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PubMed2006

Use of item response analysis to investigate measurement properties and clinical validity of data for the dynamic gait index.

BACKGROUND AND PURPOSE: The Dynamic Gait Index (DGI) is a standardized clinical assessment that aids in evaluating a subject's ability to modify gait in response to changing demands. The purpose of this study was to use Rasch measurement theory to examine whether the DGI rating scale meets suggested psychometric guidelines, whether the hierarchical order of DGI tasks is consistent with a clinically logical testing procedure, and whether the DGI represents a unidimensional construct. SUBJECTS: Subjects were 84 community-dwelling male veterans (age range=64-88 years; mean+/-SD=75+/-6.47 years). METHODS: Data were retrieved retrospectively from the participants' clinical records. The Rasch measurement model with the WINSTEPS program was used in this study because it offers distinct advantages over traditional psychometric approaches. RESULTS: Overall, the DGI showed sound item psychometric properties. Each of the original 4 rating scale categories appeared to distinctly identify subjects at different ability levels. The analysis revealed a clear item difficulty hierarchical order that is generally consistent with clinical expectations. In addition, fit statistics and principal components analysis indicated that the 8 items of the DGI appear to represent a single construct. DISCUSSION AND CONCLUSION: The results suggest that the rating scale of the DGI is used appropriately for community-dwelling older subjects with balance problems. The findings support the continued use of this well-constructed scale for clinical and research assessment in a community-dwelling population of older subjects.

Aged↗
PubMed1997

Human immunodeficiency virus risk awareness. Evaluation of a CME program for family physicians.

OBJECTIVE: To determine whether a continuing medical education (CME) program on AIDS risk awareness would enhance physicians' knowledge of HIV and AIDS, their "intent-to-change" practice behaviour, and their ability to integrate their knowledge into hypothetical clinical scenarios; and to identify participant characteristics that affect their knowledge of risks and how they intend to behave regarding HIV testing. DESIGN: Before-and-after study using a questionnaire. SETTING: The city of Winnipeg and 16 rural communities in Manitoba. PARTICIPANTS: Convenience sample of physicians who attended the AIDS Risk Awareness Program and completed a questionnaire before the presentation (96 of 142 eligible physicians). MAIN OUTCOME MEASURE: A two-point or greater change on a Likert scale in the desired direction for each questionnaire item. RESULTS: Physicians were classified as sensitized or less sensitized depending on previous experience with HIV-positive and AIDS patients. Less sensitized physicians significantly improved their scores in all three areas. Sensitized physicians and women physicians significantly improved their knowledge and reported more intent to ask patients routinely about HIV risk behaviours. Physicians' sex, age, religion, and years in practice had an effect on these improvements. CONCLUSIONS: The AIDS Risk Awareness Program was successful in improving physicians' knowledge, attitude to intent-to-change behaviour and ability to integrate knowledge into practice scenarios. Physicians with true learning needs benefited the most from the CME program.

Adult↗
PubMed2004

Integrated HIV prevention and care strengthens primary health care: lessons from rural Haiti.

Three decades ago, the world's ministries of health declared primary health care--the delivery of basic preventive and curative services--a top priority. Since then, however, the world's poorest countries have not met most primary health care goals. Twenty-six years after the Declaration of Alma Ata, we are said to be living in a time of "limited resources," a phrase that construes various health interventions as competing priorities. As HIV has become the leading infectious cause of adult death in much of the world, it is difficult to argue that AIDS prevention and care are not ranking priorities for primary health care, yet precisely such arguments have held sway among international health policy makers. We present new information emerging from the scale-up of an established and integrated AIDS prevention-and-care program, based initially in a squatter settlement in central Haiti, to a second site in rural Haiti. The program includes robust prevention efforts as well as community-based therapy for advanced AIDS; three related components--women's health and active case finding and therapy for tuberculosis and sexually transmitted infections--were central to this effort. We tracked changes in key indices over the 14 months following the introduction of these services to a public clinic in central Haiti. We found that integrated AIDS prevention and care, including the use of antiretroviral agents, to be feasible in resource-poor settings and that such efforts may have favorable and readily measured impact on a number of primary health care goals, including vaccination, family planning, tuberculosis case finding and cure, and health promotion. Other collateral benefits, though less readily measured, include improved staff morale and enhanced confidence in public health and medicine. We conclude that improving AIDS prevention and treatment can help to reinvigorate flagging efforts to promote universal primary health care.

Adult↗
PubMed2000

Benchmarking in health-system pharmacy: experience at Glens Falls Hospital.

