|| Neural Tube Defects Among Infants Across Regions of the United States
|| Seminal HIV-1 Viral Load (SVL) Is Reduced by Antiretroviral Therapy (ART) and Is Correlated with Plasma HIV-1 Viral Load (PVL)
||People with Disabilities and Their Caregivers: Injury to Caregivers During the Provision of Care
|| Provision of Care and Outcomes for Patients Attending a Primary Care Diabetes Education Intervention at the VAMC New Orleans
||Racial Differences in Barriers to Antiretroviral Adherence
||Relationship Between Special Taxing Authority, Public Hospitals and Population Health Outcomes
|| Unmet Needs for Dental and Medical Care Among Patients with HIV
||Disease Risk in a Cohort of HTLV-Infected Jamaican Children Followed for Nine Years
||Family and Environmental Factors Influencing Dietary Fat Intake as Perceived by Underserved African American Parents
|| Agency/Client Relationships to Length of Stay in Home Health Care: A Multilevel Analysis
||Applying Geographic Information Systems (GIS) Technology to Injury Research, Prevention, and Control
||Urban Sampling Frames Using City Directories
||Pharmacists and HIV prevention: Attitudes and Practices Regarding the Sale of Syringes to Injection Drug Users
||Farm Residence Increased Risk of Hearing Loss Among Youth
||Hazardous Chemical Database
Neural Tube Defects Among Infants Across Regions of the United States
Rebecca Baker, University of South Carolina School of Public Health
Other Author: Dr. Maureen Sanderson, University of South Carolina School of Public Health
Previous studies have identified different birth prevalence rates of neural tube defects (NTDs) depending on geographic region of birth. The National Natality File for 1996 was used to conduct a population-based case-control study to assess the association between geographic region of birth and NTDs. All infants with NTDs (n=1395), defined as anencephaly and spina bifida, were identified. Approximately four infants without NTDs were randomly selected for each case (n=5466) to form the comparison group. Region was divided into Northeast, Midwest , South, and West, using Northeast as the referent group. We used logistic regression to examine the association. Maternal race and season were assessed as potential effect modifiers; maternal education, maternal age, maternal diabetes, marital status, gravidity, parity, previous terminations, and infant sex were assessed as potential confounders. There was no evidence of either, so the crude association is reported. Compared with infants born in the Northeast, there was a significantly decreased relative risk for infants born in the West (odds ratio (OR)=0.50, 95% confidence interval (CI) 0.40-0.62), while infants born in the South (OR=1.01, 95% CI 0.84-1.21) and Midwest (OR=.99, 95% CI 0.81-1.20) had comparable rates. These findings differ from previous studies, which have shown consistently that infants born in the South have an increased risk of NTDs compared with infants born in the rest of the country. Efforts should be taken to examine this decrease relative to other regions, perhaps due to an increase in awareness of public health recommendations for folic acid use during pregnancy.
Seminal HIV-1 Viral Load (SVL) is Reduced by Antitretroviral Therapy (ART) and is Correlated with Plasma HIV-1 Viral Load (PVL)
Paulo Feijó Barroso, Department of International Health, Johns Hopkins School of Public Health
Objectives: To evaluate the correlation of SVL and PVL and the effect of ART in SVL in Brazilian patients. Methods: HIV-1 RNA was measured in plasma and whole semen by the Nuclisens? assay before introduction of ART (BL) and at 1, 2, 3 and 6 months thereafter.
Results: Correlation of SVL and PVL was statistically significant at all time points (p< 0.001). Spearman?s rho were: 0.46 (n=103); 0.44 (n=88), 0.62 (n=85), 0.65 (n=88) and 0.65 (n=85) at BL,1,2,3 and 6 months respectivelly. At baseline 27 of 103 (26%) patients had undetectable SVL. This percentage increased after introduction of ART (67% , 71% , 72% and 75% at 1,2,3 and 6 months). At baseline median PVL was 42,000 cps/ml and median SVL was 6,400 cps/ml. 69 patients had detectable SVL and at least one follow-up measurement. Of those, 59 (85%) were on double therapy and 10 (15%) were on triple therapy . The introduction of ART was associated with significative reductions in SVL and PVL. Mean reduction in SVL and PVL (in log10 95% CI and n) were: 1 month: 1.41 (1.17-1.64, 68) and 1.54 (1.31-1.76, 68); 2 months 1.53 (1.25-1.80, 64) and 1.63 (1.40-1.87, 65); 3 months 1.51 (1.20-1.81, 65) and 1.64 (1.38-1.91, 65) and 6 months 1.65(1.34-1.96, 64) and 1.52 ( 1.25- 1.79, 66).
