South Asian immigrant cardiovascular risk assessment in Houston, Texas 2005

Background. Heart disease is the leading cause of death and stroke is the third leading cause of deaths for all people in the United States. South Asian Americans have a higher risk of developing cardiovascular diseases than native United States residents. ^ Purpose. This study examines the cardiovascular risk factors in the South Asian immigrant community residing in Southwest Houston. This study also explores the level of health insurance available to the South Asian in Houston. ^ Methods. One hundred sixty-two South Asian patients aged 18 years and older received cardiovascular screening from January 1 st, 2005 to March 31st, 2005 at Ibn Sina Community Clinic; blood pressure was measured twice in both arms after resting five minutes. Height and weight were also recorded. Demographic data was collected through personal interview (questionnaire) and blood samples were drawn to collect laboratory data. ^ Results. There were 162 eligible South Asian patients, among whom 127 (78%) participated in the study. There were no significant differences between the responders and the non-responders in terms of demographics and clinical characteristics. Laboratory data revealed a mean total cholesterol of 201 ± 34 mg/dl, 54 percent had high total cholesterol above 200 mg/dl. The mean fasting glucose was 108 ± 43 mg/dl, and body mass index (BMI) was 28 ± 4 kg/m2. The prevalence of hypertension was comparable with the general U.S. population; 38 percent of the South Asian males and 29 percent of females had hypertension. The prevalence of diabetes was also compared; 21 percent of SA males (3% for white American males) and 7 percent of SA females (2% for white American females) were found to have undiagnosed diabetes. Of the sample 12 percent had both hypertension and diabetes; 21 percent had both hypertension and high BMI, and 19 percent had hypertension and high total cholesterol levels. ^ Conclusion. The present study shows that the South Asians in this sample are at greater risk of developing cardiovascular diseases than other ethnicities. The high prevalence of hypertension, type 2 diabetes, higher total cholesterol levels with overweight and obesity, and less leisure time physical activity are important cardiovascular risk factors for South Asians population. ^

Houston police officer attitudes towards the mentally ill: CIT trained and non-CIT trained

The purpose of this study was to develop a better understanding of police officer attitudes towards the mentally ill and what impact that might have on their behavior. Focused on the effects of Crisis Intervention Team (CIT) training on Houston police officers, this research wanted to determine if CIT training decreases attitudes of authoritarianism and increases attitudes of self-efficacy in dealing with the mentally ill—other factors assessed were age, years of service, ethnicity, and gender. Results confirmed that CIT training had an effect on an officer's attitudes with CIT officers being less authoritarian and having more self-efficacy with respect to dealing with the mentally ill as compared to non-CIT officers. Because of these results, this study could offer support in tailoring training programs to have successful officer-mentally ill person interactions. ^

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

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

Translation and cultural adaptation of the Stigma-Devaluation scale for use among family caregivers of mentally ill relatives in Jordan

Background/significance. Mental illness stigma is a matter of great concern to family caregivers. Few research studies have been conducted in the Arab World on family caregivers' perception of stigma associated with caring for a mentally ill relative. Review of the literature on measurement of the concept of stigma related to caring for a mentally ill relative yielded no instrument appropriate for use in a Jordanian sample. Reliable and valid instruments to measure stigma perception among family caregivers are needed for research and practice, particularly in Arabic speaking populations. ^ Purpose. The purposes of this study were: (1) translate the Stigma-Devaluation scale (SDS) into Arabic, modifying it to accurately reflect the cultural parameters specific to Jordan, and (2) test the reliability, the content and construct validity of the Arabic version of the SDS for use among a sample of family members of mentally ill relatives in Jordan. ^ Design. Methodologic, cross-sectional. ^ Methods. The SDS was translated into Arabic language, modified and culturally adapted to the Jordanian culture by a translation model which incorporates a cultural adaptation process. The Arabic SDS was evaluated in a sample of 164 family caregivers in the outpatient mental health clinic in Irbid-Jordan. Cronbach's alpha estimation of internal consistency was used to assess the reliability of the SDS. Construct validity was determined by confirmatory factor analysis (CFA). Measurements of content validity and reading level of the Arabic SDS were included. ^ Findings. Content Validity Index was determined to be 1.0. Reading level of the Arabic SDS was considered at a 6th grade or lower Cronbach's alpha coefficient of the modified Arabic SDS total scale was .87. Initial results of CFA did not fully support the proposed factor structures of the SDS or its subscales. After modifications, the indices indicated that the modified model of each subscale had satisfactory fit. ^ Conclusion. This study provided psychometric evidence that the modified Arabic SDS translated and culturally adapted instrument, is valid and conceptually consistent with the content of the original English SDS in measuring stigma perception among families of mentally ill relatives in Jordan. ^

Has implementation of integrated mental health services in primary care programs positively impacted health outcomes among the mentally ill in developing countries?

Objective. The World Health Organization (WHO) estimates that nearly 450 million people suffer from a mental disorder in the world. Developing countries do not have the health system structure in place to support the demand of mental health services. This study will conduct a review of mental health integration in primary care research that is carried out in low-income countries identified as such from the World Bank economic analysis. The research follows the standard of care that WHO has labeled appropriate in treatment of mental health populations. Methods. This study will use the WHO 10 principles of mental health integration into primary care as the global health standard of care for mental health. Low-income countries that used these principles in their national programs will be analyzed for effectiveness of mental health integration in primary care. Results. This study showed that mental health service integration in primary care did have an effect on health outcomes of low-income countries. However, information did not lead to significant quantitative results that determined how positive the effect was. Conclusion. More ethnographic research is needed in low-income countries to truly assess how effective the program is in integrating with the health system currently in place.^ ^

Identifying characteristics of mentally ill homeless individuals who are successfully linked to health and social services post-incarceration via the jail inreach project

Healthcare for the Homeless—Houston (HHH) received a research grant from The Medallion Foundation, Inc. in March 2006 to pilot The Jail Inreach Project, an intensive “inreach” initiative to assess the impact of providing continuity of mental and primary health care services for homeless individuals who suffer from mental illness and/or substance abuse being released from jail. This pilot project was initiated by HHH, in collaboration with the Harris County Sheriff’s Office and the Mental Health Mental Retardation Authority of Harris County (MHMRA). Those who are flagged as “frequent flyers” and who are diagnosed with a mental illness are referred to the Jail Inreach Project. In order to maximize the effectiveness of the discharge plan, case managers offer the option of meeting the client at the time of release and bring them to the HHH clinic located four blocks from the jail. Participation in both the program and the option for direct release to the care of a case manager are voluntary.^ The purpose of this study is to determine the outcomes of the Jail Inreach Project and addresses the following objectives: (1) to evaluate the characteristics of inmates that chose to be released from jail to the direct care of an HHH case manager versus those who opt for self release and (2) to determine the number and percent of inmates that are linked to services and relationship with type of release (direct versus indirect), (3) to determine if there is a relationship between outcomes and characteristics and (4) to determine what outcomes are a function of release, controlling for characteristics. Statistical analysis, including frequencies, cross tabulations, chi-square and logistical regression, found that those who opt for self release are six times less likely to be successfully linked to services and that gender is the most significant predictor of choosing self release. Men are far more likely to opt for self release than women engaged in this program. These findings help inform policy and program design and development that addresses the difference in service utilization and successful linkage to services post-incarceration. Successful linkage to services, thus continuity of and access to care, further impact the effects of the revolving door phenomenon of mentally ill homeless individuals cycling between the streets, jails and hospital emergency centers.^

Factors related to employment among chronically mentally ill patients

A descriptive study of demographic and psychosocial factors believed to be associated with employment was carried out through face-to-face interviews with 417 chronically mentally-ill patients. Subjects had been hospitalized a minimum of two times for psychiatric treatment, had been discharged from at least one of these hospitalizations in the two years prior to the study, and were currently residing within a specific community mental health center catchment area in Texas. The study group ranged in age from 16 to 68 years and over one-half had chart diagnoses of schizophrenia.^ A structured interview was developed which addressed current employment status, length of current employment, job title of current or last job, and detailed work history for the prior five years. Four measures of social support were included in the interview. Each subject was asked to identify one recent work and one recent non-work situation which had been stressful or very demanding. A coping questionnaire was verbally administered to measure the ways in which subjects had coped with these specific stressful situations.^ Analysis of results revealed that 27 percent of the sample was gainfully employed at time of interview. Differences between the employed and unemployed groups were analyzed by t-test an chi square. The employed demonstrated significantly more weeks of employment in the prior five years than the unemployed. The current jobs of the employed required a significantly higher relationship to "things" or inanimate objects than the last jobs of the unemployed. Subjects diagnosed as schizophrenic were significantly less likely to be employed than subjects with other diagnoses.^ Employed subjects scored significantly higher on three of four measures of social support than unemployed subjects, including reported frequency of social group attendance and/or meetings with mental health professionals. Problem-focused coping was used significantly more by the employed than by the unemployed to deal with stressful situations in the work, but not the non-work, context. ^

Procedure for the identification of population characteristics for targeting intervention services on the basis of outcome-goal priorities: Case management services for the chronic mentally ill

Although the processes involved in rational patient targeting may be obvious for certain services, for others, both the appropriate sub-populations to receive services and the procedures to be used for their identification may be unclear. This project was designed to address several research questions which arise in the attempt to deliver appropriate services to specific populations. The related difficulties are particularly evident for those interventions about which findings regarding effectiveness are conflicting. When an intervention clearly is not beneficial (or is dangerous) to a large, diverse population, consensus regarding withholding the intervention from dissemination can easily be reached. When findings are ambiguous, however, conclusions may be impossible.^ When characteristics of patients likely to benefit from an intervention are not obvious, and when the intervention is not significantly invasive or dangerous, the strategy proposed herein may be used to identify specific characteristics of sub-populations which may benefit from the intervention. The identification of these populations may be used both in further informing decisions regarding distribution of the intervention and for purposes of planning implementation of the intervention by identifying specific target populations for service delivery.^ This project explores a method for identifying such sub-populations through the use of related datasets generated from clinical trials conducted to test the effectiveness of an intervention. The method is specified in detail and tested using the example intervention of case management for outpatient treatment of populations with chronic mental illness. These analyses were applied in order to identify any characteristics which distinguish specific sub-populations who are more likely to benefit from case management service, despite conflicting findings regarding its effectiveness for the aggregate population, as reported in the body of related research. However, in addition to a limited set of characteristics associated with benefit, the findings generated, a larger set of characteristics of patients likely to experience greater improvement without intervention. ^

RESPIRATORY COMPENSATION MECHANISMS IN THE UPPER AND LOWER RESPIRATORY TRACTS OF AN ANIMAL MODEL AFTER SUBCHRONIC INHALATION EXPOSURE TO FORMALDEHYDE: IMPLICATIONS FOR TOXICOLOGY RISK ASSESSMENT (DEPOSITION, DOSE RECEIVED, RESPONSE)

The potential for significant human populations to experience long-term inhalation of formaldehyde and reports of symptomatology due to this exposure has led to a considerable interest in the toxicologic assessment of risk from subchronic formaldehyde exposures using animal models. Since formaldehyde inhalation depresses certain respiratory parameters in addition to its other forms of toxicity, there is a potential for the alteration of the actual dose received by the exposed individual (and the resulting toxicity) due to this respiratory effect. The respiratory responses to formaldehyde inhalation and the subsequent pattern of deposition were therefore investigated in animals that had received subchronic exposure to the compound, and the potential for changes in the formaldehyde dose received due to long-term inhalation evaluated. Male Sprague-Dawley rats were exposed to either 0, 0.5, 3, or 15 ppm formaldehyde for 6 hours/day, 5 days/week for up to 6 months. The patterns of respiratory response, deposition and the compensation mechanisms involved were then determined in a series of formaldehyde test challenges to both the upper and to the lower respiratory tracts in separate groups of subchronically exposed animals and age-specific controls (four concentration groups, two time points). In both the control and pre-exposed animals, there was a characteristic recovery of respiratory parameters initially depressed by formaldehyde inhalation to at or approaching pre-exposure levels within 10 minutes of the initiation of exposure. Also, formaldehyde deposition was found to remain very high in the upper and lower tracts after long-term exposure. Therefore, there was probably little subsequent effect on the dose received by the exposed individual that was attributable to the repeated exposures. There was a diminished initial minute volume response in test challenges of both the upper and lower tracts of animals that had received at least 16 weeks of exposure to 15 ppm, with compensatory increases in tidal volume in the upper tract and respiratory rate in the lower tract. However, this dose-related effect was probably not relevant to human risk estimation because this formaldehyde dose is in excess of that experienced by human populations. ^

Assessing the Environmental Protection Agency's guidelines for cumulative risk assessment: Are they suitable for state agencies and EPA regional offices?

