Female genital cutting in the Gambia: can education of women bring change?

BACKGROUND: In the Gambia, three out of four women of reproductive age have undergone Female Genital Cutting (FGC). Many studies and policy advocates suggest that for such a practice that is deeply rooted in culture, a more holistic approach focusing on educating the population will have sustainable impact. This research examined whether educational level of women has an association with their attitude towards the practice of FGC. METHODS: Data from the 2013 Gambia Demographic Health Survey (GDHS) were analyzed. The sample included 6217 households: 10,233 females aged between 15 to 49 years and 3831 males between 15-59 years. This study focused only on women participants. The outcome variable was the attitude of women toward the practice of FGC. RESULTS: In multivariate regression model, women who were circumcised are found to have 80 times higher odds of supporting FGC [Odds Ratio = 80 (95% CI 50.93-124.4)] compared to uncircumcised women. Women with primary and secondary level education have lower odds of supporting FGC [OR = 0.73 (95% CI 0.915-0.007)) and those with higher education had the lowest odds [OR = 0.28 (95% CI 0.147-0.543)) of supporting FGC relative to women with no education at all. CONCLUSIONS: Education and awareness programs targeting women who are married and older, those with less education and those who are already circumcised can help change attitudes towards the practice of FGC.

How are the surviving workers of the Rana Plaza factory collapse in Bangladesh doing: quality of life, participation restriction, income and occupation.

PURPOSE: On April 24, 2013 a building called "Rana Plaza" that housed several garment factories collapsed in Bangladesh. Around 1134 people died and more than 2500 sustained serious injuries. This study evaluates the change in income and occupation of the Rana Plaza survivors as well as their level of community participation and quality of life two years after the incident. It also aimed to gain insight into these survivors' success or failure in economic reintegration. METHODS: A cross-sectional survey collected data from the injured garment workers using convenience sampling method. The Short Form 36 Items Questionnaire measured their quality of life, and the Participation Scale measured their community participation restriction level. Poor economic reintegration was defined when a survivor was not working or had an income less than 3000 Taka [US$36]/month. RESULTS: Data were collected from 338 Rana Plaza survivors all of who were previously garment workers. Their income decreased substantially after the disaster. The majority were now engaged in earning livelihood from retail shop management and animal husbandry. A total of 124 survivors (36.6%) were found to be poorly economically reintegrated; females were found to be at greater odds (twice) of poor economic reintegration than males. Those with severe participation restriction scores had four times greater odds and who reported moderate restriction had two times greater odds of poor economic reintegration compared to those with no restriction. CONCLUSIONS: Survivors of Rana Plaza factory disaster were facing many health and economic challenges two years after the event. Implications for rehabilitation Rehabilitation service providers should document and describe the health status correctly to understand the burden and monitor the effectiveness of their intervention. Government needs to develop and strengthen rehabilitation capacity as more workers will be injured as the country rapidly industrializes. Factory owners should create light duty work opportunities and provide other workplace modification for injured workers to re-enter the workforce.

Characterisation of persons with lower limb amputation who attended a tertiary rehabilitation centre in Bangladesh.

Objective: We aimed to describe the causes, types, and consequences of lower limb amputation and the demographics of subjects with such amputation who attended a tertiary rehabilitation center in Bangladesh, Centre for the Rehabilitation of the Paralysed.Methods: Cross-sectional data were collected from subjects with lower limb amputation who attended a specialized rehabilitation center between January 2014 and August 2016. Telephone interviews were conducted using a structured questionnaire. Descriptive analysis, paired t-test, and Fisher's exact test were conducted as well as a regression analysis was performed.Results: A total of 332 respondents, aged 5 to 76 years (mean 37.5± SD 13.8), with lower limb amputation participated in the study. Of the respondents, the majority were male (87.7%) and lived in rural areas (64.8%). Road traffic accidents were the leading cause (58.7%) of amputation followed by peripheral vascular diseases (7.5%) and hit by sharp objects (7.2%). Age (odds ratio: 0.9) and driving as occupation (odds ratio: 7.3) were found to be statistically significant covariates for amputation from road traffic accidents. The mean duration between having an amputation and receiving the first prosthetic fitting was 6.4 years (±8.9). Among the study participants, 30.7% lost their jobs after amputation and their mean monthly income reduced significantly (p < 0.01) from US$119.9 (±421.5) to US$45.8 (±63.1).Conclusion: Majority of the lower limb amputations resulted from traumatic road traffic accidents. Younger males and drivers were found to be more prone to amputation from road traffic accidents. Lower limb amputation creates great health and economic disparity in the amputee's lives.Implications for rehabilitationMajority of the lower limb amputation cases in Bangladesh were attributable to road traffic accidents-a largely preventable cause.The mean time between amputation and prosthetic fitting was more than 6 years which implies lack of awareness and inaccessibility of prosthetic management.Policymakers, regulators, law enforcement, and traffic safety advocates should take urgent actions to prevent road traffic accidents and raise awareness about and improve availability of prosthetic rehabilitation in Bangladesh.

