Chronic volatile substance abuse among the adult Kickapoo traditional tribe of Texas: Disease and disability profiles, neuropsychosocial consequences, and social implications for treatment

The purpose of this study, based on secondary data from attendees at a substance abuse clinic for the Kickapoo Healing Grounds in Eagle Pass, Texas, is two fold: (1) to elucidate neuro-behavioral performance of volatile substance abusers in the Kickapoo tribe and (2) to determine factors associated with their treatment completion and rehabilitation as measured by their employment at follow-up. Volatile substance abuse (VSA) is associated with a host of neurological manifestations, and secondary prevention or clinical treatment and rehabilitation remains the mainstay of control efforts. Very little is known about VSA in general, and especially among Native American populations. It is anticipated that the results will help determine and assist other tribes and non-tribal substance abuse centers with treatment planning for volatile substance abusers among Native American populations. ^

Prediction of cardiovascular disease risk factors in Mexican-American children from parental risk factors, and social and demographic characteristics in the HHANES

Objectives. Cardiovascular disease (CVD) including CVD secondary to diabetes type II, a significant health problem among Mexican American populations, originates in early childhood. This study seeks to determine risk factors available to the health practitioner that can identify the child at potential risk of developing CVD, thereby enabling early intervention. ^ Design. This is a secondary analysis of cross-sectional data of matched Mexican American parents and children selected from the HHANES, 1982–1984. ^ Methods. Parents at high risk for CVD were identified based on medical history, and clinical and physical findings. Factor analysis was performed on children's skinfold thicknesses, height, weight, and systolic and diastolic blood pressures, in order to produce a limited number of uncorrelated child CVD risk factors. Multiple regression analyses were then performed to determine other CVD markers associated with these Factors, independently for mothers and fathers. ^ Results. Factor analysis of children's measurements revealed three uncorrelated latent variables summarizing the children's CVD risk: Factor1: ‘Fatness’, Factor2: ‘Size and Maturity’, and Factor3: ‘Blood Pressure’, together accounting for the bulk of variation in children's measurements (86–89%). Univariate analyses showed that children from high CVD risk families did not differ from children of low risk families in occurrence of high blood pressure, overweight, biological maturity, acculturation score, or social and economic indicators. However, multiple regression using the factor scores (from factor analysis) as dependent variables, revealed that higher CVD risk in parents, was significantly associated with increased fatness and increased blood pressure in the children. Father's CVD risk status was associated with higher levels of body fat in his children and higher levels of blood pressure in sons. Mother's CVD risk status was associated with higher blood pressure levels in children, and occurrence of obesity in the mother associated with higher fatness levels in her children. ^ Conclusion. Occurrence of cardiovascular disease and its risk factors in parents of Mexican American children, may be used to identify children at potentially higher risk for developing CV disease in the future. Obesity in mothers appears to be an important marker for the development of higher levels of body fatness in children. ^

The influence of staff and organizational characteristics on social environment in substance abuse treatment facilities

The staff of 20 substance abuse treatment facilities were administered the Ward Atmosphere Scale, an instrument which measures treatment environment. Ten facilities were freestanding and ten were hospital based, and were drawn from a large, not-for-profit national chain using a random selection process. Controlling for several staff and facility attributes, it was found that no substantial effects on treatment environment existed due to facility type, freestanding or hospital-based. Implications of the study exist in selection of facility type for purchasers of substance abuse treatment and for the hiring and training of clinical staff for treatment facilities. Study findings also suggest that inadequate or insufficient measures exist to examine the construct 'treatment environment'. ^

Parental substance abuse as a risk factor for physical child abuse and neglect: A systematic review of the literature

Case control and retrospective studies have identified parental substance abuse as a risk factor for physical child abuse and neglect (Dore, Doris, & Wright, 1995, May; S. R. Dube et al., 2001; Guterman & Lee, 2005, May; Walsh, MacMillan, & Jamieson, 2003). The purpose of this paper is to present the findings of a systematic review of prospective studies from 1975 through 2005 that include parental substance abuse as a risk factor for physical child abuse or neglect. Characteristics of each study such as the research question, sample information, data collection methods and results, including the parent assessed and definitions of substance abuse and physical child abuse and neglect, are discussed. Five studies were identified that met the search criteria. Four of five studies found that parental substance abuse was a significant variable in predicting physical child abuse and neglect.^

Does parental monitoring influence the use of alcohol and drugs among inner city 7th grade students?

