Texas Department of Health organizational structure changes: A reflection of public health policy and agency expansion, September 1, 1946--June 30, 1994

The premise of this study is that changes in the agency's organizational structure reflect changes in government public health policy. Based on this premise, this study tracks the changes in the organizational structure and the overall expansion of the Texas Department of Health to understand the evolution of changing public health priorities in state policy from September 1, 1946 through June 30, 1994, a period of growth and new responsibilities. It includes thirty-seven observations of organizational structure as depicted by organizational charts of the agency and/or adapted from public documents. ^ The major questions answered are, what are the changes in the organizational structure, why did they occur and, what are the policy priorities reflected in these changes in and across the various time periods. ^ The analysis of the study included a thorough review of the organizational structure of the agency for the time-span of the study, the formulation of the criteria to be used in ascertaining the changes, the delineation of the changes in the organizational structure and comparison of the observations sequentially to characterize the change, the discovery of reasons for the structural changes (financial, statutory - federal and state, social and political factors), and the determination of policy priorities for each time period and their relation to the expansion and evolution of the agency. ^ The premise that the organizational structure of the agency and the changes over time reflect government public health policy and agency expansion was found to be true. ^

Identifying and removing barriers to cycling as a viable means of transportation in Houston, Texas

The citizens of Houston, Texas, spend much time commuting. It has repeatedly been named among the “Fattest Cities” by Men’s Fitness Magazine (The fittest and fattest cities in America – Men’s Fitness. ). Obesity is one of its major public health problems as Houstonians often do not engage in enough physical activity to help them maintain their ideal weights. The use of bicycles provides a healthy and ecological alternative to commuting by driving. However, because urban cyclists must often share the roads with motorized vehicles, cyclists are often exposed to high levels of emissions. As vulnerable users of the roadways, urban cyclists also face the threat of injury. Nevertheless, there are some programs that encourage the use of bicycles. Laws and ordinances not only reveal public policy relating to bicycling but are a means to develop policy which can encourage bicycling. ^

Associations between ambient levels of combustion pollutants and small for gestational age infants in Texas

There is scant evidence regarding the associations between ambient levels of combustion pollutants and small for gestational age (SGA) infants. No studies of this type have been completed in the Southern United States. The main objective of the project presented was to determine associations between combustion pollutants and SGA infants in Texas using three different exposure assessments. ^ Birth certificate data that contained information on maternal and infant characteristics were obtained from the Texas Department of State Health Services (TX DSHS). Exposure assessment data for the three aims came from: (1) U.S. Environmental Protection Agency (EPA) National Air Toxics Assessment (NATA), (2) U.S. EPA Air Quality System (AQS), and (3) TX Department of Transportation (DOT), respectively. Multiple logistic regression models were used to determine the associations between combustion pollutants and SGA. ^ For the first study looked at annual estimates of four air toxics at the census tract level in the Greater Houston Area. After controlling for maternal race, maternal education, tobacco use, maternal age, number of prenatal visits, marital status, maternal weight gain, and median census tract income level, adjusted ORs and 95% confidence intervals (CI) for exposure to PAHs (per 10 ng/m3), naphthalene (per 10 ng/m3), benzene (per 1 µg/m3), and diesel engine emissions (per 10 µg/m3) were 1.01 (0.97–1.05), 1.00 (0.99–1.01), 1.01 (0.97–1.05), and 1.08 (0.95–1.23) respectively. For the second study looking at Hispanics in El Paso County, AORs and 95% confidence intervals (CI) for increases of 5 ng/m3 for the sum of carcinogenic PAHs (Σ c-PAHs), 1 ng/m3 of benzo[a]pyrene, and 100 ng/m3 in naphthalene during the third trimester of pregnancy were 1.02 (0.97–1.07), 1.03 (0.96–1.11), and 1.01 (0.97–1.06), respectively. For the third study using maternal proximity to major roadways as the exposure metric, there was a negative association with increasing distance from a maternal residence to the nearest major roadway (Odds Ratio (OR) = 0.96; 95% CI = 0.94–0.97) per 1000 m); however, once adjusted for covariates this effect was no longer significant (AOR = 0.98; 95% CI = 0.96–1.00). There was no association with distance weighted traffic density (DWTD). ^ This project is the first to look at SGA and combustion pollutants in the Southern United States with three different exposure metrics. Although there was no evidence of associations found between SGA and the air pollutants mentioned in these studies, the results contribute to the body of literature assessing maternal exposure to ambient air pollution and adverse birth outcomes. ^

A study of the cost and effect of newborn screening for Congenital Adrenal Hyperplasia in Texas

Congenital Adrenal Hyperplasia (CAH), due to 21-Hydroxylase deficiency, has an estimated incidence of 1:15,000 births and can result in death, salt-wasting crisis or impaired growth. It has been proposed that early diagnosis and treatment of infants detected from newborn screening for CAH will decrease the incidence of mortality and morbidity in the affected population. The Texas Department of Health (TDH) began mandatory screening for CAH in June, 1989 and Texas is one of fourteen states to provide neonatal screening for the disorder.^ The purpose of this study was to describe the cost and effect of screening for CAH in Texas during 1994 and to compare cases first detected by screen and first detected clinically between January 1, 1990 and December 31, 1994. This study used a longitudinal descriptive research design. The data was secondary and previously collected by the Texas Department of Health. Along with the descriptive study, an economic analysis was done. The cost of the program was defined, measured and valued for four phases of screening: specimen collection, specimen testing, follow-up and diagnostic evaluation.^ There were 103 infants with Classical CAH diagnosed during the study and 71 of the cases had the more serious Salt-Wasting form of the disease. Of the infants diagnosed with Classical CAH, 60% of the cases were first detected by screen and 40% were first detected because of clinical findings before the screening results were returned. The base case cost of adding newborn screening to an existing program (excluding the cost of specimen collection) was $357,989 for 100,000 infants. The cost per case of Classical CAH diagnosed, based on the number of infants first detected by screen in 1994, was \$126,892. There were 42 infants diagnosed with the more benign Nonclassical form of the disease. When these cases were included in the total, the cost per infant to diagnose Congenital Adrenal/Hyperplasia was $87,848. ^

An examination of the rate of high school completion experienced by handicapped and nonhandicapped students in the state of Texas

This research examines the graduation rate experienced by students receiving public education services in the state of Texas. Special attention is paid to that subgroup of Texas students who meet Texas Education Agency criteria for handicapped status. The study is guided by two research questions: What are the high school completion rates experienced by handicapped and nonhandicapped students attending Texas public schools? and What are the predictors of graduation for handicapped and nonhandicapped students?^ In addition, the following hypotheses are explored. Hypothesis 1: Handicapped students attending a Texas public school will experience a lower rate of high school completion than their nonhandicapped counterparts. Hypothesis 2: Handicapped and nonhandicapped students attending school in a Texas public school with a budget above the median budget for Texas public schools will experience a higher rate of high school completion than similar students in Texas public schools with a budget below the median budget. Hypothesis 3: Handicapped and nonhandicapped students attending school in large Texas urban areas will experience a lower rate of high school completion than similar students in Texas public schools in rural areas. Hypothesis 4: Handicapped and nonhandicapped students attending a Texas public school in a county which rates above the state median for food stamps and AFDC recipients will experience a lower rate of high school completion than students living in counties below the median.^ The study will employ extant data from the records of the Texas Education Agency for the 1988-1989 and the 1989-1990 school years, from the Texas Department of Health for the years of 1989 and 1990, and from the 1980 Census.^ The study reveals that nonhandicapped students are graduating with a two year average rate of.906, while handicapped students following an Individualized Educational Program (IEP) achieve a two year average rate of.532, and handicapped students following the regular academic program present a two year average graduation rate of only.371. The presence of other handicapped students, and the school district's average expense per student are found to contribute significantly to the completion rates of handicapped students. Size groupings are used to elucidate the various impacts of these variables on different school districts and different student groups.^ Conclusions and implications are offered regarding the need to reach national consensus on the definition and computation of high school completion for both handicapped and nonhandicapped students, and the need for improved statewide tracking of handicapped completion rates. ^

Source of health insurance and immunization rates: Findings from the 1996 Texas immunization survey

This study was a further investigation of the 1996 Texas Immunization Survey conducted by the Associateship for Disease Control and Prevention of the Texas Department of Health. The 1996 survey was conducted through 4,599 completed telephone interviews of families with a child between the ages of 3–35 months concerning the immunization status of Texas children. The present study determined differences in immunization rates for children aged 3–35 months for the last shot in the immunization series that should be completed before 2 years of age, a total of four shots, both overall and for different health insurance groups. Life tables were used to determine the percentage and distribution over time of completed vaccination rates for each shot. Emphasis was placed on the proportion of children that were immunized at the end of the recommended range of the immunization schedule, and at 2 years of age. Univariate and multivariate analysis was also performed in order to ascertain which risk factors predict whether or not a child will be immunized. RESULTS: Between 80–90% were immunized for the last shot of Hepatitis B; Measles, Mumps, and Rubella; and Polio at 2 years of age. Approximately 2/3 of the sample was immunized for Diphtheria, Pertussis, and Tetanus. Most of the children were immunized by the end of the recommended range of the immunization schedule except for Measles, Mumps, and Rubella. Children of parents with private indemnity insurance were significantly more likely to have received two of the four shots; children of uninsured parents were significantly less likely to have received three of the four shots. In multivariate analysis, maternal education was the only variable that consistently predicted immunization status for the different shots. Results indicate that a substantial gap exists for immunization rates between children with private insurance and uninsured children, despite recent policy changes to provide immunizations free of charge. Health care providers should pay extra attention to the poor and uninsured to make sure that all children receive timely immunizations. ^

Use of pulsed-field gel electrophoresis in surveillance of Salmonella in Houston, Texas

Background. Pulsed-field gel electrophoresis (PFGE) is a laboratory technique in which Salmonella DNA banding patterns are used as molecular fingerprints for epidemiologic study for "PFGE clusters". State and national health departments (CDC) use PFGE to detect clusters of related cases and to discover common sources of bacteria in outbreaks. ^ Objectives. Using Houston Department of Health and Human Services (HDHHS) data, the study sought: (1) to describe the epidemiology of Salmonella in Houston, with PFGE subtype as a variable; and (2) to determine whether PFGE patterns and clusters detected in Houston were local appearances of PFGE patterns or clusters that occurred statewide. ^ Methods. During the years 2002 to 2005, the HDHHS collected and analyzed data from routine surveillance of Salmonella. We implemented a protocol, between May 1, 2007 and December 31, 2007, in which PFGE patterns from local cases were sent via e-mail to the Texas Department of State Health Services, to verify whether the local PFGE patterns were also part of statewide clusters. PFGE was performed from 106 patients providing a sample from which Salmonella was isolated in that time period. Local PFGE clusters were investigated, with the enhanced picture obtained by linking local PFGE patterns to PFGE patterns at the state and national level. ^ Results. We found that, during the years 2002 to 2005, there were 66 PFGE clusters, ranging in size from 2 to 22 patients within each cluster. Between different serotypes, there were marked differences in the sizes of PFGE clusters. A common source or risk factor was found in fewer than 5 of the 66 PFGE clusters. With the revised protocol, we found that 19 of 66 local PFGE patterns were indistinguishable from PFGE patterns at Texas DSHS. During the eight months, we identified ten local PFGE clusters with a total of 42 patients. The PFGE pattern for eight of the ten clusters matched the PFGE patterns for cases reported to Texas DSHS from other geographic areas. Five of the ten PFGE patterns matched PFGE patterns for clusters under investigation at PulseNet at the national level. HDHHS epidemiologists identified a mode of transmission in two of the ten local clusters and a common risk factor in a third local cluster. ^ Conclusion. In the extended-study protocol, Houston PFGE patterns were linked to patterns seen at the state and national level. The investigation of PFGE clusters was more efficacious in detecting a common transmission when local data were linked to state and national data. ^

The association between mental health and hypertension in the 2005 Department of Defense Population Survey

Major objectives within Healthy People 2010 include improving hypertension and mental health management of the American population. Both mental health issues and hypertension exist in the military which may decrease the health status of military personnel and diminish the ability to complete assigned missions. Some cases may be incompatible with military service even with optimum treatment. In the interest of maintaining a fit fighting force, the Department of Defense regularly conducts a survey of health related behaviors among active duty military personnel. The 2005 DoD Survey was conducted to obtain information regarding health and behavioral readiness among active duty military personnel to assess progress toward selected Healthy People 2010 objectives. ^ This study is a cross-sectional prevalence design looking at the association of hypertension treatment with mental health issues (either treatment or perceived need for treatment) within the military population sampled in the 2005 DoD Survey. There were 16,946 military personnel in the final cross-sectional sample representing 1.3 million active duty service members. The question is whether there is a significant association between the self-reported occurrence of hypertension and the self-reported occurrence of mental health issues in the 2005 DoD Survey. In addition to these variables, this survey examined the contribution of various sociodemographic, occupational, and behavioral covariates. An analysis of the demographic composition of the study variables was followed by logistic analysis, comparing outcome variables with each of the independent variables. Following univariate regression analysis, multivariate regression was performed with adjustment (for those variables with an unadjusted alpha level less than or equal to 0.25). ^ All the mental health related indicators were associated with hypertension treatment. The same relationship was maintained after multivariate adjustment. The covariates remaining as significant (p < 0.05) in the final model included gender, age, race/ethnicity and obesity. There is a need to recognize and treat co-morbid medical diagnoses among mental health patients and to improve quality of life outcomes, whether in the military population or the general population. Optimum health of the individual can be facilitated through discovery of treatable cases, to minimize disruptions of military missions, and even allow for continued military service. ^

Health impacts of extreme weather: Flood fatalities in Texas

Floods are the leading cause of fatalities related to natural disasters in Texas. Texas leads the nation in flash flood fatalities. From 1959 through 2009 there were three times more fatalities in Texas (840) than the following state Pennsylvania (265). Texas also leads the nation in flood-related injuries (7753). Flood fatalities in Texas represent a serious public health problem. This study addresses several objectives of Healthy People 2010 including reducing deaths from motor vehicle accidents (Objective 15-15), reducing nonfatal motor vehicle injuries (Objective 15-17), and reducing drownings (Objective 15-29). The study examined flood fatalities that occurred in Texas between 1959 and 2008. Flood fatality statistics were extracted from three sources: flood fatality databases from the National Climatic Data Center, the Spatial Hazard Event and Loss Database for the United States, and the Texas Department of State Health Services. The data collected for flood fatalities include the date, time, gender, age, location, and type of flood. Inconsistencies among the three databases were identified and discussed. Analysis reveals that most fatalities result from driving into flood water (77%). Spatial analysis indicates that more fatalities occurred in counties containing major urban centers – some of the Flash Flood Alley counties (Bexar, Dallas, Travis, and Tarrant), Harris County (Houston), and Val Verde County (Del Rio). An intervention strategy targeting the behavior of driving into flood water is proposed. The intervention is based on the Health Belief model. The main recommendation of the study is that flood fatalities in Texas can be reduced through a combination of improved hydrometeorological forecasting, educational programs aimed at enhancing the public awareness of flood risk and the seriousness of flood warnings, and timely and appropriate action by local emergency and safety authorities.^

The association between stress and physical fitness testing in the 2005 Department of Defense population survey

Objective. The purpose of this study was to examine the association of perceived stress and passing the fitness test in a cohort of Department of Defense active duty members. Reports of this association have been suggested in numerous articles. Methods. The 2005 DoD Survey of Health Related Behaviors Among Active Duty Military Personnel was used to examine the association between the participants’ perceived levels of stress from family and/or work related sources and the respondents’ last required fitness test taking into account potential confounder of the association. Measures of association were obtained from logistic regression models. Results. Participants who experienced “some” or “a lot” of stress either from work sources (OR 0.69, 95% CI: 0.58-0.87) or from personal/family sources (OR 0.70, 95% CI: 0.57-0.86) were less likely to pass the fitness test when compared to their counterparts who experienced “none” or “a little” stress. Additionally, those who reported “some” or “a lot” of stress either from work sources (OR 0.54, 95% CI: 0.41-0.70) or from personal/family sources (OR 0.54, 95% CI: 0.44-0.67) that interfered with their military duties were also less likely to pass the fitness test. The multivariate adjustment only slightly reduced the unadjusted association. Conclusions . An association exists between perceived stress levels and outcome of fitness testing. The higher the level of stress perceived, the less likely the person will be to pass the fitness test. Stress-related intervention might be useful to help the military members to achieve the level of fitness needed to perform their duties.^

Food availability in the home and dietary intake of the Harris County Department of Education Head Start population

Background. The prevalence of obesity and overweight children has been an ongoing health epidemic in the US for the last several decades. The problem has consistently worsened and has disproportionately been the most prevalent among low socioeconomic status (SES) populations. Food availability in the home has been suggested to be a potential factor related to overweight and obesity, as availability is likely associated with intake. Food availability of low SES preschool aged children has not been well examined. The purpose of this study was to explore the food environment of the Harris County Department of Education (HCDE) Head Start population, and describe reported frequency of intake of particular food groups. The effect of food availability on reported intake was also examined.^ Methods. This was a cross-sectional study of secondary data analysis. Data obtained from 17 HCDE Head Start Centers was analyzed using PASW 18 Statistical Software. Demographic analyses included population, age, gender, race, parent occupation, type of home, and language spoken in the home. Descriptive statistics included reported availability of foods in the home as well as frequency of intake.^ Regression analysis examined the relationship of availability of foods on intake. The food categories included were: dark leafy green and orange vegetables, other vegetables, fruits, soda, salty snacks, and sweet snacks. For both vegetable categories reported intake of fresh, frozen, and canned vegetables were included. For the fruit category, intake of fresh, frozen, canned, and dried fruits were reported.^ Results. Results showed that 90-95% of parents reported having vegetables and fruits available in the home. However, the only significant relationship between availability and intake was for fresh fruit and dried fruit. No associations were seen among the vegetable groups. Other vegetables (bell peppers, eggplant, tomatoes, onions, iceberg lettuce, asparagus) that were frozen, approached significance for availability on intake, however once adjusted for confounders the relationship was no longer present. Among soda, salty snacks, and sweet snacks the only significant relationship was seen for soda availability and intake. Salty snacks and sweet snacks presence in the home was not a predictor of increased frequency of intake.^ Conclusions. This research supported the hypothesis that availability of foods has an impact on intake for fresh fruits, dried fruits and soda. No associations were seen for vegetables, salty snacks and sweet snacks. Additionally, most of the parents reported having fruits and vegetables in the home, but reported intakes were not meeting the Dietary Guidelines for Americans recommendations. Strengths of the study included the large sample size taken from numerous HCDE Head Start Centers. Limitations included questionable reliability of participant’s responses, ability to generalize to other populations, and the use of secondary data rather than prospectively collected data.^

Systematic review of current trends of cardiovascular disease (CVD) and association between health insurance coverage and CVD mortality among women aged 60--65 in Texas in 2000--2011

