UTILIZATION OF EVALUATION RESULTS

The issue over utilization of evaluation results has been receiving increasing attention lately. However, a continuing problem has been the lack of knowledge of the specific determinants of the utilization of evaluation results, the extent that these results are used, and the absence in the literature of empirical investigations of those determinants. The purposes of the current study were to examine the patterns of utilization of the recommendations made to an organization following an extensive evaluation, and to quantitatively examine some determinants of that utilization. During the course of the ten-month study, a number of important points regarding evaluation studies, and the utilization of their results were identified. Primary among these was the fact that a definition of utilization that requires adoption of recommendations is limited. Tremendous amounts of organizational activity may accrue from the results of an evaluation regardless of whether the results are adopted. In addition, none of the characteristics of the recommendations that were examined proved to be significant predictors of the extent of their utilization other than whether adoption was considered an authority decision or the results of staff concensus. ^

AN ESTIMATION OF IN UTERO DRUG EXPOSURE BY DETERMINANTS OF FREQUENCY AND DISTRIBUTION OF MATERNAL DRUG CONSUMPTION

Data derived from 1,194 gravidas presenting at the observation unit of a city/county hospital between October 11, 1979 through December 7, 1979 were evaluated with respect to the proportion ingesting drugs during pregnancy. The mean age of the mother at the time of the interview was 22.0 years; 43.0 percent were Black; 34.0 percent Latin-American, 21.0 percent White and 2.0 percent other; mean gravida was 2.5 pregnancies; mean parity was 1.0; and mean number of previous abortions was 0.34. Completed interview data was available for 1,119 gravida, corresponding urinalyses for 997 subjects. Ninety and one-tenth percent (90.1 percent) of the subjects reported ingestion of one or more drug preparation(s) (prescription, OTC, or substances used for recreational purposes) during pregnancy with a range of 0 to 11 substances and a mean of 2.7. Dietary supplements (vitamins and minerals) were most frequently reported followed by non-narcotic analgesics. Seventy-six and one tenth percent (76.1 percent) of the population reported consumption of prescription medication, 42.5 percent reported consumption of over-the-counter medications, 45.7 percent reported consumption of a substance for recreational purposes and 4.3 percent reported illicit consumption of a substance. For selected substances, no measurable difference was found between obtaining the information from the interview method or from a urinalysis assay. ^

AVIAN ROTAVIRUSES

The prevalence of antirotavirus antibodies in chickens and turkeys in the Gonzales, Texas and Llano, Texas areas was studied. Caged layer chicken flocks were found to have a prevalence of 64% when samples were taken randomly. This compares to 45% in chicken broiler breeder flocks and 92% in turkey breeding flocks. The natural occurrence of turkey rotavirus infection in two separate field studies showed an increase in mortality varying from 9% to 45% above expected death losses. Clinically, pasted vents, lacitude, and general malaise were noted in affected poults. Lesions noted on post mortem examination were; slight ballooning of the small intestine, excessively large ceca, and mild hyperemia of the small and large intestines.^ The use of maternal antibody from simian rotavirus immunized chickens' eggs for preventing murine rotavirus infection in infant mice was investigated. There was a reduction from 91% to 15% incidence when infant mice were treated twice daily with egg yolk immunoglobulin.^ The need for a convenient, easily grown and rapidly reproducing model for avian and mammalian rotaviruses led to the use of coturnix chicks. The turkey rotavirus was adapted to the quail chicks be serial passage. Transmission and scanning electron microscopy as well as micropathological methods were used in the study of the pathogenesis of rotavirus infection in quail and infant mice. ^

