Healthy by Design: Using a Gender Focus to Influence Complete Streets Policy.

BACKGROUND: Public health leaders in Yellowstone County, Montana, formed an alliance to address community-wide issues. One such issue is Complete Streets, with its vision of safe streets for all. This case study focuses on development and adoption of a Complete Streets policy. It examines how a community coalition, Healthy By Design, infused a gender focus into the policymaking process. METHODS: An incremental and nonlinear policymaking process was aided by a focus on gender and health equity. The focus on a large constituency helped to frame advocacy in terms of a broad population's needs, not just special interests. RESULTS: The city council unanimously adopted a Complete Streets resolution, informed by a gender lens. Healthy By Design further used gender information to successfully mobilize the community in response to threats of repeal of the policy, and then influenced the adoption of a revised policy. CONCLUSIONS: Policies developed with a focus on equity, including gender equity, may have broader impact on the community. Such policies may pave the way for future policies that seek to transform gender norms toward building a healthier community for all residents.

The effectiveness of screening with interferon-gamma release assays in a university health care setting with a diverse global population.

OBJECTIVE: This analysis examined the effectiveness of utilizing interferon-gamma release assay (IGRA) technology in a TB (TB) screening program at a university. PARTICIPANTS: Participants were 2299 students at a Montana university who had presented to the university health center for TB screening during 2012 and 2013. METHODS: A retrospective study was conducted utilizing data from student health center medical records. Time and financial expenditures were determined, and the cost of the present screening process and 2 alternative scenarios was calculated. RESULTS: The current process is the most costly and time-consuming scenario for TB testing. Testing exclusively with IGRAs is the least labor-intensive for staff and creates revenue, whereas a dual method, utilizing IGRAs for high-risk students and skin tests for others, provides a solution that better responds to the demographic of the population. CONCLUSIONS: This assessment shows that IGRAs are a cost-effective tool for screening a global student population.

Using gender-based analyses to understand physical inactivity among women in Yellowstone County, Montana.

Physical inactivity contributes to many health problems. Gender, the socially constructed roles and activities deemed appropriate for men and women, is an important factor in women's physical inactivity. To better understand how gender influences participation in leisure-time physical activity, a gender analysis was conducted using sex-disaggregated data from a county-wide health assessment phone survey and a qualitative analysis of focus group transcripts. From this gender analysis, several gender-based constraints emerged, including women's roles as caregivers, which left little time or energy for physical activity, women's leisure time activities and hobbies, which were less active than men's hobbies, and expectations for women's appearance that made them uncomfortable sweating in front of strangers. Gender-based opportunities included women's enjoyment of activity as a social connection, less rigid gender roles for younger women, and a sense of responsibility to set a good example for their families. The gender analysis was used to gain a deeper understanding of gender-based constraints and opportunities related to physical activity. This understanding is being used in the next step of our research to develop a gender-specific intervention to promote physical activity in women that addresses the underlying causes of physical inactivity through accommodation or transformation of those gender norms.

Telemonitoring improves home health utilization outcomes in rural settings.

We have examined the hypothesis that home telemonitoring, when added to conventional home care in rural settings, results in less acute care hospitalization and more discharge to the community. Five US rural home health agencies of different types participated in the study. All agencies were not-for-profit and served low-income patients in designated health professional shortage areas or medically underserved areas/populations. A prospective treatment group was telemonitored daily in the home during the period 1 October 2006 to 31 May 2009 (n = 1419). An historical control group was selected sequentially backwards from 30 September 2006 (n = 1502). Both groups had home health services for approximately 50 days (P = 0.76). We used logistic regression modelling, with covariate data captured from the Outcome and Assessment Information Set (OASIS) data set, to assess the effect of group on outcome. Home telemonitoring was found to reduce the odds of any acute care hospitalization (OR = 0.59, P < 0.001) and to increase the odds of discharge to the community (OR = 1.36, P = 0.003).