Objective. To examine associations between parental monitoring and adolescent alcohol/drug use. ^ Methods. 981 7th grade students from 10 inner-city middle schools were surveyed at the 3 month follow-up of an HIV, STD, and pregnancy prevention program. Data from 549 control subjects were used for analyses. Multinomial logistic regression was used to examine associations between five parental monitoring variables and substance use, coded as: low risk [never drank alcohol or used drugs (0)], moderate risk [drank alcohol, no drug use (1)], and high risk [both drank alcohol and used drugs or just used drugs (2)]. ^ Results. Participants were 58.3% female, 39.6% African American, 43.8% Hispanic, mean age 13.3 years. Lifetime alcohol use was 47.9%. Lifetime drug use was 14.9%. Adjusted for gender, age, race, and family structure, each individual parental monitoring variable (perceived parental monitoring, less permissive parental monitoring, greater supervision (public places), greater supervision (teen clubs), and less time spent with older teens) was significant and protective for the moderate and high risk groups. When all 5 variables were entered into a single model, only perceived parental monitoring was significantly associated (OR=0.40, 95% CI 0.29-0.55) for the moderate risk group. For the high risk group, 3 variables were significantly protective (perceived parental monitoring OR=0.28, CI 0.18-0.42, less time spent with older teens OR=0.75, CI 0.60-0.93, and greater supervision (public places) OR=0.79, CI 0.64-0.99). ^ Conclusion. The association between parental monitoring and substance abuse is complex and varied for different risk levels. Implications for intervention development are addressed. ^

The association of area socioeconomic status and cancer screening: A systematic review and multilevel study

Background. The gap between actual and ideal rates of routine cancer screening in the U.S., particularly for colorectal cancer screening (CRCS) (1;2), is responsible for an unnecessary burden of morbidity and mortality, particularly for disadvantaged groups. Knowledge about the effects of individual and area influences is being advanced by a growing body of research that has examined the association of area socioeconomic status (SES) and cancer screening after controlling for individual SES. The findings from this emerging and heterogeneous research in the cancer screening literature have been mixed. Moreover, multilevel studies in this area have not yet adequately explored the possibility of differential associations by population subgroup, despite some evidence suggesting gender-specific effects. ^ Objectives and methods. This dissertation reports on a systematic review of studies on the association of area SES and cancer screening and a multilevel study of the association between area SES and CRCS. The specific aims of the systematic review are to: (1) describe the study designs, constructs, methods, and measures; (2) describe the association of area SES and cancer screening; and (3) identify neglected areas of research. ^ The empiric study linked a pooled sample of respondents aged ≥50 years without a personal history of colorectal cancer from the 2003 and 2005 California Health Interview Surveys with a comprehensive set of census-tract level area SES measures from the 2000 U.S. Census. Two-level random intercept models were used to test 2 hypotheses: (1) area SES will be associated with adherence to two modalities of CRCS after controlling for individual SES; and (2) gender will moderate the relationship between area socioeconomic status and adherence to both modalities of CRCS. ^ Results. The systematic review identified 19 eligible studies that demonstrated variability in study designs, methods, constructs, and measures. The majority of tested associations were either not statistically significant or significant and in the positive direction, indicating that as area SES increased, the odds of CRCS increased. The multilevel study demonstrated that while multiple aspects of area SES were associated with CRCS after controlling for individual SES, associations differed by screening modality and in the case of endoscopy, they also differed by gender. ^ Conclusions. Conceptual and methodologic heterogeneity and weaknesses in the literature to date limit definitive conclusions about the underlying relationships between area SES and cancer screening. The multilevel study provided partial support for both hypotheses. Future research should continue to explore the role of gender as a moderating influence with the aim of identifying the mechanisms linking area SES and cancer prevention behaviors. ^

A review of cataract in stable and conflict zones in Africa

Aim. To review and explore cataract prevalence in stable and unstable countries by examining published and unpublished ocular literature about Africa from 1980 onwards.^ Methods. Searches using OVID, Proquest Dissertations, WHO, and Ebsco Host were done. The review was restricted to articles utilizing WHO definitions of blindness and low vision. Random cluster sampling technique with a minimum sample size of 1,500, and reporting causes of blindness categorized by age and gender were inclusion considerations in the selected articles. ^ Results. Blindness and low vision increased with conflict. Women and the elderly were more likely to have vision impairing cataract. Cataract was the leading cause of blindness; the prevalence range was 22%–81% for the reviewed nations.^ Conclusion. Instability was connected to higher cataract prevalence and worse visual outcome across all characteristics examined except cataract surgical rates. ^