TRANSMISSION DYNAMICS OF ENTERIC BACTERIA IN DAY-CARE CENTERS, HOUSTON, TEXAS

An investigation was undertaken to evaluate the role of fomites in the transmission of diarrhea in day-care centers (DCC) and to elucidate the paths by which enteric organisms spread within this setting.^ During a nine-month period (December 1980-August 1981) extensive culturing of inanimate objects, as well as children and staff was done routinely each month and again repeated during diarrhea outbreaks. Air was sampled from the classrooms and toilets using a Single-Stage Sieve Sampler (Ross Industries, Midland, VA.). Stool samples were collected from both ill and well children and staff in the affected rooms only during outbreaks. Environmental samples were processed for Shigella, salmonella and fecal coliforms while stools were screened for miscellaneous enteropathogens.^ A total of 11 outbreaks occurred in the 5 DCC during the study period. Enteric pathogens were recovered in 7 (64%) of the outbreaks. Multiple pathogens were identified in 3 outbreaks. The most frequently identified pathogen in stools was Giardia lamblia which was recovered in 5 (45%) of the outbreaks. Ten of the 11 (91%) outbreaks occurred in children less than 12 months of age.^ Environmental microbiology studies together with epidemiologic information revealed that enteric organisms were transmitted from person-to-person. On routine sampling, fecal coliforms were most frequently isolated from tap handles and diaper change areas. Contamination with fetal coliforms was wide-spread during diarrhea outbreaks. Fecal coliforms were recovered with significantly greater frequency from hands, toys and other classroom objects during outbreaks than during non-outbreak period. Salmonella typhimurium was recovered from a table top during an outbreak of Salmonellosis. There was no association between the level of enteric microbial contamination in the toilet areas and the occurrence of outbreaks. No evidence was found to indicate that enteric organisms were spread by the airborne route via aerosols.^ Toys, other classroom objects and contaminated hands probably play a major role in the transmission of enteropathogens during day-care center outbreaks. The presence of many enteric agents in the environment undoubtedly explains the polymicrobial etiology of the day-care center associated diarrhea outbreaks. ^

A COMPARISON OF NEONATAL MORTALITY BETWEEN HOSPITALS WITH LEVEL III NEWBORN INTENSIVE CARE UNITS AND ALL OTHER HOUSTON HOSPITALS

A number of medical and social developments have had an impact on the neonatal mortality over the past ten to 15 years in the United States. The purpose of this study was to examine one of these developments, Newborn Intensive Care Units (NICUs), and evaluate their impact on neonatal mortality in Houston, Texas.^ This study was unique in that it used as its data base matched birth and infant death records from two periods of time: 1958-1960 (before NICUs) and 1974-1976 (after NICUs). The neonatal mortality of single, live infants born to Houston resident mothers was compared for two groups: infants born in hospitals which developed NICUs and infants born in all other Houston hospitals. Neonatal mortality comparisons were made using the following birth-characteristic variables: birthweight, gestation, race, sex, maternal age, legitimacy, birth order and prenatal care.^ The results of the study showed that hospitals which developed NICUs had a higher percentage of their population with high risk characteristics. In spite of this, they had lower neonatal mortality rates in two categories: (1) white 3.5-5.5 pounds birthweight infants, (2) low birthweight infants whose mothers received no prenatal care. Black 3.5-5.5 pounds birthweight infants did equally well in either hospital group. While the differences between the two hospital groups for these categories were not statistically significant at the p < 0.05 level, data from the 1958-1960 period substantiate that a marked change occurred in the 3.5-5.5 pounds birthweight category for those infants born in hospitals which developed NICUs. Early data were not available for prenatal care. These findings support the conclusion that, in Houston, NICUs had some impact on neonatal mortality among moderately underweight infants. ^

THE BACON CHOW STUDY: THE RELATIONSHIP BETWEEN INFECTIOUS ILLNESS AND GROWTH OF INFANTS

Multiple dietary deficiencies and high rates of infectious illness are major health problems leading to malnutrition and limitation of growth of children in developing countries. Longitudinal studies which provide information on illness incidence and growth velocity are needed in order to untangle the complex interrelationship between nutrition, illness and growth. From 1967 to 1973, researchers led by Dr. Bacon Chow of the Johns Hopkins University School of Hygiene undertook a quasi-experimental prospective study in Suilin Township, Taiwan to determine the effects of a nutritional supplement to the diets of pregnant and lactating women on the growth, development and resistance to disease of their offspring. This dissertation presents results from the analysis of infant morbidity and postnatal growth.^ Maternal nutritional supplementation has no apparent effect on the postnatal growth or morbidity of infants. Significant sex differences exist in growth response to illness and in illness susceptibility. Male infants have more diarrhea and upper respiratory illness. Respiratory illness is positively associated with growth rate in weight in the first semester of life. Diarrhea is significantly negatively associated with growth in length in the second semester. Small-for-date infants are more susceptible to illness in general and have a different pattern of growth response than large-for-date infants.^ Principal components analysis of illness data is shown to be an effective technique for making more precise use of ambiguous morbidity data. Multiple regression with component scores is an accurate method for estimating variance in growth rate predicted by indepenent illness variables. A model is advanced in which initial postnatal growth rate determines subsequent susceptibility to nutritional stress and infection. Initial growth rate is a function of prenatal nutrition, but is not significantly affected by maternal supplementation during gestation or lactation. Critical evaluation is made of nutritional supplementation programs which do not afford disease control.^

