Process evaluation of intervention program for prevention of early sexual activity and alcohol use among Hispanic teenagers

Hispanic teens are a high-risk population for initiation of early sexual activity and alcohol use which in turn has numerous social and health consequences. One strategy to address prevention of these behaviors is to implement a capacity building intervention that promotes parent child communication, encompasses their cultural values and community participation. This study describes the process evaluation of a pilot intervention program amongst Hispanic teens and their families living along the Texas-Mexico border. “Girls Lets Talk” is a small group intervention with 10-14 year old teens and their female adult family members that involves education regarding effects of alcohol use and sexual activity as well as activities for monitoring and refusal skills to prevent risky behaviors. Two waves of the program each consisting of at least seven mother daughter dyads were conducted. During the designing process, community advisory board meetings and focus groups were held to review course materials and ensure they were appropriate to the Mexican American culture. Parent and adolescent surveys were administered at the beginning and end of the intervention to assess for psychosocial outcome variables. All sessions received high mean satisfactory scores (mean of 4.00 or better on a five point scale) for both adult and adolescent participants. Qualitative feedback was obtained via debriefing sessions to evaluate experience as well as alter recruitment strategies. A Wilcoxon Sign Rank analysis of the pre and post intervention surveys was done that showed significant changes in some outcome variables such as intentions and confidence for monitoring behaviors for adults and beliefs regarding sexual activity. “Girls Lets Talk” is a promising example of how a process evaluation plan can help develop a theory based health promotion program using the community based participatory research approach. The intervention may also be effective in altering intentions and enhancing self-efficacy among parents and teens in order to decrease risky behaviors such as early sexual activity and alcohol use.^

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. ^

PREDICTIVE VARIABLES FOR WEIGHT CHANGE 2 YEARS FOLLOWING PARTICIPATION IN A WEIGHT LOSS INTERVENTION PROGRAM

A historical prospective study was designed to assess the man weight status of subjects who participated in a behavioral weight reduction program in 1983 and to determine whether there was an association between the dependent variable weight change and any of 31 independent variables after a 2 year follow-up period. Data was obtained by abstracting the subjects records and from a follow-up questionnaire administered 2 years following program participation. Five hundred nine subjects (386 females and 123 males) of 1460 subjects who participated in the program, completed and returned the questionnaire. Results showed that mean weight was significantly different (p < 0.001) between the measurement at baseline and after a 2 year follow-up period. The mean weight loss of the group was 5.8 pounds, 10.7 pounds for males and 4.2 pounds for females after a 2 year follow-up period. A total of 63.9% of the group, 69.9% of males and 61.9% of females were still below their initial weight after the 2 year follow-up period. Sixteen of the 31 variables assessed utilizing bivariate analyses were found to be significantly (p (LESSTHEQ) 0.05) associated with weight change after a 2 year follow-up period. These variables were then entered into a multivariate linear regression model. A total of 37.9% of the variance of the dependent variable, weight change, was accounted for by all 16 variables. Eight of these variables were found to be significantly (p (LESSTHEQ) 0.05) predictive of weight change in the stepwise multivariate process accounting for 37.1% of the variance. These variables included: Two baseline variables (percent over ideal body weight at enrollment and occupation) and six follow-up variables (feeling in control of eating habits, percent of body weight lost during treatment, frequency of weight measurement, physical activity, eating in response to emotions, and number of pounds of weight gain needed to resume a diet). It was concluded that a greater amount of emphasis should be placed on the six follow-up variables by clinicians involved in the treatment of obesity, and by the subjects themselves to enhance their chances of success at long-term weight loss. ^

An analysis of Texas's school based HPV vaccine mandate: A public health risk communication failure: HPVETO!