Social cognitive theory and factors associated with Mexican-American parents' beliefs, attitudes and practices regarding communication with their adolescent children about sex

Latinos have the highest teen birth rate nationally. Cameron County, Texas is primarily Latino (Mexican-American). This mixed-method study (n=43) examines Mexican-American parents of adolescents' beliefs, attitudes and practices regarding communication with their adolescent children about sex. Social Cognitive Theory (SCT) constructs self-efficacy, behavioral determinism, environment, outcome expectations and reciprocal determinism can be influences on frequency and quality of parent-adolescent sex communication.^ This study describes Mexican-American parents' of adolescents recollections of their own experiences associated with learning about sexuality. It also examines the attitudes and practices regarding communication about sex and the self-efficacy and behavioral capability of participants to teach their adolescent children about sex and sexually transmitted infections. ^ Negative childhood experiences (shame, lies and trauma) of the parents in this study played a key role in terms of their desire to communicate more comprehensively about sexuality with their own children than did their parents. While participants' reported low self-efficacy and behavioral capability to communicate with their adolescent children about sex, they reported relatively high frequency and quality of communication, with 75% of participants receiving a high quality score and over 44% reporting frequent communication with their adolescent children about sex. A Chi square analysis and Fisher's Exact Score revealed no association between acculturation status, gender or having a child who has mothered/fathered a baby and the frequency or quality of communication about sex with adolescent children. Study participants also gave specific recommendations for method, content and setting of sex education for their children and themselves. Promotora delivery of information and education in a comfortable, culturally appropriate neighborhood setting, as well as parent –child learning sessions were identified as possible approaches to address improve self-efficacy and behavioral capability of parents communicating with their adolescent children about sex.^ The results of this analysis provide public health practitioners and interested community entities data to identify and develop interventions that use a theoretical, evidence-based framework for culturally appropriate interventions to encourage and equip Mexican-American parents to effectively communicate with their adolescent children about sexuality, and ultimately to address the high rates of teen pregnancy in this U.S.-Mexico border community. ^

Assessing and applying evidence-based interventions at the community level in India as a model policy to reduce neonatal mortality rates in Nigeria

Background. The United Nations' Millennium Development Goal (MDG) 4 aims for a two-thirds reduction in death rates for children under the age of five by 2015. The greatest risk of death is in the first week of life, yet most of these deaths can be prevented by such simple interventions as improved hygiene, exclusive breastfeeding, and thermal care. The percentage of deaths in Nigeria that occur in the first month of life make up 28% of all deaths under five years, a statistic that has remained unchanged despite various child health policies. This paper will address the challenges of reducing the neonatal mortality rate in Nigeria by examining the literature regarding efficacy of home-based, newborn care interventions and policies that have been implemented successfully in India. ^ Methods. I compared similarities and differences between India and Nigeria using qualitative descriptions and available quantitative data of various health indicators. The analysis included identifying policy-related factors and community approaches contributing to India's newborn survival rates. Databases and reference lists of articles were searched for randomized controlled trials of community health worker interventions shown to reduce neonatal mortality rates. ^ Results. While it appears that Nigeria spends more money than India on health per capita ($136 vs. $132, respectively) and as percent GDP (5.8% vs. 4.2%, respectively), it still lags behind India in its neonatal, infant, and under five mortality rates (40 vs. 32 deaths/1000 live births, 88 vs. 48 deaths/1000 live births, 143 vs. 63 deaths/1000 live births, respectively). Both countries have comparably low numbers of healthcare providers. Unlike their counterparts in Nigeria, Indian community health workers receive training on how to deliver postnatal care in the home setting and are monetarily compensated. Gender-related power differences still play a role in the societal structure of both countries. A search of randomized controlled trials of home-based newborn care strategies yielded three relevant articles. Community health workers trained to educate mothers and provide a preventive package of interventions involving clean cord care, thermal care, breastfeeding promotion, and danger sign recognition during multiple postnatal visits in rural India, Bangladesh, and Pakistan reduced neonatal mortality rates by 54%, 34%, and 15–20%, respectively. ^ Conclusion. Access to advanced technology is not necessary to reduce neonatal mortality rates in resource-limited countries. To address the urgency of neonatal mortality, countries with weak health systems need to start at the community level and invest in cost-effective, evidence-based newborn care interventions that utilize available human resources. While more randomized controlled studies are urgently needed, the current available evidence of models of postnatal care provision demonstrates that home-based care and health education provided by community health workers can reduce neonatal mortality rates in the immediate future.^

