An evaluation of the Texas "A Woman's Right to Know" booklet: A state mandated patient education document for induced abortion

Many patient educational documents are written at a grade level higher than the level at which most individuals can read. This discrepancy can lead to treatment noncompliance and negative health outcomes. Therefore, it is important that patients receive readable health information. The Texas "A Woman's Right to Know" booklet is a state mandated informational document provided to women seeking abortion services. Given the significance of the abortion procedure, it is imperative that women considering having an abortion receive accurate and readable health materials. However, no published studies were found that evaluated the readability of the "A Woman's Right to Know" booklet. Therefore, the purpose of this study was to assess the readability of the "A Woman's Right to Know" booklet. To assess the readability, the Flesch-Kincaid readability test was used to evaluate the reading grade level of the entire "A Woman's Right to Know" booklet and each of the 7 sections of the booklet. The results showed that the readability of the entire booklet as well as each section of the booklet was written below the 8th grade reading level. Although the booklet was written below the estimated United States reading level (8th grade), the reading level of this booklet may still be too high for people in Texas who read below the 8th grade level. Based on these results, it is recommended that health care professionals involved in the distribution and explanation of the "A Woman's Right to Know" booklet provide their patients with both written and verbal medical information. The patients should be allowed to ask questions about the abortion procedure so that they can make the most informed choice.^

Texas Health & Safety Code, Section 165.002 - Right to Breastfeed in Texas

The language used in Section 165.002 of the Texas Health and Safety Code renders breastfeeding women vulnerable and susceptible to harassment, discrimination, and persecution via the Texas Penal Code, Sec. 30.05 (Criminal Trespassing), Sec. 21.08 (Indecent Exposure), and Sec. 21.22 (Indecency with a Child). ^ The overall goal of this paper is to develop a solution to this problem via a proposed law or legislative action that offers protection and support for breastfeeding women who choose to nurse in public. Data to inform these recommendations were collected through a literature review and structured interviews with several breastfeeding stakeholders. A literature review of state and federal breastfeeding legislation was conducted to compare and contrast differences between existing legislation in the United States. Interviews were conducted with breastfeeding legislation stakeholders, which included state legislators who have been active in breastfeeding legislation, breastfeeding mothers, and representatives from the Central Texas Healthy Mothers Healthy Babies Coalition (Centex HMHB Coalition), Texas Breastfeeding Coalition (TXBF coalition), La Leche League International, and the Texas Business Association. Data from the literature and legislation reviews and interviews were transcribed and examined for common themes using qualitative data techniques. ^ Overall, most of the stakeholders came to a general consensus on three points, (1) breastfeeding women are supported by stakeholders within the community, (2) other legislation or penal codes should not override the right to breastfeed, and (3) the current breastfeeding legislation needs to be improved to adequately support breastfeeding women. The interviews with breastfeeding legislation stakeholders yielded two major recommendations for the improvement of Section 165.002 of the Texas Health and Safety Code: advocacy efforts to change the wording of the legislation and education to inform people about the legislation. ^ The right to breastfeed is an important public health issue in that it provides a host of health benefits for mothers and children, and is more economical and environmentally superior to alternative feeding methods. While breastfeeding in public is not illegal nor ever has been, adequate legislation is important to affirm this right for women so that they can confidently feed their children without embarrassment or harassment.^