Genital human papillomavirus (HPV) is of public health concern because persistent infection with certain HPV types can cause cervical cancer. In response to a nationwide push for cervical cancer legislation, Texas Governor Rick Perry bypassed the traditional legislative process and issued an executive order mandating compulsory HPV vaccinations for all female public school students prior to their entrance in the sixth grade. By bypassing the legislative process Governor Perry did not effectively mitigate the risk perception issues that arose around the need for and usefulness of the vaccine mandate. This policy paper uses a social policy paradigm to identify perception as the key intervening factor on how the public responds to risk information. To demonstrate how the HPV mandate failed, it analyzes four factors, economics, politics, knowledge and culture, that shape perception and influence the public's response. By understanding the factors that influence the public's perception, public health practitioners and policy makers can more effectively create preventive health policy at the state level. ^

Determining acquisition and cessation antecedents to adolescent cigarette smoking for development of intervention strategies

Our national focus and emphasis on the promotion of healthy behavior choices regarding tobacco and other drugs continues to target adolescents. Multiple studies have shown that adolescence is the optimum period for the prevention of substance use initiation as life-long patterns of health behaviors are established during this critical developmental stage. Tobacco use is associated with an increase in morbid and mortal health conditions of which prevalence increases throughout the lifespan. Attention to the antecedents of preventable health conditions aims to modify the risks and identify health promotion factors. Modifying antecedent factors for tobacco initiation in youth and identifying protective factors for successful smoking cessation has major public health implications across the lifespan. Of foremost interest are those risk factors and resultant behaviors that predict a youth's probability of initiating cigarette use and their cessation of cigarette use. Specifically, this dissertation supports previous results identifying intervention variables on the initiation/cessation continuum model especially with the established predictors of smoking (decisional balance and susceptibility) and with more recently identified predictors of smoking (nicotine dependence and withdrawal symptoms) in current and former smokers in a sample of high school students in Austin and Houston, Texas. These results offer insight for the development of appropriate intervention program strategies for our youth. ^

A formative evaluation of the American Diabetes Association's Choosing Health and Sensible Exercise childhood obesity intervention

Background. The increasing prevalence of overweight among youth in the United States, and the parallel rise in related medical comorbidities has led to a growing need for efficient weight-management interventions. Purpose. The aim of this study was to evaluate the effects of the Choosing Health and Sensible Exercise (C.H.A.S.E.) childhood obesity prevention program on Body Mass Index (BMI), physical activity and dietary behaviors. Methods. This study utilized de-identified data collected during the fall 2006 session of the C.H.A.S.E. program. A total of 65 students at Woodview Elementary School and Deepwater Elementary School participated in this intervention. The C.H.A.S.E. program is a 10-week obesity prevention program that focuses on nutrition and physical activity education. Collection of height and weight data, and a health behavior survey was conducted during the first and last week of the intervention. Paired t-tests were used to determine statistically significant differences between pre- and post-intervention measurements. One-way analysis of variance was used to adjust for potential confounders, such as gender, age, BMI category ("normal weight", "at risk overweight", or "overweight"), and self-reported weight loss goals. Data were analyzed using STATA, v. 9.2. Results. A significant decrease in mean BMI (p< 0.05) was found after the 10-week intervention. While the results were statistically significant for the group as a whole, changes in BMI were not significant when stratified by age, sex, or ethnicity. The mean overall scores for the behavior survey did not change significantly pre- and post-intervention; however, significant differences were found in the dietary intention scale, indicating that students were more likely to intend to make healthier food choices (p<0.05). No statistically significant decreases in BMI were found when stratified for baseline BMI-for-age percentiles or baseline weight loss efforts (p>0.05). Conclusion. The results of this evaluation provide information that will be useful in planning and implementing an effective childhood obesity intervention in the future. Changes in the self-reported dietary intentions and BMI show that the C.H.A.S.E. program is capable of modifying food choice selection and decreasing BMI. Results from the behavior questionnaire indicate that students in the intervention program were making changes in a positive direction. Future implementation of the C.H.A.S.E. program, as well as other childhood obesity interventions, may want to consider incorporating additional strategies to increase knowledge and other behavioral constructs associated with decreased BMI. In addition, obesity prevention programs may want to increase parental involvement and increase the dose or intensity of the intervention. ^

Association of part-time employment and sexual risk-taking behaviors among middle school students