Geospatial Analysis of Refugee Access to Primary Care Physicians in San Antonio, Texas.

This study investigated refugee access to primary care physicians (PCP) in San Antonio, Texas. Catholic Charities of San Antonio (CCSA) is the primary agency responsible for connecting refugees to a PCP. Data on refugees were collected from CCSA between May to September 2013 (N = 547). PCPs information was accessed at the Texas Medicaid and Healthcare Partnership (TMHP) website. The 2SFCA method was used in geographic information systems (GIS) to analyze the ratio of healthcare providers relative to refugees within varying walking distances. The highest concentration of accessibility was at 20 min distance in the Medical Center area. The highest concentration of accessibility at all walking distances were also in the Medical Center area. The univariate and multivariate analyses did not result in significant findings for the association between demographic variables and the accessibility scores. These findings recommend building new and more relationships with healthcare providers where PCPs access is low.

Electronic medical orders for life-sustaining treatment in New York State: Length of stay, direct costs in an ICU setting.

OBJECTIVE: In the United States, approximately 20% patients die annually during a hospitalization with an intensive care unit (ICU) stay. Each year, critical care costs exceed $82 billion, accounting for 13% of all inpatient hospital costs. Treatment of sepsis is listed as the most expensive condition in US hospitals, costing more than $20 billion annually. Electronic Medical Orders for Life-Sustaining Treatment (eMOLST) is a standardized documentation process used in New York State to convey patients' wishes regarding cardiopulmonary resuscitation and other life-sustaining treatments. No study to date has looked at the effect of eMOLST as an advance care planning tool on ICU and hospital costs using estimates of direct costs. The objective of our study was to investigate whether signing of eMOLST results in any reduction in length of stay and direct costs for a community-based hospital in New York State. METHOD: A retrospective chart review was conducted between July 2016 and July 2017. Primary outcome measures included length of hospital stay, ICU length of stay, total direct costs, and ICU costs. Inclusion criteria were patients ≥65 years of age and admitted into the ICU with a diagnosis of sepsis. An independent samples t test was used to test for significant differences between those who had or had not completed the eMOLST form. RESULT: There were no statistical differences for patients who completed or did not complete the eMOLST form on hospital's total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU. SIGNIFICANCE OF RESULTS: Completing an eMOLST form did not have any effect on reducing total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU.

Traumatic life events and development of post-traumatic stress disorder among female factory workers in a developing country.