In the field of health risk analysis, cumulative risk assessment (CRA) is a necessary, although undeniably more complex approach to understanding the mixture of stressors, whether chemical or psychosocial, that exist in our environment, in all the pathways through which the chemicals may evolve—air, soil, or water, as well as the accumulation of these exposures over time. Related, or attached to the developing awareness of scientists understanding this mix of combined health effects is the burgeoning of the environmental justice movement, in which educated community advocates and even affected community members have called attention to evidence of a higher pollution burden in minority and/or lower SES communities. The intention of this paper is to 1) examine the development and understanding of CRA, primarily by the U.S. Environmental Protection Agency; 2) to assess several states agencies and some EPA regional offices' interpretation of CRA, again based primarily on EPA guidance, and 3) to analyze how CRA might be refined in its implementation—giving some cues as to how the EPA may more effectively interact with communities interested in CRA.^

ACCURACY OF THE BRCAPRO RISK ASSESSMENT MODEL IN MALES PRESENTING TO MD ANDERSON FOR BRCA TESTING

ACCURACY OF THE BRCAPRO RISK ASSESSMENT MODEL IN MALES PRESENTING TO MD ANDERSON FOR BRCA TESTING Publication No. _______ Carolyn A. Garby, B.S. Supervisory Professor: Banu Arun, M.D. Hereditary Breast and Ovarian Cancer (HBOC) syndrome is due to mutations in BRCA1 and BRCA2 genes. Women with HBOC have high risks to develop breast and ovarian cancers. Males with HBOC are commonly overlooked because male breast cancer is rare and other male cancer risks such as prostate and pancreatic cancers are relatively low. BRCA genetic testing is indicated for men as it is currently estimated that 4-40% of male breast cancers result from a BRCA1 or BRCA2 mutation (Ottini, 2010) and management recommendations can be made based on genetic test results. Risk assessment models are available to provide the individualized likelihood to have a BRCA mutation. Only one study has been conducted to date to evaluate the accuracy of BRCAPro in males and was based on a cohort of Italian males and utilized an older version of BRCAPro. The objective of this study is to determine if BRCAPro5.1 is a valid risk assessment model for males who present to MD Anderson Cancer Center for BRCA genetic testing. BRCAPro has been previously validated for determining the probability of carrying a BRCA mutation, however has not been further examined particularly in males. The total cohort consisted of 152 males who had undergone BRCA genetic testing. The cohort was stratified by indication for genetic counseling. Indications included having a known familial BRCA mutation, having a personal diagnosis of a BRCA-related cancer, or having a family history suggestive of HBOC. Overall there were 22 (14.47%) BRCA1+ males and 25 (16.45%) BRCA2+ males. Receiver operating characteristic curves were constructed for the cohort overall, for each particular indication, as well as for each cancer subtype. Our findings revealed that the BRCAPro5.1 model had perfect discriminating ability at a threshold of 56.2 for males with breast cancer, however only 2 (4.35%) of 46 were found to have BRCA2 mutations. These results are significantly lower than the high approximation (40%) reported in previous literature. BRCAPro does perform well in certain situations for men. Future investigation of male breast cancer and men at risk for BRCA mutations is necessary to provide a more accurate risk assessment.

The development of poultry farms risk assessment tool for avian influenza in Imo State, Nigeria

Background: Nigeria was one of the 13 countries where avian influenza outbreak in poultry farms was reported during the 2006 avian influenza pandemic threat and was also the first country in Africa to report the presence of H5N1influenza among its poultry population. There are multiple hypotheses on how the avian influenza outbreak of 2006 was introduced to Nigeria, but the consensus is that once introduced, poultry farms and their workers were responsible for 70% of the spread of avian influenza virus to other poultry farms and the population. ^ The spread of avian influenza has been attributed to lack of compliance by poultry farms and their workers with poultry farm biosecurity measures. When poultry farms fail to adhere to biosecurity measures and there is an outbreak of infectious diseases like in 2006, epidemiological investigations usually assess poultry farm biosecurity—often with the aid of a questionnaire. Despite the importance of questionnaires in determining farm compliance with biosecurity measures, there have been few efforts to determine the validity of questionnaires designed to assess poultry farms risk factors. Hence, this study developed and validated a tool (questionnaire) that can be used for poultry farm risk stratification in Imo State, Nigeria. ^ Methods: Risk domains were generated using literature and recommendations from agricultural organizations and the Nigeria government for poultry farms. The risk domains were then used to develop a questionnaire. Both the risk domain and questionnaire were verified and modified by a group of five experts with a research interest in Nigeria's poultry industry and/or avian influenza prevention. Once a consensus was reached by the experts, the questionnaire was distributed to 30 selected poultry farms in Imo State, Nigeria that participated in this study. Survey responses were received for all the 30 poultry farms that were selected. The same poultry farms were visited one week after they completed the questionnaires for on-site observation. Agreement among survey and observation results were analyzed using a kappa test and rated as poor, fair, moderate, substantial, or nearly perfect; and internal consistency of the survey was also computed. ^ Result: Out of the 43 items on the questionnaire, 32 items were validated by this study. The agreement between the survey result and onsite observation was analyzed using kappa test and ranged from poor to nearly perfect. Most poultry farms had their best agreements in the contact section of the survey. The least agreement was noted in the farm management section of the survey. Thirty-two questions on the survey had a coefficient alpha > 0.70, which is a robust internal consistency for the survey. ^ Conclusion: This study developed 14 risk domains for poultry farms in Nigeria and validated 32 items from the original questionnaire that contained 43 items. The validated items can be used to determine the risk of introduction and spread of avian influenza virus in poultry farms in Imo State, Nigeria. After further validations in other states, regions and poultry farm sectors in Nigeria; this risk assessment tool can then be used to determine the risk profile of poultry farms across Nigeria.^

