The role of the experience and expression of anger in future cardiovascular profiles in young adolescents

Cardiovascular disease (CVD) is this nation's leading source of morbidity and mortality, with health disparities evident. Despite inconsistencies in the literature, there is a growing body of evidence that links anger and CV reactivity (CVR) to future CVD. Because CVD is a life-long process with beginnings in childhood, and because adolescents experience and express anger frequently, the need to understand the role that anger has in future CV profiles is important. If identifiable patterns are found, nursing interventions can be implemented at the most beneficial point in the lifespan. This study examined data collected as part of The Heartfelt Study (N = 374), which investigated anger in relation to 24-hour ambulatory blood pressure (BP) and CVR in a multi-ethnic (African, Hispanic, and European American) sample of adolescents (Time 1). This investigator conducted a follow-up for all The Heartfelt Study participants, 11 to 13 years old at the beginning of study, still in attendance at the middle school (N = 44) one year later (Time 2) to determine: (1) changes in anger over time were associated with changes in ambulatory CV profiles: systolic (SBP), diastolic (DBP), heart rate (HR), and pulse pressure (PP) over time; and (2) the extent to which CVR, initiated by talking about a recent anger-producing event, related to future ambulatory CV profiles. A mixed-effects regression for repeated measures was used to analyze the data and found that SBP reactivity at Time 1 was significantly (β = 0.2341, t = 5.91, p < 0.0001) associated with ambulatory SBP at Time 2 and PP reactivity at Time 1 was significantly (β = 0.1530, t = 5.70, p < 0.0001) associated with ambulatory PP at Time 2. Changes in anger over time were not associated with changes in ambulatory BP measures over time. Further research on anger and CVR among adolescents over longer periods of time is recommended. ^

Adolescent Pregnancy Prevention in San Jose, Costa Rica : Assessment of an Educational Intervention

This thesis explores adolescent pregnancy in San Jose, Costa Rica and examines a school-based pregnancy prevention intervention. The relationships between school, gender and risk of adolescent pregnancy are also analyzed, and recommendations are made for effective pregnancy prevention programming. The Purral region of Guadalupe on the outskirts of San Jose, Costa Rica, suffers a higher rate of adolescent pregnancy compared to the rest of the country. In response to this problem, the International Health Central American Institute (IHCAI) implemented a sexual health education program in two local secondary schools in 2006. Very little information about the program is available. It is known that the program was initially evaluated through assessments of the participants’ knowledge before and after the educational sessions. There was no evaluation of the youth attitudes or behaviors, adolescent pregnancies, or long-term impact. The author worked with IHCAI in San Jose, Costa Rica to perform an assessment of the longer term effects of this sexual health education program. They developed a questionnaire to evaluate the knowledge, attitudes, and behaviors surrounding sexual health of youth in the Purral community. Researchers at IHCAI later used this survey to collect data from adolescents who had participated in the educational intervention and those who had not. This thesis analyzes the data collected by IHCAI to assess the effectiveness of the - 2 - educational intervention and the influence of other factors on the knowledge, attitudes, and behaviors of adolescents in the Purral region. The thesis begins with an overview of adolescent pregnancy, Costa Rica and the Purral region, and a description of the education intervention implemented by IHCAI. The research goal, logic model, and methods are then described. The results are reported, and the thesis then concludes with discussion of the results as well as study limitations and recommendations for future research and intervention. This thesis will be used to guide IHCAI’s continuation and expansion of adolescent pregnancy prevention programming.

Family Myths, Beliefs, and Customs as a Research/Educational Tool to Explore Identity Formation

This paper outlines a qualitative research tool designed to explore personal identity formation as described by Erik Erikson and offers self-reflective and anonymous evaluative comments made by college students after completing this task. Subjects compiled a list of 200 myths, customs, fables, rituals, and beliefs from their family of origin and then reflected upon the relevance and meaning of such items. The research and instructional tool described in the paper should be of considerable interest to teachers who work to promote self-reflection amongst adolescents as well as case study researchers and therapists who wish to study identity formation and values.

