Exploring professional orientations to community voice in professional practice settings: The IMAP process

The tension between technical experts and the populations they seek to serve is well established in the literature examining professional social problem solving. In this piece, I examine this tension as one between the distinct discursive worlds of technical expertise and community voice. I develop an analytic process, IMAP, for exploring this tension by looking at a wide variety of professional orientations around a relatively fixed concept of community voice. IMAP involves I&barbelow;dentifying social problem solvers, M&barbelow;apping social problem solvers' claims, A&barbelow;nalyzing professional orientations that arise from this mapping, and P&barbelow;redicting, diagnosing, and remediating conflicts. IMAP can be used by analysts external to social problem solving settings or by social problem solvers themselves. The use of IMAP by external experts poses questions of expert alignment with either of the discursive worlds. I examine two cases in public health practice settings: a mobile immunization service and the efforts of a foundation to improve health in an inner-city neighborhood. I develop four modal types that can be anticipated in social problem solving settings or, more specifically, in public health practice. Understanding of these “world views” can enhance mutual understanding between public health professionals and between public health professionals and the communities they seek to serve. IMAP might also address ongoing conflicts to clarify differences in unspoken normative commitments and the impact of these on social problem solving. I discuss implications of the research for public health practice and further research in the area. ^

Theory of uncertainty in illness in patients with cancer of unknown primary origin: Structure providers as antecedents of uncertainty in a population of cancer patients with an unknown primary diagnosis

Uncertainty has been found to be a major component of the cancer experience and can dramatically affect psychosocial adaptation and outcomes of a patient's disease state (McCormick, 2002). Patients with a diagnosis of Carcinoma of Unknown Primary (CUP) may experience higher levels of uncertainty due to the unpredictability of current and future symptoms, limited treatment options and an undetermined life expectancy. To date, only one study has touched upon uncertainty and its' effects on those with CUP but no information exists concerning the effects of uncertainty regarding diagnosis and treatment on the distress level and psychosocial adjustment of this population (Parker & Lenzi, 2003). ^ Mishel's Uncertainty in Illness Theory (1984) proposes that uncertainty is preceded by three variables, one of which being Structure Providers. Structure Providers include credible authority, the degree of trust and confidence the patient has with their doctor, education and social support. It was the goal of this study to examine the relationship between uncertainty and Structure Providers to support the following hypotheses: (1) There will be a negative association between credible authority and uncertainty, (2) There will be a negative association between education level and uncertainty, and (3) There will be a negative association between social support and uncertainty. ^ This cross-sectional analysis utilized data from 219 patients following their initial consultation with their oncologist. Data included the Mishel Uncertainty in Illness Scale (MUIS) which was used to determine patients' uncertainty levels, the Medical Outcomes Study-Social Support Scale (MOSS-SSS) to assess patients, levels of social support, the Patient Satisfaction Questionnaire (PSQ-18) and the Cancer Diagnostic Interview Scale (CDIS) to measure credible authority and general demographic information to assess age, education, marital status and ethnicity. ^ In this study we found that uncertainty levels were generally higher in this sample as compared to other types of cancer populations. And while our results seemed to support most of our hypothesis, we were only able to show significant associations between two. The analyses indicated that credible authority measured by both the CDIS and the PSQ was a significant predictor of uncertainty as was social support measured by the MOSS-SS. Education has shown to have an inconsistent pattern of effect in relation to uncertainty and in the current study there was not enough data to significantly support our hypothesis. ^ The results of this study generally support Mishel's Theory of Uncertainty in Illness and highlight the importance of taking into consideration patients, psychosocial factors as well as employing proper communication practices between physicians and their patients.^

Planning and implementation efficacy as a determinant of health risk communication outcomes: Case studies of the U.S. Public Health Service (PHS)