A woman's right to know: A policy review of abortion legislation in Texas

Introduction: Despite its legalization, abortion remains a controversial issue, one that has many divided on either side of the political spectrum. While there have been several changes made to abortion policy over the past few decades, one that continues to have many asking questions is the Woman’s Right to Know Act, a piece of state imposed abortion legislation that has implemented strict restrictions and requirements of women seeking abortion, including pre-abortion mandatory counseling and a 24 hour waiting period. This project analyzed four controversial components of the mandatory counseling materials in Texas in an attempt to examine the scientific validity behind this legislation. Methods: In order to understand the scientific validity behind the content of the preabortion mandatory counseling, I conducted a systematic literature review to analyze: the purported link between abortion and breast cancer, the existence of fetal pain, the risk of abortion to future fertility, and the negative psychological effects of abortion. An electronic search in EBSCO and PubMed of review articles published between 1995 and 2010 resulted in fourteen reviews. Results: Results of the systematic review found (1) inconclusive evidence suggesting a link between abortion and breast cancer, (2) that fetal pain likely does not occur until the third trimester of pregnancy, (3) that associations exist between induced abortion and subsequent preterm birth and placenta previa, and (4) that there is mixed evidence relating to the negative psychological effects that exist among women having had an abortion and those who have not had abortion. Conclusion: Based on these conclusions, a recommendation was made to revise the current state mandated counseling materials to reflect more accurate and scientifically-based information about abortion and its potential risks.^

Youth empowerment evaluation to improve afterschool programming

Community-based participatory research necessitates that community members act as partners in decision making and mutual learning and discovery. In the same light, for programs/issues involving youth, youth should be partners in knowledge sharing and evaluation (Checkoway & Richards-Schuster, 2004). This study is a youth-focused empowerment evaluation for the Successful Youth program. Successful Youth is a multi-component youth development after-school program for Latino middle school youth, created with the goal of reducing teen pregnancy. An empowerment evaluation is collaborative and participatory (Balcazar and Harper 2003). The three steps of an empowerment evaluation are: (1) defining mission, (2) taking stock, and (3) planning for the future (Fetterman 2001).^ In a program where youth are developing leadership skills, making choices, and learning how to self reflect and evaluate, the empowerment evaluation could not be more aligned with promoting and enhancing these skills. In addition, an empowerment evaluation is designed to "foster improvement and self-determination" and "build capacity" (Fetterman 2001). Four empowerment groups were conducted with approximately 6-9 Latino 7th grade students per group. All participants were enrolled in the Successful Youth program. Results indicate points where students' perceptions of the program were aligned with the program's mission and where gaps were identified. Students offered recommendations for program improvements. Additionally, students enjoyed expressing their feelings about the program and appreciated that their opinions were valued. Youth recommendations will be brought to program staff; and, where possible, gaps will be addressed. Empowerment evaluations with youth will continue during the duration of the program so that youth involvement and input remains integral in the evaluation and to ascertain whether the program's goals are being met. ^

An assessment of self-concept and violence within a delinquent adolescent population

The purpose of this study was to provide further data on the relationship between self-concept and violence focusing on a delinquent adolescent population. Recent research has explored the relationship between self-concept and violence with most of the research being done with adult populations. Within the literature, there are two opposing views on the question of this relationship. The traditional view supports the idea that low self-esteem is a cause of violent behavior while the non-traditional view supports the idea that high self-esteem may be a contributor to violent behavior. ^ Using a sample of 200 delinquent adolescents 100 of whom had committed acts of violence and 100 who had not, a group comparison study was done which addressed the following questions, (1) within a delinquent population of violent and non-violent adolescents, is there a relationship between violence and self-concept? (2) what is that relationship; (3) using the Piers-Harris Children's Self-Concept Scale, can it be determined that attributes such as behavior, anxiety, popularity, happiness, and physical appearance as they relate to self-concept are more predictive than others in determining who within a delinquent population will commit acts of violence. For the purposes of this study, delinquent adolescents were those who had official records of misconduct with either the school or juvenile authorities. Adolescents classified as violent were those who had committed acts such as assault, use of a weapon, use of deadly force, and sexual assault while adolescents classified as non-violent had committed anti-social acts such as, truancy, talking back and rule breaking. ^ The study concluded that there is a relationship between adolescent violence and self-concept. However, there was insufficient statistical evidence that self-concept is a predictor of violence. ^