The assumptions and effects of conservative procedures in low -dose risk assessment for setting safety standards

Conservative procedures in low-dose risk assessment are used to set safety standards for known or suspected carcinogens. However, the assumptions upon which the methods are based and the effects of these methods are not well understood.^ To minimize the number of false-negatives and to reduce the cost of bioassays, animals are given very high doses of potential carcinogens. Results must then be extrapolated to much smaller doses to set safety standards for risks such as one per million. There are a number of competing methods that add a conservative safety factor into these calculations.^ A method of quantifying the conservatism of these methods was described and tested on eight procedures used in setting low-dose safety standards. The results using these procedures were compared by computer simulation and by the use of data from a large scale animal study.^ The method consisted of determining a "true safe dose" (tsd) according to an assumed underlying model. If one assumed that Y = the probability of cancer = P(d), a known mathematical function of the dose, then by setting Y to some predetermined acceptable risk, one can solve for d, the model's "true safe dose".^ Simulations were generated, assuming a binomial distribution, for an artificial bioassay. The eight procedures were then used to determine a "virtual safe dose" (vsd) that estimates the tsd, assuming a risk of one per million. A ratio R = ((tsd-vsd)/vsd) was calculated for each "experiment" (simulation). The mean R of 500 simulations and the probability R $<$ 0 was used to measure the over and under conservatism of each procedure.^ The eight procedures included Weil's method, Hoel's method, the Mantel-Byran method, the improved Mantel-Byran, Gross's method, fitting a one-hit model, Crump's procedure, and applying Rai and Van Ryzin's method to a Weibull model.^ None of the procedures performed uniformly well for all types of dose-response curves. When the data were linear, the one-hit model, Hoel's method, or the Gross-Mantel method worked reasonably well. However, when the data were non-linear, these same methods were overly conservative. Crump's procedure and the Weibull model performed better in these situations. ^

AN ASSESSMENT OF THE CURRENT STATUS OF MENTAL ILLNESS IN BENDEL STATE OF NIGERIA: IMPLICATIONS FOR PUBLIC MENTAL HEALTH POLICY AND EDUCATION

This descriptive study assesses the current status of mental illness in Bendel State of Nigeria to determine its implications for mental health policy and education. It is a study of the demographic characteristics of psychiatric patients in the only two modern western psychiatric facilities in Bendel State, the various treatment modalities utilized for mental illness, and the people's choice of therapeutic measures for mental illness in Bendel State.^ This study investigated ten aspects of mental illness in Bendel State (1) An increase of the prevalence of mental illness (psychiatric disorder) in Bendel State. (2) Unaided, unguided, and uncared for mentally ill people roaming about Bendel State. (3) Pluralistic Treatment Modalities for mentally ill patients in Bendel State. (4) Traditional Healers treating more mentally ill patients than the modern western psychiatric hospitals. (5) Inadequate modern western psychiatric facilities in Bendel State. (6) Controversy between Traditional Health and modern western trained doctors over the issue of possible cooperation between traditional and modern western medicine. (7) Evidence of mental illness in all ethnic groups in Bendel State. (8) More scientifically based and better organized modern western psychiatric hospitals than the traditional healing centers. (9) Traditional healers' level of approach with patients, and accessibility to patients' families compared with the modern western trained doctors. (10) An urgent need for an official action to institute a comprehensive mental health policy that will provide an optimum care for the mentally ill in Bendel State, and in Nigeria in general.^ Of the eight popular treatment modalities generally used in Bendel State for mental illness, 54% of the non-patient population sampled preferred the use of traditional healing, 26.5% preferred the use of modern western treatment, and 19.5% preferred religious healers.^ The investigator concluded at this time not to recommend the integration of Traditional Healing and modern western medicine in Nigeria. Rather, improvement of the existing modern western psychiatric facilities and a proposal to establish facilities to enable traditional healing and modern western medicine to exist side by side were highly recommended. ^