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

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

Strange bedfellows: The ethics and politics of medical futility in Texas

Background: Futile medical treatments are interventions that are not associated with a benefit to the patient. The definition and concept of medical futility are controversial. The Texas Advance Directives Act (TADA) was passed in 1999 to address medically inappropriate interventions by allowing providers to withdraw inappropriate interventions against a surrogate decision maker's wishes following a review, attempt to transfer the patient, and 10-day waiting period. The original legislation was a negotiated compromise by players across the political spectrum. However, in recent years there has been increasing controversy regarding TADA and attempts to alter its applicability in Texas. ^ Purpose: The purpose of this project was to apply Paul Sabatier's advocacy coalition framework (ACF) to gain understanding into the historical, ethical, and political basis of the initial compromise, and determine the sources of conflict that have led to increased opposition to TADA. ^ Methods: Using the ACF model, key actors within the medical futility policy debate in Texas were aggregated into coalitions based on shared beliefs. A narrative summary based analysis identified the core elements of the policy subsystem, as well as the constraints and resources of the subsystem actors. Externalities that promoted adjustments to coalition beliefs and tactics used by coalition participants were analyzed. Data sources included review of the published literature regarding medical futility, as well as analysis of published newspaper accounts and editorials regarding the medical futility issue in Texas, legislative testimony, and review of weblogs and online commentaries dealing with the issue. ^ Results: Primary coalition participants in developing compromise legislation in 1999 were the Providers and Vitalists, with Autonomists gaining a prominent role starting in 2006. Internal factors associated with the breakdown of consensus included changes to the makeup of the governing coalition and changes in individual case information available to the Vitalist coalition. Externalities related to the intertwining of the Sun Hudson case and the Terri Schiavo case generated negative publicity for the TADA from progressive and conservative viewpoints. Dissemination of information in various venues regarding contentious cases was associated with more polarization of viewpoints, and realignment of coalition alliances. ^ Conclusions: The ACF provided an outline for the initial compromise over the creation of the Texas Advance Directives Act as well as the eventual loss of consensus. The debate between the Provider, Vitalist, and Autonomist coalitions has been affected by internal policy evolution, changes in the governing coalition, and important externalities. The debate over medical futility in Texas has had much broader implications in the dispute over Health Care Reform.^

Social integration, health behaviors and health status among Mexican-American women in the *southwestern United States

Using the Hispanic Health and Nutrition Examination Survey (HHANES), this research examined several health behaviors and the health status of Mexican American women. This study focused on determining the relative impact of social contextual factors: age, socioeconomic status, quality of life indicators, and urban/rural residence on (a) health behaviors (smoking, obesity and alcohol use) and (b) health status (physician's assessment of health status, subject's assessment of health status and blood pressure levels). In addition, social integration was analyzed. The social integration indicators relate to an individual's degree of integration within his/her social group: marital status, level of acculturation (a continuum of traditional Mexican ways to dominant U.S. cultural ways), status congruency, and employment status. Lastly, the social contextual factors and social integration indicators were examined to identify those factors that contribute most to understanding health behaviors and health status among Mexican American women.^ The study found that the social contextual factors and social integration indicators proved to be important concepts in understanding the health behaviors. Social integration, however, did not predict health status except in the case of the subject's assessment of health status. Age and obesity were the strongest predictors of blood pressure. The social contextual factors and obesity were significant predictors of the physician's assessment of health status while acculturation, education, alcohol use and obesity were significant predictors of the subject's assessment of health status. ^

An examination of the Gonorrhea Cases & Places Study: An analysis of the Theory of Gender and Power, Situational/Environmental Variables Theory, and Sexual Script Theory as it relates to risky sexual behavior in African American adults