BACKGROUND: Post-traumatic stress disorder (PTSD) may be more prevalent and burdensome in developing countries. AIMS: The goals of this study were to (1) determine the prevalence of PTSD, (2) identify types and number of traumas related to screening positive for PTSD and (3) determine other sociodemographic risk factors and health/medical conditions that may be correlated to PTSD among garment-factory workers and a comparable working population in Bangladesh. METHOD: A survey was administered to a convenient sample of 607 lower socio-economic status (SES) working women in Bangladesh, 310 of who were garment workers. The primary outcome PTSD was measured by the PTSD Checklist. The Life Events Checklist determined the number and type of traumatic events. RESULTS: The prevalence of PTSD was found to be 17.79% - 7.25% in garment workers and 21.55% in the comparison worker group. In multivariate analysis, PTSD was found to be significantly associated with age, income, chronic pain and number of stressful events. Participants between 45-50 years of age had the greatest odds of reporting PTSD - 15.68 fold (95% confidence interval (CI) = 4.08, 60.29) compared with those younger than 24 years. PTSD was more common in those with lower income (2,000-4,000 taka) (odds ratio (OR) = 1.60; 95% CI = 0.79, 3.26), who had chronic pain (OR = 2.48; 95% CI = 1.51, 4.07) and who experienced over three traumatic life events (OR = 11.25; 95% CI = 4.59, 27.59). The mean number of traumatic events experienced by this entire population was 4.9 with PTSD being more likely in those who experienced physical assault (OR = 6.35; 95% CI = 4.07, 9.90), who caused serious harm or death to someone else (OR = 4.80; 95% CI = 1.36, 16.87) and who had exposure to combat or war (OR = 4.76; 95% CI = 1.17, 19.34). CONCLUSION: Undiagnosed and untreated PTSD impacts the quality of life and decrease worker productivity among working-age women in this developing country.

Development of a return to work tool for primary care providers for patients with low back pain: A pilot study.

CONTEXT: Low back pain (LBP) is a common cause of disability in adults and primary care physicians (PCPs) are commonly the first medical practitioners to assess these patients. Despite this, PCPs often feel unprepared to make return to work (RTW) recommendations. AIMS: The purpose of our project was to develop RTW guidelines for patients with LBP in the form of an accessible and adaptable electronic medical records (EMR) integrated tool. SETTINGS AND DESIGN: All licensed physicians and physician extenders who see patients over the age of 18 years, presenting with acute LBP who are currently employed were eligible for participation. PCPs were randomized with and without the RTW guidelines and charts were reviewed to assess if PCPs made RTW recommendations. SUBJECTS AND METHODS: RTW guidelines were developed using the Oswestry LBP Disability Questionnaire and the Official Disability Guidelines and integrated into the EMR. STATISTICAL ANALYSIS USED: A Chi-square analysis was used to compare physicians in the interventional and control groups. RESULTS: Forty-four PCPs were randomized into the intervention group and 37 into the control group. In the intervention group, 301 patient encounters met the inclusion criteria for acute LBP. Of these, RTW recommendations were used in 7.3% encounters. Comparatively, there were 256 cases of LBP in the control group and RTW recommendations were offered in 1.6% of encounters (P < 0.001). CONCLUSION: This study showed that PCPs with access to the RTW guidelines in an EMR-integrated tool were significantly more likely to make such recommendations.

Community integration and life satisfaction among individuals with spinal cord injury living in the community after receiving institutional care in Bangladesh.

PURPOSE: This study reports level of community integration and life satisfaction among individuals who sustained traumatic spinal cord injuries, received institutional rehabilitation care services, and went back to live in the community in Bangladesh. It examines the impact of type of injury, demographic characteristics, socio-economic profile, and secondary health conditions on community integration and life satisfaction and explores the association between these two measures. METHOD: Individuals with spinal cord injury were telephone interviewed by the Centre for the Rehabilitation of the Paralysed, Bangladesh from February to June of 2014. Data were collected from the subjects on type of injury, demographic and socio-economic profile, and secondary health conditions. The outcome measures were determined by using two validated tools - Community Integration Questionnaire and Life Satisfaction 9 Questionnaire. RESULTS: Total community integration and life satisfaction scores were 15.09 and 3.69, respectively. A significant positive relationship between community integration and life satisfaction was revealed. Type of injury, gender, and age were found to be significant predictors of both community integration and life satisfaction scores. Higher education was significantly related to community integration and life satisfaction scores. CONCLUSION: Participants scored low in total community integration and life satisfaction, suggesting there is a great need to develop interventions by governmental and non-governmental organizations to better integrate individuals with spinal cord injury in the community. Implications for Rehabilitation Government and non-government organizations should offer disability friendly public transportation facilities for individuals with spinal cord injury so that they can return to education, resume employment, and involve in social activities. Entrepreneurs and businesses should develop assistive devices featuring low technology, considering the rural structure and housing conditions in Bangladesh. Innovations being made in assistive technology should be supported by subsidies and grants. They should also plan to offer injury appropriate employment opportunities for individuals who suffer major injuries like spinal cord injury in Bangladesh. Housing facilities with accessible bathrooms, kitchens and stairs should be designed and offered for this population to improve their ability to self-care and decrease the dependence on caregivers for household tasks such as - cooking meals and taking care of children.