This study was conducted under the auspices of the Subcommittee on Risk Communication and Education of the Committee to Coordinate Environmental Health and Related Programs (CCEHRP) to determine how Public Health Service (PHS) agencies are communicating information about health risk, what factors contributed to effective communication efforts, and what specific principles, strategies, and practices best promote more effective health risk communication outcomes.^ Member agencies of the Subcommittee submitted examples of health risk communication activities or decisions they perceived to be effective and some examples of cases they thought had not been as effective as desired. Of the 10 case studies received, 7 were submitted as examples of effective health risk communication, and 3, as examples of less effective communication.^ Information contained in the 10 case studies describing the respective agencies' health risk communication strategies and practices was compared with EPA's Seven Cardinal Rules of Risk Communication, since similar rules were not found in any PHS agency. EPA's rules are: (1) Accept and involve the public as a legitimate partner. (2) Plan carefully and evaluate your efforts. (3) Listen to the public's specific concerns. (4) Be honest, frank, and open. (5) Coordinate and collaborate with other credible sources. (6) Meet the needs of the media. (7) Speak clearly and with compassion.^ On the basis of case studies analysis, the Subcommittee, in their attempts to design and implement effective health risk communication campaigns, identified a number of areas for improvement among the agencies. First, PHS agencies should consider developing a focus specific to health risk communication (i.e., office or specialty resource). Second, create a set of generally accepted practices and guidelines for effective implementation and evaluation of PHS health risk communication activities and products. Third, organize interagency initiatives aimed at increasing awareness and visibility of health risk communication issues and trends within and between PHS agencies.^ PHS agencies identified some specific implementation strategies the CCEHRP might consider pursuing to address the major recommendations. Implementation strategies common to PHS agencies emerged in the following five areas: (1) program development, (2) building partnerships, (3) developing training, (4) expanding information technologies, and (5) conducting research and evaluation. ^

Women physicians' specialty choices

Three hypotheses have been offered to explain the historical specialty selection by women physicians. They are: (1) women choose the specialty for which the training requirements and working conditions interfere least with their commitments to marriage and children; (2) women tend to select the more "feminine" specialties such as pediatrics and psychiatry, and to avoid the "masculine" fields such as surgery; and (3) women have been deliberately excluded from male-dominated fields such as surgery. While the above hypotheses may be true to a greater or lesser degree, none of them has been adequately tested.^ The major study hypotheses are as follows: (1) female physicians' choice of specialty is influenced by the following reasons: (a) family responsibilities; (b) sex role expectations; and (c) sex discrimination; (2) female physicians' choice of specialty is also influenced by their age and ethnicity; and (3) the primary reasons for choosing a given specialty vary by type of specialty.^ The reasons for specialty selection will be explored based on a survey of women graduates of one of the oldest medical schools in the United States, The University of Texas Medical Branch (UTMB) in Galveston, Texas (n = 930). The survey response rate was 75.3% (700 respondents).^ The results for the first study hypothesis showed that fewer than 14% of the respondents agreed that sex role expectations, sex discrimination and family responsibilities played a role in their choice of specialty. Fifty nine percent of the respondents disagreed with the idea that sex role expectations influenced specialty selection and 64% disagreed that family responsibilities had an effect on the selection of their specialty. Around half (49%) were uncertain of the influence of sex discrimination. It was concluded that sex discrimination, sex role expectations and family responsibilities did not have a major impact on specialty selection.^ With respect to the second hypothesis, age was significant in Internal Medicine, Obstetrics/Gynecology and Psychiatry. Women physicians in Internal Medicine and Obstetrics/Gynecology were significantly younger (less than 45 years old) while physicians in Psychiatry were significantly older (45 years or older) than other specialties studied.^ The third hypothesis was confirmed: the reasons for choosing a given specialty varied by specialty.^ Respondents' comments written on the survey provided insight into other possible reasons for specialty selection including exploration of the role of mentoring and job satisfaction.^ The retrospective cross-sectional study design used in this study does not adequately capture the fact that different reasons may be given for the choice of specialty at different points in time, e.g., as the time of choosing a residency program versus several years into the future.^ In conclusion, approaches that explore the range of reasons that women elect to enter and stay within a given specialty must be explored to gain richer understanding of the complex and dynamic nature of women physicians' professional lives. (Abstract shortened by UMI.) ^

Minimum income for healthy living

Objectives: We sought to estimate the costs of implementing the current recommendations for healthy choices for a mother with two young children in Atlanta, Georgia. ^ Methods: Current recommendations for healthy choices promoted by the federal government or other credible source were compiled and operationalized into specific conditions or behaviors. The costs of implementing these choices in Atlanta were estimated by using internet searches of retailers/suppliers, phone interviews, and direct observation. The least expensive option was chosen when options were available. ^ Results: Recommendations for choosing a healthy neighborhood, home, school, child care, food, physical activity, and maintaining healthy relationships as well as access to health care were considered. Total costs for this family of three totaled $38,181. Housing, child care, and health insurance contributed to 78% of the total costs. ^ Conclusions: The minimum income needed to choose healthy choices falls short of current wages, and eligibility levels and benefits for income support. ^

