A qualitative assessment of the impact of Texas policy changes on nutrition in child care centers in Travis County, Texas

Background. Over half of children in the United States under age five spend 32 hours a week in child care, facilities, where they consume approximately 33-50% of their food intake. ^ Objectives. The aim of this research was to identify the effects of state nutrition policies on provision of food in child care centers. ^ Subjects. Eleven directors or their designee from ten randomly selected licensed child care centers in Travis County, Texas were interviewed. Centers included both nonprofit and for-profit centers, with enrollments ranging from 19 to 82. ^ Methods. Centers were selected using a web-based list of licensed child care providers in the Austin area. One-on-one interviews were conducted in person with center directors using a standard set of questions developed from previous pilot work. Interview items included demographic data, questions about state policies regarding provision of foods in centers, effects of policies on child care center budgets and foods offered, and changes in the provision of food. All interviews were audiotaped and transcribed, and themes were identified using standard qualitative techniques. ^ Results. Four of the centers provided both meals and snacks, four provided snacks only, and two did not provide any food. Directors of centers that provided food were more likely to report adherence to the Minimum Standards than directors of centers that did not. In general, center directors reported that the regulations were loosely enforced. In contrast, center directors were more concerned about a local city-county regulation that required food permits and new standards for kitchens. Most of these local regulations were cost prohibitive and, as a result, centers had changed the types of foods provided, which included providing less fresh produce and more prepackaged items. Although implementation of local regulations had reduced provision of fruits and vegetables to children, no adjustments were reported for allocation of resources, tuition costs or care of the children. ^ Conclusions. Qualitative data from a small sample of child care directors indicate that the implementation and accountability of food- and nutrition-related guidelines for centers is sporadic, uncoordinated, and can have unforeseen effects on the provision of food. A quantitative survey and dietary assessment methods should be conducted to verify these findings in a larger and more representative sample.^

HOUSE-TO-HOUSE SURVEY OF ACCESS TO AND USE OF PUBLIC HEALTH FACILITIES IN METROPOLITAN LAGOS, NIGERIA

One of the broad objectives of the Nigerian health service, vigorously being pursued at all levels of government, is to make comprehensive health care available and accessible to the population at the lowest possible cost, within available resources. Some state governments in the federation have already introduced free medical service as a practical way to remove financial barriers to access and in turn to encourage greater utilization of publicly funded care facilities.^ To aid health planners and decision makers in identifying a shorter corridor through which urban dwellers can gain access to comprehensive health care, a health interview survey of the metropolitan Lagos was undertaken. The primary purpose was to ascertain the magnitude of access problems which urban households face in seeking care from existing public facilities at the time of need. Six categories of illness chosen from the 1975 edition of the International Classification of Disease were used as indicators of health need.^ Choice of treatment facilities in response to illness episode was examined in relation to distance, travel time, time of use and transportation experiences. These were graphically described. The overall picture indicated that distance and travel time coexist with transportation problems in preventing a significant segment of those in need of health care from benefitting in the free medical service offered in public health facilities. Within this milieu, traditional medicine and its practitioners became the most preferred alternative. Recommendations were offered for action with regard to decentralization of general practitioner (GP) consultations in general hospitals and integration of traditional medicine and its practitioners into public health service. ^

Effects of a dog walking program with older adults in long-term care

The purpose of this study was to determine if walking a dog would increase motivation to adhere to a walking program and result in an increase in walking endurance and mobility among institutionalized elderly. An experimental pre and post test two group randomly assigned study design was utilized. Thirty subjects, 20 females and 10 males with an average age of 72, were enrolled from three long-term care facilities. The walking program was 3 times a week for 6 weeks. The experimental group walked with a certified therapy dog and the handler. The control group walked with only the handler. The Outcome Expectations for Exercise Scale (OEES) was used to measure the perceived benefits of exercise. The 2-minute walk test and the 30 second chair stand test were administered before and after the walking program. The OEES scores did not significantly predict adherence to the program. The pre- and post-chair stand test and the 2-minute walk test did not show statistical significant differences between groups. All of the participants did show an increase (7 minutes) in walking time during the 6 week period (p=0.048). The mean pre and post walk test scores for participants with stroke/arthritis were significantly less than those without stroke/arthritis (p=0.013). The experimental group had 12 subjects with stroke/arthritis compared with 6 in the control group. The walk test means in feet walked were 362.44 ± 130.36 (control) vs. 201.27 ± 106.25 (experimental), p=0.001. The results indicate walking practice has the potential to increase walking time and endurance. Because residents of long-term care facilities were not allowed outside the facilities without accompaniment, the presence of the dog handler was key to their walking. Analysis of conversations during the walks indicated that for participants who walked with dogs, the dogs did serve as motivation for continuing in the program. ^