Conclusions: ART decreased SVL and the extent of this decline was similar to that of PVL. If associated with diminished transmissibility, these findings may have important implications for the dynamics of the HIV epidemic.
People with Disabilities and Their Caregivers: Injury to Caregivers During the Provision of Care
Sepideh Farivar, Boston University
Other Authors: K. Spaulding, M. Pietrusewicz and A. Meyers, Boston University.
Paid and unpaid caregivers enable people with disabilities (PWDs) to live independently by meeting some or all daily living (ADL and IADL) needs. If a caregiver is ill or injured, there is a double jeopardy, to the person injured and to the PWD who may be unable to find a substitute or alternate source of care. This jeopardy is further complicated by 1) limited fiscal incentives to paid providers of personal assistance services (PAS) low pay; no benefits; 2) robust economy, which creates more lucrative job opportunities, and 3) regulatory changes that make PAS providers eligible for disability insurance and Workers' Compensation.
Baseline data from a statewide (MA) longitudinal study of 656 independently-living adults with major disabilities show a dependency in a median of 3 ADL and 1 IADL domains; 56% use and 68% need but do not have PAS. Eight % reported that paid or unpaid caregivers had experienced injuries (overwhelmingly, back injuries) in the year before the survey. Bivariate analysis suggests that PWDs whose caregivers experience injuries are significantly more likely than their counterparts to be male (65% vs 40%; p=.001); younger (Md age = 39 vs 42, p=.02 ); and more likely to report spinal cord injury as cause of their disability (37% vs 17%; p=.001). They report more hours of paid and unpaid assistance (Md=5 vs 2, and 4 vs 1, p=.0002 and .0215, respectively), more unmet ADL needs (Md=1 vs 0 domains, p=.0001) and dependency in more ADL domains (Md = 7 vs 2, p=.0001).
Provision of Care and Outcomes for Patients Attending a Primary Care Diabetes Education Intervention at the VAMC New Orleans
Jill Catalano Feig, MD, Tulane University School of Public Health and Tropical Medicine & VAMC New Orleans
Other Authors: Leann Myers, PhD; Jian He, MD, PhD; Jill E. White, RN, MA; Carol Vadiee, NP; Harry Pigman, MD; Cathy Lazarus, MD; and M.A. Krousel-Wood, MD, MSPH.
Prior studies have shown a correlation between diabetes education and improved outcomes. Few of these studies have addressed outcomes for Veterans Affairs patients in the primary care arena. The objective was to determine if patients with diabetes mellitus who have attended primary care diabetes education and diabetes clinic (DME&C) are provided more prevention screening and have improved outcomes over those diabetics seen in other clinics.
Thirty-seven diabetic men were identified as having attended DME&C between 4/1/98 and 8/15/98 at the VAMC New Orleans. Seventy-four controls (2 per cohort) who had not attended these clinics were matched on race and age. The presence of baseline hypertension (HTN), renal insufficiency (RI), insulin use, and body mass index (BMI) were assessed for all subjects. Hemoglobin A1C (HA1C) levels were abstracted prior to attendance, and at 3 and 6 months after enrollment. Emergency department (ED) visits after the intervention date, as well as practitioner referral for eye exams and proteinuria testing were assessed for both groups using multiple categorical regression. Subset analysis on patients having all data points reveals a significant decrease in HA1C for cohort subjects at three months (p = 0.035), but this was not sustained at 6 months. There was not significant difference between ED visits (p=0.20), renal testing (p=0.78), or eye exam referral (p=0.88) for either group. Patients enrolled in a specialized DME&C have improved HA1C when compared to non-enrolled counterparts, but may not receive improved screening services or visit the ED less frequently.