The experience of Glens Falls Hospital (GFH) with the Benchmarking Program coordinated by The Clinical Pharmacokinetics Laboratory at Millard Fillmore Hospital is described. GFH, a community hospital in upstate New York with 442 licensed beds, serves a patient population drawn from a five-county area. In 1998, GFH developed a multidisciplinary pharmacy task force charged with generating strategic initiatives for curtailing drug costs. Proposals for various programs, including specific goals, were developed with the aid of trends reported in the individual hospital reports provided by the Benchmarking Program. The data obtained through these reports helped GFH's pharmacy staff establish goals for the appropriate use of many agents, including vancomycin, and allowed GFH to assess the impact of its initiatives through comparisons with similar hospitals across the United States. In 1995, vancomycin expenditures at GFH substantially exceeded those for benchmark hospitals of similar types, but, with the implementation of new vancomycin guidelines aimed at reducing inappropriate use in 1996, the difference was eliminated. The individual hospital reports generated by the Benchmarking Program provide valuable data that can be used to assess pharmacy performance, set drug expenditure goals, and design programs to reduce antimicrobial resistance.

Benchmarking↗
PubMed1993

The Kingston Project. III. The effects of high energy supplement and metronidazole on malnourished children rehabilitated in the community: morbidity and growth.

In the Kingston Project malnourished children referred from public health clinics to a metabolic ward were treated at home using community health aides within the existing health service. We have previously provided anthropometric results showing significantly greater gains in weight and length for groups given a high energy supplement (3.31 MJ daily) for 3 months during treatment, and greatest gains for a group treated with metronidazole at the beginning of supplementation [Heikens et al., Eur. J. Clin. Nutr. 43, 145-160 (1989); 47, 160-173 (1993)]. We now present findings on morbidity and relate these to the separate interventions and to growth velocities. Although referral was solely on nutritional criteria, 65% of the sample were found to have additional illnesses at enrollment. During the study period (6 months) upper respiratory tract infections (URTI) were the commonest illness in all groups; there were significantly more gastroenteric infections in the group given the supplement, but not the antibiotic, treatment; the children who received only the standard health service care were ill more often and for longer periods than children in the other groups. Diarrhoea, fever and dysentery prevalences were all found to relate significantly to weight velocity, and although prevalences differed between treatment groups, the detrimental effect on velocity was similar whichever the group.

Child, Preschool↗
PubMed2002

Bridge to dentistry: one dental school's approach to improving its enrollment of underrepresented minorities.

Presently, 25.7% of the U.S. population is comprised of Blacks/African Americans, Hispanics, and Native Americans. The dental school enrollment of underrepresented minorities (URM) does not reflect this demographic distribution. In 1994, URM students comprised 12.68% of enrolled dental students, but in 1999, enrollment decreased to 10.53%. This trend is evident at Baylor College of Dentistry (BCD). Bridge to Dentistry involves formal linkages with local school districts, Texas colleges and universities, community organizations, dental clinics, community dentists, and BCD. The program is unique in that it targets students from kindergarten through dental school. The key components are awareness, attraction, preliminary education, facilitated-entry, admissions, financial aid, and retention. Some important features of the program are visits to area schools, visits to colleges and universities, summer enrichment programs, and academic advising. Preliminary results indicate the effectiveness of the program. BCD has increased its enrollment of URM students 325% over that of 1998. In 1998, 4.7% of the college's first-year student enrollment was URMs. In 2001, 14.6% of Baylor's first-year student enrollment was URMs. Since 1995, BCD has retained 90.6% of its URM students.

Black or African American↗
PubMedDate not supplied

An evaluation of community-based HIV services for women in New York State.

The proportion of women in New York State diagnosed with acquired immune deficiency syndrome (AIDS) is increasing dramatically. In 1987, only 12% of cumulative AIDS cases in New York were among women; by 1993, 26% of new cases of AIDS were. This evaluation describes community-based HIV programs that provide services to women in New York State and are funded by the State Department of Health's AIDS Institute. The evaluation assesses the success different programs have had in reaching and engaging women. It also describes the problems organizations face in serving their target populations. Four sets of data were collected and analyzed to assess the care being received by female clients. Programs appear to be reaching women who are human immunodeficiency virus (HIV) positive or at high risk of HIV infection, and once engaged, female clients find the services helpful. However, agencies report difficulties in finding and using the strategies that are most effective with women. Agencies appear to do a better job of addressing their female clients' economic needs than those related to gender, such as reproductive health care, family services, and access to clinical trials.

Adolescent↗
PubMed1989

HIV infection and pregnancy.