Assessing the impact of leadership on nurse job satisfaction and the desire for unionization in health care settings

This dissertation focuses on the leadership styles of managers, the impact these leadership styles have on the job satisfaction of staff nurses, and the proclivity of nurses to consider unionization. The aims of the dissertation include conducting a literature review on topics of leadership style, job satisfaction, and unionization; identifying and elucidating pertinent constructs with respect to shared interrelationships and how they could be measured; and developing a means of assessing if and to what extent transformational and transactional leadership styles affect nurse proclivity to unionize.^ The instrumentation selected includes the Multifactor Leadership Survey, Job Satisfaction Survey, and a newly created Union Preference Survey. Each survey instrument was evaluated as to its appropriateness to administer at a non-consultant level within a health care facility. Options other than self-administering the survey instruments include online access for participants, which provides confidentiality and encourages more responses. ^ The next part of the dissertation is a plan for health care facilities to use the survey tool by administering it themselves. The plan provides a general description of the survey tool, administering the instrument, rating the instrument, and leadership development. Integration of the three surveys is presented in a non-statistical format by coordinating the results of the three survey instrument responses. Recommendations are presented on how to improve leadership development warranted for improvement.^ The conclusions reached are that nurses’ preference for unions is influenced by the leadership style of direct report managers, as rated by staff nurses, and the nurses’ job satisfaction, which is in turn in part dependent on their managers’ leadership style. Thus, changes in leadership style can have a profound impact on nurse job satisfaction and on nurses’ preference for unionization.^

Use of intranet and other interventions to increase influenza vaccination among health care workers

Influenza (the flu) is a serious respiratory illness that can cause severe complications, often leading to hospitalization and even death. Influenza epidemics occur in most countries every year, usually during the winter months. Despite recommendations from the Centers for Disease Control and Prevention (CDC) and efforts by health care institutions across the United States, influenza vaccination rates among health care workers in the United States remain low. How to increase the number of vaccinated health care workers is an important public health question and is examined in two journal articles included here. ^ The first journal article evaluates the effectiveness of an Intranet intervention in increasing the proportion of health care workers (HCWs) who received influenza vaccination. Hospital employees were required go to the hospital's Intranet and select "vaccine received," "contraindicated," or "declined" from the online questionnaire. Declining employees automatically received an online pop-up window with education about vaccination; managers were provided feedback on employees' participation rates via e-mail messages. Employees were reminded of the Intranet requirement in articles in the employee newsletter and on the hospital's Intranet. Reminders about the Intranet questionnaire were provided through managers and newsletters to the HCWs. Fewer than half the employees (43.7%) completed the online questionnaire. Yet the hospital witnessed a statistically significant increase in the percentage of employees who received the flu vaccine at the hospital – 48.5% in the 2008-09 season as compared to 36.5%, 38.5% and 29.8% in the previous three years (P < 0.05). ^ The second article assesses current interventions employed by hospitals, health systems and nursing homes to determine which policies have been the most effective in boosting vaccination rates among American health care workers. A systematic review of research published between January 1994 and March 2010 suggests that education is necessary but not usually sufficient to increase vaccine uptake. Education about the flu and flu vaccines is most effective when complemented with easy access and making the vaccine free, although this combination may not be sufficient to achieve the desired vaccination levels among HCWs. The findings point toward adding incentives for HCWs to get vaccinated and requiring them to record their vaccination status on a declination/consent form – either written or electronic. ^ Based on these findings, American health care organizations, such as hospitals, nursing homes, and long-term care facilities, should consider using online declination forms as a method for increasing influenza vaccination rates among their employees. These online forms should be used in conjunction with other policies, including free vaccine, mobile distribution and incentives. ^ To further spur health care organizations to adopt policies and practices that will raise influenza vaccination rates among employees, The Joint Commission – an independent, not-for- profit organization that accredits and certifies more than 17,000 health care organizations and programs in the United States – should consider altering its standards. Currently, The Joint Commission does not require signed declination forms from employees who eschew vaccination; it only echoes the CDC's recommendations: "Health care facilities should require personnel who refuse vaccination to complete a declination form." Because participation in Joint Commission accreditation is required for Medicare reimbursement, action taken by the Joint Commission to require interventions such as mandatory declination/consent forms might result in immediate action by health care organizations to follow these new standards and lead to higher vaccination rates among HCWs.^ 1“Frequently Asked Questions for H1N1 and Seasonal Influenza.” The Joint Commission - Infection Control: http://www.jointcommission.org/PatientSafety/InfectionControl/h1n1_faq.htm. ^