Objective. The purpose of the study is to provide a holistic depiction of behavioral & environmental factors contributing to risky sexual behaviors among predominantly high school educated, low-income African Americans residing in urban areas of Houston, TX utilizing the Theory of Gender and Power, Situational/Environmental Variables Theory, and Sexual Script Theory. Methods. A cross-sectional study was conducted via questionnaires among 215 Houston area residents, 149 were women and 66 were male. Measures used to assess behaviors of the population included a history of homelessness, use of crack/cocaine among several other illicit drugs, the type of sexual partner, age of participant, age of most recent sex partner, whether or not participants sought health care in the last 12 months, knowledge of partner's other sexual activities, symptoms of depression, and places where partner's were met. In an effort to determine risk of sexual encounters, a risk index employing the variables used to assess condom use was created categorizing sexual encounters as unsafe or safe. Results. Variables meeting the significance level of p<.15 for the bivariate analysis of each theory were entered into a binary logistic regression analysis. The block for each theory was significant, suggesting that the grouping assignments of each variable by theory were significantly associated with unsafe sexual behaviors. Within the regression analysis, variables such as sex for drugs/money, low income, and crack use demonstrated an effect size of ≥ ± 1, indicating that these variables had a significant effect on unsafe sexual behavioral practices. Conclusions. Variables assessing behavior and environment demonstrated a significant effect when categorized by relation to designated theories.

Diffusion and implementation of a tobacco prevention program: A replication study

Tobacco use is a major health hazard, and the onset of tobacco use occurs almost entirely in the teenage years. For this reason, schools are an ideal site for tobacco prevention programs. Although studies have shown that effective school-based tobacco prevention programs exist, all too frequently these programs are not used. In order for effective programs to achieve their potential impact, strategies for speeding the diffusion of these programs to school districts and seeing that, once adopted, programs are implemented as they are intended, must be developed and tested.^ This study (SC2) set out to replicate the findings of an earlier quasi-experimental study (The Smart Choices Diffusion Study, or SC1) in which strategies based on diffusion theory and social learning theory were found to be effective in encouraging adoption and implementation of an effective tobacco prevention program in schools. To increase awareness and encourage adoption, intervention strategies in both studies utilized opinion leaders, messages highlighting positive aspects of the program, and modeling of benefits and effective use through videotape and newsletters. To encourage accurate implementation of the curriculum, teacher training for the two studies utilized videotaped modeling and practice of activities by teachers. SC2 subjects were 38 school districts that make up one of Texas' 20 education service regions. These districts had served as the comparison group in SC1, and findings for the SC1 comparison and intervention groups were utilized as historic controls.^ SC2 achieved a 76.3% adoption rate and found that an average of 84% of the curriculum was taught with an 82% fidelity to methods utilized by the curriculum. These rates and rates for implementation of dissemination strategies were equal to or greater than corresponding rates for SC1. The proportion of teachers implementing the curriculum in SC2 was found to be equal to SC1's video-trained districts but lower than the SC1 workshop-trained group.^ SC2's findings corroborate and support the findings from the earlier study, and increase our confidence in its findings. Taken together, the findings from SC2 and SC1 point to the effectiveness of their theory-based intervention strategies in encouraging adoption and accurate implementation of the tobacco prevention curriculum. ^

The determinants of physician and pharmacist utilization and equity of access under Korean universal health insurance

This study examines the social and behavioral determinants of two types of primary care, seeing a physician or a pharmacist, for Koreans and evaluates the equity of the Korean national health insurance system. The study applies the Aday and Andersen access framework to cross-sectional data from the 1992 Korean National Health Interview Survey (N = 21,841).^ The study found that in Korea, the elderly were most likely, and children least likely, to have used physician services. Women, household heads, those in small families, and the less educated were more likely than their counterparts to use physician and pharmacist services. Health status and need were important determinants of Koreans seeing a doctor or a pharmacist. Differences in need substantially accounted for the original differences observed between subgroups. Resources associated with having insurance coverage, a regular source of care, and place of residence (rural/urban) ameliorated to some extent the subgroup differences in the use of physicians' and pharmacists' services among Koreans. They were also major independent predictors of access. Having insurance remains a particularly important predictor of who uses physician services. Among the insured, trade-offs in the use of physician and pharmacist services were found in the current system, i.e., uninsured and poor Koreans were more likely to use pharmacist services, while insured and rural Koreans were more likely to use doctor services. Among the insured, cost sharing rates are lower for physician than for pharmacist services. Self-employed persons were less likely than government and industrial workers to use physician services. An underlying expectation under universal health insurance was that the Korean health care system would be equitable. The research results, however, did not fully support this expectation.^ The policy implications of these findings are that measures are required to extend insurance coverage to the uninsured, to equalize differences in benefit packages between health plans, and to expand the availability of physicians in rural areas. Further research is also needed to understand those who do not currently have a regular source of care and why and the access barriers that may exist for selected demographic subgroups (those in large families and unmarried or divorced/widowed persons). ^