Restaurant Inspection Reports as a Proxy Measure for Occupational Health and Safety: South Asian Restaurant Workers in New York City.

There is a great need to develop workplace health and safety surveillance systems for small businesses to systematically understand the cause, nature, and severity of injuries and illness of their workers. Restaurants can be hazardous workplaces for the nature of the business, materials handled, and tasks completed. Some of the traditional South Asian establishments/restaurants rely heavily on the traditional way of food preparation. Workers in these places may work in less than ideal conditions with minimal or no workplace health and safety regulations or programs. We have explored a unique idea of using NYC's restaurant inspection reports as a possible surveillance tool using the overall restaurant grade and specific violations. Findings show 19% of the Indian, 26% of Bangladeshi, and 15% of Pakistani restaurants did not achieve grade A in these inspections suggesting that around 20% of these restaurants workers are more likely to work in a relatively hazardous or unhygienic working conditions. Using restaurant inspection grade as a proxy measure for employee safety and working conditions may prove to be a useful and practical measure for such an industry.

Prevalence and risk factors of depression among garment workers in Bangladesh.

BACKGROUND: Depression is a growing health issue in both developed and developing countries. General unawareness at the population level, lack of training among health care providers and scarcity of resources including treatment opportunities may conceal the real burden of depression in developing countries, and more epidemiological studies on its prevalence and risk factors are critically needed. AIM: This study reports the prevalence of depression and its associated risk factors among female garment factory workers in Bangladesh - a major supplier country of clothes for the Western market. This research should generate useful evidence for national and international stakeholders who have an interest in improving health, safety and well-being of outsourced factory workers. METHODS: A survey was conducted on a sample of 600 lower socio-economic status working women including garment workers. This survey collected data on demographic and health profile of these workers. The primary outcome was depression as measured by Patient Health Questionnaire 9. It also obtained data on traumatic life events and post-traumatic stress disorder. RESULTS: The prevalence of depression was 23.5%: 20.9% among garment workers and 26.4% among others. Part-time employment (odds ratio-OR): 2.36, 95% confidence interval (95% CI): 1.01-5.51), chronic pain (OR: 1.67, 95% CI: 1.01-2.78), two or more traumatic life events (OR: 6.43, 95% CI: 2.85-14.55) and dysuria (OR: 2.50, 95% CI: 1.02-6.15) were found to be significantly associated with depression among these workers in multivariate regression model. Depression prevalene lowered by 11% among these workers for every additional monthly earning of 1,000 taka (US$12). CONCLUSION: Depression is a multifaceted health issue with many personal, social, economic and health determinants and consequences. This study demonstrates that the prevalence of moderate-to-severe depression among working women in Bangladesh is quite high. Prevention and treatment of depression in developing countries and societies can reduce suffering, lower incidence of suicide, and prevent economic loss. Creating awareness on outsourced workers' poor mental health may help in developing initiatives to protect and preserve their well-being.

Self-efficacy, disability level and physical strength in the injured workers: findings from a major factory disaster in Bangladesh.

