted analysis on a per-protocol basis and according to the cytotoxin associated gene A product of the H. pylori infection status. Also we compared the rate of adverse events across the two arms. On intent-to-treat and per-protocol analyses, 44.3% and 52.9%, respectively, of the children receiving the novel quadruple sequential eradication cleared their infection compared to 12.2% and 15.4% in the arms receiving iron or placebo only, respectively. Such differences were statistically significant (p<0.001). The study medications were well accepted and safe. In conclusion, we found in this study population, of mostly asymptomatically H. pylori infected children, living in the US along the border with Mexico, that the quadruple sequential eradication therapy cleared the infection in only half of the children receiving this treatment. Research is needed to assess the antimicrobial susceptibility of the strains of H. pylori infecting this population to formulate more effective therapies. ^

Bayesian estimation of multilevel item response model with missing data

This study proposed a novel statistical method that modeled the multiple outcomes and missing data process jointly using item response theory. This method follows the "intent-to-treat" principle in clinical trials and accounts for the correlation between outcomes and missing data process. This method may provide a good solution to chronic mental disorder study. ^ The simulation study demonstrated that if the true model is the proposed model with moderate or strong correlation, ignoring the within correlation may lead to overestimate of the treatment effect and result in more type I error than specified level. Even if the within correlation is small, the performance of proposed model is as good as naïve response model. Thus, the proposed model is robust for different correlation settings if the data is generated by the proposed model.^

UNDERSTANDING INTERRUPTIONS IN HEALTHCARE: DEVELOPING A MODEL

Developing a Model Interruption is a known human factor that contributes to errors and catastrophic events in healthcare as well as other high-risk industries. The landmark Institute of Medicine (IOM) report, To Err is Human, brought attention to the significance of preventable errors in medicine and suggested that interruptions could be a contributing factor. Previous studies of interruptions in healthcare did not offer a conceptual model by which to study interruptions. As a result of the serious consequences of interruptions investigated in other high-risk industries, there is a need to develop a model to describe, understand, explain, and predict interruptions and their consequences in healthcare. Therefore, the purpose of this study was to develop a model grounded in the literature and to use the model to describe and explain interruptions in healthcare. Specifically, this model would be used to describe and explain interruptions occurring in a Level One Trauma Center. A trauma center was chosen because this environment is characterized as intense, unpredictable, and interrupt-driven. The first step in developing the model began with a review of the literature which revealed that the concept interruption did not have a consistent definition in either the healthcare or non-healthcare literature. Walker and Avant’s method of concept analysis was used to clarify and define the concept. The analysis led to the identification of five defining attributes which include (1) a human experience, (2) an intrusion of a secondary, unplanned, and unexpected task, (3) discontinuity, (4) externally or internally initiated, and (5) situated within a context. However, before an interruption could commence, five conditions known as antecedents must occur. For an interruption to take place (1) an intent to interrupt is formed by the initiator, (2) a physical signal must pass a threshold test of detection by the recipient, (3) the sensory system of the recipient is stimulated to respond to the initiator, (4) an interruption task is presented to recipient, and (5) the interruption task is either accepted or rejected by v the recipient. An interruption was determined to be quantifiable by (1) the frequency of occurrence of an interruption, (2) the number of times the primary task has been suspended to perform an interrupting task, (3) the length of time the primary task has been suspended, and (4) the frequency of returning to the primary task or not returning to the primary task. As a result of the concept analysis, a definition of an interruption was derived from the literature. An interruption is defined as a break in the performance of a human activity initiated internal or external to the recipient and occurring within the context of a setting or location. This break results in the suspension of the initial task by initiating the performance of an unplanned task with the assumption that the initial task will be resumed. The definition is inclusive of all the defining attributes of an interruption. This is a standard definition that can be used by the healthcare industry. From the definition, a visual model of an interruption was developed. The model was used to describe and explain the interruptions recorded for an instrumental case study of physicians and registered nurses (RNs) working in a Level One Trauma Center. Five physicians were observed for a total of 29 hours, 31 minutes. Eight registered nurses were observed for a total of 40 hours 9 minutes. Observations were made on either the 0700–1500 or the 1500-2300 shift using the shadowing technique. Observations were recorded in the field note format. The field notes were analyzed by a hybrid method of categorizing activities and interruptions. The method was developed by using both a deductive a priori classification framework and by the inductive process utilizing line-byline coding and constant comparison as stated in Grounded Theory. The following categories were identified as relative to this study: Intended Recipient - the person to be interrupted Unintended Recipient - not the intended recipient of an interruption; i.e., receiving a phone call that was incorrectly dialed Indirect Recipient – the incidental recipient of an interruption; i.e., talking with another, thereby suspending the original activity Recipient Blocked – the intended recipient does not accept the interruption Recipient Delayed – the intended recipient postpones an interruption Self-interruption – a person, independent of another person, suspends one activity to perform another; i.e., while walking, stops abruptly and talks to another person Distraction – briefly disengaging from a task Organizational Design – the physical layout of the workspace that causes a disruption in workflow Artifacts Not Available – supplies and equipment that are not available in the workspace causing a disruption in workflow Initiator – a person who initiates an interruption Interruption by Organizational Design and Artifacts Not Available were identified as two new categories of interruption. These categories had not previously been cited in the literature. Analysis of the observations indicated that physicians were found to perform slightly fewer activities per hour when compared to RNs. This variance may be attributed to differing roles and responsibilities. Physicians were found to have more activities interrupted when compared to RNs. However, RNs experienced more interruptions per hour. Other people were determined to be the most commonly used medium through which to deliver an interruption. Additional mediums used to deliver an interruption vii included the telephone, pager, and one’s self. Both physicians and RNs were observed to resume an original interrupted activity more often than not. In most interruptions, both physicians and RNs performed only one or two interrupting activities before returning to the original interrupted activity. In conclusion the model was found to explain all interruptions observed during the study. However, the model will require an even more comprehensive study in order to establish its predictive value.

Laparoscopic-Simulator Box: a Simple Design for Surgical Residency Programs to Improve Trainees’ Laparoscopic Skills

Introduction: Since the introduction and evolution of laparoscopic surgery, there have been some concerns related to surgical training in this field. Laparoscopic box trainers and virtual simulators appear as useful devices which have been demonstrating effectiveness in learning surgical skills. However, these tools remain inaccessible for many centers around the world. Our intent is to share our experience in successful design to inspire others in surgical residency programs to build such boxes for training in laparoscopic techniques and also to encourage the use of simulators in educational centers. [See PDF for complete abstract]

A discourse-theoretic approach to negotiated rulemaking

In 1996 and in 1997, Congress ordered the Secretary of Health and Human Services to undertake a process of negotiated rulemaking, which is authorized under the Negotiated Rulemaking Act of 1990, on three separate rulemaking matters. Other Federal agencies, including the Environmental Protection Agency and the Occupational Health and Safety Administration, have also made use of this procedure. As part of the program to reinvent government, President Clinton has issued an executive order requiring federal agencies to engage in some negotiated rulemaking procedures. I present an analytic, interpretative and critical approach to looking at the statutory and regulatory provisions for negotiated rulemaking as related to issues of democratic governance surrounding the problem of delegation of legislative power. The paradigm of law delineated by Jürgen Habermas, which sets law the task of achieving social or value integration as well as integration of systems, provides the background theory for a critique of such processes. My research questions are two. First, why should a citizen obey a regulation which is the result of negotiation by directly interested parties? Second, what is the potential effect of negotiated rulemaking on other institutions for deliberative democracy? For the internal critique I argue that the procedures for negotiated rulemaking will not produce among the participants the agreement and cooperation which is the legislative intent. For the external critique I argue that negotiated rulemaking will not result in democratically-legitimated regulation. In addition, the practice of negotiated rulemaking will further weaken the functioning of the public sphere, as Habermas theorizes it, as the central institution of deliberative democracy. The primary implication is the need to mitigate further development of administrative agencies as isolated, self-regulating systems, which have been loosened from the controls of democratic governance, through the development of a robust public sphere in which affected persons may achieve mutual understanding. ^

A literature review of the use of DDT to fight malaria

Background. First synthesized in 1874, dichlorodiphenyltrichloroethane (DDT) was not used until the second half of World War II after its insecticidal properties were discovered in 1939. For decades DDT has been used globally with the intent of eradicating malaria. This began in 1955 when the eighth World Health Assembly launched a global campaign selecting DDT as the chemical of choice for the eradication of malaria. The United States banned DDT use in 1972 partially due to the publication of “Silent Spring” by Rachel Carson in 1962 which suggested that DDT was harmful to the environment, wildlife and is a carcinogen. ^ Objectives. To critically review the literature on DDT, and evaluate its importance in malaria prevention and control. Methods: The design of this systematic literature review is a narrative summary and evaluation of the papers reviewed. The data came from searches using PubMed and MEDLINE which are free and publicly available databases. Inclusive criteria that were considered during the search are English language peer reviewed journal articles published in the last 20 years. The keywords were: “insecticidal and agricultural use of DDT”, “human impact of malaria”, “economic impact of malaria”, “benefits of DDT”, “effects of DDT”, “importance of malaria control”, and alternatives to DDT for malaria control. ^ Results. Malaria continues to be one of the most common infectious diseases and creates a tremendous global public health problem. WHO recommends DDT for malaria vector control because compared to other pesticides, it is the most persistent in indoor spraying. ^ Conclusion. Indoor spraying of DDT in malaria endemic areas may cause increased exposure of the chemical to humans; however I conclude that the overall benefits outweigh the risks because more lives are saved due to fewer infections with malaria.^

THE APPLICATION OF PATH ANALYSIS TO ASSESSMENT OF IRON NUTRITIONAL STATUS IN MAN

Path analysis has been applied to components of the iron metabolic system with the intent of suggesting an integrated procedure for better evaluating iron nutritional status at the community level. The primary variables of interest in this study were (1) iron stores, (2) total iron-binding capacity, (3) serum ferritin, (4) serum iron, (5) transferrin saturation, and (6) hemoglobin concentration. Correlation coefficients for relationships among these variables were obtained from published literature and postulated in a series of models using measures of those variables that are feasible to include in a community nutritional survey. Models were built upon known information about the metabolism of iron and were limited by what had been reported in the literature in terms of correlation coefficients or quantitative relationships. Data were pooled from various studies and correlations of the same bivariate relationships were averaged after z- transformations. Correlation matrices were then constructed by transforming the average values back into correlation coefficients. The results of path analysis in this study indicate that hemoglobin is not a good indicator of early iron deficiency. It does not account for variance in iron stores. On the other hand, 91% of the variance in iron stores is explained by serum ferritin and total iron-binding capacity. In addition, the magnitude of the path coefficient (.78) of the serum ferritin-iron stores relationship signifies that serum ferritin is the most important predictor of iron stores in the proposed model. Finally, drawing upon known relations among variables and the amount of variance explained in path models, it is suggested that the following blood measures should be made in assessing community iron deficiency: (1) serum ferritin, (2) total iron-binding capacity, (3) serum iron, (4) transferrin saturation, and (5) hemoglobin concentration. These measures (with acceptable ranges and cut-off points) could make possible the complete evaluation of all three stages of iron deficiency in those persons surveyed at the community level. ^