Racial Differences in Barriers to Antiretroviral Adherence
Takeda L. Freeman,
University of Alabama at Birmingham School of Public Health
Other Authors: K.E.Stewart, R. DeMasi and M.S. Saag
The advent of new, more potent antiretroviral medications has increased survival for many persons with HIV. Unfortunately, these new regimens require strict adherence if optimal viral suppression is to be maintained. Multiple types of barriers may inhibit perfect adherence. This study examined the relationship of patient perceived barriers and reported adherence, and explored whether racial or gender differences existed in perceived barriers. We conducted a cross-sectional analysis of a patient population of an ongoing prospective cohort study in an outpatient HIV clinic. We administered a computerized version of the Patient Medication Adherence Questionnaire (PMAQ), an instrument that measures adherence and perceived barriers. Adherence was defined as reporting no missed doses of medication within the last 4 weeks. Higher total barrier scores reflected more reported barriers.
For every five point increase in barrier score, there was a 37% increase in risk of being non-adherent, OR=1.37 (1.09, 1.71). When including race and/or sex in the model, there was minimal change in the association. Whites were more likely to report that medications were not convenient (p=0.02) and they were taking more medication than desired (p=0.014). Blacks reported having no storage place for medications (p=0.024), ceasing medications when feeling better (p=0.033), not taking medications when away from home (p=0.014), and they were embarrassed to get refills (p=0.019). These findings lend support to the argument that perceived barriers are affecting adherence behavior, and that education programs for HIV patients would benefit from addressing barriers to adherence specifically relevant to cultural groups.
Relationship Between Special Taxing Authority, Public Hospitals and Population Health Outcomes
Linda S. Gipson,
MSN, MBA, Doctoral Candidate, University of South Florida,College of Public Health
Other Author: James Studnicki, ScD, MBA, MPH
With the introduction of expanded insurance programs for poor children, changing management control of public hospitals and continued emphasis on public sector budget reduction, the need for local government health care special taxing authority has come under increasing scrutiny. Although the safety net provided by the public hospital has been described anecdotally, systematic analysis of its impact on the population health status has not previously been reported. This study examines the impact of locally assessed health care special tax revenues and publicly controlled hospitals on population health outcomes at the county level of analysis. Sixty seven Florida counties were characterized on the basis of the local investment in public health and compared relative to 116 key health outcome indicators for the period 1992-1996. Comparison of means was performed to identify relationships between public hospitals, special taxing districts, and health status of the county. Multivariate techniques were utilized to identify their relative contribution to the variations observed in health status. Finally, all short-term acute care general hospitals were categorized on the basis of ownership and control and their financial performance was analyzed.
A consistent pattern of association was observed between the existence of a public hospital and/or a special taxing district within a county and multiple dimensions of enhanced health status. Lower age-adjusted mortality was demonstrated for deaths from all causes, as well as for the major diseases of public health importance. Important differences were also observed in other areas, including trauma mortality, infectious disease morbidity and race specific outcomes.
Unmet Needs for Dental and Medical Care Among Patients with HIV
Kevin C. Heslin,
University of California at Los Angeles, School of Public Health
Other Authors: William E. Cunningham, MD, MPH; Marvin Marcus, DDS, MPH; Ian Coulter, PhD; James Freed, DDS, MPH; Claudia Der-Martirosian, PhD; Samuel A. Bozzette, MD, PhD; Martin F. Shapiro, PhD; and Ronald M. Andersen, PhD
Oral health conditions experienced by people with HIV are frequently more severe than those of the general population, making access to both dental and medical care crucial. Available evidence suggests that racial and ethnic minorities, women, and injection drug users with HIV have relatively greater unmet needs for medical care and dental care than do less disadvantaged groups. However, no previous study has distinguished patients with unmet needs for either dental or medical care alone from those who have unmet needs for both types of services. It is important to identify this latter group, because they may be at greater risk for the particular health problems related to poor access to adequate dental and medical care. Using a nationally representative probability sample of HIV-positive patients in the United States , this paper examines the correlates of unmet needs for dental care alone, for medical care alone, and for both dental and medical care. Multinomial logit regression shows that people of Alaskan Native, American Indian, Asian, Pacific Islander, or mixed racial background are more likely to report unmet needs for both dental and medical care than are whites. Of particular policy concern, the uninsured and those insured by Medicaid without dental benefits have more than three times the odds of unmet needs for both types of care than do the privately insured. To serve both the dental and medical needs of diverse populations affected by HIV disease, an expansion of state health insurance programs may be necessary.