INTRODUCTION: In 24 April 2013, Rana Plaza - a high-rise building in Bangladesh where garments were being made for the Western markets collapsed. In this study, we report on the surviving workers' physical strength, self-efficacy, and disability level one year after the disaster. METHODS: This cross-sectional study took place at the Centre for the Rehabilitation of the Paralysed (CRP) which provided care for more than 600 victims. For this study, upper extremity strength among the survivors was assessed by dynamometer hand grip (HG) and lower extremity strength by five time sit to stand test (FTSST). The WHODAS tool measured level of disability and General Self-Efficacy questionnaire measured self-efficacy. Post-traumatic stress disorder (PTSD) prevalence was determined by the PCL-scale. RESULTS: The study recruited 181 injured workers. The mean disability score among them was 49.8 (SD 17.5) and mean self-efficacy score was 24.9 (SD 6.9). In multivariate models, after adjusting for age, gender, education, injury profile, employment, marital status and job category, self-efficacy was found to be higher among those who scored above median HG test score [ß= -2.32 (95% CI: -4.63, -0.01)] and FTSST performance score [ß= -2.69 (95% CI: -4.93, -0.46)]. The disability level was found to be significantly associated with PTSD score [ß = 0.84 (95% CI: 0.62, 1.06)] and self-efficacy score [ß= -0.45 (95% CI: -0.78, -0.13)]. CONCLUSIONS: There is an immense need to develop and deliver effective post-injury recovery, rehabilitation and return-to-work programs for injured workers in resource poor countries. Implications for Rehabilitation The study findings suggest that one year after the factory disaster in Bangladesh, the injured workers are suffering from a high degree of disability, low physical performance and reporting low self-efficacy. The national and international stakeholders including Western buyers, aid agencies, NGOs, worker advocacy groups, consumer associations and the government of Bangladesh can be updated on the progress made so far. There is an immense need to develop and deliver effective post-injury recovery, rehabilitation and return-to-work programs for injured workers in resource poor countries. International organizations like ILO, WHO, World Bank can help developing countries in building these capacities.

U.S. military service and the prevalence of metabolic syndrome: Findings from a cross-sectional analysis of the Cooper Center Longitudinal Study, 1979-2013.

U.S. military service confers both health benefits and risks potentially associated with a clustering of cardiovascular risk factors called metabolic syndrome. However, the association between prior military service and metabolic syndrome has not sufficiently been examined. The purpose of the study was to compare the prevalence of metabolic syndrome by prior military service status. Among 42,370 men (887 with prior military service) examined from 1979 to 2013 at the Cooper Clinic (Dallas, TX), we used a cross-sectional study design to examine the association between military service and metabolic syndrome. First, an unadjusted log binomial regression model was performed by regressing the prevalence of metabolic syndrome on prior service. This was followed by performing Kleinbaum's modeling strategy for assessing confounding. The same methodology was used to explore the association between individual metabolic syndrome risk factors and prior service. Prior military service was not significantly associated with the prevalence of metabolic syndrome (PR=0.98, 0.89-1.07). None of the variables explored were identified as confounders. Participants with prior military service had lower prevalence of both elevated levels of triglycerides (PR=0.89, 0.80-0.99) and low levels of high-density lipoprotein-cholesterol (PR=0.78, 0.70-0.88). They had a higher prevalence of elevated resting systolic blood pressure (PR=1.23, 1.12-1.35). However, none of these associations were significant after adjusting for identified confounders: age; cardiorespiratory fitness; and exam year. Study findings indicate that military service was not independently associated with the prevalence of metabolic syndrome or its components. Future research is warranted longitudinally assessing the impact of military service on long-term outcomes.

Hospital support services and the impacts of outsourcing on occupational health and safety.

BACKGROUND: Outsourcing labor is linked to negative impacts on occupational health and safety (OHS). In British Columbia, Canada, provincial health care service providers outsource support services such as cleaners and food service workers (CFSWs) to external contractors. OBJECTIVES: This study investigates the impact of outsourcing on the occupational health safety of hospital CFSWs through a mixed methods approach. METHODS: Worker's compensation data for hospital CFSWs were analyzed by negative binomial and multiple linear regressions supplemented by iterative thematic analysis of telephone interviews of the same job groups. RESULTS: Non-significant decreases in injury rates and days lost per injury were observed in outsourced CFSWs post outsourcing. Significant decreases (P < 0.05) were observed in average costs per injury for cleaners post outsourcing. Outsourced workers interviewed implied instances of underreporting workplace injuries. CONCLUSIONS: This mixed methods study describes the impact of outsourcing on OHS of healthcare workers in British Columbia. Results will be helpful for policy-makers and workplace regulators to assess program effectiveness for outsourced workers.

Stakeholders' Perspectives About and Priorities for Economic Evaluation of Health and Safety Programs in Healthcare.

