A Community Health Advisor Program to reduce cardiovascular risk among rural African-American women.

The Uniontown, Alabama Community Health Project trained and facilitated Community Health Advisors (CHAs) in conducting a theory-based intervention designed to reduce the risk for cardiovascular disease (CVD) among rural African-American women. The multiphased project included formative evaluation and community organization, CHA recruitment and training, community intervention and maintenance. Formative data collected to develop the training, intervention and evaluation methods and materials indicated the need for programs to increase knowledge, skills and resources for changing behaviors that increase the risk of CVD. CHAs worked in partnership with staff to develop, implement, evaluate and maintain strategies to reduce risk for CVD in women and to influence city officials, business owners and community coalitions to facilitate project activities. Process data documented sustained increases in social capital and community capacity to address health-related issues, as well as improvements in the community's physical infrastructure. This project is unique in that it documents that a comprehensive CHA-based intervention for CVD can facilitate wide-reaching changes in capacity to address health issues in a rural community that include improvements in community infrastructure and are sustained beyond the scope of the originally funded intervention.

Longitudinal study of elbow and shoulder pain in youth baseball pitchers.

PURPOSE: Previous studies among young pitchers have focused on the frequency and description of elbow injuries. The purpose of this study was to evaluate the frequency of elbow and shoulder complaints in young pitchers and to identify the associations between pitch types, pitch volume, and other risk factors for these conditions. METHODS: A prospective cohort study of 298 youth pitchers was conducted over two seasons. Each participant was contacted via telephone after each game pitched to identify arm complaints. Generalized estimating equations were used to assess associations between arm complaints and independent variables. RESULTS: The frequency of elbow pain was 26%; that of shoulder pain, 32%. Risk factors for elbow pain were increased age, increased weight, decreased height, lifting weights during the season, playing baseball outside the league, decreased self-satisfaction, arm fatigue during the game pitched, and throwing fewer than 300 or more than 600 pitches during the season. Risk factors for shoulder pain included decreased satisfaction, arm fatigue during the game pitched, throwing more than 75 pitches in a game, and throwing fewer than 300 pitches during the season. CONCLUSION: Arm complaints are common, with nearly half of the subjects reporting pain. The factors associated with elbow and shoulder pain were different, suggesting differing etiologies. Developmental factors may be important in both. To lower the risk of pain at both locations, young pitchers probably should not throw more than 75 pitches in a game. Other recommendations are to remove pitchers from a game if they demonstrate arm fatigue and limit pitching in nonleague games.

Developing community capacity and improving health in African American communities.

Community-based programs have produced mixed results. Community capacity is thought to be a major determinant of program effectiveness. Thus, enhancing community capacity may increase the beneficial effects of existing programs and enhance future program effectiveness. This highlights the need to focus on understanding the components of capacity and the methods of enhancing capacity. Although we are just beginning to examine and understand key concepts, community capacity is probably influenced by both relatively nonmodifiable characteristics (such as demographic factors, institutional resources, and social structures) and relatively modifiable characteristics (such as knowledge, skills, and the ability and willingness of members and agencies to work collaboratively). In their relationships with community members and agencies, academicians and public health practitioners may help acquire categorical funding to enhance opportunities to build community capacity and their own capacity as well. The relationship between academicians/practitioners and community members/agencies probably is influenced by a host of characteristics which determine the degree to which capacity can be built. This paper discusses: the key components of capacity; the factors that influence building capacity through collaborations; a community health advisor (CHA) model which both builds on sociocultural aspects of African American culture and is consistent with methods for building community capacity; and how modifications to this model allow it to be compatible with categorically funded projects.

Psychosocial factors associated with self-reported male condom use among women attending public health clinics.

