Formation and psychometric evaluation of a health-related quality of life instrument for children living with HIV in India.

In-depth interviews and focus group discussions were conducted to inform the development of an instrument to measure the health-related quality of life of children living with HIV. The QOL-CHAI instrument consists of four generic core scales of the "Pediatric Quality of Life Inventory" and two HIV-targeted scales-"symptoms" and "discrimination." A piloting exercise involving groups of children living with HIV and HIV-negative children born to HIV-infected parents provided evidence for the acceptable psychometric properties and usability of the instrument. It is expected that the QOL-CHAI can serve well as a brief, standardized, and culturally appropriate instrument for assessing health-related quality of life of Indian children living with HIV.

Improving the implementation of a condom availability program in urban high schools.

PURPOSE: We conducted an intervention to improve the implementation of a high school condom availability program, and evaluated its effect on students' awareness of the program and acquisition of condoms. METHODS: Twelve public high schools in the Los Angeles, CA area participated, half each in the intervention and control conditions. Project staff facilitated intervention schools' self-assessment of compliance with the school district's condom availability policy, creating an action plan by determining which mandatory program elements were lacking and identifying steps to improve compliance. Staff provided technical assistance and follow-up to assist schools in improving program implementation. From 2005 to 2009 (T1-T5), 29,823 students were randomly selected by classroom and they completed surveys. We tested for changes in students' awareness and acquisition of condoms over time between conditions using mixed model logistic regression analyses. Records of condom orders by schools also were reviewed. RESULTS: Awareness increased significantly among intervention versus control participants from T1 to T3 (adjusted odds ratio [AOR]: 1.28; 95% confidence interval [CI]: 1.01, 1.62), T4 (AOR: 2.17; 95% CI: 1.70, 2.76), and T5 (AOR: 2.78; 95% CI: 2.18, 3.56). Acquisition of condoms increased significantly among intervention versus control participants from T1 to T4 (AOR: 1.69; 95% CI: 1.23, 2.32) and T5 (AOR: 1.81; 95% CI: 1.32, 2.49). Results were similar across gender and different levels of sexual experience. Orders of condoms increased markedly in intervention schools by T5. CONCLUSIONS: Feasible minor enhancements to condom availability program implementation improved program delivery, resulting in increased student awareness of the program and acquisition of condoms.

Comparison of extramural clinical rotation days: did the Pipeline program make a difference?

Extramural clinical rotations are implemented by dental schools for a combination of clinical and didactic or behavioral goals. In the United States, the Pipeline, Profession, and Practice: Community-Based Dental Education program was launched to increase the number of underrepresented minority students who are recruited and retained in dental education, to expand the dental curriculum in cultural competence, and to incorporate community-based extramural rotations into the dental schools' clinical curriculum. The objective of this study was to conduct an impact analysis regarding the change in number of extramural clinical rotation weeks for Pipeline and non-Pipeline program students over the time period of 2003 to 2007. National data from the American Dental Education Association's senior survey and other secondary sources were used to determine what student, school, and community characteristics are associated with a difference in the student report of the number of required weeks they expect to spend during their last year in dental school providing care at extramural clinic settings. Students reported a mean of 7.2 weeks for Pipeline students and 6.4 weeks for non-Pipeline students in 2003, increasing to 8.2 weeks for Pipeline students and 6.6 weeks for non-Pipeline students (p<0.05) in 2007. The multivariable model showed the Pipeline program increased significantly the number of rotational weeks reported by students. Three other variables significantly increased rotation weeks: 1) a lower baseline number of reported weeks in community rotations; 2) a lower level of debt student reported upon graduation; and 3) student reports of a higher orientation toward service to others as a reason to enter dentistry.

Media literacy as a violence-prevention strategy: a pilot evaluation.

Youth violence is a major unresolved public health problem in the United States and media exposure to violence is a synergistic source of this national problem. One media literacy curriculum designed specifically to address this issue is Beyond Blame: Challenging Violence in the Media. The purpose of this pilot study was to examine the curriculum's feasibility as a full-scale intervention. Intervention and control groups were similar with respect to knowledge of the Beyond Blame curriculum at baseline. Intervention students scored much higher on the posttest compared with the control students. The majority (90.2%) of the intervention students reported a significant increase in pre- to posttest score compared with only 18.8% of the control students (p < .0001). The magnitude of the score increase for intervention students was much greater than those in the control group. Several intervention students (N = 49; 19.9%) improved their score by 12 or more points compared with the control students who showed only a 1- to 7-point score increase (N = 3; 18.8%; p < .0001). The pre-and posttest scores were similar for males and females. Three of the six intervention classrooms scored higher on both the pretest and posttest compared with the other three classrooms.

The effects of a disease management program on self-reported health behaviors and health outcomes: evidence from the "Florida: a healthy state (FAHS)" Medicaid program.

Premature morbidity and mortality from chronic diseases account for a major proportion of expenditures for health care cost in the United States. The purpose of this study was to measure the effects of a disease management program on physiological and behavioral health indicators for Medicaid patients in Florida. A two-year prospective study of 15,275 patients with one or more chronic illnesses (congestive heart failure, hypertension, diabetes, or asthma) was undertaken. Control of hypertension improved from baseline to Year 1 (adjusted odds ratio = 1.60, p < .05), with maintenance at Year 2. Adjusted cholesterol declined by 6.41 mg/dl from baseline to Year 1 and by 12.41 mg/dl (p < .01) from baseline to Year 2. Adjusted average medication compliance increased by 0.19 points (p < .01) in Year 1 and 0.29 points (p < .01) in Year 2. Patients in the disease management program benefited in terms of controlling hypertension, asthma symptoms, and cholesterol and blood glucose levels.

The association between an electric pump loan program and the timing of requests for formula by working mothers in WIC.

An electric pump loan program designed to facilitate breastfeeding for low-income mothers returning to full-time work was evaluated. All mothers were WIC participants in the Los Angeles area. Electric pump loans were made until the infant's first birthday or until the mother requested formula from WIC. