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PubMed1994

Ethics, epidemiology, and women's health.

Ethical issues arise throughout the conduct of epidemiologic studies, in the processes of determining the study question, designing the protocol, and implementing the study. There also is an ethical dimension when studies are not done, for example, in studies of the effect of drugs and chemicals on male reproductive capacity. Harm as well as risk must be considered in the conduct of epidemiologic studies. The ethical principles that govern research, while independently justifiable, may come into conflict. Principles that govern research also may conflict with those that predominate in clinical practice. An example is the current controversy over unblinding anonymous, newborn human immunodeficiency virus seroprevalence studies to identify potentially infected infants. As women's health becomes more prominent on the research agenda, the resolution of these conflicts will become a complex challenge to epidemiologists, ethicists, clinicians, and the communities they serve.

AIDS Serodiagnosis↗
PubMed2007

Does multidisciplinary rehabilitation benefit whiplash recovery?: results of a population-based incidence cohort study.

STUDY DESIGN: Population-based, incidence cohort. OBJECTIVES: To evaluate a government policy of funding community and hospital-based fitness training and multidisciplinary rehabilitation for whiplash. SUMMARY OF BACKGROUND DATA: Although insurance benefits commonly include rehabilitation for whiplash, its effectiveness is unknown. METHODS: All Saskatchewan adults treated for whiplash (n = 6,021) over a 2-year period were followed up at 6 weeks, 3, 6, 9, and 12 months. Recovery was defined by self-report of improvement. Recovery times were compared between those attending fitness training at health clubs (n = 833), multidisciplinary outpatient rehabilitation (n = 468), and multidisciplinary inpatient rehabilitation (n = 135) to those receiving usual insured individual care. RESULTS: Recovery was 32% slower in those receiving fitness training within 69 days of injury (P = 0.001) and 19% slower when received within 119 days of injury (P = 0.041). Recovery was 50% slower in those receiving outpatient rehabilitation within 119 days of injury (P = 0.001). Attending inpatient rehabilitation did not influence recovery rates during the follow up (P = 0.131). Multivariable adjustment for important prognostic factors did not change these results. CONCLUSIONS: We found no evidence to support the effectiveness of a population-based program of fitness training and multidisciplinary rehabilitation for whiplash. Rehabilitation programs should be tested in randomized trials before being recommended to injured populations.

Adult↗
PubMed2006

Randomized trial of the Early Start program of home visitation: parent and family outcomes.

OBJECTIVE: To examine the extent to which the Early Start program of home visitation had beneficial consequences in the areas of maternal health, family functioning, family economic circumstances, and exposure to stress and adversity. METHODS: The study used a randomized, controlled trial design in which 220 families receiving the Early Start program were contrasted with a control series of 223 families not receiving the program. Families were enrolled in the program after population screening conducted by community health nurses. Families were enrolled in the program for up to 36 months. Outcomes were assessed at 6, 12, 24, and 36 months after trial entry. RESULTS: There was a consistent lack of association between maternal and family outcomes and group membership. There were no significant differences between the Early Start and control series in any comparisons. CONCLUSIONS: This evaluation suggested that the Early Start program failed to lead to parent- and family-related benefits. This absence of benefit for parent/family outcomes is contrasted with the benefits found previously for child-related outcomes, including child health, preschool education, child abuse and neglect, parenting, and behavioral adjustment. This comparison suggests that home visitation programs may provide benefits for child-related outcomes in the absence of parent- or family-related outcomes.

Child Welfare↗
PubMed2004

[Weight-control intervention in overweight subjects at high risk of cardiovascular disease: a trial of a public health practical training program in a medical school].

OBJECTIVE: To evaluate the effectiveness of a weight-control intervention for overweight subjects at high risk of cardiovascular disease (CVD) at a worksite conducted by medical students as a public health practical training program. METHODS: A total of 45 men and women who were obese (BMI > or = 24.0 kg/m2) and found to be hypertensive (SBP > or = 140 mmHg or DBP > or = 90 mmHg) or suffering from hypercholesterolemia (total serum cholesterol > or = 220 mg/dl) in an annual health check up in November 2001 were invited to participate in a weight-control intervention program. Eight individuals agreed (intervention group) and other sixteen control subjects whose sex and age (+/- 3 years) were matched to the intervention subjects were selected. The duration of the program was three months (from July to October 2002) and a 2 kg weight reduction in that period was set as the goal. The baseline survey consisted of a dietary questionnaire and a health quiz. Subjects had two counseling sessions and received four personal letters in the three months. A semi-quantitative food frequent questionnaire, a photograph method (Diet Agent Service, Matsushita Electric Works, Ltd.) and three day food records were conducted for dietary surveys. Changes in bodyweight, BMI, blood pressure, and serum total cholesterol concentration from November 2001 to November 2002 were compared between the intervention and control groups. Food group intakes and nutrient intakes were compared between weight reduction achievers and non-achievers. RESULTS: Mean bodyweight changes from November 2001 to November 2002 were -2.3 kg (SD 3.3 kg) for the intervention group and +0.3 kg (SD 1.5 kg) for the control group, the difference being significant (p = 0.013). For the intervention group mean bodyweight change from July to October 2002 was -1.5 kg (SD 2.4 kg). For total serum cholesterol, the mean changes were -32.1 mg/dl vs. +0.5 mg/dl (p = 0.005), for SBP -9.5 mmHg vs. +4.7 mmHg (p = 0.083) and for DBP -2.8 mmHg vs. +1.4 mmHg (p = 0.438). These were thought to be consequences of weight-control intervention. From dietary surveys, weight reduction achievers increased fish intake and decreased fats, snacks and sweets. Those who answered the health quiz more correctly demonstrated more reduction of bodyweight. CONCLUSIONS: Effectiveness of a weight-control intervention for reduction of CVD risk factors was found in the present public health practical training program for medical students. Dietary advice based on various dietary surveys was indicated to be effective in the weight-control program. A population strategy to distribute health information appeared necessary for effective health education programs for high-risk subjects.

Cardiovascular Diseases↗
PubMedDate not supplied

Preventing out-of-home placement for high-risk children.

Preventing the removal of high-risk children from their families is investigated through two community-based programs. One program followed a day treatment model; the other used a home-based approach. These programs treated populations that shared common features but also had important differences. In both programs, a high percentage of children were maintained in the home and were still at home one year after discharge. It is suggested that such community-based intervention programs enhance the likelihood that high-risk children can remain with their families.

Adolescent↗
PubMedDate not supplied

[Complementary echo flow imaging and digital angiography in the supra-aortic area for indication and intervention of carotid revascularization in 1587 subjects in the OPI (Stroke Prevention) program].

The availability of non invasive carotid ultrasound imaging techniques actually allows planning and carrying on of large screening programs for detection of atherosclerotic carotid occlusive disease. The aim of non invasive ultrasound patient selection is to limit the practice of invasive carotid angiography only to patients for whom carotid endarterectomy is likely to be a therapeutic choice. PURPOSE. Testing the efficacy of sequential use of color coded echo flow imaging (echo color Doppler: ECD) and arterial digital angiography (ADA) respectively in the second and third phases of a screening program for detection and treatment of carotid occlusive disease in a resident population (OPI program). METHODS. From January 29th 1990 through March 31st 1992, 1,587 subjects underwent ECD out of 16,379 subjects that participated in the first level investigations. 404 of these (25.5%) were affected with carotid occlusive disease, 271 (17%) had inframural non stenosing carotid lesions and 228 (14.3%) carotid kinkings. At ECD, 71 showed lesions as severe as to be susceptible of surgical operation and underwent ADA. The percentage of carotid stenosis was calculated on the ADA imagins, applying the method suggested by the North American Symptomatic Carotid Endarterectomy Trial. RESULTS. Overall sensitivity and specificity of ECD versus ADA were 94% and 95.2% respectively. Cases in which ECD overestimated the lesion as compared to ADA results were recorded as false positive, while cases in which ECD underestimated the lesion were recorded as false negative. CONCLUSIONS. Both ultrasound imaging and ADA are useful in screening programs for carotid occlusive disease: informations different and complementary to the definition of the lesions can be obtained from each procedures in subsequent phases. Morphologic findings of carotid ECD are essentially consistent with ADA, thus allowing to carry on safely non invasive long-term follow-up programs for operated subjects as well as for people bearing carotid lesions originally not susceptible of surgical treatment.