Internet as a medium to seek partners among men who have sex with men

While there are reports of developing sexual relationships on the Internet (I) among MSM, there are few reports that have examined the process of developing sexual relationships on the I and comparing to that in real life (IRL). This study examines the process to provide insight into how MSM make decisions about courtship, engages in negotiations for sex, and choose sexual partners and examines the comparative sexual risks taken between I vs. IRL negotiation. This self-selected convenience sample at a national level (n=1001) of MSM recruited through the I, systematically explored the different steps, the process of courtship in a flow chart of I and IRL dating to portray the process of filtering, courtship and/or negotiation for sex. Risk behaviors in both environments are presented along with interactions that create predictable sequences or "scripts". These sequences constitute 'filtering' and 'sexual positioning'. Differences between I & IRL suggest discussion of HIV/STD status to have consistent differences for all variables except 'unprotected sex' meaning no condom use. There was more communication on the I in regards to self revealing information or variables relating to reducing risks which enable 'filtering' (including serosorting). Data indicate more steps in the I process, providing more complex, multiple steps to filter and position with regard not only to HIV/STD risk but also to negotiate position for complementary sexual interest. The study established a pattern of MSM's courtships or negotiation for sex and a pattern of acquisition, and more I negotiation. Data suggest negotiation opportunities which could lend to intervention to advise people how to negotiate safely. ^ Previous studies have reviewed MSM and drug use. This is a study to review the process of drug use associated with sexual behavior regarding the Internet (I) and in real life (IRL) using a self-selected, convenience sample of MSM (n=1001) recruited nation-wide through the Internet. Data on MSM and drugs illustrate the Internet being used as a tool to filter for drug use among MSM. MSM's drug use in both environments highlights the use of sexual performance drugs with an IRL pursuit of intimacy or negotiation for sex. IRL encounters were more likely to involve drug use (both recreational and sexual performance-enhancing) than Internet encounters. This may be due to more IRL meetings occurring at bars, clubs or parties where drug use is a norm. Compared with IRL, the Internet may provide a venue for persons who do not want to use drugs to select partners with similar attitudes. This suggests that filtering may be occurring as part of the internet negotiation. Data indicated that IRL persons get drunk/high before having sex in past 60 days significantly more often than Internet participants. Age did not alter the pattern of results. Thus drug filtering is really not recreational drug filtering or selecting for PNP, but appears to be situationally-based. Thus, it should perhaps be seen as another form of filtering to select drug-free partners, rather than using the Internet to specifically recruit and interact with other recreational drug users. ^

Assessing fun in serious games: Formative evaluation of games from two diabetes prevention interventions

Purpose. To determine the usability of two video games to prevent type 2 diabetes and obesity among youth through analysis of data collected during alpha-testing. ^ Subjects. Ten children aged 9 to 12 were selected for three 2-hour alpha testing sessions.^ Methods. "Escape from Diab" and "Nanoswarm" were designed to change dietary and physical inactivity behaviors, based on a theoretical framework of mediating variables obtained from social cognitive theory, self-determination theory, elaboration likelihood model, and behavioral inoculation theory. Thirteen mini-games developed by the software company were divided into 3 groups based on completion date. Children tested 4-5 mini-games in each of three sessions. Observed game play was followed by a scripted interview. Results from observation forms and interview transcripts were tabulated and coded to determine usability. Suggestions for game modifications were delivered to the software design firm, and a follow-up table reports rationale for inclusion or exclusion of such modifications.^ Results. Participants were 50% frequent video game players and 20% non game-players. Most (60%) were female. The mean grade (indicating likeability as a subset of usability) across all games given by children was significantly greater than a neutral grade of 80% (89%, p < 0.01), indicating a positive likeability score. The games on average also received positive ratings for fun, helpfulness of instructions and length compared to neutral values (midpoint on likert scales) (all p < 0.01). Observation notes indicated that participants paid attention to the instructions, did not appear to have much difficulty with the games, and were "not frustrated", "not bored", "very engaged", "not fidgety" and "very calm" (all p < 0.01). The primary issues noted in observations and interviews were unclear instructions and unclear purpose of some games. Player suggestions primarily involved ways to make on screen cues more visible or noticeable, instructions more clear, and games more elaborate or difficult.^ Conclusions. The present study highlights the importance of alpha testing video game components for usability prior to completion to enhance usability and likeability. Results indicate that creating clear instructions, making peripheral screen cues more eye-catching or noticeable, and vigorously stating the purpose of the game to improve understandability are important elements. However, future interventions will each present unique materials and user-interfaces and should therefore also be thoroughly alpha-tested. ^