Modified 3+3 design for phase I clinical trials

Phase I clinical trial is mainly designed to determine the maximum tolerated dose (MTD) of a new drug. Optimization of phase I trial design is crucial to minimize the number of enrolled patients exposed to unsafe dose levels and to provide reliable information to the later phases of clinical trials. Although it has been criticized about its inefficient MTD estimation, nowadays the traditional 3+3 method remains dominant in practice due to its simplicity and conservative estimation. There are many new designs that have been proven to generate more credible MTD estimation, such as the Continual Reassessment Method (CRM). Despite its accepted better performance, the CRM design is still not widely used in real trials. There are several factors that contribute to the difficulties of CRM adaption in practice. First, CRM is not widely accepted by the regulatory agencies such as FDA in terms of safety. It is considered to be less conservative and tend to expose more patients above the MTD level than the traditional design. Second, CRM is relatively complex and not intuitive for the clinicians to fully understand. Third, the CRM method take much more time and need statistical experts and computer programs throughout the trial. The current situation is that the clinicians still tend to follow the trial process that they are comfortable with. This situation is not likely to change in the near future. Based on this situation, we have the motivation to improve the accuracy of MTD selection while follow the procedure of the traditional design to maintain simplicity. We found that in 3+3 method, the dose transition and the MTD determination are relatively independent. Thus we proposed to separate the two stages. The dose transition rule remained the same as 3+3 method. After getting the toxicity information from the dose transition stage, we combined the isotonic transformation to ensure the monotonic increasing order before selecting the optimal MTD. To compare the operating characteristics of the proposed isotonic method and the other designs, we carried out 10,000 simulation trials under different dose setting scenarios to compare the design characteristics of the isotonic modified method with standard 3+3 method, CRM, biased coin design (BC) and k-in-a-row design (KIAW). The isotonic modified method improved MTD estimation of the standard 3+3 in 39 out of 40 scenarios. The improvement is much greater when the target is 0.3 other than 0.25. The modified design is also competitive when comparing with other selected methods. A CRM method performed better in general but was not as stable as the isotonic method throughout the different dose settings. The results demonstrated that our proposed isotonic modified method is not only easily conducted using the same procedure as 3+3 but also outperforms the conventional 3+3 design. It can also be applied to determine MTD for any given TTL. These features make the isotonic modified method of practical value in phase I clinical trials.^

Instrumental variable method for the causal relationship between soluble receptor for advanced glycation end-products (sRAGE) and risk of pancreatic cancer

This thesis project is motivated by the potential problem of using observational data to draw inferences about a causal relationship in observational epidemiology research when controlled randomization is not applicable. Instrumental variable (IV) method is one of the statistical tools to overcome this problem. Mendelian randomization study uses genetic variants as IVs in genetic association study. In this thesis, the IV method, as well as standard logistic and linear regression models, is used to investigate the causal association between risk of pancreatic cancer and the circulating levels of soluble receptor for advanced glycation end-products (sRAGE). Higher levels of serum sRAGE were found to be associated with a lower risk of pancreatic cancer in a previous observational study (255 cases and 485 controls). However, such a novel association may be biased by unknown confounding factors. In a case-control study, we aimed to use the IV approach to confirm or refute this observation in a subset of study subjects for whom the genotyping data were available (178 cases and 177 controls). Two-stage IV method using generalized method of moments-structural mean models (GMM-SMM) was conducted and the relative risk (RR) was calculated. In the first stage analysis, we found that the single nucleotide polymorphism (SNP) rs2070600 of the receptor for advanced glycation end-products (AGER) gene meets all three general assumptions for a genetic IV in examining the causal association between sRAGE and risk of pancreatic cancer. The variant allele of SNP rs2070600 of the AGER gene was associated with lower levels of sRAGE, and it was neither associated with risk of pancreatic cancer, nor with the confounding factors. It was a potential strong IV (F statistic = 29.2). However, in the second stage analysis, the GMM-SMM model failed to converge due to non- concaveness probably because of the small sample size. Therefore, the IV analysis could not support the causality of the association between serum sRAGE levels and risk of pancreatic cancer. Nevertheless, these analyses suggest that rs2070600 was a potentially good genetic IV for testing the causality between the risk of pancreatic cancer and sRAGE levels. A larger sample size is required to conduct a credible IV analysis.^