Background. Previous research shows inconsistent results as to the association between part-time employment and sexual behavior among younger teens. Studies of older teens cannot be generalized to younger teens because of the wide differences in types of work performed, nature of work environments, and work intensity. Objective. Examine the relationship between part-time employment and sexual behavior in a cross-sectional sample of public middle school students in Houston, Texas. Methods . The study presents a secondary analysis of data from the It’s Your Game…Keep it Real baseline data collection (11/2004–1/2005). It’s Your Game… is an intervention program for middle school students designed to prevent Sexually Transmitted Infections. Statistical analysis. Univariate and multivariate logistic regression analyses were conducted to examine the association between part-time employment and vaginal intercourse: (a) ever had sex; and (b) current sexual activity. Results. Overall, 13.2% of students worked for pay; male students were 1.5 times as likely as females to be working. Of all the students, 11.0% had had sexual intercourse; students who worked were 3 times more likely to be sexually experienced than those who did not. Among students who were sexually experienced, 67.0% were currently sexually active. After adjusting for the other covariates, Hispanic students were almost 3.6 times more likely to report current sexual activity compared to students in other racial/ethnic groups. In univariate analysis, students who worked 1-5 hrs/week were more likely to be sexually experienced than those not currently employed, and the likelihood increased with number of hours worked. There is a similar pattern in the multivariate model, but the odds ratios are too close for the evidence to be more than suggestive. Of sexually experienced students, students working 1-5 hrs/week were 2.7 times more likely to report current sexual intercourse than those not working; those working >5 hrs/week were 4.7 times more likely. The multivariate model showed a similar increase in likelihood, and adjustment for covariates increased these associations: students who worked 1-5 hrs/week were 3.6 times more likely to report current sexual intercourse, and students who worked >5 hrs/week were 4.5 times more likely, than students not currently employed.^

Doctor-patient communication in the medical interaction: Context, implications, and practice

Effective communication; whether from an interpersonal, mass media, or global perspective, is a critical component in public health. It is an essential conduit in increasing public awareness of available health resources, potential health hazards and related disease prevention strategies, and in delivering better health care. Within this context, available literature asserts doctor-patient communication as central to healthcare delivery. It has been shown to affect patient health outcomes, satisfaction with care, adherence to treatment recommendations, and even understanding of medical information. While research supports the essential imperative of interventions aimed at teaching doctors and patients the communication skills necessary for a successful and meaningful medical interaction, most interventions to date, focus on teaching these communication skills to doctors and seem to rely, largely, on mass media for providing patients with the information needed to increase communication efficacy. This study sought to fill a significant gap in the doctor-patient communication literature by reviewing the context of the doctor-patient exchange in the medical interaction, the implications of this exchange in resulting care of the patient, and the potential improvements to practice through interventions aimed at improving the communication exchange. Closing with an evaluation of a patient-centered communication intervention, the “How to Talk to Your Doctor” (HTTTYD) program that combines previously identified optimal strategies for improving communication between doctors and patients, this study examined the patients’ perspective of their potential as better communicators in the medical interaction. ^ Specific Aims, Hypotheses or Questions (Aim I) To examine the context of health communication within a public health framework and its relation to health care delivery. (Aim II) To review doctor-patient communication as a central focus within health care delivery and the resulting implications to patient care. (Aim III) To assess the utility of interventions to improve doctor-patient communication. Specifically, to evaluate the effectiveness of a patient-centered community education intervention, the “How to Talk to Your Doctor” (HTTTYD) program, aimed at improving patient communication efficacy.^

Physician perceptions of risk regarding mood disorders and pharmacological management during pregnancy: What is current practice?