Disease Risk in a Cohort of HTLV-I Infected Jamaican Children Followed for Nine Years
Elizabeth M. Maloney,
Uniformed Services University of the Health Sciences, National Cancer Institute, National Institutes of Health
Other Authors: Terry L. Thomas, Uniformed Services University; Barrie Hanchard, University of the West Indies; Paulette Palmer, University of the West Indies; Kevin Brooks, University of the West Indies; Sylvia Cohn, Research Triangle Institute; Jacqueline Murphy, Research Triangle Institute; and Angela Manns, National Cancer Institute
HTLV-I infection is known to be associated with infective dermatitis (ID), a disease with a mean age of onset of two years. However, HTLV-I prevalence has also been reported to be high (14%) among Jamaican patients with atopic eczema who had a mean age of 7 years. In a cohort of Jamaican children followed since birth, we sought to estimate the relative risk (RR) of illness associated with perinatally acquired HTLV-I infection, as well as the hematologic correlates of infection. This analysis was based on physical exam data obtained at clinic visits every six months from age 2.5 years through a maximum of 9 years. A total of 26 HTLV-I infected and 188 HTLV-I uninfected children comprise the study sub-cohorts. The risk of atopic eczema (>3 events) was significantly higher among the HTLV-I infected sub-cohort [RR = 3.18, 95% CI = 1.28-7.86), adjusted for sex and maternal income]. Additionally HTLV-I infected children had a significantly elevated risk of developing seborrheic dermatitis [RR = 7.31, 95% CI = 2.51-21.29)]. HTLV-I infection was significantly associated with low eosinophil count and lymphocytosis [OR = 2.51, 95% CI = 1.07-5.95; OR = 2.98, 95% CI = 1.07-8.29), respectively]. These data suggest that atopic eczema and seborrheic dermatitis may be additional disease outcomes associated with perinatally acquired HTLV-I infection.
Family and Environmental Factors Influencing Dietary Fat Intake as Perceived by Underserved African American Parents
Susie Nanney, MS, RD,
Saint Louis University School of Public Health
Other Authors: D. Haire-Joshu, PhD; R. Brownson, PhD; C. Houston, MS, RD
Associations between environmental factors and cancer risk are not well documented in young, underserved, African American parents, and may impact the outcome of dietary interventions in this high-risk group. The purpose of this presentation is to assess perceptions of participants in The High 5, Low Fat Program, designed to reduce cancer risk in African Americans by limiting dietary fat intake to 30% total calories. This ongoing study will test a dietary intervention on 1400 African American participants in a national parent education program, using a quasi-experimental, nested cohort design. We report baseline data from 457 parents (99% female, MN age=29) who completed a telephone survey. Measures included (1) a modified 60-item Block food frequency questionnaire, and (2) 5 Likert scale items, assessing perceptions of fat intake and cancer risk, and family and environmental influences on diet. Results indicated that in general, parents consume a high fat diet (MN=38% fat calories), believe fat intake is associated with risk for cancer (90%), and are very confident they can lower their fat intake (62%). Decisions to lower fat intake were most likely correlated with family traditions (55%), and environmental factors such as price (59%), and food availability (58%). We conclude that African American parents are aware of general links between diet and cancer, but may not personally recognize their ability to alter these dietary risks due to perceived family and environmental barriers. Interventions need to individualize dietary information and develop strategies that include family and environmental support of dietary change.