Cardiovascular disease (CVD) is highly preventable, yet it is a leading cause of death among women in Texas. The primary goals of this research were to examine past and current trends of CVD, as well as identify whether there is an association between the insurance coverage and mortality from CVD among women aged 60–65 in Texas between 2000 and 2011. ^ The systematic review of the research is based on the guidelines and recommendations set by the Centre for Reviews and Dissemination for conducting reviews in health care. Over 47 citations of peer-reviewed articles from Ovid MEDLINE and PubMed databases and five websites were identified, of which 7 studies met inclusion criteria for the first systematic review to examine the trends of CVD in Texas. Ten citations of peer-reviewed articles from Ovid MEDLINE and PubMed databases and five web sites were reviewed for the second systematic review (to study the association between insurance coverage and cardiovascular health among Texas women 60–64 years of age), of which 3 studies met inclusion criteria and were included in the research. The results of the study highlighted key gaps in the existing literature and important areas for the further research, as well as determined directions for future public health CVD prevention programs in Texas. ^ Based on the conducted research, the major determinants of premature mortality among women attributed to cardiovascular disease are based on individual level characteristics, more specifically sex, age, race/ethnicity, and education. The results indicate that African American and non-Hispanic white women are more likely to have higher CVD mortality rates than Hispanic women due to higher prevalence of cardiac risk factors. The data also shows higher levels of mortality from CVD in the southeastern United States, with Texas ranking as the third state with the highest prevalence of CVD among women. According to the Texas Department of State Health Services, there are approximately 56,000 deaths caused by CVD annually in Texas, which represents about one death every ten minutes. Coronary artery disease and stroke were the causes of 31.2 percent of all female deaths in Texas in 2009, meaning that approximately 68 women die from any form of cardiac disease in Texas each day. ^ The data of the reviewed studies indicate that women' lack of health insurance was significantly associated with a higher prevalence of cardiovascular disease. The uninsured women were more likely to be unaware of their risk factors and more likely to have undiagnosed diabetes—a co-morbidity factor of CVD. One of the studies also reports strong correlation between state rates of uninsured and lower rates of preventive care. Given these strong correlations, those who were chronically uninsured were at a higher risk of mortality than the insured, due to prolonged periods of time without basic access to preventive and medical care. ^ Suggested recommendations to decrease CVD mortality rates in Texas are consistent with the existing literature and include state policy development that addresses elimination of health disparities, consideration of potential benefits of universal health coverage by the legislative policymakers, and maintenance of solid partnerships between public health agencies and hospitals to educate on, diagnose, and treat CVD among the female population in Texas. ^

Correlation of tuberculosis and human immunodeficiency virus in Harris County, Texas from 2009 through 2010 using Geographic Information Systems

A population based ecological study was conducted to identify areas with a high number of TB and HIV new diagnoses in Harris County, Texas from 2009 through 2010 by applying Geographic Information Systems to determine whether distinguished spatial patterns exist at the census tract level through the use of exploratory mapping. As of 2010, Texas has the fourth highest occurrence of new diagnoses of HIV/AIDS and TB.[31] The Texas Department of State Health Services (DSHS) has identified HIV infected persons as a high risk population for TB in Harris County.[29] In order to explore this relationship further, GIS was utilized to identify spatial trends. ^ The specific aims were to map TB and HIV new diagnoses rates and spatially identify hotspots and high value clusters at the census tract level. The potential association between HIV and TB was analyzed using spatial autocorrelation and linear regression analysis. The spatial statistics used were ArcGIS 9.3 Hotspot Analysis and Cluster and Outlier Analysis. Spatial autocorrelation was determined through Global Moran's I and linear regression analysis. ^ Hotspots and clusters of TB and HIV are located within the same spatial areas of Harris County. The areas with high value clusters and hotspots for each infection are located within the central downtown area of the city of Houston. There is an additional hotspot area of TB located directly north of I-10 and a hotspot area of HIV northeast of Interstate 610. ^ The Moran's I Index of 0.17 (Z score = 3.6 standard deviations, p-value = 0.01) suggests that TB is statistically clustered with a less than 1% chance that this pattern is due to random chance. However, there were a high number of features with no neighbors which may invalidate the statistical properties of the test. Linear regression analysis indicated that HIV new diagnoses rates (β=−0.006, SE=0.147, p=0.970) and census tracts (β=0.000, SE=0.000, p=0.866) were not significant predictors of TB new diagnoses rates. ^ Mapping products indicate that census tracts with overlapping hotspots and high value clusters of TB and HIV should be a targeted focus for prevention efforts, most particularly within central Harris County. While the statistical association was not confirmed, evidence suggests that there is a relationship between HIV and TB within this two year period.^