Mood disorders are the most common form of mental illness and one of the leading causes of morbidity worldwide. Major depressive disorder and bipolar disorder have a lifetime prevalence of 16.2% and 4.4%, respectively. Women comprise a substantial proportion of this population, and an estimated 500,000 pregnancies each year involve women with a psychiatric condition. Management with psychotropic medications is considered standard of care for most patients with mood disorders. However, many of these medications are known human teratogens. Because pregnant women with mood disorders face a high risk of relapse if unmanaged, the obstetrician faces a unique challenge in providing the best care to both mother and baby. It has been suggested that many obstetricians overestimate the teratogenic risks associated with psychotropic medications, while concurrently underestimating the risks associated with unmanaged mood disorders. This may be due a knowledge gap regarding the most current teratogen information, and lack of official management guidelines. Therefore, the purpose of this study is to determine the current knowledge base of obstetricians regarding the teratogenic effects of common psychotropic medications, as wells as to capture current management practices for pregnant women with mood disorders. A total of 117 Texas obstetricians responded to a survey regarding teratogen knowledge and management practice. It was common for respondents to encounter women who disclose both having a mood disorder and taking a psychotropic medication during pregnancy. Many respondents did not utilize up-to-date drug counseling resources, and were unaware of or over-estimated the teratogenic risks of common medications used to treat mood disorders. Finally, many respondents reported wanting to refer pregnant patients with mood disorders to psychiatrists for co-management, but are reportedly restricted in doing so due to accessibility or insurance issues. This study demonstrates that there is a knowledge gap among obstetricians regarding the teratogenicity of common psychotropic medications utilized to manage a patient population they frequently encounter. Further, obstetricians have vastly different risk perceptions of these medications, resulting in various management approaches and recommendations. Future research should focus on establishing standard practice guidelines, as well as better accessibility to psychiatric services for pregnant women.

An intervention mapping approach: Identification of human trafficking victims by health professionals

Background. Today modern day slavery is known as human trafficking and is a growing pandemic that is a grave human rights violation. Estimates suggest that 12.3 million people are working under conditions of force, fraud or coercion. Working toward eradication is a worthy effort; it would free millions of humans from slavery, mostly women and children, as well as uphold basic human rights. One tactic to eradicating human trafficking is to increase identification of victims among those likely to encounter victims of human trafficking.^ Purpose. This study aims to develop an intervention that improves certain stakeholders' ability, in the health clinic setting, to appropriately identify and report victims of human trafficking to the National Human Trafficking Resource Center.^ Methods. The Intervention Mapping (IM) process was used by program planners to develop an intervention for health professionals. This methodology is a six step process that guides program planners to develop an intervention. Each step builds on the others through the execution of a needs assessment, and the development of matrices based on performance objectives and determinants of the targeted health behavior. The end product results in an ecological, theoretical, and evidence based intervention.^ Discussion. The IM process served as a useful protocol for program planners to take an ecological approach as well as incorporate theory and evidence into the intervention. Consultation with key informants, the planning group, adopters, implementers, and individuals responsible for institutionalization also contributed to the practicality and feasibility of the intervention. Program planners believe that this intervention fully meets recommendations set forth in the literature.^ Conclusions. The intervention mapping methodology enabled program planners to develop an intervention that is appropriate and acceptable to the implementer and the recipients.^

Ethnic/racial diversity, maternal stress, lactation and very low birthweight infants.

OBJECTIVE: (1) To compare maternal characteristics and psychological stress profile among African-American, Caucasian and Hispanic mothers who delivered very low birthweight infants. (2) To investigate associations between psychosocial factors, frequency of milk expression, skin-to-skin holding (STS), and lactation performance, defined as maternal drive to express milk and milk volume. STUDY DESIGN: Self-reported psychological questionnaires were given every 2 weeks after delivery over 10 weeks. Milk expression frequency, STS, and socioeconomic variables were collected. RESULT: Infant birthweight, education, and milk expression frequency differed between groups. Trait anxiety, depression and parental stress in a neonatal intensive care unit (PSS:NICU) were similar. African-American and Caucasian mothers reported the lowest scores in state anxiety and social desirability, respectively. Maternal drive to express milk, measured by maintenance of milk expression, correlated negatively with parental role alteration (subset of PSS:NICU) and positively with infant birthweight and STS. Milk volume correlated negatively with depression and positively with milk expression frequency and STS. CONCLUSION: Differences between groups were observed for certain psychosocial factors. The response bias to self-reported questionnaires between groups may not provide an accurate profile of maternal psychosocial profile. With different factors correlating with maintenance of milk expression and milk volume, lactation performance can be best enhanced with a multi-faceted intervention program, incorporating parental involvement in infant care, close awareness and management of maternal mental health, and encouragement for frequent milk expression and STS.