Cost factors in implementing telemonitoring programs in rural home health agencies.

The purpose of this quantitative study was to examine costs and implementation factors associated with development of telemonitoring programs in eight rural home health agencies. although the telemonitoring group (n = 1,513) averaged fewer visits per episode than the control group (n = 1,573), cost analysis data, including labor, travel, and equipment costs, failed to support the hypothesis that decreased utilization of skilled nursing visits alone could offset the costs of the telemonitoring technology. this study indicates that agencies must achieve savings through improved outcome performance to offset telemonitoring expenses.

Correlating reading comprehension and health numeracy among adults with low literacy.

OBJECTIVE: Using the Test of Functional Health Literacy for Adults (TOFHLA), a pilot study was conducted to assess whether reading comprehension and numeracy scores sufficiently correlate in health contexts among adults with low literacy skills. METHODS: The TOFHLA was administered to 144 adults with low literacy enrolled in a health literacy program prior to the start of coursework. Raw scores for reading and numeracy were calculated. Weighted numeracy scores were calculated and compared to raw reading comprehension scores. RESULTS: Among 143 participants, 20% (n=28) had a higher numeracy score than reading comprehension score, while an additional 20% scored lower in numeracy than in reading comprehension. CONCLUSION: This study found that reading comprehension and numeracy skill in the context of understanding health information do not necessarily correlate for specific disadvantaged groups. This finding calls attention to the need to further examine numeracy as a construct which is conceptually separate from reading comprehension, and highlights the importance of including a numerate component in health literacy evaluations. PRACTICE IMPLICATIONS: The results of this study have important implications for medical decision-makers, health educators, and health promoters working with traditional methods of assessing health literacy.

Interjurisdictional collaboration: local public health officials versus county commissioners.

OBJECTIVE: This study's primary objective was to determine where the viewpoints of public health officials and county commissioners differed on interjurisdictional collaboration in public health service delivery. DESIGN: After cataloging literature findings on interjurisdictional collaboration, an original questionnaire for 2 population groups within a cross-sectional design was developed. SETTING: The questionnaire was administered in a rural or frontier state (Montana) that operates a generally decentralized public health system. PARTICIPANTS: Respondents (n = 83) were 29 lead local public health officials representing 34 counties, and 54 county commissioners representing 33 counties. OUTCOME MEASURES: Sixteen reasons to collaborate, 13 barriers to collaboration, and 18 policy considerations that would lead respondents to support or oppose a collaborative system were assessed, along with perceptions of current and ideal levels of interjurisdictional collaboration using the 4-level National Association of County and City Health Officials scale. RESULTS: Viewpoints of public health officials and county commissioners were found to differ significantly on 7 of 47 items. The potential benefit of improved surge capacity to manage large-scale events or emergencies was found by public health officials to be a more important reason to collaborate across jurisdictional lines. Long-standing commitment to home rule, current political climate, perceived threats to local elected officials, loss of local input into public health services and priorities, and lack of collaborative government and staffing models were all identified by public health officials as greater barriers to interjurisdictional collaboration. County commissioners were more likely to neither support nor oppose using existing disaster and emergency services district boundaries to define public health regional boundaries. CONCLUSIONS: Public health officials and county commissioners seem to have similar viewpoints on reasons to collaborate and policy considerations, but different viewpoints on barriers to collaboration. Reconciling those key differences is critical to effecting system change.

Using telemonitoring to construct knowledge about homebound patient populations: vital-signs alert rates.