Although coexistent HIV infection and pregnancy are still rare in most communities, as the prevalence of HIV and AIDS continues to rise, the practicing physician can expect to see this more frequently. The internist plays a crucial role in educating these patients as to the importance of "safe sex" practices and pregnancy prevention. As with any complex medical problem, once pregnant, these patients are best managed with a team approach, involving the obstetrician, internist, neonatologist, and social worker.

Acquired Immunodeficiency Syndrome↗
PubMed2004

HIV risk and prevention in a post-vaccine context.

Initial HIV vaccines are likely to be only partially efficacious; increased risk behaviors in response to future HIV vaccine availability have the potential to subvert the effectiveness of vaccines in controlling the AIDS epidemic. To assess attitudes, beliefs and behavioral intentions in response to hypothetical availability of FDA-approved HIV vaccines, we conducted 9 focus groups among participants (N = 99; median age = 33 years; 48% female; 22% African American, 44% Latino, 28% White) recruited from STD clinics, needle exchange programs, and Latino community based health organizations, using purposive, venue-based sampling, and interviewed 9 key informant service providers. Data were analyzed using narrative thematic analysis and Ethnograph qualitative software. Participants predicted a "lightening up" of safer sex behaviors among at least half of their peers and, to a lesser extent, a relaxing of safer needle use practices in response to HIV vaccine availability. Both participants and providers urged HIV preventive interventions that: (1) provide education and awareness regarding partial efficacy vaccines, (2) combat the belief in an HIV vaccine as a "magic bullet," and (3) stressed the need for sustained behavioral risk reduction interventions in the face of continued HIV risk and other STDs.

AIDS Vaccines↗
PubMedDate not supplied

Can evidence change the rate of back surgery? A randomized trial of community-based education.

CONTEXT: Timely adoption of clinical practice guidelines is more likely to happen when the guidelines are used in combination with adjuvant educational strategies that address social as well as rational influences. OBJECTIVE: To implement the conservative, evidence-based approach to low-back pain recommended in national guidelines, with the anticipated effect of reducing population-based rates of surgery. DESIGN: A randomized, controlled trial. SETTING: Ten communities in western Washington State with annual rates of back surgery above the 1990 national average (158 operations per 100,000 adults). PARTICIPANTS: Spine surgeons, primary care physicians, patients who were surgical candidates, and hospital administrators. INTERVENTION: The five communities randomized to the intervention group received a package of six educational activities tailored to local needs by community planning groups. Surgeon study groups, primary care continuing medical education conferences, administrative consensus processes, videodisc-aided patient decision making, surgical outcomes management, and generalist academic detailing were serially implemented over a 30-month intervention period. OUTCOME MEASURE: Quarterly observations of surgical rates. RESULTS: After implementation of the intervention, surgery rates declined in the intervention communities but increased slightly in the control communities. The net effect of the intervention is estimated to be a decline of 20.9 operations per 100,000, a relative reduction of 8.9% (P = 0.01). CONCLUSION: We were able to use scientific evidence to engender voluntary change in back pain practice patterns across entire communities.

Education, Medical, Continuing↗
PubMed1994

Parameters to aid in the design and analysis of community trials: intraclass correlations from the Minnesota Heart Health Program.

Community trials involve the assignment of intact social groups to study conditions and are becoming increasingly common in epidemiologic research. In both the design and analysis of these studies, whether cross-sectional or cohort, allowance must be made for the dependence of elements within intact groups if variances are to be properly estimated. In the design phase, the statistician needs estimates of the level of dependence likely to be encountered. In the analysis phase, external estimates of the level of dependence may be useful in preventing the erosion of power associated with small numbers of intact groups assigned to each condition. We report the intraclass correlation coefficients of the city-year component of variance as estimated in the Minnesota Heart Health Program for a variety of community survey variables and illustrate their use in both design and analysis. Of 23 variables assessed, all but two showed positive estimates of city-year intraclass correlations. In these data, estimates of intraclass correlation coefficients generally were in the range 0.002-0.012.

Analysis of Variance↗
PubMed1990

Community awareness and utilization of growth chart in a semi-urban Nigerian community.