Process to develop a State Model Law to reduce prescription drug trafficking while protecting pain management

This paper will discuss the intersection of pill mills and the under-treatment of pain, while addressing the unintended consequence that cracking down on pill mills actually has on medical professionals' treatment of legitimate pain in clinical settings. Moreover, the impact each issue has on the spectrum of related policy, regulatory issues and legislation will be analyzed while addressing the national impact on medical care. Lastly, this paper will outline a process to develop a State Model Law on this subject. This process will include suggestions for the future and how we can move forward to adequately address public safety needs and how we can attempt to mitigate the unintended impact prescription drug trafficking has had on a patient's right to appropriate pain management. This balance is achievable and this paper will address ways we can find this elusive balancing point through the development of a State Model Law. ^

The Choosing Healthy Options of Starches (CHOOS) diet and dietary intake self-monitoring for weight loss among adolescent females

Previous research has shown dietary intake self-monitoring, and culturally tailored weight loss interventions to be effective tools for weight loss. Technology can be used to tailor weight loss interventions to better suit adolescents. There is a lack of research to date on the use of personal digital assistants (PDAs) to self-monitor dietary intake among adolescents. The objective of this study was to determine the difference in dietary intake self-monitoring frequency between using a Personal Digital Assistant (PDA) or paper logs as a diet diary in obese adolescent females; and to describe differences in diet adherence, as well as changes in body size and self-efficacy to resist eating. We hypothesized dietary intake self-monitoring frequency would be greater during PDA use than during paper log use. This study was a randomized crossover trial. Participants recorded their diet for 4 weeks: 2 weeks on a PDA and 2 weeks on paper logs. Thirty-four obese females ages 12-20 were recruited for participation. Thirty were included in analyses. Participants recorded more entries/day while using the paper logs (4.10 entries/day ± 0.63) than while using the PDA (3.01 entries/day ±0.75) (p<0.001). Significantly more meals and snacks were skipped during paper log use (0.81/day ± 0.65) than during PDA use (0.23/day ± 0.22) (p=0.011). Changes in body size (BMI, weight, and waist circumference) and self-efficacy to resist eating did not differ significantly between PDA and paper log use. When compared to paper logs, participants felt the PDA was more convenient (p=0.020), looked forward to using the PDA more (p=0.008), and would rather continue using the PDA than the paper logs (p=0.020). The findings of this study indicate use of a PDA as a dietary intake self-monitoring tool among adolescents would not result in increased dietary intake self-monitoring to aid in weight loss. Use of paper logs would result in greater data returned to clinicians, though use of PDAs would likely get adolescents more excited about adhering to recommendations to record their diet. Future research should look at updated communication devices, such as cell phones and other PDAs with additional features, and the role they can play in increasing dietary intake self-monitoring among adolescents.^

STRATEGIES FOR THE TRANSFER OF APPROPRIATE TECHNOLOGY TO DEVELOPING COUNTRIES: THE IMPLEMENTATION AND DEVELOPMENT OF ENVIRONMENTAL HEALTH PROGRAMS IN TUNISIA