This study identified and prioritized resources and outcomes that should be considered in more comprehensive and scientifically rigorous health and safety economic evaluations according to healthcare sector stakeholders. A literature review and stakeholder interviews identified candidate resources and outcomes and then a Delphi panel ranked them. According to the panel, the top five resources were (a) health and safety staff time; (b) training workers; (c) program planning, promotion, and evaluation costs; (d) equipment purchases and upgrades; and (e) administration costs. The top five outcomes were (a) number of injuries, illnesses, and general sickness absences; (b) safety climate; (c) days lost due to injuries, illnesses, and general sickness absences; (d) job satisfaction and engagement; and (e) quality of care and patient safety. These findings emphasize stakeholders' stated priorities and are useful as a benchmark for assessing the quality of health and safety economic evaluations and the comprehensiveness of these findings.

Economic Burden of Hearing Loss for the U.S. Military: A Proposed Framework for Estimation.

The goal of this multiphased research is to develop methods to comprehensively determine the economic impact of hearing impairment and noise-induced hearing injury among active duty U.S. Service Members. Several steps were undertaken to develop a framework and model for economic burden analysis: (1) a literature review identifying studies reporting the cost of health conditions and injuries in the Department of Defense, (2) consultation with a panel of subject matter experts who reviewed these cost items, and (3) discussions with DoD data stewards and review of relevant data dictionaries and databases. A Markov model was developed to represent the cumulative economic effect of events along the career span, such as retraining after hearing impairment and injury, by synthesizing inputs from various sources. The model, as developed and proposed in this study, will be a valuable decision-making tool for the DoD to identify high-risk groups, take proactive measures, and develop focused education, customized equipping, and return-to-duty and reintegration programs, thereby maximizing the retention of skilled, experienced, and mission-ready Service Members.

The impact of hearing impairment and noise-induced hearing injury on quality of life in the active-duty military population: challenges to the study of this issue.

The objectives of this research were to 1) summarize the available evidence on the impact of hearing loss on quality of life (QOL) among U.S. active-duty service members, 2) describe the QOL instruments that have been used to quantify the impact of hearing loss on quality of life, 3) examine national population-level secondary databases and report on their utility for studying the impact of hearing loss on QOL among active-duty service members, and 4) provide recommendations for future studies that seek to quantify the impact of hearing loss in this population. There is a lack of literature that addresses the intersection of hearing impairment, the military population, and quality of life measures. For audiological research, U.S. military personnel offer a unique research population, as they are exposed to noise levels and blast environments that are highly unusual in civilian work settings and can serve as a model population for studying the impact on QOL associated with these conditions. Our team recommends conducting a study on the active-duty service member population using a measurement instrument suitable for determining decreases in QOL specifically due to hearing loss.

A cost-benefit analysis of peer coaching for overhead lift use in the long-term care sector in Canada.

OBJECTIVES: To evaluate whether a peer-coaching programme for patient lift use in British Columbia, Canada, was effective and cost-beneficial. METHODS: We used monthly panel data from 15 long-term care facilities from 2004 to 2011 to estimate the number of patient-handling injuries averted by the peer-coaching programme using a generalised estimating equation model. Facilities that had not yet introduced the programme served as concurrent controls. Accepted lost-time claim counts related to patient handling were the outcome of interest with a denominator of full-time equivalents of nursing staff. A cost-benefit approach was used to estimate the net monetary gains at the system level. RESULTS: The coaching programme was found to be associated with a reduction in the injury rate of 34% during the programme and 56% after the programme concluded with an estimated 62 lost-time injury claims averted. 2 other factors were associated with changes in injury rates: larger facilities had a lower injury rate, and the more care hours per bed the lower the injury rate. We calculated monetary benefits to the system of $748 431 and costs of $894 000 (both in 2006 Canadian dollars) with a benefit-to-cost ratio of 0.84. The benefit-to-cost ratio was -0.05 in the worst case scenario and 2.31 in the best case scenario. The largest cost item was peer coaches' time. A simulation of the programme continuing for 5 years with the same coaching intensity would result in a benefit-to-cost ratio of 0.63. CONCLUSIONS: A peer-coaching programme to increase effective use of overhead lifts prevented additional patient-handling injuries but added modest incremental cost to the system.

Women's experiences after Planned Parenthood's exclusion from a family planning program in Texas.