BACKGROUND: Previous research has identified factors associated with condom use. However, less information exists on the impact that a history of sexually transmitted disease (STD) has on condom use. GOAL: To identify factors associated with self-reported male condom use that relate to a history of STD. STUDY DESIGN: Women attending STD clinics completed a survey that assessed sexual behavior, STD history, and psychosocial characteristics. Binomial regression was used to estimate the association between these factors and condom use. RESULTS: Of the 12 factors included in the regression model, 11 were significant for all women. When the analysis was stratified by STD history, high condom use self-efficacy, high convenience of condom use, and high frequency of condom use requests were significantly associated with increased condom use among women with or without a history of STD. Factors such as greater perceived condom use norms, higher perceived level of risk, and greater need for condom use in long-term relationships were significantly associated with increased condom use among women with a history of STD. Factors such as shorter duration of a relationship, less violence in the relationship, and lifetime drug use were associated with increased condom use among women with no history of STD. CONCLUSIONS: The pattern of psychosocial factors determining condom use is modified by a positive history of STD. These findings suggest that a history of STD could be an important factor in targeting condom use interventions.

A multi-project systems approach to developing community trust and building capacity.

Community characteristics are being recognized as important determinants for effective community-based programs. Community capacity to collaboratively identify issues, establish collective goals, and mobilize resources is built on experience with such interactions and trust among collaborators. Conceptual approaches and methods to develop community capacity rarely have been a focus of research programs, at least in part due to categorical funding, which often limits the scope and duration of interventions, thereby limiting capacity development. This approach uses multiple categorical funding sources to create sustained community programs involving multiple systems to increase capacity. Quasi-experimental evidence of increases in community capacity within two Alabama communities is presented.

Developing a video intervention to model effective patient-physician communication and health-related decision-making skills for a multiethnic audience.

The ENDOW study is a multisite, community-based project designed to improve decision-making and patient-physician communication skills for midlife African-American, white, and Hispanic women facing decisions about hysterectomy. Based on results of initial focus groups, a patient education video was developed in English and Spanish to serve as the centerpiece of various interventions. The video uses community women to model appropriate decision-making and patient-physician communication skills. Women in the target populations rated the video as useful to very useful and would recommend it to others. The use of theory-driven approaches and pilot testing of draft products resulted in the production of a well-accepted, useful video suitable for diverse populations in intervention sites in several states.

Mobility impairments in crash-involved older drivers.

OBJECTIVE: To evaluate potential associations of impairments in physical function with motor vehicle crash involvement in older drivers. METHODS: Case participants were randomly selected residents of Mobile County, Alabama, greater or less than 65 years old who had sustained an at-fault motor vehicle crash in 1996. Similarly selected crash-free controls were frequency matched to cases on gender and age. Self-report data on demographic variables, medical conditions, medications, driving exposure, and function were collected by telephone interviewers. RESULTS: Relative to crash-free subjects, crash-involved drivers were significantly more likely to report difficulty walking one fourth mile and moving outdoors. Marginally significant associations were observed for trouble carrying a heavy object 100 yards and for the occurrence of falls in the prior year. Increasing numbers of functional limitations were directly related to the odds of crash involvement. DISCUSSION: In comparison to crash-free controls, crash-involved older drivers are more likely to report other mobility-related impairments, possibly including falls.

Developing community capacity and improving health in African American communities.

Community-based programs have produced mixed results. Community capacity is thought to be a major determinant of program effectiveness. Thus, enhancing community capacity may increase the beneficial effects of existing programs and enhance future program effectiveness. This highlights the need to focus on understanding the components of capacity and the methods of enhancing capacity. Although we are just beginning to examine and understand key concepts, community capacity is probably influenced by both relatively nonmodifiable characteristics (such as demographic factors, institutional resources, and social structures) and relatively modifiable characteristics (such as knowledge, skills, and the ability and willingness of members and agencies to work collaboratively). In their relationships with community members and agencies, academicians and public health practitioners may help acquire categorical funding to enhance opportunities to build community capacity and their own capacity as well. The relationship between academicians/practitioners and community members/agencies probably is influenced by a host of characteristics which determine the degree to which capacity can be built. This paper discusses: the key components of capacity; the factors that influence building capacity through collaborations; a community health advisor (CHA) model which both builds on sociocultural aspects of African American culture and is consistent with methods for building community capacity; and how modifications to this model allow it to be compatible with categorically funded projects.