Three home health agencies conducted daily telemonitoring of patients in western Montana. The agencies all used monitoring equipment of the same type, which provided up to six vital-signs measurements (heart rate, oxygen saturation, systolic blood pressure, diastolic blood pressure, glucose and bodyweight). There were 337 patients in all, two-thirds of whom were female. These patients were monitored for a total of 16,999 person-days. The rate of occurrence of any vital-sign measurement falling outside acceptable ranges was 33.8 per patient per 60-day period. The highest alert rate for a specific vital sign was for decreased SpO(2) (6.4 per patient per 60-day period). The central station nurse took follow-up action at a rate of 26.0 per patient per 60-day period; case manager nurses took follow-up action at a rate of 8.2 per patient per 60-day period. There were some differences between male and female patients in the alert rates, and between the agencies. The alert rates measured in the present study are expected to be useful to home care administrators in estimating the staffing requirements for telemonitoring.

Timeline follow-back versus global self-reports of tobacco smoking: a comparison of findings with nondaily smokers.

Methods assessing nondaily smoking are of concern because biochemical measures cannot verify self-reports beyond 7 days. This study compared 2 self-reported smoking measures for nondaily smokers. A total of 389 college students (48% women, 96% White, mean age=19 years) smoking between 1 and 29 days out of the past 30 completed computer assessments in 3 cohorts, with the order of administration of the measures counterbalanced. Values from the 2 measures were highly correlated. Comparisons of timeline follow-back (TLFB) with the global questions for the total sample of nondaily smokers yielded statistically significant differences (p<.001), albeit small, between measures with the TLFB resulting on average in 2.38 more total cigarettes smoked out of the past 30 days, 0.46 fewer smoking days, and 0.21 more cigarettes smoked per day. Analyses by level of smoking showed that the discordance between the measures differed by frequency of smoking. Global questions of days smoked resulted in frequent reporting in multiples of 5 days, suggesting digit bias. Overall, the 2 measures of smoking were highly correlated and equally effective for identifying any smoking in a 30-day period among nondaily smokers.

Cultural identification and smoking among American Indian adults in an urban setting.

OBJECTIVES: Among American Indians (AIs), an important relationship has been theorized between cultural identification and substance abuse, including smoking. We investigated the relationship between cultural identification and smoking among AI adults. DESIGN: Using the Orthogonal Cultural Identification Scale (OCIS), we examined the relationship between AI and White cultural identification and cigarette use in a sample of AI recruited at an urban Indian center (n=217). RESULTS: We found that high AIs identification predicted smoker status and high White identification predicted non-smoker status when controlling for age and reservation residence. Orthogonal cultural identification status (categorized as high White/high AI, high White/low AI, low White/high AI, or low White/low AI) did not predict smoker status when controlling for age and reservation residence. OCIS item analysis revealed that positive responses to the individual OCIS items 'My family lives by the American Indian way of life,' 'I live by the American Indian way of life,' and 'I am a success in the American Indian way of life' predicted smoker status when controlling for age and reservation residence. CONCLUSIONS: Our data suggest that, among some groups of urban AIs, recreational smoking is associated with AI cultural identification.

Examination of a brief Smoking Consequences Questionnaire for college students.

This study examined the factor structure of a brief version of the Smoking Consequences Questionnaire-Adult (SCQ-A) among 315 college freshman and sophomore smokers. A comparison of results from two confirmatory factor analyses demonstrated that a nine-factor model provided superior fit to a four-factor model. Furthermore, results revealed a lack of factorial invariance of factor loadings for daily and nondaily smokers, and of latent mean structures for smoking category and gender. In addition, concurrent validity tests demonstrated that positive expectancies increased with smoking rate and nicotine dependence. These results and their implications are discussed.

The influence of licence status on Kansas child fatalities due to motor vehicle crashes.

The influence of driver licensure on child motor vehicle crash (MVC) deaths in Kansas was investigated. Fatalities from 1994-2000 due to MVCs were extracted from the Kansas State Child Death Review Board and the Fatality Analysis Reporting Systems databases. It was found that 14% (52 of 363) of child fatalities from MVCs in Kansas occurred in vehicles where the driver was not licensed. Driver licence status was associated with use of safety restraints, the victim's age and race, weekend driving and rural county location. All child deaths involving unlicensed drivers were preventable. New legislation on vehicle sanctions may be required to assist law enforcement. Safety restraint laws should be enforced and promoted to the public. Transportation options are necessary for unlicensed drivers, particularly if they have young children and live in a rural community. Thus, a multi-system approach involving law enforcement, accident prevention strategies and transportation options will save the lives of children.