Agency/Client Relationships to Length of Stay in Home Health Care: A Multilevel Analysis
Karen E. Peters,
University of Illinois at Chicago School of Public Health
The location and magnitude of variability in length of stay (LOS) in home health care has important implications for addressing inequality and inefficiency in the delivery of such services. This paper examines the influence that organizational factors of home health care agencies have on average client length of stay, controlling for client characteristics using data from the 1992 National Home Health and Hospice Care Survey (NHHCS). Findings from random intercepts models using HLM indicate that approximately 29% of variance could be explained by agency level variables and being chain affiliated was marginally associated with reduced average LOS. These findings suggest that organizational form does result in some differences in average LOS (e.g. chain-affiliated agencies have shorter average LOS). Furthermore, the models developed to predict average length of stay behave similarly regardless of organizational form suggesting stability of the modeling process. Lastly, variables hypothesized a priori to be mutable to organizational level interventions (agency size, number of health staff) were not significantly associated with average length of stay in multivariate analysis, suggesting that agencies develop 'economies of scale' in their operations. If variation in health service delivery 'runs counter' to stated objectives for service provision, there is a need to consider policy or practice options to reduce the amount of variation. Policy changes and current reform must consider the impact on home care service provision because organizational arrangements such as chain affiliation may result in differential responses which may have unintended consequences for a number of stakeholders in the industry.
Applying Geographic Information Systems (GIS) Technology to Injury Research, Prevention, and Control
Stephen Strotmeyer, MPH, University of Pittsburgh Graduate School of Public Health
Unintentional exposure to carbon monoxide (CO) is a major environmental hazard leading to approximately 10,000 medically treated poisonings in the United States each year. This insidious public health problem deserves effective prevention/intervention efforts. This study demonstrates the utility of applying GIS technology to injury epidemiology research. Electronic mortality and morbidity data for Allegheny County during 1995 for unintentional CO poisonings was procured using the external-cause-of-injury code (E-code). ARCview 3.1 was used to create maps and conduct spatial analyses. Covariates representing median educational and income levels, housing and population densities were overlaid with the geographically referenced attribute data. Survey data sampling residents about CO detector installation were mapped and overlaid with the poisoning data to spatially assess high-risk municipalities for future intervention.
There were 20 fatalities and 44 hospitalizations resulting from CO poisonings in Allegheny County in 1995. Municipalities at highest risk for poisonings were concentrated in the east. These communities had the highest frequencies and rates. Several of these neighborhoods reported low levels of CO detector ownership, further increasing risk for unintentional CO poisonings. These results demonstrate a continuum of communities with concentrated CO poisonings, ideal for implementing an intervention. GIS applications enhance surveillance systems, improve risk factor identification, target intervention communities and assist in the evaluation program design. This geographic approach reestablishes the importance of place, allowing researchers to clearly visualize the clustering of adverse health events. Based on this analysis, a grant proposal was submitted for a prevention initiative intervention to reduce morbidity and mortality associated with CO poisonings.
Urban Sampling Frames Using City Directories
Jennifer J. Thompson,
University of Oklahoma Health Sciences Center
Other Author: David W. Smith, University of Oklahoma College of Public Health
In order to sample households in the relatively small inner city areas of Oklahoma City (OKC) with 4 zip codes and Tulsa with 6 zip codes where telephone ownership rates range from 75% to 94%, we evaluated city directories available on CD-ROM. These directories include all addresses and typically provide the name, telephone number, and other characteristics of the resident or business. We reviewed several commercial directories for ease of use. We selected one for further examination that included 32,471 residential listings in OKC and 38,727 in Tulsa , similar to the 1990 Census figures. Many listings had no name or phone number, 31% in OKC and 40% in Tulsa and another 13% in OKC had a name but no phone. To assess their eligibility, we randomly sampled and examined 1400 of these listings each in OKC and Tulsa .
In each city, 52% of the sampled listings were clearly inhabited homes while 27% (OKC) and 26% ( Tulsa ) were not inhabitable, including vacant lots, boarded up, condemned or burned buildings, businesses, and churches. The remaining 19% (OKC) and 22% ( Tulsa ) were inhabitable, including for rent, for sale, or vacant buildings. Directories vary in their ease of use for sampling since they are designed for commercial mailing. The selected directory has high coverage of residential buildings and permits easy selection of simple random samples with standard computer software.