Relations among chronic medical conditions, medications, and automobile crashes in the elderly: a population-based case-control study.

Older drivers have elevated crash rates and are more likely to be injured or die if they have a crash. Medical conditions and medications have been hypothesized as determinants of crash involvement. This population-based case-control study sought to identify medical conditions and medications associated with risk of at-fault crashes among older drivers. A total of 901 drivers aged 65 years and older were selected in 1996 from Alabama Department of Public Safety driving records: 244 at-fault drivers involved in crashes; 182 not at-fault drivers involved in crashes; and 475 drivers not involved in crashes were enrolled. Information on demographic factors, chronic medical conditions, medications, driving habits, visual function, and cognitive status was collected. Older drivers with heart disease (odds ratio (OR) = 1.5, 95% confidence interval (CI): 1.0, 2.2) or stroke (OR = 1.9, 95% CI: 0.9, 3.9) were more likely to be involved in at-fault automobile crashes. Arthritis was also associated with an increased risk among females (OR =1.8, 95% CI: 1.1, 2.9). Use of nonsteroidal antiinflammatory drugs (OR = 1.7, 95% CI 1.0, 2.6), angiotensin converting enzyme inhibitors (OR = 1.6, 95 CI: 1.0, 2.7), and anticoagulants (OR = 2.6, 95% CI: 1.0, 73) was associated with an increased risk of at-fault involvement in crashes. Benzodiazepine use (OR = 5.2, 95% CI: 0.9, 30.0) was also associated with an increased risk. Calcium channel blockers (OR = 0.5, 95% CI: 0.2, 0.9) and vasodilators (OR = 0.3, 95% CI: 0.1, 1.0) were associated with a reduced risk of crash involvement. The identification of medical conditions and medications associated with risk of crashes is important for enhancing the safety and mobility of older drivers.

Detrusor myopathy in young beagle dogs.

Hematoxylin and eosin-stained sections of urinary bladder were examined microscopically from 449 male and female beagle dogs after 2- to 4-week toxicology studies. Degenerative lesions (detrusor myopathy) of the urinary bladder muscular tunic were present in 59 of 449 (13%) dogs. Myopathic lesions consisted of focal to multifocal areas of smooth muscle fiber atrophy with cytoplasmic basophilia and vacuolation, individual cell necrosis, enlarged smooth muscle nuclei and nucleoli, and occasional mitotic figures. Adjacent areas of arteritis and periarteritis were present in 10 of 59 (17%) beagles with detrusor myopathy suggesting a possible ischemic pathogenesis of the smooth muscle lesions. There was no significant difference in prevalence of myopathy in beagles administered vehicle or various test compounds. Prior urinary catheterization procedures appeared to augment the prevalence of myopathy; some lesions were adjacent to minor, iatrogenically traumatized urinary bladder mucosa. Muscle lesions were not observed in urinary bladders from mongrel dogs, monkeys, cats, rats, or microswine. When compared to crossbred dogs and other laboratory species, the beagle dog thus appears to be sensitive to development of detrusor myopathy.

Diabetes and automobile crashes in the elderly. A population-based case-control study.

OBJECTIVE: The aim of this study was to estimate the association between diabetes and its complications and at-fault automobile crashes among older drivers. RESEARCH DESIGN AND METHODS: This was a population-based case-control study. Case subjects were drivers aged > or = 65 years who had been involved in a crash during 1996 in which they were at fault. Two control groups were selected: 1) crash-involved not-at-fault subjects and 2) non-crash-involved subjects. Telephone interviewers collected information on demographic characteristics, driving habits, diabetes sequelae and treatment, other chronic medical conditions, and visual function. RESULTS: Overall, there was no association between diabetes and at-fault crash involvement. The adjusted odds ratio (OR) for diabetes was 1.1 (CI 0.7-1.9) when case subjects were compared with either control group. However, the adjusted OR for diabetes was 2.5 (0.9-7.2) among subjects who had been involved in a crash in the 4 years preceding 1996, while it was only 0.9 (0.5-1.7) among those who had not. There was no evidence of an association between treatment modalities and at-fault crash involvement. Case subjects were, although not significantly (P = 0.25), more likely (OR 2.4) to report neuropathy compared with both control groups, and retinopathy was not associated with increased crash risk. CONCLUSIONS: This study provides no evidence that older drivers with diabetes are at increased risk for automobile crashes. There remains the possibility that those with diabetes who have more severe disease or have had multiple crashes are at increased risk.

Driving after stroke: driving exposure, advice, and evaluations.

OBJECTIVE: Little is known about the extent to which stroke survivors return to driving and the advice and/or evaluations they receive about driving. This study sought to estimate the prevalence of driving after stroke and to determine whether stroke survivors receive advice and evaluation about driving. DESIGN: A convenience sample of stroke survivors was surveyed regarding driving status following stroke, driving exposure, advice received about driving, and evaluation of driving performance. PARTICIPANTS: Two hundred ninety stroke survivors who were between 3 months to 6 years poststroke. RESULTS: Thirty percent of stroke survivors who drove before the stroke resumed driving after the stroke. Stroke survivors are often poorly informed by health care professionals about driving, with 48% reporting that they did not receive advice about driving and 87% reporting that they did not receive any type of driving evaluation. Almost one third of poststroke drivers had high exposure, driving 6 to 7 days per week and/or 100 to 200 miles per week. CONCLUSIONS: These findings suggest that many stroke survivors are making decisions about their driving capabilities without professional advice and/or evaluation. The results also suggest that rehabilitation professionals need to devote more attention and resources to driving issues when working with stroke survivors and their families.

Why a peer intervention program for Mexican-American women failed to modify the secular trend in cancer screening.

INTRODUCTION: We evaluated an intervention program for Mexican-American women to increase Pap smear and mammography screening. METHODS: The three-year intervention included the presentation of role models in the media and reinforcement by peer volunteers. We used a two-community (intervention and comparison) pre-post test design. Activities were targeted to a mainly Spanish-speaking, poverty-level, immigrant population. Pre- and postintervention screening rates were based on independent random samples of Mexican-American women 40 years and older. RESULTS: Women reported a 6% absolute increase in Pap smear use similar to the 7% increase in the comparison community. Both communities experienced large but similar increases in recent mammography use (17% and 19%). Adjusting for differences in demographic factors, intervention and comparison changes remained identical. CONCLUSIONS: Our peer intervention failed to accelerate the secular trend in cancer screening low-income Mexican-American women. Likely, promotional activities were too diffuse and the comparison community was contaminated with similar interventions. Strong social and market forces make it difficult to measure the effect of a specialized intervention on cancer screening rates.

Prevention campaigns for hard-to-reach populations at risk for HIV infection: theory and implementation.

Using applied behavioral science techniques that have been successful in other areas of health promotion, community-level campaigns were implemented in 5 cities to prevent HIV infection among hard-to-reach, at-risk populations: men who have sex with men but do not self-identify as gay; women who engage in sex for money or drugs; injecting drug users (IDUs), female sex partners of IDUs; and youth in high-risk situations. Communication materials presented positive role models for risk-reducing behaviors, and peer networks prompted and reinforced the behavior change process. This article describes the first year of intervention experience and documents the practical application of theoretical concepts of persuasion and learning. The use of theory and data to develop 188 educational messages is illustrated and training methods and experiences are reported for 150 peer leaders, 104 other community networkers, and 22 outreach workers. These activities are feasible and appear to offer an effective, general approach for diverse, special populations.

Community level cancer control in a Texas barrio: Part II--Base-line and preliminary outcome findings.