Lifestyle modification counseling in patients with gastroesophageal reflux disease.

The purpose of this study was to determine the rate of documented counseling on lifestyle modifications in patients presenting to the primary care setting with a diagnosis of gastroesophageal reflux disease. Retrospective chart review was conducted for 502 active patients with a primary or secondary diagnosis of gastroesophageal reflux disease from two internal medicine clinics at the University of Kansas School of Medicine-Wichita. Charts were reviewed for documented counseling on four specific lifestyle modifications: (a) smoking and alcohol cessation, (b) dietary changes, (c) head of bed elevation, and (e) postprandial avoidance of recumbency. Only 12% of patients in this sample received documented counseling on lifestyle modifications. Of those patients receiving documented counseling, 71% were counseled on dietary changes, 41% smoking or alcohol cessation, 28% head of bed elevation, and 21% postprandial avoidance of recumbency. Documentation indicated that patients with gastroesophageal reflux disease are not adequately counseled regarding recommended lifestyle modifications.

The potential for clinically significant drug-drug interactions involving the CYP 2D6 system: effects with fluoxetine and paroxetine versus sertraline.

BACKGROUND: Patients taking antidepressants are more likely to also be taking multiple medications, increasing the risk of adverse drug-drug interactions (DDIs). Because of substantial inhibition of one or more cytochrome P450 (CYP) enzymes at therapeutic doses, the selective serotonin reuptake inhibitors fluoxetine, fluvoxamine, and paroxetine have a higher risk of CYP-mediated DDIs than citalopram, escitalopram, and sertraline, which do not substantially inhibit any CYP enzyme. METHODS: Prescribing patterns in 2,779 Veterans Affairs (VA) patients who had a prescription for an antidepressant in the preceding year and a current prescription for at least one systemically active drug were analyzed to determine 1) prevalence of drug combinations with potential to cause CYP-mediated DDIs, 2) frequency of combinations of fluoxetine, paroxetine, or sertraline with drugs whose metabolism is principally dependent on CYP 2D6, and 3) use of reduced doses of CYP 2D6 substrate/drugs with narrow therapeutic indices in patients on fluoxetine or paroxetine compared with sertraline. RESULTS: In 2,779 patients, 55 pairs of drugs with the potential to cause CYP-mediated DDIs occurred in 300 patients (11%), but only 26 of the patients and 6 of the drug pairs were identified by the VA Drug Alert System. Of the 461 patients receiving fluoxetine and/or paroxetine, 39 (8%) were also receiving a CYP 2D6-model substrate/drug with a narrow therapeutic index, 14 (36%) of whom were receiving high enough doses to be at moderate to high risk of a serious DDI. CONCLUSIONS: VA patients on fluoxetine, paroxetine, and sertraline were equally likely to be on drugs whose metabolism is dependent on CYP 2D6, including drugs with narrow therapeutic indices. No differences were found in doses of tricyclic antidepressants (i.e., "victim" drugs), which have narrow therapeutic indices and serious dose-dependent toxicity, when co-prescribed with fluoxetine or paroxetine versus sertraline (i.e., "perpetrator" drugs), despite predictable differences in CYP 2D6-mediated clearance of these drugs.

Breast cancer counts: numeracy in breast cancer information on the Web.

BACKGROUND: The purpose of this study was to determine the numeracy information included in three prominent breast cancer Web sites. METHODS: A content analysis was performed, grouping numeracy items into 15 categories. Interrater reliability was high. RESULTS: Of the 3,206 items identified, 14.3% were numbers, 33.9% were descriptive measures (e.g., many, lower), 27.3% were statistical terms (e.g., predictive, risk), and 12.4% were temporal terms (e.g., before, always). CONCLUSIONS: Findings suggest that there is an abundance of numeric information presented in breast cancer Web sites, much of which may be conceptually too advanced for the intended audience.