EXPOSURE OF PHARMACY PERSONNEL TO ANTINEOPLASTIC DRUGS

This dissertation consists of two parts: (1) Exposure of pharmacy personnel to antineoplastic drugs. The Salmonella reversion test was used to measure the mutagenic activities of urine concentrates from individuals preparing antineoplastic drugs for intravenous administration. Longitudinal studies were performed in which the total urine produced in 24-hour periods was collected, starting on a Sunday at 7 P.M. after a duty-free weekend and extending over an eight-day period. There was no detectable increase in mutagenic activity in the urine concentrates of three pharmacy administrators who had no contact with these drugs. All six individuals admixing drugs in open-faced, horizontal laminar flow hoods displayed a two-fold increase in mutagenesis by the fourth day with peak values of 2.7 to 24-fold occurring on days five and six, reduced values by day seven with a return to the spontaneous level by day eight. When four of the six positive individuals in the preceding experiment admixed comparable amounts of antineoplastic drugs in a closed-faced, vertical laminar flow hood, no increase in mutagenic activity was detected in their urine concentrates over the eight-day period. (2) Estimate of potential carcinogenic risks of antineoplastic drugs. Excision repair is the major repair system that is involved with the elimination of chemically induced DNA (deoxyribonucleic acid) lesions. This DNA excision repair capability increases in mammalian species with longer life span such as humans. In this study, the effect of functional DNA excision repair on the mutagenesis invoked by 17 antineoplastic drugs was determined by using a Salmonella/Microsome assay which was expanded to include some uvr('+) counterparts of the excisionless (uvrB) tester strains routinely employed. Although extrapolation cannot be made from bacteria to humans, one should be able to make a qualitative comparison as to which antineoplastic drugs are more potentially carcinogenic to humans based on the effects of excision repair on their mutagenesis in bacteria. The tested antineoplastic drugs were divided into three classes: those requiring excision repair for mutagenesis; those producing nonrepairable genetic damage; and those producing mostly repairable premutational DNA lesions. ^

MARITAL STATUS AND CARDIOVASCULAR RISK (SERUM, CHOLESTEROL, CIGARETTE, SMOKING, BLOOD, PRESSURE, SYSTOLIC)

There were three purposes of this study. The first was to describe the association between stable marital status and serum cholesterol, systolic blood pressure and cigarette smoking. The second purpose was to determine whether individuals who were married at one point and became widowed or divorced/separated had higher serum cholesterol, higher systolic blood pressure or were more likely to smoke prior to the change in marital status compared with individuals who did not change marital status. The third purpose was to determine whether the changes in marital status described above were related to increases in serum cholesterol or in cigarette smoking behavior. The rationale for the study was to determine whether previously reported associations between marital status categories and cardiovascular mortality may be mediated through higher values of risk correlates for cardiovascular disease among unmarried individuals.^ The study group selected for this dissertation was a sample from the Hypertension Detection and Follow-up Program (HDFP) population. The HDFP population was aged 30-69 years at the initial visit and included blacks and whites, males and females. The population was followed five years after the initial visit and periodic measurements of serum cholesterol, blood pressure and cigarette smoking behavior were obtained.^ Serum cholesterol was not associated with stable marital status category or with marital status prior to change. Changes in serum cholesterol were associated with marital status categories after change but the serum cholesterol values deceased rather than increased. Married individuals were shown to have higher serum cholesterol values compared with unmarried. Selection of the HDFP population may have influenced an ability to detect a significant association between marital status and serum cholesterol but it is doubtful that use of a general population would alter the direction of the association.^ Systolic blood pressure was significantly higher at the initial visit among unmarried white males and females compared with their married counterparts. No association between systolic blood pressure was found among black males or females. Those individuals who were married at the initial visit who experienced a change in marital status were found to have higher systolic blood pressure prior to the change in marital status. . . . (Author's abstract exceeds stipulated maximum length. Discontinued here with permission of author.) UMI ^

