The influence of propoxyphene withdrawal on opioid use in veterans.

PURPOSE: Our aim is to determine if propoxyphene withdrawal from the US market was associated with opioid continuation, continued chronic opioid use, and secondary propoxyphene-related adverse events (emergency department visits, opioid-related events, and acetaminophen toxicity). METHODS: Medical service use and pharmacy data from 19/11/08 to 19/11/11 were collected from the national Veterans Healthcare Administration healthcare databases. A quasi-experimental pre-post retrospective cohort design utilizing a historical comparison group provided the study framework. Logistic regression controlling for baseline covariates was used to estimate the effect of propoxyphene withdrawal. RESULTS: There were 24,328 subjects (policy affected n = 10,747; comparison n = 13,581) meeting inclusion criteria. In the policy-affected cohort, 10.6% of users ceased using opioids, and 26.6% stopped chronic opioid use compared with 3.8% and 13.5% in the historical comparison cohort, respectively. Those in the policy-affected cohort were 2.7 (95%CI: 2.5-2.8) and 3.2 (95%CI: 2.9-3.6) times more likely than those in the historical comparison cohort to discontinue chronic opioid and any opioid use, respectively. Changes in adverse events and Emergency Department (ED) visits were not different between policy-affected and historical comparison cohorts (p > 0.05). CONCLUSIONS: The withdrawal of propoxyphene-containing products resulted in rapid and virtually complete elimination in propoxyphene prescribing in the veterans population; however, nearly 90% of regular users of propoxyphene switched to an alternate opioid, and three quarters continued to use opioids chronically.

Cross-sectional study to assess the association of population density with predicted breast cancer risk.

The Gail and CARE models estimate breast cancer risk for white and African-American (AA) women, respectively. The aims of this study were to compare metropolitan and nonmetropolitan women with respect to predicted breast cancer risks based on known risk factors, and to determine if population density was an independent risk factor for breast cancer risk. A cross-sectional survey was completed by 15,582 women between 35 and 85 years of age with no history of breast cancer. Metropolitan and nonmetropolitan women were compared with respect to risk factors, and breast cancer risk estimates, using general linear models adjusted for age. For both white and AA women, tisk factors used to estimate breast cancer risk included age at menarche, history of breast biopsies, and family history. For white women, age at first childbirth was an additional risk factor. In comparison to their nonmetropolitan counterparts, metropolitan white women were more likely to report having a breast biopsy, have family history of breast cancer, and delay childbirth. Among white metropolitan and nonmetropolitan women, mean estimated 5-year risks were 1.44% and 1.32% (p < 0.001), and lifetime risks of breast cancer were 10.81% and 10.01% (p < 0.001), respectively. AA metropolitan residents were more likely than those from nonmetropolitan areas to have had a breast biopsy. Among AA metropolitan and nonmetropolitan women, mean estimated 5-year risks were 1.16% and 1.12% (p = 0.039) and lifetime risks were 8.94%, and 8.85% (p = 0.344). Metropolitan residence was associated with higher predicted breast cancer risks for white women. Among AA women, metropolitan residence was associated with a higher predicted breast cancer risk at 5 years, but not over a lifetime. Population density was not an independent risk factor for breast cancer.

The evaluation of Arkansas Act 1220 of 2003 to reduce childhood obesity: conceptualization, design, and special challenges.

This article describes the evaluation of the Arkansas Act 1220 of 2003, a comprehensive legislative proposal to address the growing epidemic of childhood obesity through changes in the school environment. In addition, the article discusses specific components of the evaluation that may be applicable to other childhood obesity policy evaluation efforts. The conceptual framework for the evaluation, research questions, and evaluation design are described, along with data collection methods and analysis strategies. A mixed methods approach, including both quantitative (surveys, telephone interviews) and qualitative (key informant interviews, records reviews) approaches, was utilized to collect data from a range of informant groups including parents, adolescents, school principals, school district superintendents, and other stakeholders. Challenges encountered with the evaluation are discussed, as are strategies to overcome those challenges. Now in its 9th year, this evaluation has documented substantial changes to school policies and environments but fewer changes to student and family behaviors. The evaluation may inform the methods of other evaluations of childhood obesity prevention policies, as well as inform policymakers about how quickly they might expect implementation of such policies in their own states and localities and anticipate both positive and adverse outcomes.

Creating and using index scores in the analysis of school policy implementation and impact.