Improving the health and well-being of women at risk for neural tube defect recurrence

There is growing interest in providing women with internatal care, a package of healthcare and ancillary services that can improve their health during the period after the termination of one pregnancy but before the conception of the next pregnancy. Women who have had a pregnancy affected by a neural tube defect can especially benefit from internatal care because they are at increased risk for recurrence and improvements to their health during the inter-pregnancy period can prevent future negative birth outcomes. The dissertation provides three papers that inform the content of internatal care for women at risk for recurrence by examining descriptive epidemiology to develop an accurate risk profile of the population, assessing whether women at risk for recurrence would benefit from a psychosocial intervention, and determining how to improve health promotion efforts targeting folic acid use.^ Paper one identifies information relevant for developing risk profiles and conducting risk assessments. A number of investigations have found that the risk for neural tube defects differs between non-Hispanic Whites and Hispanics. To understand the risk difference, the descriptive epidemiology of spina bifida and anencephaly was examined for Hispanics and non-Hispanic Whites based on data from the Texas Birth Defects Registry for the years 1999 through 2004. Crude and adjusted birth prevalence ratios and corresponding 95% confidence intervals were calculated between descriptive epidemiologic characteristics and anencephaly and spina bifida for non-Hispanic Whites and for Hispanics. In both race/ethnic groups, anencephaly expressed an inverse relationship with maternal age and a positive linear relationship with parity. Both relationships were stronger in non-Hispanic Whites. Female infants had a higher risk for anencephaly in non-Hispanic Whites. Lower maternal education was associated with increased risk for spina bifida in Hispanics.^ Paper two assesses the need for a psychosocial intervention. For mothers who have children with spina bifida, the transition to motherhood can be stressful. This qualitative study explored the process of becoming a mother to a child with spina bifida focusing particularly on stress and coping in the immediate postnatal environment. Semi-structured interviews were conducted with six mothers who have children with spina bifida. Mothers were asked about their initial emotional and problem-based coping efforts, the quality and kind of support provided by health providers, and the characteristics of their meaning-based coping efforts; questions matched Transactional Model of Stress and Coping (TMSC) constructs. Analysis of the responses revealed a number of modifiable stress and coping transactions, the most salient being: health providers are in a position to address beliefs about self-causality and prevent mothers from experiencing the repercussions that stem from maintaining these beliefs. ^ Paper three identifies considerations when creating health promotion materials targeting folic acid use. A brochure was designed using concepts from the Precaution Adoption Process Model (PAPM). Three focus groups comprising 26 mothers of children with spina bifida evaluated the brochure. One focus group was conducted in Spanish-only, the other two focus groups were conducted in English and Spanish combined. Qualitative analysis of coded transcripts revealed that a brochure is a helpful adjunct. Questions about folic acid support the inclusion of an insert with basic information. There may be a need to develop different educational material for Hispanics so the importance of folic acid is provided in a situational context. Some participants blamed themselves for their pregnancy outcome which may affect their receptivity to messages in the brochure. The women's desire for photographs that affect their perception of threat and their identification with the second role model indicate they belong to PAPM Stage 2 and 3. Participants preferred colorful envelopes, high quality paper, intimidating photographs, simple words, conversational style sentences, and positive messages.^ These papers develop the content of risk assessment, psychosocial intervention, and health promotion components of internatal care as they apply to women at risk for recurrence. The findings provided evidence for considering parity and maternal age when assessing nutritional risk. The two dissimilarities between the two race/ethnic groups, infant sex and maternal education lent support to creating separate risk profiles. Interviews with mothers of children with spina bifida revealed the existence of unmet needs-suggesting that a psychosocial intervention provided as part of internatal care can strengthen and support women's well-being. Segmenting the audience according to race/ethnicity and PAPM stage can improve the relevance of print materials promoting folic acid use.^