This dissertation focuses on Project HOPE, an American medical aid agency, and its work in Tunisia. More specifically this is a study of the implementation strategies of those HOPE sponsored projects and programs designed to solve the problems of high morbidity and infant mortality rates due to environmentally related diarrheal and enteric diseases. Several environmental health programs and projects developed in cooperation with Tunisian counterparts are described and analyzed. These include (1) a paramedical manpower training program; (2) a national hospital sanitation and infection control program; (3) a community sewage disposal project; (4) a well reconstruction project; and (5) a solid-waste disposal project for a hospital.^ After independence, Tunisia, like many developing countries, encountered several difficulties which hindered progress toward solving basic environmental health problems and prompted a request for aid. This study discusses the need for all who work in development programs to recognize and assess those difficulties or constraints which affect the program planning process, including those latent cultural and political constraints which not only exist within the host country but within the aid agency as well. For example, failure to recognize cultural differences may adversely affect the attitudes of the host staff towards their work and towards the aid agency and its task. These factors, therefore, play a significant role in influencing program development decisions and must be taken into account in order to maximize the probability of successful outcomes.^ In 1969 Project HOPE was asked by the Tunisian government to assist the Ministry of Health in solving its health manpower problems. HOPE responded with several programs, one of which concerned the training of public health nurses, sanitary technicians, and aids at Tunisia's school of public health in Nabeul. The outcome of that program as well as the strategies used in its development are analyzed. Also, certain questions are addressed such as, what should the indicators of success be, and when is the time right to phase out?^ Another HOPE program analyzed involved hospital sanitation and infection control. Certain generic aspects of basic hospital sanitation procedures were documented and presented in the form of a process model which was later used as a "microplan" in setting up similar programs in other Tunisian hospitals. In this study the details of the "microplan" are discussed. The development of a nation-wide program without any further need of external assistance illustrated the success of HOPE's implementation strategies.^ Finally, although it is known that the high incidence of enteric disease in developing countries is due to poor environmental sanitation and poor hygiene practices, efforts by aid agencies to correct these conditions have often resulted in failure. Project HOPE's strategy was to maximize limited resources by using a systems approach to program development and by becoming actively involved in the design and implementation of environmental health projects utilizing "appropriate" technology. Three innovative projects and their implementation strategies (including technical specifications) are described.^ It is advocated that if aid agencies are to make any progress in helping developing countries basic sanitation problems, they must take an interdisciplinary approach to progrm development and play an active role in helping counterparts seek and identify appropriate technologies which are socially and economically acceptable. ^

Survey analysis on dental infection control & occupational safety from India---1999 & 2010

The objective was to study knowledge, attitudes, practice (KAP) and needs regarding infection control measures using two cross-sectional surveys from 1999 and 2010 conducted in India. Both data collection instruments had only about 35 comparable variables in common. In 1999, there were 456 respondents (dentists) who completed a self-administered survey instrument compared to 272 respondents in 2010. Both the 1999 and 2010 samples were mutually independent with no overlap, had regional differences, and therefore, were not completely comparable for changes in KAP over time. While almost all respondents from both surveys felt that education in dental safety was needed and wanted mandatory dental safety curriculum in dental schools, severe inadequacies in dental safety knowledge, protection against immunizable diseases, and practice of universal precaution were noted. Data from the study demonstrated that there is a substantial opportunity to improve the knowledge, attitude and practice of dental infection control and occupational safety in India. Few respondents (27%) reported that the infectious disease status of a patient is always known and a significant number reported that they had the right to refuse care for patients of known infectious disease status. This indicates that Stigma in treating HIV/AIDS patients remains a concern, which in turn suggests that a stronger focus on educating dentists about dental safety and on stigma and infectious disease is needed. Information obtained from this study could be utilized for developing policies oriented towards increasing dental safety educational efforts, in both dental schools as curriculum, and for practicing dentists through professional updates or continuing dental education.^