OUT-OF-HOSPITAL CHILDBEARING CENTERS IN THE UNITED STATES: A DESCRIPTIVE STUDY OF THE DEMOGRAPHIC AND MEDICAL-OBSTETRIC CHARACTERISTICS OF WOMEN BEGINNING LABOR THEREIN 1972-1979

There is currently much interest in the appropriate use of obstetrical technology, cost containment and meeting consumers' needs for safe and satisfying maternity care. At the same time, there has been an increase in professionally unattended home births. In response, a new type of service, the out-of-hospital childbearing center (CBC) has been developed which is administratively and structurally separate from the hospital. In the CBC, maternity care is provided by certified nurse-midwives to carefully screened low risk childbearing families in conjunction with physician and hospital back-up.^ It was the purpose of this study to accomplish the following objectives: (1) To describe in a historical prospective study the demographic and medical-obstetric characteristics of patients laboring in eleven selected out-of-hospital childbearing centers in the United States from May 1, 1972, to December 15, 1979. Labor is defined as the onset of regular contractions as determined by the patient. (2) To describe any differences between those patients who require transfer to a back-up hospital and those who do not. (3) To describe administrative and service characteristics of eleven selected out-of-hospital childbearing centers in the United States. (4) To compare the demographic and medical-obstetric characteristics of women laboring in eleven selected out-of-hospital childbearing centers with a national sample of women of similar obstetric risk who according to birth certificates delivered legitimate infants in a hospital setting in the United States in 1972.^ Research concerning CBCs and supportive to the development of CBCs including studies which identified factors associated with fetal and perinatal morbidity and mortality, obstetrical risk screening, and the progress of technological development in obstetrics were reviewed. Information concerning the organization and delivery of care at each selected CBC was also collected and analyzed.^ A stratified, systematic sample of 1938 low risk women who began labor in a selected CBC were included in the study. These women were not unlike those described previously in small single center studies reported in the literature. The mean age was 25 years. Sixty-three per cent were white, 34 per cent Hispanic, 88 per cent married, 45 per cent had completed at least two years of college, nearly one-third were professionals and over a third were housewives. . . . (Author's abstract exceeds stipulated maximum length. Discontinued here with permission of school.) UMI ^

OCCUPATIONAL CAUSES OF LUNG CANCER IN NEW MEXICO'S ANGLOS AND HISPANICS

Although, elevated risk for lung cancer has been associated with certain industries and occupations in previous studies, the lack of cigarette smoking information in many of these investigations resulted in estimates that could not be adjusted for the effects of smoking. To determine lung cancer risk due to occupation and smoking, for New Mexico's Anglos and Hispanics, a population-based case-control study was conducted. Incident cases diagnosed 1980-1982, and controls from the general population, were interviewed for lifetime occupational and smoking histories. Specific high risk industries and occupations were identified in advance and linked with industrial and occupational codes for hypotheses-testings. Significantly elevated risks were found for welders (RR = 3.5) and underground miners (RR = 2.0) with adjustment for smoking. Because shipbuilding was the industry of employment for only five of the 18 cases who were welders, exposures other than asbestos could be causal agents. Among the underground for only five of the 18 cases who were welders, exposures other than asbestos could be causal agents. Among the underground miners, uranium, copper, lead and zinc, coal, and potash mining industries were represented. Low prevalence of employment in some of the industries and occupations of interest resulted in inconclusive results. ^

QUALITY OF MATERNITY CARE IN RURAL TEXAS (MEXICAN-AMERICAN)