BACKGROUND: Epidemic increases in childhood obesity and associated health risks are resulting in efforts to implement school policies related to nutrition and physical activity (NPA). With multicomponent policy efforts, challenges exist in characterizing the extent of policy change across the breadth of NPA policies. METHODS: Aggregated policy indices were created to characterize NPA policy implementation in Arkansas public schools from 2004 through 2009. Index scores are presented by year, domain, and school level. RESULTS: Both mean and median index scores increased over time, with greater changes seen in nutrition than in physical activity policy scores. The composite index score was heavily dependent on the nutrition index score and, thus, is relatively less useful for the purposes of our evaluation. Policy index scores varied by school level, rurality, enrollment size, and percentage of students eligible for federal meal programs. CONCLUSIONS: The policy index approach facilitates the consideration of the effect of school policy change in a holistic, aggregated way. School characteristics influence policy adoption, and thus, should be taken into consideration in the promotion of policy change.

Public policy versus individual rights in childhood obesity interventions: perspectives from the Arkansas experience with Act 1220 of 2003.

Childhood obesity is a major public health problem. Experts recommend that prevention and control strategies include population-based policies. Arkansas Act 1220 of 2003 is one such initiative and provides examples of the tensions between individual rights and public policy. We discuss concerns raised during the implementation of Act 1220 related to the 2 primary areas in which they emerged: body mass index measurement and reporting to parents and issues related to vending machine access. We present data from the evaluation of Act 1220 that have been used to address concerns and other research findings and conclude with a short discussion of the tension between personal rights and public policy. States considering similar policy approaches should address these concerns during policy development, involve multiple stakeholder groups, establish the legal basis for public policies, and develop consensus on key elements.

Development and evaluation of the school cafeteria nutrition assessment measures.

BACKGROUND: Foods provided in schools represent a substantial portion of US children's dietary intake; however, the school food environment has proven difficult to describe due to the lack of comprehensive, standardized, and validated measures. METHODS: As part of the Arkansas Act 1220 evaluation project, we developed the School Cafeteria Nutrition Assessment (SCNA) measures to assess food availability in public school cafeterias (n = 113). The SCNA provides a measure to evaluate monthly school lunch menus and to observe foods offered in school cafeterias during the lunch period. These measures provide information on the availability of fruit, vegetables, grains (whole or white), chips (reduced fat or regular), side dishes, main dishes, beverages, à la carte selections, and desserts, as well as information on healthier preparation of these items. Using independent raters, the inter-rater reliability of the measure was determined among a subsample of these schools (n = 32). RESULTS: All food categories assessed, with the exception of the side dish and chip categories, had inter-rater reliability rates of 0.79 or greater, regardless of school type. The SCNA scores encompassed the majority of the possible scores, indicating the ability for the measures to differentiate between school cafeterias in the availability of healthier options. CONCLUSION: These measures allow comprehensive, rapid measurement of school cafeteria food availability with high inter-rater reliability for public health and school health professionals, communities, and school personnel. These measures have the potential to contribute to school health efforts to evaluate cafeteria offerings and/or the impact of policy changes regarding school foods.

Establishment of a southern breast cancer cohort.

Breast cancer continues to be among the most common cancers affecting women in the United States. Researchers investigating the area are turning their attention to novel prevention, detection, and treatment options. Recent molecular epidemiology research has highlighted the effects of both genetic and environmental exposures on an individual's risk of developing breast cancer and predicted response to treatment. Cohort designs are a potentially powerful tool that researchers can utilize to investigate the genetic and environmental factors affecting breast cancer risk and treatment options. This paper describes the recruitment of a community-based cohort of women in a southern state. The Spit for the Cure Cohort (SFCC), being developed by researchers at the University of Arkansas for Medical Sciences (Little Rock, AR), is designed to be representative of the female population of the state with oversampling of women with a history of breast cancer and women of color. To date, the SFCC includes more than 14,000 women recruited from all 75 counties of Arkansas and six neighboring states. Methods used to recruit and maintain the cohort and collect both questionnaire data and genetic material are described, as are the demographic characteristics of the cohort as it currently exists. The recruitment methods utilized for the SFCC are rapidly building a breast cancer cohort and providing a large biorepository for molecular epidemiology research.

Social services utilization and need among a community sample of persons living with HIV in the rural south.