Psychosocial and environmental predictors of calcium intake, physical activity and bone health among adolescent girls

Objectives. The purpose of this study was to identify the psychosocial and environmental predictors and the pathways they use to influence calcium intake, physical activity and bone health among adolescent girls. Methods. A secondary data analysis using a cross-sectional and longitudinal study design was implemented to examine the associations of interest. Data from the Incorporating More Physical Activity and Calcium in Teens (IMPACT) study collected in 2001-2003 were utilized for the analyses. IMPACT was a 1½ year nutrition and physical activity intervention study conducted among 718 middle-school girls in central Texas. Hierarchical regression modeling and Structural Equation Modeling (SEM) were used to determine the psychosocial predictors of calcium intake, physical activity and bone health at baseline. Hierarchical regression was used to determine if psychosocial factors at baseline were significant predictors of calcium intake and physical activity at follow-up. Data was adjusted for included BMI, lactose intolerance, ethnicity, menarchal status, intervention and participation in 7th grade PE/athletics. Results. Results of the baseline regression analysis revealed that calcium self-efficacy and milk availability at home were the strongest predictors of calcium intake. Friend engagement in physical activity, physical activity self-efficacy and participation in sports teams were the strongest predictors of physical activity. Finally, physical activity outcome expectations, social support and participation in sports teams were significant predictors of stiffness index at baseline. Results of the baseline SEM path analysis found that outcome expectations and milk availability at home directly influenced calcium intake. Knowledge and calcium self-efficacy indirectly influenced calcium intake with outcome expectations as the mediator. Physical activity self-efficacy and social support had significant direct and indirect influence on physical activity with participation in sports teams as the mediator. Participation in sports teams had a direct effect on both physical activity and stiffness index. Results of regression analysis for baseline predicting follow-up showed that participation in sports teams, self-efficacy, outcome expectations and social support at baseline were significant predictors of physical activity at follow-up. Conclusion. Results of this study reinforce the relevance of addressing both, psychosocial and environmental factors which are critical when developing interventions to improve bone health among adolescent girls. ^

Culture and the social context of health inequalities

There has been a great deal of interest and debate recently concerning the linkages between inequality and health cross-nationally. Exposures to social and health inequalities likely vary as a consequence of different cultural contexts. It is important to guide research by a theoretical perspective that includes cultural and social contexts cross-nationally. If inequality affects health only under specific cultural conditions, this could explain why some of the literature that compares different societies finds no evidence of a relationship between inequality and health in certain countries. A theoretical framework is presented that combines sociological theory with constructs from cultural psychology in order to identify pathways that might lead from cultural dimensions to health inequalities. Three analyses are carried out. The first analysis explores whether there is a relationship between cultural dimensions at the societal level and self-rated health at the individual level. The findings suggest that different cultural norms at the societal level can produce both social and health inequalities, but the effects on health may differ depending on the socio-cultural context. The second analysis tests the hypothesis that health is affected by the density of social networks in a society, levels of societal trust, and inequality. The results suggest that commonly used measures of social cohesion and inequality may have both contextual and compositional effects on health in a large number of countries, and that societal measures of social cohesion and inequality interact with individual measures of social participation, trust, and income, moderating their effects on health. The third analysis explores whether value systems associated with vertical individualist societies may lead to health disparities because of their stigmatizing effects. I test the hypothesis that, within vertical individualist societies, subjective well-being will be affected by a social context where competition and the Protestant work ethic are valued, mediated by inequality. The hypothesis was not supported by the available cross-national data, most likely because of inadequate measures, missing data, and the small sample of vertical individualist countries. The overall findings demonstrate that cultural differences are important contextual factors that should not be overlooked when examining the causes of health inequalities. ^

Locus of control as a predictor of students dropping out of high school

Education is related to health. In cross-sectional data, education level has been associated with physical functioning. Also, lower levels of education have been associated with health behaviors including smoking, alcohol use, and greater body weight. In school, students may benefit from greater exposed to health-related messages, while students who have dropped out may be more susceptible to influences regarding negative health behaviors such as smoking. ^ Improved school retention might improve long-term health outcomes. However, there is limited evidence regarding modifiable factors that predict likelihood of dropping out. Two likely psychosocial measures are locus of control and parent-child academic conversations. In the current study, data from two waves of a population-based longitudinal survey, the National Education Longitudinal Survey, were utilized to evaluate whether these two psychosocial measures could predict likelihood of dropping out, for students (n = 16,749) in tenth grade at 1990, with dropout status determined at 1992, while controlling for recognized sociodemographic predictors including parental income, parental education level, race/ethnicity, and sex. Locus of control was measured with the Pearlin Mastery Scale, and parent-child academic conversations were measured by three questions concerning course selection at school, school activities and events, and things the student studied in class. ^ In a logistic regression model, with the sociodemographic control measures entered in a first step before entry of the psychosocial measures in a second step, this study determined that lower levels of locus of control were associated with greater likelihood of dropping out after two years (odds ratio (OR) = 1.11, 95% confidence interval (CI) 108 to 1.15, p < .001), and two of the three parent-child academic discussion items were associated with greater likelihood of dropping out after two years (OR = 1.69, CI 1.48-1.93, p < .001; OR = 1.22, CI 1.05-1.41, p = .01; OR = 1.01, CI .88-1.15, p = .94). ^ It is possible that interventions aimed at improving locus of control, and aimed at building parent-child academic conversations, could lower the likelihood of students dropping out, and this in turn could yield improved heath behaviors and health status in the child's future. ^