Taxonomy development and knowledge representation of nurses' personal cognitive artifacts.

Nurses prepare knowledge representations, or summaries of patient clinical data, each shift. These knowledge representations serve multiple purposes, including support of working memory, workload organization and prioritization, critical thinking, and reflection. This summary is integral to internal knowledge representations, working memory, and decision-making. Study of this nurse knowledge representation resulted in development of a taxonomy of knowledge representations necessary to nursing practice.This paper describes the methods used to elicit the knowledge representations and structures necessary for the work of clinical nurses, described the development of a taxonomy of this knowledge representation, and discusses translation of this methodology to the cognitive artifacts of other disciplines. Understanding the development and purpose of practitioner's knowledge representations provides important direction to informaticists seeking to create information technology alternatives. The outcome of this paper is to suggest a process template for transition of cognitive artifacts to an information system.

A study in nursing home effectiveness in Texas

This exploratory study was conducted to examine the relationship between nursing home organizational variables and variations in financial efficiency and effectiveness in Texas nursing homes. Efficiency was defined in terms of nursing home profit, contribution margin, and administrative costs. Effectiveness was defined as the level of the quality of care measured by Texas Department of Health annual surveys of Medicaid certified facilities.^ A sample of 318 intermediate care facilities was selected from a population of 1,026 Texas nursing homes operating in 1987. Location was not found to be related to nursing home effectiveness. Nursing home ownership was positively related to financial efficiency. A moderate amount of quality of care variation was explained by examining nursing home size, employee turnover rate, labor hours per patient day and occupancy rate.^ The number of labor hours per patient day and employee turnover rate were significantly related negatively to both measures of profitability and quality of care. ^

Confidential inquiry into perinatal mortality in the Lower Rio Grande Valley, 1988

A review of 1985 neonatal death statistics in the Lower Rio Grande Valley of Texas revealed an excessive perinatal death rate among Hispanics compared to Anglos. In order to identify factors contributing to perinatal mortality in the region and to determine if existing perinatal services were adequate, a confidential inquiry into each 1988 perinatal death was performed.^ Medical risk factors in the mothers were infrequent. The most commonly noted pregnancy complication was polyhydramnios. This complication is often associated with anencephalus which was the most frequent birth anomaly detected in the region.^ The study results did not reveal an association between lay midwife deliveries in the region and excessive perinatal mortality nor did perinatal mortality appear to be associated with a lack of neonatal intensive care facilities. Lack of prenatal care was the most commonly encountered preventable factor associated with perinatal death. It was not possible to determine if the level of care for Anglos and Hispanics differed because of the low number of Anglo deaths although the socioeconomic level of deaths in each of the ethnic groups was the same. ^