HIV prevalence has increased faster in the southern USA than in other areas, and persons living with HIV (PLWHIV) in the south are often rural, impoverished, or otherwise under-resourced. Studies of urban PLWHIV and those receiving medical care suggest that use of social services can enhance quality of life and some medical outcomes, but little is known about patterns of social service utilization and need among rural southern PLWHIV. The AIDS Alabama needs assessment survey, conducted in 2007, sampled a diverse community cohort of 476 adult PLWHIV representative of the HIV-positive population in Alabama (66% male, 76% Black, and 26% less than high school education). We developed service utilization/need (SUN) scores for each of 14 social services, and used regression models to determine demographic predictors of those most likely to need each service. We then conducted an exploratory factor analysis to determine whether certain services clustered together for the sample. Case management, assistance obtaining medical care, and financial assistance were most commonly used or needed by respondents. Black respondents were more likely to have higher SUN scores for alcohol treatment and for assistance with employment, housing, food, financial, and pharmacy needs; respondents without spousal or partner relationships had higher SUN scores for substance use treatment. Female respondents were more likely to have higher SUN scores for childcare assistance. Black respondents and unemployed respondents were more likely to have SUN scores in the highest quartile of the overall score distribution. Factor analysis yielded three main factors: basic needs, substance use treatment, and legal/medical needs. These data provide important information about rural southern PLWHIV and their needs for ancillary services. They also suggest clusters of service needs that often occur among PLWHIV, which may help case managers and other service providers work proactively to identify important gaps in care.

Public health professionals as policy entrepreneurs: Arkansas's childhood obesity policy experience.

In response to a nationwide rise in obesity, several states have passed legislation to improve school health environments. Among these was Arkansas's Act 1220 of 2003, the most comprehensive school-based childhood obesity legislation at that time. We used the Multiple Streams Framework to analyze factors that brought childhood obesity to the forefront of the Arkansas legislative agenda and resulted in the passage of Act 1220. When 3 streams (problem, policy, and political) are combined, a policy window is opened and policy entrepreneurs may advance their goals. We documented factors that produced a policy window and allowed entrepreneurs to enact comprehensive legislation. This historical analysis and the Multiple Streams Framework may serve as a roadmap for leaders seeking to influence health policy.

Changes in school environments with implementation of Arkansas Act 1220 of 2003.

Changes in school nutrition and physical activity policies and environments are important to combat childhood obesity. Arkansas Act 1220 of 2003 was among the first and most comprehensive statewide legislative initiatives to combat childhood obesity through school-based change. Annual surveys of principals and superintendents have been analyzed to document substantial and important changes in school environments, policies, and practices. For example, results indicate that schools are more likely to require that healthy options be provided for student parties (4.5% in 2004, 36.9% in 2008; P

Overweight children, weight-based teasing and academic performance.

BACKGROUND: School performance of overweight children has been found to be inferior to normal weight children; however, the reason(s) for this link between overweight and academic performance remain unclear. Psychosocial factors, such as weight-based teasing, have been proposed as having a possible mediating role, although they remain largely unexplored. METHODS: Random parental telephone survey data (N=1 071) of public school students collected as part of the statewide evaluation of Arkansas Act 1220, a law to reduce childhood obesity, were used. Overweight status (body mass index > 85th percentile for gender and age) and weight-based teasing were examined as predictors of poorer school performance. RESULTS: Overweight status was a significant predictor of poorer school performance (OR=1.51; 95% CI=1.01, 2.25), after adjustment for gender, school level, free and reduced lunch participation, and race. However, the addition of weight-based teasing to the model (with weight category and covariates) reduced the weight category parameter estimate by 24%, becoming non-significant (OR=1.40; 95% CI=0.93, 2.10) and indicating a possible mediating effect of weight-based teasing on the relationship between weight category and school performance. Weight-based teasing was significantly associated with school performance, with lower odds of strong school performance among weight-based teased children (OR=0.44; 95% CI=0.27, 0.74). CONCLUSION: Psychosocial variables, such as weight-based teasing, should be considered in future research examining the impact of childhood obesity on school performance and in future intervention studies.

Promoting dietary change among state health employees in Arkansas through a worksite wellness program: the Healthy Employee Lifestyle Program (HELP).