Prevalence of depressive symptoms among Hispanic women attending a public health clinic

Background. Estimates of perinatal depression have ranged from 5% to more than 25% of women (Gavin et al. 2005). Although Hispanics have one of the highest birthrates, few studies have looked at the prevalence of depression among this population. This study aims to describe the prevalence of depressive symptoms among a sample of Hispanic women. Methods. A convenience sample of 439 Hispanic women were screened for depression using the Center for Epidemiologic Studies Depression Scale. Sociodemographic data relating to pregnancy were also collected. Results. Although bivariate analysis found several variables to be significant, multivariate analysis found only marital and pregnancy status to be significant in predicting depression. Conclusions. While marital and pregnancy status proved to the strongest predictors for depression, future research would benefit from collecting information on timing of pregnancy and postpartum to further explore the role of pregnancy status and depressive symptoms. ^

Health, education and community: Assets and needs of a small urban community in north east Tamaulipas, Mexico: A community based participatory research assessment

This study explored the health, education, social assets, needs, attitudes, and behaviors of residents of Ferrocarril #4, a small urban community in Tamaulipas, Mexico. A collaborative Participatory Action Research approach was used to emphasize community involvement. Using Triangulation to ensure validity, qualitative methods included key informant in depth interviews, participant observation and participatory discussion groups with women and men. A personal interview with a probability sample of women was done. The median age of interviewees was 37 years. The majority was married or had a partner. Over half of respondents completed grades 6-9. Employed women (25%) earned a median weekly salary equivalent to ∼56 USD. Women with health insurance (67.7%) were covered mainly through Social Security and Seguro Popular. One in 5 reported bad health. Barriers to care were primarily money and transportation. To improve health care, women wanted a full service clinic in or close to the community and affordable health care. Socially, 28% of respondents had no close friends in the community and most did not participate in beneficial community activities. Many women did not socialize with others and help from neighbors was situational. Primary school teachers lacked parental support and it interfered with classroom efforts. Healthy community discussion groups focused on personal and environmental hygiene and safety. Valuable assets exist in the community. To date, collaborative efforts resulted in a school First Aid station, a school nurse visit weekly, posting of emergency contact phone numbers in the school and community center, and development of a student health information form. ^

The School Sealant Program: An evaluation of the oral health education component

Dental caries is a common preventable childhood disease leading to severe physical, mental and economic repercussions for children and their families if left untreated. A needs assessment in Harris County reported that 45.9% of second graders had untreated dental caries. In order to address this growing problem, the School Sealant Program (SSP), a primary preventive initiative, was launched by the Houston Department of Health and Human Services (HDHHS) to provide oral health education, and underutilized dental preventive services to second grade children from participating Local School Districts (LSDs). ^ To determine the effectiveness and efficiency of the SSP, a program evaluation was conducted by the HDHHS between September 2007 and June 2008 for the Oral Health Education (OHE) component of the SSP. The objective of the evaluation was to assess short term changes in oral health knowledge of the participants and determine if these changes, if any, were due to the OHE sessions. An 8-item multiple choice pre/post test was developed for this purpose and administered to the participants before and immediately after the OHE sessions. ^ The present project analyzed pre and post test data of 1,088 second graders from 22 participating schools. Changes in overall and topic-specific knowledge of the program participants before and after the OHE sessions were analyzed using the Wilcoxon's signed rank test. ^ Results. The overall knowledge assessment showed a statistically significant (p <0.001) increase in the dental health knowledge of the participants after the oral health education sessions. Participants in the higher scoring category (7-8 correct responses) increased from 9.5% at baseline to 60.8% after the education sessions. Overall knowledge increased in all school regions with the highest knowledge gains seen in the Central and South regions. Males and females had similar knowledge gains. Significant knowledge differences were also found for each of the topic specific categories (functions of teeth, healthy diet, healthy habits, dental sealants; p<0.001) indicating an increase in topic specific knowledge of the participants post-health education sessions. ^ Conclusions. The OHE sessions were successful in increasing the short term oral health knowledge of the participants. ^