FACTORS INFLUENCING THE PATTERNS OF PHYSICIAN VISITS TO NURSING HOME RESIDENTS

This study was designed to identify some of the factors related to patterns of physician visits to nursing home residents. The relationship of ten resident and organizational characteristics to patterns of physician visits was investigated through secondary analysis of data abstracted from the 1973-74 National Nursing Home Survey of the National Center for Health Statistics. The study sample was composed of 11,135 of the 19,013 nursing home residents who participated in the survey.^ The analytic results revealed that all ten variables had a statistically significant relationship to patterns of physician visits, mainly due to the large sample size. The degrees of association between the variables, measured by the Cramer's V statistic, ranged from moderate to very weak.^ Certification status of the nursing home under Medicare and/or Medicaid was shown to be most strongly related to patterns of physician visits, followed by primary source of payment for nursing home care, and residence prior to nursing home admission. Several variables thought to be related to patterns of physician visits were found to have a very weak relationship: age of the resident, marital status, length of stay, primary diagnosis, number of chronic conditions, activities of daily living status, and levels of care.^ In order to get a more precise picture of the relative influence of certification status and primary source of payment when the other variables were statistically controlled, these two variables were combined into a single variable. The results revealed that the combined effects of certification status and primary source of payment were sustained, regardless of differences in the residents' personal, utilization, and health status characteristics, and the levels of care that they received. The results also indicated that the five groups created by combining the two variables differed in patterns of physician visits. For example, private pay residents in intermediate care facilities (ICF's) and non-certified facilities were more likely to receive unscheduled visits than private pay residents in skilled nursing homes (SNH's), residents in SNH's supported by Medicare or Medicaid, and residents in ICF's supported by Medicaid. ^

Understanding mental illness in Nigeria: Bringing culture and traditional medicine into mental health policy

One of the major challenges in treating mental illness in Nigeria is that the health care facilities and mental health care professionals are not enough in number or well equipped to handle the burden of mental illness. There are several barriers to treatment for individual Nigerians which include the following: such as the lack of understanding of the root causes of mental illness, lack of financial support to get mental treatment, lack of social support (family, friends, neighbors), the fear of stigmatization concerning being labeled as mentally ill or being in association with the mentally ill, and the consultation of traditional native healers who may be unknowingly prolonging illness, rather than addressing and treating them due to lack of formal education and standardization of their treatments. Another barrier is the non-health nature of the mental health services in Nigeria. Traditional healers are essentially the mental health system. The elderly, women, and children are the most vulnerable groups in times of strife and hardships. Their mental well-being must be taken into account as well as their special needs in times of personal or societal crisis. ^ Nigerian mental health policy is geared toward forming a mental health system, but in actuality only a mental illness care system is the observed result of the policy. The government of Nigeria has drafted a mental health policy, yet its actual implementation into the Nigerian health infrastructure and society waits to be materialized. The limited health legislation or policy implementations tend to favor those who have access to these urban areas and the facilities' health services. Nigerians living in rural areas are at a disadvantage; many of them may not even be aware of services available to help them understand and treat mental illness. Perhaps, government driven health interventions geared toward mental illness in rural areas would reach an underserved Nigerians and Africans in general. Issues with political instability and limited infrastructure often hinder crucial financial resources and legislation from reaching the people that are truly in need of governmental leadership in regards to mental health policy.^ Traditional healers are a severely untapped resource in the treatment of mental illness within the Nigerian population. They are abundant within Nigerian communities and are meeting a real need for the mentally ill. However, much can be done to remove the barriers that prevent the integration of traditional healers within the mental health system and improve the quality of care they administer within the population. Mental illness is almost exclusively coped with through traditional medicine practices. Mobilization and education from each strata of Nigerian society and government as well as input from the medical community can improve how traditional medicine is utilized as a treatment for clinical illness and help alleviate the heavy burden of mental illness in Nigeria. Currently, there is no existing policy making structure for a working mental health system in Nigeria, and traditional healers are not taken into account in any formulation of mental health policy. Advocacy for mental illness is severely inadequate due to fear of stigmatization, with no formally recognized national of regional mental health association.^