Aged↗
PubMedDate not supplied

Reaching poor populations with cancer prevention and early detection programs.

The American Cancer Society (ACS), Philadelphia Division, through its Nurses' Education Committee (NEC), accepted the challenge to provide cancer prevention and early detection programs to several culturally diverse populations to directly reach the underserved, the working poor, and healthcare professionals who care for the poor. Populations selected included (1) students enrolled in nursing-assistant programs, (2) committed members of the ACS's NEC, (3) registered nurses employed by the local department of public health, and (4) a group of female immigrants from Russia.

Female↗
PubMed1999

A job-satisfaction measure for internal medicine residency program directors.

PURPOSE: To develop a job-satisfaction measure that encompasses the multifaceted job of internal medicine residency program directors. METHOD: Questions were devised to measure program directors satisfaction with various facets of their jobs. In 1996, the authors surveyed all non-military internal medicine program directors in the United States. RESULTS: Of the program directors surveyed, 301 (78%) responded. More respondents than non-respondents held the title of department chairperson in addition to the title of program director (22% vs 7%). Factor analysis and correlation analysis yielded a multifaceted measure (termed PD-Sat) composed of 20 questions and six facets (work with residents, colleague relationships, resources, patient care, pay, and promotion) that made sense based on literature review and discussions with program directors (face validity). The PD-Sat had good internal reliability (Cronbach's alpha = .88), as had each of its six facets (Cronbach's alphas = .60-.90). The six facets correlated modestly with one another (Pearson's r2 = .12-.67), suggesting they were measuring different aspects of a common concept. The PD-Sat correlated significantly with an established four-question global job-satisfaction scale used in previous studies (Pearson's r2 = .33) demonstrating concurrent validity. Scores on the PD-Sat predicted whether program directors were considering, seeking, or making a job change (predictive validity). The PD-Sat performed comparably well in subsets of program directors who were and were not department chairs, suggesting that it might be applicable to different populations of program directors. CONCLUSION: The authors have developed a new facet-specific job-satisfaction measure that is reliable and valid for assessing the job satisfaction of internal medicine program directors. Because job descriptions for program directors in other specialties are similar, it may also be useful in these populations.

Adult↗
PubMed2004

Assessing multiple risk behaviors in primary care. Screening issues and related concepts.

The concept of behavioral risk refers to health behaviors that increase the likelihood of a variety of illness conditions. With increased scientific research, it has become clear that this concept is useful in understanding the linkage between behavior and health. This paper reviews scientific, conceptual, and practical issues related to the identification of health risk behaviors in primary care. It includes both a literature review and an analysis of the feasibility of screening and health risk appraisal from a public health perspective, giving special attention to four behavioral risk factors: cigarette smoking, alcohol misuse, physical inactivity, and unhealthy diet. The review indicates that there are a wide variety of acceptable screening tests that can be used for population screening programs, and a large number of health risk appraisal instruments to employ in medical and work settings where preventive health services are available. Given the variety of available assessment procedures, the choice of a given instrument will depend on the target population, the purpose of the program, the time available for assessment, and a number of other practical considerations, such as cost. Multiple risk factor screening is feasible, but there is no single instrument or procedure that is optimal for all risk factors or populations. Based on the results of this review, the specific test or combination of tests is less important than the use of screening to make both patients and healthcare providers more aware of the critical importance of monitoring behavioral risk factors on a routine basis. We conclude that while further research and development work needs to be done, sufficient progress has been made to warrant a more ambitious effort that would bring behavioral risk factor screening into the mainstream of preventive medicine and public health.

Alcohol Drinking↗
PubMed2002

Development and use of a population based injury surveillance system: the all Wales Injury Surveillance System (AWISS).