An evaluation of the Texas "A Woman's Right to Know" booklet: A state mandated patient education document for induced abortion

Many patient educational documents are written at a grade level higher than the level at which most individuals can read. This discrepancy can lead to treatment noncompliance and negative health outcomes. Therefore, it is important that patients receive readable health information. The Texas "A Woman's Right to Know" booklet is a state mandated informational document provided to women seeking abortion services. Given the significance of the abortion procedure, it is imperative that women considering having an abortion receive accurate and readable health materials. However, no published studies were found that evaluated the readability of the "A Woman's Right to Know" booklet. Therefore, the purpose of this study was to assess the readability of the "A Woman's Right to Know" booklet. To assess the readability, the Flesch-Kincaid readability test was used to evaluate the reading grade level of the entire "A Woman's Right to Know" booklet and each of the 7 sections of the booklet. The results showed that the readability of the entire booklet as well as each section of the booklet was written below the 8th grade reading level. Although the booklet was written below the estimated United States reading level (8th grade), the reading level of this booklet may still be too high for people in Texas who read below the 8th grade level. Based on these results, it is recommended that health care professionals involved in the distribution and explanation of the "A Woman's Right to Know" booklet provide their patients with both written and verbal medical information. The patients should be allowed to ask questions about the abortion procedure so that they can make the most informed choice.^

Improving the health and well-being of women at risk for neural tube defect recurrence

There is growing interest in providing women with internatal care, a package of healthcare and ancillary services that can improve their health during the period after the termination of one pregnancy but before the conception of the next pregnancy. Women who have had a pregnancy affected by a neural tube defect can especially benefit from internatal care because they are at increased risk for recurrence and improvements to their health during the inter-pregnancy period can prevent future negative birth outcomes. The dissertation provides three papers that inform the content of internatal care for women at risk for recurrence by examining descriptive epidemiology to develop an accurate risk profile of the population, assessing whether women at risk for recurrence would benefit from a psychosocial intervention, and determining how to improve health promotion efforts targeting folic acid use.^ Paper one identifies information relevant for developing risk profiles and conducting risk assessments. A number of investigations have found that the risk for neural tube defects differs between non-Hispanic Whites and Hispanics. To understand the risk difference, the descriptive epidemiology of spina bifida and anencephaly was examined for Hispanics and non-Hispanic Whites based on data from the Texas Birth Defects Registry for the years 1999 through 2004. Crude and adjusted birth prevalence ratios and corresponding 95% confidence intervals were calculated between descriptive epidemiologic characteristics and anencephaly and spina bifida for non-Hispanic Whites and for Hispanics. In both race/ethnic groups, anencephaly expressed an inverse relationship with maternal age and a positive linear relationship with parity. Both relationships were stronger in non-Hispanic Whites. Female infants had a higher risk for anencephaly in non-Hispanic Whites. Lower maternal education was associated with increased risk for spina bifida in Hispanics.^ Paper two assesses the need for a psychosocial intervention. For mothers who have children with spina bifida, the transition to motherhood can be stressful. This qualitative study explored the process of becoming a mother to a child with spina bifida focusing particularly on stress and coping in the immediate postnatal environment. Semi-structured interviews were conducted with six mothers who have children with spina bifida. Mothers were asked about their initial emotional and problem-based coping efforts, the quality and kind of support provided by health providers, and the characteristics of their meaning-based coping efforts; questions matched Transactional Model of Stress and Coping (TMSC) constructs. Analysis of the responses revealed a number of modifiable stress and coping transactions, the most salient being: health providers are in a position to address beliefs about self-causality and prevent mothers from experiencing the repercussions that stem from maintaining these beliefs. ^ Paper three identifies considerations when creating health promotion materials targeting folic acid use. A brochure was designed using concepts from the Precaution Adoption Process Model (PAPM). Three focus groups comprising 26 mothers of children with spina bifida evaluated the brochure. One focus group was conducted in Spanish-only, the other two focus groups were conducted in English and Spanish combined. Qualitative analysis of coded transcripts revealed that a brochure is a helpful adjunct. Questions about folic acid support the inclusion of an insert with basic information. There may be a need to develop different educational material for Hispanics so the importance of folic acid is provided in a situational context. Some participants blamed themselves for their pregnancy outcome which may affect their receptivity to messages in the brochure. The women's desire for photographs that affect their perception of threat and their identification with the second role model indicate they belong to PAPM Stage 2 and 3. Participants preferred colorful envelopes, high quality paper, intimidating photographs, simple words, conversational style sentences, and positive messages.^ These papers develop the content of risk assessment, psychosocial intervention, and health promotion components of internatal care as they apply to women at risk for recurrence. The findings provided evidence for considering parity and maternal age when assessing nutritional risk. The two dissimilarities between the two race/ethnic groups, infant sex and maternal education lent support to creating separate risk profiles. Interviews with mothers of children with spina bifida revealed the existence of unmet needs-suggesting that a psychosocial intervention provided as part of internatal care can strengthen and support women's well-being. Segmenting the audience according to race/ethnicity and PAPM stage can improve the relevance of print materials promoting folic acid use.^