INFLUENCE OF A CLINIC BASED IMMUNIZATION INFORMATION SYSTEM ON INFANT IMMUNIZATIONS

This study focuses on the impact of a clinic-based intervention program on the immunization status of limited-income urban children. The intervention program consisted of an information session for clinic health care providers and the placement of individualized immunization information labels on clinic notes at the time of each visit. The degree of impact of the intervention on immunization administration was ascertained through a comparison of two similar groups of infants born in the same months of the year immediately before (N = 201) and after (N = 203) the information session and initiation of the labeling system. The timeliness of administration of each diphtheria, pertussis, tetanus and trivalent oral polio vaccine (DPT/TOPV) in the first year series of three was compared pre- to postintervention. Significantly more third immunizations were given the postintervention subjects within ten days of the recommended time of application ( p = .0361). Life table analysis indicated that the probability of an infant's passing one year of age without the administration of the third immunization decreased for postintervention infants (p = .0515). The intervention was most successful in assuring administration of the series of immunizations in those infants who were seen by the health care provider for at least 50% of their first year visits. Results indicate that minor changes in the format of information given a relatively continuous provider can increase completion of immunization series in infants. ^

Drinking water quality perception along the U.S.-Mexico border

Drinking water-related exposures within populations living in the United States-Mexico border region, particularly among Hispanics, is an area that is largely unknown. Specifically, perceptions that may affect water source selection is an issue that has not been fully addressed. This study evaluates drinking water quality perceptions in a mostly Hispanic community living along the United States-Mexico border, a community also facing water scarcity issues. Using a survey that was administered during two seasons (winter and summer), data were collected from a total of 608 participants, of which 303 were living in the United States and 305 in Mexico. A (random) convenience sampling technique was used to select households and those interviewed were over 18 years of age. Statistically significant differences were observed involving country of residence (p=0.002). Specifically, those living in Mexico reported a higher use of bottled water than those living in the United States. Perception factors, especially taste, were cited as main reasons for not selecting unfiltered tap water as a primary drinking water source. Understanding what influences drinking water source preference can aid in the development of risk communication strategies regarding water quality. ^

Prevalence of depressive symptoms in urban middle and high school Hispanic and African American students

This cross-sectional study examined the prevalence of depressive symptoms in urban Hispanic and African American middle and high school students (N=1,292) using data collected from a multi-component, multi-wave violence and substance use intervention program targeted at a large urban school district in Texas. Chi-square analysis was used to examine differences in race/ethnicity, gender, grade level and whether or not a student had been held back/repeated a grade in school. Univariate and multivariate logistic regression were used to analyze the association between depressive symptoms and demographic variables. Being female and being held back/repeating a grade was significantly associated with depressive symptoms in both univariate and multivariate analyses. Overall 16% of the students reported depressive symptoms; Hispanic youth had a higher prevalence of depressive symptoms (16.8%) than the African American youth (14.8%). Minority females and those who had been held back/repeated a grade reported a prevalence of 19.4% and 21.2%, respectively. Further research is needed to understand why Hispanic youth continue to report a higher prevalence of depressive symptoms than other minorities. Additionally research is required to further explore the association between academic performance and depressive symptoms in urban minorities, specifically the effect of being held back/repeating a grade.^

The association of food sources of calcium with weight class in adolescent girls

To determine the association of food sources of calcium with weight class in adolescent girls, the major food sources of calcium were determined for 718 sixth grade girls at three different time periods during an 18 month school-based health intervention program using a FFQ. To determine weight class, the BMI of each girl was stratified using CDC age and gender specific criteria at each time period. The percent contribution of the major food sources of calcium to total calcium intake was compared among the different weight classes at each time period, among those girls who had changed weight class at the different time periods and for those girls who did not change weight class at the different time periods. The mean total calcium intake increased by 20% between the first two time periods and by 12% between the first and last time periods with the intervention despite baseline total calcium intake already being greater than the recommended 1300 mg/day. The percent contribution of the major food sources of calcium were highly correlated among the weight classes that were compared throughout the study. Those girls who remained in the normal weight class throughout the study had the most consistent intake of food sources of calcium. Their top four food sources of calcium were different types of milk which provided greater than 50% of their total calcium intake. Despite there being no significant differences in the major food sources of calcium among the different weight classes, these data show a successful intervention for increasing calcium intake among adolescent girls. ^