OBJECTIVE: We assessed the impact on depot medroxyprogesterone continuation when a large care provider was banned from a state-funded family planning program. STUDY DESIGN: We used three methods to assess the effect of the ban: (a) In a records review, we compared how many state program participants returned to two Planned Parenthood affiliates for a scheduled dose of depot medroxyprogesterone acetate (DMPA) immediately after the ban; (b) We conducted phone interviews with 224 former Planned Parenthood patients about DMPA use and access to contraception immediately after the ban; (c) We compared current contraceptive method of our interviewees to that of comparable DMPA users in the National Survey of Family Growth 2006-2010 (NSFG). RESULTS: (a) Fewer program clients returned for DMPA at a large urban Planned Parenthood, compared to a remotely located affiliate (14.4%, vs. 64.8%), reflecting different levels of access to alternative providers in the two cities. (b) Among program participants who went elsewhere for the injection, only 56.8% obtained it at no cost and on time. More than one in five women missed a dose because of barriers, most commonly due to difficulty finding a provider. (c) Compared to NSFG participants, our interviewees used less effective methods of contraception, even more than a year after the ban went into effect. CONCLUSIONS: Injectable contraception use was disrupted during the rollout of the state-funded family planning program. Women living in a remote area of Texas encountered more barriers. IMPLICATIONS: Requiring low-income family planning patients to switch healthcare providers has adverse consequences.

Developing and Implementing a Citywide Asthma Action Plan: A Community Collaborative Partnership.

OBJECTIVES: Asthma affects 1 in 10 children in the United States, with higher prevalence among children living in poverty. Organizations in San Antonio, Texas, partnered to design and implement a uniform, citywide asthma action plan to improve asthma management capacity in schools. METHODS: The asthma action plan template was modified from that of the Global Initiative for Asthma. School personnel were trained in symptom recognition, actions to take, and use of equipment before the asthma action plan implementation. The annual Asthma Action Plan Summit was organized as a forum for school nurses, healthcare providers, and members of the community to exchange ideas and strategies on implementation, as well as to revise the plan. RESULTS: The asthma action plan was implemented in all 16 local school districts. Feedback received from school nurses suggests that the citywide asthma action plan resulted in improved asthma management and student health at schools. CONCLUSIONS: The evidence in this study suggests that community organizations can successfully collaborate to implement a citywide health initiative similar to the asthma action plan.

Investigation of Pertussis Cases in a Texas County, 2008-2012.

OBJECTIVES: Within the past 25 years, there has been a dramatic increase in the incidence of pertussis cases in the United States. As such, this investigation reports on the high-risk groups and describes risk factors of pertussis cases in a large Texas county. METHODS: This study was a cross-sectional analysis of data collected by health department employees using the Texas Department of State Health Service's Pertussis Case Track Record, which is the standard investigation form for collecting vital information on pertussis cases. We extracted and analyzed county-level data for a 5-year period (2008-2012). The study population at risk included all current residents in this county, and cases included all who were clinically diagnosed as having confirmed or probable pertussis cases that were reported to the health department according to the Centers for Disease Control and Prevention case definition. The vaccination status of a case was defined as fully vaccinated, partially vaccinated, or not vaccinated. RESULTS: A total of 198 probable and confirmed pertussis cases were included in this analysis. Most of the cases were infants younger than 1 year old (n = 107). The largest category of cases was not vaccinated and of the rest, 32.8% were partially vaccinated, 17.2% had unknown vaccination status, and 13.1% were fully vaccinated. Only 48 (24.2%) sources of exposure were identified and they included fathers (14.6%), sisters (14.6%), brothers (14.6%), other children (14.6%), and mothers (12.5%). Many sources of exposure (n = 26, 54.1%) were unaware of their vaccination history. Hispanics accounted for 84.5% of cases in the younger than 1 year old group and 88.9% of cases were in the 1 to 2 years old group. With respect to race/ethnicity and vaccination status of the cases, 39.46% of Hispanics, 32% of whites, and 50% of blacks were reported to be unvaccinated. CONCLUSIONS: Increasing pertussis vaccination coverage among children, as well as providing booster shots to adults with special attention on the Hispanic population, may prove to be an effective strategy for health departments.