If we call them, will they change? Feasibility of a telephone adaptation of motivational interviewing aimed at parents to reduce television time among 2nd and 4th grade children

Television viewing is a sedentary behavior that is modifiable. Reducing media-related behaviors via parent-focused interventions may hold promise for decreasing childhood obesity. This feasibility study examines a novel parent-centered brief telephone-delivered Motivational Enhancement Interview (MEI) to encourage parents of 2nd and 4th graders to set a rules limiting TV time or remove the TV from the child's bedroom. This quasi-experimental sub-study was part of the larger CATCH: En Vivo pilot study conducted in a Hispanic population in the Texas Rio Grande Valley. Parents in the MEI condition were contacted via telephone and encouraged to meet the American Academy of Pediatrics (AAP) recommended 2 hours per day or less of TV. Unconditional logistic regression was used to analyze the data. At post-test, 85% of parents of 4th graders in the MEI group (compared to 71% at pre-test) reported having a rule limiting TV time. The adjusted odds ratio for the MEI group compared to the control group was 3.88, 95% CI (0.72-20.99). At pre-test, 63.16% of 2nd graders had a television in their bedrooms. The 2nd grade MEI intervention reduced that number to 41.03% (OR=0.25, 95%CI (0.08-0.82)). This first look at using MEI to target parents of children to modify TV behavior presents evidence on a promising strategy for modifying children's home media environment and warrants further investigation. ^

Hypertension and cognitive decline among patients of Alzheimer's disease

Objective. The main aim of our study is to assess the effect of hypertension on the decline in cognitive impairment among Alzheimer’s patients. Methods. We analyzed the data of AD patients enrolled in Baylor ADMDC in a prospective study design. We divided AD patients into two groups based on the definition of hypertension. We described a decline in cognitive impairment as a change of 5 points in mini-mental state examination score (MMSE) from the baseline visit. Results. Independent of covariates, AD patients with hypertension did not exhibit a significant decline in cognitive impairment after adjustment of covariates, age, race and education (Hazard Ratio (HR) = 1.07, p value 0.58, 95% confidence interval 0.84-1.39) than AD patients without hypertension. In addition, AD patients with hypertension did not experience decline in cognitive impairment sooner than AD patients without hypertension. (P value 0.83). Conclusions . Hypertension is not associated with cognitive impairment over time among patients with Alzheimer’s disease enrolled in Baylor ADMDC after other potential confounders were taken into account. These findings should not be interpreted as a basis for discouraging appropriate medical treatment of hypertension in AD patients. Greater efforts should be made to improve the recognition of hypertension as a modifiable risk factor for decline in cognitive impairment in AD population. ^

The association of internet use and depression among spinal cord injury population

The purpose of this study was to exam the relationship between internet use and depression among a population of individuals who have sustained spinal cord injury. This was cross-sectional survey design conducted among spinal cord injury (SCI) patients in the Model Spinal Cord Injury System. We included a total of 1,011 SCI-patients who were interviewed face-to-face or by telephone interview over approximately a three year time period (2004–2006). All data were collected through a telephone survey which included the Patient Health Questionnaire-9 (PHQ-9) to assess depression. We examined various scales of this survey, included a reduced 3-item scale (items 1, 2 and 6) to avoid the presence of somatic symptoms among SCI patients from influencing classification of depression. The frequency of internet usage was grouped as daily/weekly/monthly/non user. Covariates examined as possible confounders included demographic characteristics, occupational status, educational level, injury type, daily function of living, pain level, self-perceived health status and satisfaction with life. We observed a negative association between the frequency of internet use and the level of depression. Daily use of internet was associated with lower PHQ-9 score and depression; however this association did not reach statistical significance after for the mentioned covariates. In conclusion, the factors related to lower depression in SCI patients who use the internet are complicated. Daily internet usage was associated with lower levels of depression. The accuracy of 3-item scale needs further validation and investigation. Further study of internet usage pattern in SCI patient is recommended. ^

Health impacts of extreme weather: Flood fatalities in Texas

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