The purpose of the study was to describe regionalized systems of perinatal care serving predominantly low income Mexican-American women in rural underserved areas of Texas. The study focused upon ambulatory care; however, it provided a vehicle for examination of the health care system. The questions posed at the onset of the study included: (1) How well do regional organizations with various patterns of staffing and funding levels perform basic functions essential to ambulatory perinatal care? (2) Is there a relationship between the type of organization, its performance, and pregnancy outcome? (3) Are there specific recommendations which might improve an organization's future performance?^ A number of factors--including maldistribution of resources and providers, economic barriers, inadequate means of transportation, and physician resistance to transfer of patients between levels of care--have impeded the development of regionalized systems of perinatal health care, particularly in rural areas. However, studies have consistently emphasized the role of prenatal care in the early detection of risk and treatment of complications of pregnancy and childbirth, with subsequent improvement in pregnancy outcomes.^ This study has examined the "system" of perinatal care in rural areas, utilizing three basic regional models--preventive care, limited primary care, and fully primary care. Information documented in patient clinical records was utilized to compare the quality of ambulatory care provided in the three regional models.^ The study population included 390 women who received prenatal care in one of the seven study clinics. They were predominantly hispanic, married, of low income, with a high proportion of teenagers and women over 35. Twenty-eight percent of the women qualified as migrants.^ The major findings of the study are listed below: (1) Almost half of the women initiated care in the first trimester. (2) Three-fourths of the women had or exceeded the recommended number of prenatal visits. (3) There was a low rate of clinical problem recognition. Additional follow-up is needed to determine the reasons. (4) Cases with a tracer condition had significantly more visits with monitoring of the clinical condition. (5) Almost 90% of all referrals were completed. (6) Only 60% of mothers had postpartum follow-up, while almost 90% of their newborns received care. (7) The incidence of infants weighing 2500 grams or less was 4.2%. ^

ENVIRONMENTAL EXPOSURES AND LUNG CANCER RISK AMONG WOMEN IN HARRIS COUNTY, TEXAS, 1977-1980 (OCCUPATION, SMOKING, BYSTANDER)

Excessively high, accelerating lung cancer rates among women in Harris County, Texas, prompted this case-comparison study. Objectives were to compare patterns of employment, indirect exposures, and sociodemographic variables of lung cancer cases with comparison subjects (compeers) after standardizing for possible confounders, such as age and cigarette smoking. Lung cancer cases were microscopically confirmed, white, Harris County residents. Compeers, chosen from Medicare records and Texas Department of Public Safety records, were matched on gender, race, age, resident and vital status. Personal interviews were conducted with study subjects or next-of-kin. Industries and occupations were categorized as high risk, based on previous studies.^ Almost all cases (95.0%) and 60.0% of compeers smoked cigarettes. The odds ratio for lung cancer and smoking is 13.9. Stopping smoking between ages 30-50 years carries a lower risk than stopping at age 58 or more years. Women's employment in a high risk industry or occupation results in consistently elevated, smoking-adjusted odds ratios. Frequency and duration of employment demonstrate a moderate dose-response effect. A temporal association exists with employment in a high risk occupation during 1940-1949.^ No increased risk appeared with passive smoking. Husband's employment in a construction industry or a structural occupation significantly increased the smoking-adjusted odds ratios among cases and compeers (O.R. = 2.9, 2.2). Smoking-adjusted odds ratios increased significantly when women had resided with persons employed in cement (O.R. = 3.2) or insulation (O.R. = 5.5) manufacturing, or a high rise construction industry (O.R. = 2.4). A family history of lung cancer resulted in a two-fold increase in smoking-adjusted odds ratios. Vital status of compeers affected the odds ratios.^ Work-related exposures appear to increase the risk of lung cancer in women although cigarette smoking has the single highest odds ratio. Indirect exposure to certain employment also plays a significant role in lung cancer in women. Investigations of specific direct and indirect hazardous exposures in the workplace and home are needed. Cigarette smoking is as hazardous for women as for men. Smoking should be prevented and eliminated. ^