This report details the development and use of a population based emergency room surveillance system in the UK. Despite some difficulties in accessing high quality data the system has stimulated a considerable number of research and intervention projects. While surveillance systems with high quality data collection and coding parameters remain the gold standard, imperfect systems, particularly if population based, can play a substantial part in stimulating injury prevention initiatives.

Accident Prevention↗
PubMed1986

Patterns of dyslipoproteinemia in selected North American populations. The Lipid Research Clinics Program Prevalence Study.

This article describes the assignment of dyslipoproteinemia (DLP) in several free-living North American populations and presents mean lipid and lipoprotein levels for each type. Dyslipoproteinemic phenotypes were assigned by a modified version of the National Institutes of Health (Fredrickson) phenotyping system. Criteria for assigning phenotypes included age- and sex-specific 5th and 95th percentiles for low-density lipoprotein and high-density lipoprotein cholesterol and total triglyceride, as well as other qualitative and quantitative criteria. Phenotypes IIb, III, I, and V were uncommon, confirming clinical impressions of their frequency. Lipid and lipoprotein levels in specific phenotypes were generally as expected. In the type III phenotype, however, mean cholesterol and triglyceride levels were surprisingly low. Gonadal hormone use, in the form of both oral contraceptives and postmenopausal estrogens, was reported in approximately 30% of women in these populations and was associated with dramatic differences in the frequency of DLP when compared with women not taking hormones. In general, these differences reflected the previously described effects of estrogen and progestins on lipoprotein levels. These data gathered in free-living populations: confirm clinical impressions of the rarity of some phenotypes, focus attention on those phenotypes in which diminished rather than elevated lipoproteins are found, and provide further evidence of the effect of hormones on lipid and lipoprotein levels.

Adolescent↗
PubMed2003

Hindrances to family planning program: findings from Banke, Nepal.

Reducing population growth through programs is a high priority for many developing countries. Why particularly in the rural regions of these countries, do these initiatives fail? Using a case study of a recent initiative in rural Nepal between 1998 and 2002 as an example, this opinion piece discusses possible reasons for such failure and recommends that a broader strategic approach is necessary, particularly in relation to empowering women in these communities. Banke district, Nepal, is mainly rural, consisting of 47 villages. Scarcity of family planning provisions is a dominant problem in most parts of the district. District Public Health Office (DPHO), the major family service provider lacks resources and technical capabilities. In recent years, non-government organizations (NGOs) have been collaborating and coordinating their efforts with DPHO in order to cover the larger section of the district population. A local NGO called Banke Mahila Arthick Swawlamban Sangathan (BMASS) provided family planning services in 5 of the 47 villages of Banke district, Nepal, from 1998 through 2002. Outreach activities and clinical services were the two major components of BMASS family planning program. Outreach activities included door-to-door/mass counseling, street drama, and condom distribution. Clinical services that included counseling, testing, temporary sterilization, and referrals for permanent sterilization were provided through a centrally located static clinic and mobile clinics. BMASS family planning program had almost no impact in the target villages. There was no significant increase in contraceptive use, people's motivation to limit fertility, and number of people preferring a smaller family size. The contraceptive prevalence rate increased by less than 2% after 2 years of family planning program intervention. More than 80% of the family planning clients were reported to have discontinued contraceptive use within six months. The mean age of women at the time of first child delivery (16.2 years), total fertility rate (six children per woman), and the birth intervals (13-18 months) were reported to be the same for both periods: before and two years after family planning program intervention. Further assessment of the local factors revealed that women's lack of control over fertility and higher number of desired children could have hindered the community's response to BMASS family planning program. In the target villages a woman's fertility is dependent upon the preference of husbands and in-laws. The women in general are not empowered to voice their opinion with regards to delaying fertility, spacing child-births, and limiting the number of children to be born to them. Higher number of desired children in the target villages is the outcome of low cost of child rearing and high benefits from the children. Children not only contribute significantly in household economy and provide old age security to their parents, but also consume less. To be effective, family planning programs need to be integrated into broader societal reforms that address rural economic development and the role of women in society.

Journal Article↗