In a quasiexperimental demonstration study, screening rates for breast and cervical cancers were measured among Mexican-American women in selected areas of San Antonio and Houston, Tex. This research was primarily designed to evaluate a cancer-screening promotion program in San Antonio by comparing changes in screening rates in panels from the two barrio communities. In a base-line population survey, we found a small, but significant, proportion of women (10%-15%) lacking Pap smears and a larger proportion (30%-40%) lacking mammography. In a panel study following women who lacked screening at base line, there was a trend toward greater Pap smear use among younger women and a significant increase in mammography for all age groups in San Antonio compared with groups in Houston. Although there was a difference in language use between the communities, rates of newly initiated screening within the communities were similar among monolingual Spanish speakers and among those who used English, supporting the hypothesis that the program increased both groups' participation in breast-cancer screening.

Comparing acculturation scales and their relationship to cancer screening among older Mexican-American women.

BACKGROUND: Hispanic women in the United States are less likely to participate in breast and cervical cancer screening than women of other racial and ethnic groups. To plan appropriate interventions requires an understanding of the barriers to participation, including those of acculturation and assimilation. Few studies have examined the effects of acculturation and assimilation on the cancer-screening behavior of Mexican-American women. PURPOSE: Because of the extensive use of the Cuellar acculturation scale and the more recent use of the Hazuda scale, we explore the utility of these two measures to predict Pap smear and mammography screening. Using a population-based sample of Mexican-American women aged 40 years and older, we compare the two scales with each other and describe their relationship to sociodemographic factors and to participation in cancer screening. METHODS: The data are from baseline surveys in El Paso and Houston, Tex., conducted before the implementation of community interventions to improve Pap smear and mammography screening in low-income Mexican-American women. Study subjects were 923 randomly selected Mexican-American women aged 40 years and older living in 16 El Paso census tracts and seven Houston census tracts. Personal interviews solicited information on age, martial and employment status, household annual income and size, education, health insurance coverage, Pap smear and mammogram history, and a series of acculturation dimensions. Acculturation was measured using the abbreviated version of the Cuellar scale developed for the Hispanic Health and Nutrition Examination Survey, 1982-1984, and the Hazuda scale developed for the San Antonio Heart Study. The eight-item Cuellar acculturation scale assessed the extent to which Spanish and English were spoken, preferred, read, and written; the ethnic identification of the respondent and her parents; and generational status in the United States. The Hazuda scale assessed the following dimensions of acculturation: adult proficiency in English, adult pattern of English versus Spanish language usage, value placed on preserving Mexican cultural origin, attitude toward traditional family structure and sex-role organization, and adult interaction with members of mainstream society. RESULTS: The Cuellar scale was highly correlated with Hazuda's two language dimension. The Hazuda scale dimensions, Mexican cultural values and traditional family attitudes, correlated the least with Cuellar's scale. All the acculturation dimensions, Cuellar's and Hazuda's, were strongly associated with education and health insurance coverage. With the use of multiple logistic regression to adjust for education, health insurance, and other variables, English proficiency was a predictor of both a recent Pap smear and a recent mammogram. No other language-based acculturation dimension was associated with a recent screening with adjustment for education, health insurance, and other variables. However, in controlling for these factors, we found that a woman's attitude toward traditional family structure was related inversely to mammogram screening. That is, women who held the strongest traditional Mexican family attitudes were more likely to participate in mammography screening. CONCLUSION: This study shows the importance of separating the effects of acculturation on cancer screening from those due to social and economic conditions. Results suggest that the Hazuda scale provides a more multidimensional approach than the Cuellar scale and is a superior measure of the acculturation process. Traditional Mexican family attitudes positively influence mammogram-screening behavior, and this finding has implications for cancer control interventions in this population.

Effect of social networks on cancer-screening behavior of older Mexican-American women.