INTRODUCTION: Maintaining a healthy and productive workforce is essential for employers in public and private sectors. Poor nutrition and obesity contribute to chronic diseases and influence health care costs and productivity. Research indicates that eating a healthy diet is associated with lower body mass index and reduced risk for developing chronic disease. METHODS: The Arkansas Department of Health implemented the Healthy Employee Lifestyle Program to encourage wellness among state health employees. During the pilot year, participants completed a health risk assessment at baseline and again after 1 year that assessed diet and physical activity, other health risk factors, and readiness to make behavioral changes. Participants were encouraged to eat healthfully, participate in regular exercise, report health behaviors using a Web-based reporting system, accumulate points for healthy behaviors, and redeem points for incentives. Differences in participants' (n = 214) reported dietary behaviors between baseline and follow-up were assessed using chi2 analyses and tests of symmetry. RESULTS: Consumption of sweets/desserts, fats, protein, grains, processed meats, and dairy did not differ significantly from baseline to follow-up. However, at follow-up more participants reported eating 3 or more fruits and vegetables per day than at baseline and being in the action and maintenance stages of readiness to change for eating 5 or more fruits and vegetables per day and for eating a diet low in fat. CONCLUSION: Further study is needed to examine physical activity and other health risk factors to determine whether the program merits a broader dissemination.

Arkansas Act 1220 of 2003 to reduce childhood obesity: its implementation and impact on child and adolescent body mass index.

Arkansas was among the first states to pass comprehensive legislation to combat childhood obesity, with Arkansas Act 1220 of 2003. Two distinct but complementary evaluations of the process, impact, and outcomes of Act 1220 are being conducted: first, surveillance of the weight status of Arkansas children and adolescents, using the statewide data amassed from the required measurements of students' body mass indexes (BMIs); and second, an independent evaluation of the process, impact, and outcomes associated with Act 1220. Various stakeholder groups initially expressed concerns about the Act, specifically concerns related to negative social and emotional consequences for students and an excessive demand on health care. Evaluation data, however, suggest that few adverse effects have occurred either in these areas of concern or in other concerns which have emerged over time. Schools are changing environments and implementing policies and programs to promote healthy behaviors and BMI levels have not increased since the implementation of Act 1220 in 2004. The Arkansas experience to date may serve to inform the efforts of other states to adopt policies to address the epidemic of childhood obesity.

No change in weight-based teasing when school-based obesity policies are implemented.

OBJECTIVES: To examine rates of weight-based teasing before initiation of school-based childhood obesity prevention policies (Arkansas Act 1220 of 2003) and during the 2 years following policy implementation, as well as demographic factors related to weight-based teasing. DESIGN: Analysis of consecutive random cross-sectional statewide telephone surveys conducted annually across 3 years. SETTING: Sample representative of Arkansas public school students with stratification by geographic region, school level (elementary, middle, and high school), and school size (small, medium, and large). PARTICIPANTS: Parents of children enrolled in Arkansas public schools and index adolescents 14 years or older. Intervention Statewide school-based obesity policies, including body mass index screening. MAIN OUTCOME MEASURES: Survey items about weight-based teasing, other teasing, body weight and height, and sociodemographic factors, as well as school characteristics obtained from the Common Core of Data of the National Center for Education Statistics. RESULTS: At baseline, 14% of children experienced weight-based teasing by parental report. The prevalence of weight-based teasing did not change significantly from baseline in the 2 years following school-based policy changes. Children and adolescents most likely to be teased because of weight were those who were overweight, obese, white, female, and 14 years or older, as well as those teased for other reasons. Adolescent report of weight-based teasing yielded similar patterns. CONCLUSION: Although the effectiveness of school-based obesity prevention policies remains unclear, policy changes did not lead to increased weight-based teasing among children and adolescents.

Parental recognition of overweight in school-age children.

OBJECTIVE: Examine the accuracy of parental weight perceptions of overweight children before and after the implementation of childhood obesity legislation that included BMI screening and feedback. METHODS AND PROCEDURES: Statewide telephone surveys of parents of overweight (BMI > or = 85th percentile) Arkansas public school children before (n = 1,551; 15% African American) and after (n = 2,508; 15% African American) policy implementation were examined for correspondence between parental perception of child's weight and objective classification. RESULTS: Most (60%) parents of overweight children underestimated weight at baseline. Parents of younger children were significantly more likely to underestimate (65%) than parents of adolescents (51%). Overweight parents were not more likely to underestimate, nor was inaccuracy associated with parental education or socioeconomic status. African-American parents were twice as likely to underestimate as whites. One year after BMI screening and feedback was implemented, the accuracy of classification of overweight children improved (53% underestimation). African-American parents had significantly greater improvements than white parents (P < 0.0001). DISCUSSION: Parental recognition of childhood overweight may be improved with BMI screening and feedback, and African-American parents may specifically benefit. Nonetheless, underestimation of overweight is common and may have implications for public health interventions.

Effectiveness evaluation of the N-O-T smoking cessation program for adolescents.