Pharmacists and HIV Prevention: Attitudes and Practices Regarding the Sale of Syringes to Injection Drug Users
Emory University Rollins School of Public Health
Pharmacies represent a potentially convenient and reasonable location for injection drug users (IDUs) to obtain sterile syringes. However, state laws and pharmacy regulations, as well as pharmacists' attitudes and beliefs, may restrict IDUs' access to sterile syringes from pharmacies. This study examines how state laws, pharmacy regulations, and pharmacists' attitudes and beliefs influence syringe sale practices to IDUs. Semi-structured interviews were conducted with 29 pharmacists practicing in or near high drug use neighborhoods in Atlanta and with leaders of pharmacy professional organizations and schools of pharmacy. Data analysis involved systematic coding of all interviews and analysis of emergent themes. QSR NUD*IST was utilized for data management.
Results suggest that pharmacists generally support increasing IDUs' access to sterile syringes to reduce transmission of HIV/AIDS and other blood-borne pathogens. In practice, however, many pharmacists refrain from syringe sales to non-diabetics because they assume it is illegal. Additional factors influencing pharmacists' decision to sell syringes to IDUs include their professional education and training, perception of other pharmacies' practices, general attitude toward drug users, and concern for the economic success of their business. These findings suggest a willingness among Atlanta pharmacists to undertake HIV prevention through the sale of sterile syringes to drug injectors, provided that state and local policy changes are enacted to legalize and otherwise legitimize this practice.
Farm Residence Increases Risk of Hearing Loss Among Youth
Karen Varchol, Ohio State University School of Public Health
Other Authors: J.R. Wilkins III; G.L. Mitchel; H. Engelhardt; and T.A. Bean
As part of the NIOSH-funded Ohio Farm Family Health and Hazard Survey, specially-trained nurses conducted in-home health examinations of cash-grain farmers and family members. During visits to 503 farms in Ohio , several types of health data were collected, including pure-tone air conduction audiometric testing of both ears at 7 frequencies (0.5, 1, 2, 3, 4, 6, 8 kHz). Results presented are based on the audiometric testing of 211 farm-resident youth, aged 6-19. Analyses were designed to compare/contrast the auditory thresholds of the farm-resident children to those in the general population. Because the third National Health and Nutrition Examination Survey (NHANES III) provides the most recent audiometric estimates of hearing ability among youth in the United States , analyses compared the Ohio sample to 6166 children, aged 6-19, in the NHANES III sample. Frequency-specific mean Hearing Threshold Levels (HTLs, in decibels (dB)) were similar, except at 6 kHz, where the HTLs of the Ohio youth exceeded those of the NHANES III sample by nearly 6 dB (p<0.05). Additionally, pure-tone averages were calculated for both the low (0.05, 1, 2 kHz) and high frequencies (3, 4, 6 kHz), and hearing loss classified as: "normal" (HTL (15 dB), "slight" (HTL 16-25 dB), or "mild" (HTL (26 dB), with a relative risk (of slight or greater loss) of 1.87 (95% CI 1.46, 2.40). This difference persisted when analyses were conducted on an age- and sex-specific basis. These results therefore suggest that youth living on farms are at an increased risk of high frequency hearing loss.
Hazardous Chemical Database
Environmental Health Sciences Department, School of Public Health and Health Sciences, University of Massachusetts at Amherst
The purpose of the study was to create an Occupational Hazardous Chemical Database that will contribute towards a healthier and safer workplace. The database contains information on over 1600 chemicals, and will be continuously updated through downloading from a supplementary web site. The relational database was constructed in Microsoft Access. The informational table used by the database was compiled and sorted in Microsoft Excel. A supplementary web site where current information can be downloaded was created using Claris Homepage.
This database allows convenient and quick access to occupational health related data on over 1600 chemicals. The database is the most efficient means of acquiring health and safety information about these chemicals. It can be custom tailored to suit the specific needs of the occupational environment. The user of this database will be able to quickly model the concentrations of hazardous chemicals in air from a spill. From this information, it will be possible to project when it will be safe to reenter the work environment, and the amount of dilution ventilation needed to purge an area of the vapors produced by the spill.