BACKGROUND: Previous studies have determined that Hispanic women and, in particular, Mexican-American women have the lowest rates of cancer screening of any race and ethnic group in the United States. In the development of cancer control strategies for this population, little attention has been given to factors that encourage Mexican-American women to seek cancer preventive care. Recent studies suggest that social networks can have a positive influence on cancer-screening participation. PURPOSE: We determined the extent to which differences in social networks account for variations in breast and cervical cancer-screening practices among low-income Mexican-American women. METHODS: The data analyzed in this study were obtained from a baseline survey of knowledge, attitudes, and cancer-screening practices conducted prior to implementation of community interventions designed to improve Pap smear and mammography screening in low-income Mexican-American women 40 years old and older living along the U.S.-Mexican border in El Paso County, Texas. A random selection of 1300 households served as a sampling frame to identify Mexican-American women 40 years old and older for personal interviews. Of the 549 households identified as having at least one eligible female, 450 women completed the personal interviews that provided the data for this study. Personal interviews solicited information on age, income, marital status, place of birth, education, health insurance coverage, Pap smear- and mammogram-screening practices, and six questions relating to social network. A social network score was assigned to each woman by summation of the following six variables: number of confidants, number of close friends, number of close relatives, frequency of contact with these close friends or relatives per month, church membership, and church attendance. Women were grouped into three linear strata of social network (low, medium, high) based on tertiles of the scores. Cancer-screening history was also ascertained during the interview. RESULTS: The 2-year prevalence of Pap smear and mammography use increased with social network. For each gain in social network level (low, medium, high), adjusted for sociodemographic factors, the odds ratio for Pap smear use was 1.33 (95% confidence interval = 1.02-1.73); it was 1.40 (95% confidence interval = 1.02-1.93) for mammogram use. Of the six social network components, the number of close friends was the most important predictor of mammography (P = .002) and Pap smear (P = .025) screening. CONCLUSION: Social networks appear to be an important determinant of cancer-screening behavior among low-income, older Mexican-American women.

Local health departments implement a theory-based model to increase breast and cervical cancer screening.

Su Vida, Su Salud/Your Life, Your Health is a community program to increase participation in breast and cervical cancer screening. This program illustrates the diffusion of an innovative outreach strategy from a research environment to two local health departments. The program uses A Su Salud, the communication model in which positive role models are featured in the media, and community volunteers who give positive social reinforcement. Local health departments in Galveston and Corpus Christi, TX, were selected to implement the model because of excessive mortality rates in the region and the departments' adequate level of resources and commitment. Over an 18-month period, 54 stories of role models appeared in the media in Corpus Christi, and 60 appeared in Galveston. There were 490 volunteers active in Corpus Christi and 279 in Galveston. Of 365 inquiries to the Corpus Christi program, 35 percent were from the Mexican American target group of women ages 40-70. Of 1,457 women who contacted the Galveston program, 9 percent were from the African American target group ages 40-70. Local health departments are well-suited to participation in cancer control research applications because they have direct access to high-risk populations and have the authority to institutionalize effective interventions.

Smoking cessation in Texas-Mexico border communities: a quasi-experimental panel study.

UNLABELLED: BACKGROUDd. Smoking-related disease and injury is prominent among the numerous health problems on the U.S.-Mexico border, but little is known about the methods that might help promote smoking cessation among the low-income populations in this region. METHOD: Media campaigns were combined with different forms of intensive and community-wide interpersonal communication to encourage smoking cessation in a border U.S. city and in a Mexican city. Panels of moderate to heavy smokers were followed in four groups to allow quasi-experimental comparison of smoking cessation rates. RESULTS: Over a five-year study period smoking cessation rates of 17% (self-reported) and 8% (verified) were observed in panels in the program community (N = 160). In the comparison community (N = 135) corresponding rates of smoking cessation were 7% (self-reported) and 1.5% (verified). Within the program community, no differences were observed in smoking cessation among smokers exposed to a community-wide program and those assigned to receive personal counseling. DISCUSSION: Although the observed changes in smoking were unexpectedly small in the treatment and comparison groups, the approximately 8% effect size for the community-wide program was close to what was predicted. Results indicate that such programs may yield effects similar to those of more intensive approaches, but further research with greater statistical power will be necessary to confirm that point.