Self -management behavior in patients with cystic fibrosis

Self-management is being promoted in cystic fibrosis (CF). However, it has not been well studied. Principal aims of this research were (1) to evaluate psychometric properties of a CF disease status measure, the NIH Clinical Score; (2) to develop and validate a measure of self-management behavior, the SMQ-CF scale, and (3) to examine the relation between self-management and disease status in CF patients over two years.^ In study 1, NIH Clinical Scores for 200 patients were used. The scale was examined for internal consistency, interrater reliability, and content validity using factor analysis. The Cronbach's alpha (.81) and interrater reliability (.90) for the total scale were high. General scale items were less reliable. Factor analysis indicated that most of the variance in disease status is accounted for by Factor 1 which consists of pulmonary disease items.^ The SMQ-CF measures the performance of CF self-management. Pilot testing was done with 98 CF primary caregivers. Internal consistency reliability, social desirability bias, and content validity using factor analysis were examined. Internal consistency was good (alpha =.95). Social desirability correlation was low (r =.095). Twelve factors identified were consistent with conceptual groupings of behaviors. Around two hundred caregivers from two CF centers were surveyed and multivariate analysis of variance was used to assess construct validity. Results confirmed expected relations between self-management, patient age, and disease status. Patient age accounted for 50% and disease status 18% of the variance in the SMQ-CF scale.^ It was hypothesized that self-management would positively affect future disease status. Data from 199 CF patients (control and education intervention groups) were examined. Models of hypothesized relations were tested using LISREL structural equation modeling. Results indicated that the relations between baseline self-management and Time 1 disease status were not significant. Significant relations were observed in self-management behaviors from time 1 to time 2 and patterns of significant relations differed between the two groups.^ This research has contributed to refinements in the ability to measure self-management behavior and disease status outcomes in cystic fibrosis. In addition, it provides the first steps in exploratory behavioral analysis with regard to self-management in this disease. ^

Inactivation and self -association of CaM kinase: Effects of ATP, substrate binding domains, and isozymic forms

Calcium/calmodulin-dependent protein kinase II (CaM kinase) is a multifunctional Ser/Thr protein kinase, that is highly enriched in brain and is involved in regulating many aspects of neuronal function. We observed that forebrain CaM kinase from crude homogenates, cytosolic fractions and purified preparations inactivates and translocates into the particulate fraction following autophosphorylation. Using purified forebrain CaM kinase as well as recombinant $\alpha$ isozyme, we determined that the formation of particulate enzyme was due to enzyme self-association. The conditions of autophosphorylation determine whether enzyme self-association and/or inactivation will occur. Self-association of CaM kinase is sensitive to pH, ATP concentration, and enzyme autophosphorylation. This process is prevented by saturating concentrations of ATP. However, in limiting ATP, pH is the dominant factor, and enzyme self-association occurs at pH values $\rm{<}7.0.$ Site-specific mutants were produced by substituting Ala for Thr286, Thr253, or Thr305,306 to determine whether these sites of autophosphorylation affect enzyme inactivation and self-association. The only mutation that influenced these processes was Ala286, which removed the protective effect afforded by autophosphorylation in saturating ATP. Enzyme inactivation occurs in the presence and absence of self-association and appears predominantly sensitive to nucleotide concentration, because saturating concentrations of $\rm Mg\sp{2+}/ADP$ or $\rm Mg\sp{2+}/ATP$ prevent this process. These data implicate the ATP binding pocket in both inactivation and self-association. We also observed that select peptide substrates and peptide inhibitors modeled after the autoregulatory domain of CaM kinase prevented these processes. The $\alpha$ and $\beta$ isozymes of CaM kinase were characterized independently, and were observed to exhibit differences in both enzyme inactivation and self-association. The $\beta$ isozyme was less sensitive to inactivation, and was never observed to self-associate. Biophysical characterization, and transmission electron microscopy coupled with image analysis indicated both isozymes were multimeric, however, the $\alpha$ and $\beta$ isozymes appeared structurally different. We hypothesize that the $\alpha$ subunit of CaM kinase plays both a structural and enzymatic role, and the $\beta$ subunit plays an enzymatic role. The ramifications for the functional differences observed for inactivation and self-association are discussed based on potential structural differences and autoregulation of the $\alpha$ and $\beta$ isozymes in both calcium-induced physiological and pathological processes. ^