A definition and operational framework for health numeracy.

Health numeracy has often been overshadowed by health literacy, either ignored completely or identified simply as a subset of health literacy. Only now are researchers beginning to realize the importance of health numeracy as a separate entity. One of the first steps in this evolution is to establish a distinct definition for health numeracy, something that has not been addressed in the literature to date. This paper proposes such a definition, as well as a set of clarifying categories in hopes of helping researchers both to advance the field of health numeracy and to focus their topics within the realm of health numeracy.

Complexity of medication use in the Veterans Affairs healthcare system: Part I: Outpatient use in relation to age and number of prescribers.

CONTEXT: Multiple medication use is associated with an increased incidence of adverse drug-drug interactions (DDIs), medication errors, noncompliance, hospitalization, and healthcare costs. Drugs acting systemically or gastrointestinally ("SG" drugs) are of particular concern because of their potential to interact. A better understanding is needed of the relationship between multiple medication use, particularly of SG drugs, and age, number of prescribers, and common drug regimens. OBJECTIVE: to determine the levels of multiple SG medication use in relation to age, number of prescribers, and common drug regimens in an outpatient population served by U.S. Veterans Integrated Service Network 15 (VISN 15). DESIGN, SETTING, AND PARTICIPANTS: cross-sectional analysis of the subset of 5,003 currently active patients from a stratified random sample of 7,000 potentially active outpatients (1,000 each from 7 sites comprising VISN 15) selected from the prescription database on a single day. MAIN OUTCOME MEASURES: number of SG drugs/patient; number and frequency of SG drug entities and regimens. RESULTS: Most patients (97%) were dispensed at least one SG drug: 80% received > or =2 SG drugs, of which 42% received 2-4 SG drugs, 24%, 5-7 SG drugs, and 14%, > or =8 SG drugs. 394 different SG drugs were dispensed, only 88 of which occurred in 1% or more of patients. A significant increase (p < 0.0001) in level of multiple medication use occurred with increasing age and number of prescribers. Proportions of patients receiving 8 or more SG drugs approximately doubled with each additional prescriber, up to 4 or more prescribers. No drug regimen containing 2 or more drugs occurred in 1% or more of patients; 71% of patients were receiving a unique drug regimen (based on specific SG drugs without regard to dose or administration schedule). CONCLUSIONS: The uniqueness of SG drug regimens suggests no single prescriber could have extensive clinical experience with even a small fraction of the drug regimens patients receive. These findings suggest that potential DDIs cannot be predicted based on occurrence of common drug regimens in a general patient population. A follow-up study (reported separately) investigated whether common drug regimens can be identified by selecting for a specific drug treatment (e.g., an antidepressant). The improved ability to predict DDIs is particularly relevant for psychiatric patients, who are at increased risk for DDIs because of greater frequency of multiple medication use. In addition, DDIs may present in this population in ways that mimic worsening of primary symptoms, which may lead to increased doses of the medication that is actually responsible for the problem, causing still more toxicity.

Complexity of medication use in the Veterans Affairs healthcare system: Part II. Antidepressant use among younger and older outpatients.