REPRODUCTIVE PERFORMANCE IN THE DES-EXPOSED DAUGHTERS

This research examined the relation between prenatal exposure to diethylstilbestrol (DES) and subsequent reproductive performance in females. Although previous studies have agreed that unfavorable pregnancy outcomes (spontaneous abortions, stillbirths, ectopic pregnancies, and premature births) occur with greater frequency in the exposed as compared to unexposed women, the role of exposure to DES in-utero on subsequent fertility (pregnancy achievement) remains controversial. Also, the possibility that the reproductive dysfunction reported in exposed women might be due to familial predisposition to reproductive dysfunction rather than to DES exposure has not been examined heretofore.^ The purposes of the research were to: (1) measure the overall differences in rates of live births between exposed and unexposed women; (2) determine if infertility or early unrecognized spontaneous miscarriages (as opposed to recognized fetal death) contributes to poor reproductive performance in the exposed; and (3) determine if constitutional predisposition contributes to poor reproductive performance in exposed daughters.^ The study population comprised those participants in the National Cooperative Diethylstilbestrol Adenosis (DESAD) Project who were identified through review of prenatal records. Birth interval curves (survival analyses) were used to compare the reproductive performance of exposed daughters and unexposed women. Birth interval curves were also constructed for unexposed siblings (of exposed participants) and unexposed nonsiblings to determine the role of constitutional predisposition in the reproductive performance of exposed daughters.^ The DES-daughters, as compared to unexposed women, were found to be at a reproductive disadvantage when the overall differences in rates of live births were compared.^ When the differences in rates of live births due specifically to infertility or early unrecognized spontaneous miscarriages (as opposed to recognized fetal death) were examined, the exposed maintained the reproductive disadvantage. This analysis was suggestive but not statistically significant for the first-birth-interval and was neither suggestive nor significant in the second-birth-interval. (Abstract shortened with permission of author.) ^

SOCIAL, ATTITUDINAL AND BEHAVIORAL CORRELATES OF WEIGHT CHANGE AMONG MEXICAN AMERICAN WOMEN (OBESITY, DIET, TEXAS)

In industrialized countries the prevalence of obesity among women decreases with increasing socioeconomic status. While this relation has been amply documented, its explanation and implications for other causal factors of obesity has received much less attention. Differences in childbearing patterns, norms and attitudes about fatness, dietary behaviors and physical activity are some of the factors that have been proposed to explain the inverse relation.^ The objectives of this investigation were to (1) examine the associations among social characteristics and weight-related attitudes and behaviors, and (2) examine the relations of these factors to weight change and obesity. Information on social characteristics, weight-related attitudes, dietary behaviors, physical activity and childbearing were collected from 304 Mexican American women aged 19 to 50 living in Starr County, Texas, who were at high risk for developing diabetes. Their weights were recorded both at an initial physical examination and at a follow-up interview one to two and one-half years later, permitting the computation of current Body Mass Index (weight/height('2)) and weight change during the interval for each subject. Path analysis was used to examine direct and indirect relations among the variables.^ The major findings were: (1) After controlling for age, childbearing was not an independent predictor of weight change or Body Mass Index. (2) Neither planned exercise nor total daily physical activity were independent predictors of weight change. (3) Women with higher social characteristics scores reported less frequent meals and less use of calorically dense foods, factors associated with lower risk for weight gain. (4) Dietary intake measures were not significantly related to Body Mass Index. However, dietary behaviors (frequency of meals and snacks, use of high and low caloric density foods, eating restraint and disinhibition of restraint) did explain a significant portion (17.4 percent) of the variance in weight change, indicating the importance of using dynamic measures of weight status in studies of the development of obesity. This study highlights factors amenable to intervention to reverse or to prevent weight gain in this population, and thereby reduce the prevalence of diabetes and its sequelae. ^

Is obesity associated with increased symptoms of psychiatric morbidity among Indian adolescents?

The relationship between obesity and mental health disorders has not been explored among adolescents in India. Although evidence from western countries has failed to demonstrate conclusive associations, a tremendous increase in the prevalence of obesity and overweight among urban adolescents in India, along with an absolute lack of studies into mental health of Indian adolescents, necessitate the need for research in this population. This present study used data collected from 861 urban 6th and 8th graders from Delhi, India and tested for the associations of weight status with psychiatric symptomatology and other weight related behaviors. The Strengths and Difficulties questionnaire (SDQ) was used to collect data on psychiatric symptoms. Falling into the overweight or obese category was hypothesized to be associated with borderline or abnormal scores on the SDQ scales. Results indicated a high prevalence for overweight/obesity among the population (>30%). No significant associations were demonstrated between weight status and borderline/abnormal SDQ scores on all the scales. However, significant associations were found between sedentary behaviors (screen time >2 hrs daily), positive and negative weight-control behaviors and borderline/abnormal SDQ scores on various scales. In light of these new findings, a further exploration of the relationship in this population is indicated.^