OBJECTIVE: To evaluate the effectiveness of the Not-On-Tobacco Program. METHODS: Forty-four high schools implemented the program (n=241 students), with 27 comparison schools (n=251 students). Students reported smoking in the last 7 and 30 days at baseline and follow-up. RESULTS: Those in the program had an increased likelihood of reporting 30-day abstinence at end of program (OR = 4.2) but not at 6 or 12 months. For 7-day abstinence there was no significant difference for any time point. CONCLUSIONS: In this effectiveness evaluation the N-O-T Program increased quitting during the program, but the effects were not present at 6 or 12 months.

Policy and environmental indicators for heart disease and stroke prevention: data sources in two states.

INTRODUCTION: Investigators in South Carolina and Alabama assessed the availability of data for measuring 31 policy and environmental indicators for heart disease and stroke prevention. The indicators were intended to determine policy and environmental support for adopting heart disease and stroke prevention guidelines and selected risk factors in 4 settings: community, school, work site, and health care. METHODS: Research teams used literature searches and key informant interviews to explore the availability of data sources for each indicator. Investigators documented the following 5 qualities for each data source identified: 1) the degree to which the data fit the indicator; 2) the frequency and regularity with which data were collected; 3) the consistency of data collected across time; 4) the costs (time, money, personnel) associated with data collection or access; and 5) the accessibility of data. RESULTS: Among the 31 indicators, 11 (35%) have readily available data sources and 4 (13%) have sources that could provide partial measurement. Data sources are available for most indicators in the school setting and for tobacco control policies in all settings. CONCLUSION: Data sources for measuring policy and environmental indicators for heart disease and stroke prevention are limited in availability. Effort and resources are required to develop and implement mechanisms for collecting state and local data on policy and environmental indicators in different settings. The level of work needed to expand data sources is comparable to the extensive work already completed in the school setting and for tobacco control.

Targeting diabetes preventive care programs: insights from the 2001 Behavioral Risk Factor Surveillance Survey.

INTRODUCTION: Many individuals with diabetes do not receive flu or pneumonia vaccinations or dilated eye exams, despite the documented efficacy of these practices. Understanding the individual factors associated with not receiving recommended vaccinations and exams is essential to developing effective targeted promotional programs. METHODS: Data from the 2001 Behavioral Risk Factor Surveillance Survey were analyzed to identify predictors of failure to report flu and pneumonia vaccinations and dilated eye exams. Key predictors included indicators of disease severity, access to care, and demographic characteristics. RESULTS: Significant factors varied by vaccination. For all 3 practices, failure to receive was associated with being younger, being a member of an ethnic minority group, having had no diabetes education, not taking insulin, and engaging in fewer prevention practices requiring physician contact. Other salient characteristics included having no health insurance, having less education, and reporting good general health. CONCLUSION: Promotional programs should be tailored for younger, minority patients, and those messages should encourage preventive care despite general good health or less severe disease. Indirect methods of promotion may include participation in diabetes education programs and regular contact with physicians. Additionally, health care professionals may be appropriate target groups for preventive care campaigns.

Factors associated with the failure of patients to complete cardiac rehabilitation for medical and nonmedical reasons.

PURPOSE: Cardiac rehabilitation (CR) provides effective secondary prevention services, but many patients fail to complete the recommended program. The purposes of this study were to describe completion rates in a hospital-based outpatient CR program, and to identify factors associated with patients failing to complete CR because of nonmedical and medical reasons. METHODS: Data used for the analyses were from a hospital-based CR program involving 526 discharged patients between January 1996 and February 2002. Patient discharge status was classified into three categories: complete, noncomplete-medical reasons, and noncomplete-nonmedical reasons. Logistic regression modeling identified factors associated with the groups failing to complete CR. RESULTS: The rate of CR completion was 58% (304/526). Among the 222 patients who did not complete CR, 139 (63%) had nonmedical reasons. As compared with the patients who completed CR, the adjusted odds ratio (AOR) for those who did not complete CR because of nonmedical reasons were more likely to be employed (AOR 2.2), to be obese (AOR 2.5), to be smokers (AOR 2.1), and to have shorter 6-minute walk distances (AOR 1.7). They were less likely to be women (AOR 0.6) or have diabetes (AOR 0.5). Patients not completing CR for medical reasons were more likely to be categorized as being at high clinical risk (AOR 4.2) and having shorter 6-minute walk distances (AOR 1.9). CONCLUSION: Except for low functional capacity, baseline factors associated with patients failing to complete CR differed on the basis of medical or nonmedical reasons. The development of interventions that address the special needs of patients with low functional capacity may be especially important in attempts to retain this high-risk group in CR therapy.