CONTEXT: A previous study, described in Part I of this report, found that 71% of a sample of 5,003 general outpatients in the Veterans Affairs healthcare system were receiving a unique drug regimen (i.e., total specific drug entities regardless of dose, formulation, or administration schedule). The simplest regimens contained only one drug, while the most complex regimens exceeded 20 different drugs. The purpose of the present study was to determine if patients receiving a specific therapeutic class of medications (e.g., antidepressants) have more homogeneous drug regimens. OBJECTIVE: to examine the extent and complexity of multiple medication use in younger and older adult outpatients receiving antidepressants compared with those not receiving antidepressants. The study focused on drugs that act systemically or gastrointestinally and hence have the potential to interact. DESIGN, SETTING, AND PARTICIPANTS: Two subsets of stratified random samples of outpatients selected from prescription databases of U.S. Veterans Integrated Service Network 15. The first group involved 1,991 patients deemed to be on antidepressants (AD patients): 891 aged < 60 years and 1,100 aged > or = 60 years. The second group involved 3,732 patients who had received no antidepressants within the previous 365 days but who had a supply of at least one other current prescription (NoAD patients): 1,195 aged < 60 years and 2,535 aged > or = 60 years; 2 missing age information. MAIN OUTCOME MEASURES: number of drugs, frequency of drug regimens, level of multiple medication use including and excluding antidepressants. RESULTS: Younger AD patients received 3 more drugs than younger NoAD patients. 23.6% of younger AD patients, versus 5.9% of younger NoAD patients, received > or = 8 drugs. Older AD patients received 2 more drugs than older NoAD patients. 37.6% of older AD patients, versus 12.8% of older NoAD patients, received > or = 8 drugs. In both the AD and NoAD groups, 62%-96% of patients of all ages were receiving unique drug regimens. Each drug regimen containing 2 or more drugs occurred in fewer than 1% of patients. CONCLUSIONS: AD patients were receiving more complex drug regimens and had a higher frequency of unique drug regimens than NoAD patients, even when the results were adjusted for age group and number of prescribers. The high prevalence of unique drug combinations in all patient groups in this study indicates that clinicians in this system have only limited experience with the total effects of all of the medications their patients are receiving and thus cannot rely on experience to guard against adverse multi-drug interactions. This fact is a particular concern with psychiatric medications because adverse DDIs involving these medications can mimic psychiatric symptoms and may therefore be more difficult to detect.

Prevalence of migraine among Mexican Americans in San Diego, California: survey 1.

OBJECTIVE: To determine the population-based prevalence of migraine in a cross-sectional random sample of Mexican Americans aged at least 45 years in San Diego County, California. BACKGROUND: The prevalence of migraine has been assessed in various populations in the United States and Mexico, but no study of migraine prevalence in Mexican Americans has been reported in the literature to date. DESIGN/METHODS: Using an epidemiological cross-sectional research design, the population-based prevalence and associated descriptive epidemiology of self-reported migraine was estimated in Mexican Americans aged at least 45 years in San Diego County, California from a random sample of size 657. RESULTS: The lifetime migraine prevalence was 9.2% (95% confidence interval, 6.8 to 11.6) and current prevalence was 7.4% (95% confidence interval, 5.3 to 9.5). The prevalence of migraine was higher in women than in men, higher in low income groups than in high income groups, and decreased with increasing age. Prevalence among Mexican Americans born in Mexico was twice that of American-born Mexican Americans. CONCLUSIONS: These population-based data on migraine prevalence in Mexican Americans aged 45 and over contribute substantially to the understanding of this disease. A second study addressing migraine prevalence in Mexican Americans younger than 45 years in San Diego County will be reported.

Neuroepidemiology of human T lymphotrophic virus type I associated tropic spastic paraparesis

Tropical spastic paraparesis (TSP) is a chronic neurological syndrome involving the pyramidal tracts and upper motor neurons, resulting in weakness and stiffness of the lower extremities, hyperactive tendon reflexes, spasticity, low back pain, and urinary disturbances. Clusters of endemic TSP have been noted in Africa, the Seychelles Islands, Colombia, and the Caribbean. Recently, studies have linked human T-lymphotrophic virus type-I (HTLV-I) with the endemic form of the disease. In Japan a very similar clinical syndrome has been identified as HTLV-I associated myelopathy and may be a non-tropical version of the same disease. The purpose of the present review is to examine the role Htlv-I may play in the pathogenesis of these myelopathies from a neuroepidemiological point of view. (AU)