Five hundred and eighteen mothers resident in Adeta, Sawmill and Baboko Communities of Ilorin Local Government Area of Kwara State, Nigeria, were interviewed to assess their knowledge, utilization, and understanding of the growth chart. Five health facilities in the communities studied were visited to assess the availability, utilization and understanding of growth charts by health workers. Over half (53.7%) of the mothers interviewed have heard about growth charts. The level of awareness was significantly influenced by maternal age, educational status and parity (PLO.OS). Of those who have heard about growth chart, only 155 (55.8%) have it, and 150 of these (96.8%) use it regularly. One hundred and seventy four (33.6%) of all mothers, but 62.6% of those who have heard about the chart demonstrated an understanding of the markings on it. One hundred and sixteen mothers found the growth chart useful for immunization record, nutrition advice, clinic appointment dates, and assessment of developmental milestones. Two of the five health facilities visited had, and used growth charts. The health workers, however, demonstrated a clear understanding of weighing, plotting, and interpretation of the chart, and gave appropriate advice to mothers. Ways of improving growth monitoring in the community using the growth chart are suggested.

Adult↗
PubMed2006

The rationale of interorganizational linkages to connect multiple sites of expertise, knowledge production, and knowledge transfer: an example from HIV/AIDS services for the inner city.

This paper presents the rationale for a long-running project in which various community-based and tertiary-based providers are being linked to each other in order to understand, reach, and engage high-risk, hard-to-reach inner-city residents for prevention, treatment, and management of HIV/AIDS. Not simply a program to link disparate actors, the work has developed into a more fundamental approach through which to build and maintain the infrastructure required to generate and sustain knowledge development and integration within and between systems. This work is grounded in the recognition that each type of provider, as well as patients and clients themselves, has a particular type of expertise. All forms of expertise are necessary to fight HIV/ AIDS. Different forms of expertise are necessary to diagnose, treat, prevent, and cure HIV/AIDS and its sequelae. This work suggests revisions in traditional approaches to expertise and to the content and geometry of dissemination networks, and ultimately challenges the very concepts of dissemination and the lay/scientific boundary.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Effectiveness of counseling in the health promotion of HIV-positive clients in the community.

The purpose of this study was to examine the effects of a nurse's counseling intervention on high-risk sexual behaviors of HIV-positive patients and to explore the relationship of gender, race, age, and education to high-risk sexual behaviors. A convenience sample of 20 adults who were newly diagnosed with HIV and were being treated at an inner-city out-patient clinic was used. Subjects were administered a questionnaire to determine their precounseling AIDS knowledge and precounseling sexual behaviors. A registered nurse then counseled them about safe-sex practices. After 2-3 months the questionnaire was readministered to determine the effects of counseling on AIDS knowledge and high-risk sexual behaviors. Although statistical analysis indicated a significant main effect for change in high-risk sexual behaviors after counseling, there were no significant relationships among change and the individual demographic variables of age, gender, race, and education. Pretest knowledge was not found to influence pretest behavior, nor was posttest knowledge found to affect posttest behavior. Paired t tests indicated a significant change in high-risk sexual behavior scores after counseling but no significant change in knowledge scores.

Adult↗
PubMed1997

Lack of positive outcomes from a cognitive-behavioral HIV and AIDS prevention intervention for inner-city men: lessons from a controlled pilot study.

African American men are at increasingly high risk for HIV infection, but there have been few studies of HIV risk reduction interventions for heterosexual ethnic minority men. The present study randomly assigned 81 African American men to one of two HIV prevention interventions: a four-session cognitive-behavioral skills training HIV risk reduction intervention that has been successful with other populations or a four-session HIV risk education and sensitization control condition. Men were assessed at baseline, at immediate postintervention, and at a 3-month follow-up. Forty-five percent of participants dropped out of the intervention; dropouts were younger, more likely to have used condoms, and less likely to have been tested for HIV antibodies than men who completed the study. Outcome analyses showed that both interventions significantly increased AIDS-related knowledge, initial intentions to change HIV risk behaviors, and reduced unprotected vaginal intercourse. However, there were no significant differences between groups on any of the measures at postintervention or follow-up assessments. Recognizing the limitations of our small sample size, the results of this initial study caution against generalizing skills training HIV prevention interventions that have been successful with other populations to African American heterosexual men.

Adult↗
PubMed1997

Assessing the impact of HIV risk reduction counseling in impoverished African American women: a structural equations approach.

We assessed changes in cognitive, psychological, and risky behavior latent variables after traditional or specialized AIDS education after 2 years using structural equation modeling (SEM) in a sample of impoverished at-risk African American women (N = 300). Both groups reported significant improvement at 2 years in their self-esteem and social resources. They also reported less threat perception, avoidant coping, emotional disturbance, HIV risk behavior, and drug use behavior. There was an advantage to specialized group membership. When compared with the traditional group at 2 years, women in the specialized group reported enhanced social resources, reduced emotional distress, less use of an avoidant coping style, and less drug use. We discuss advantages of culturally sensitive HIV risk reduction programs and the importance of connecting women with social services in their communities.

Adaptation, Psychological↗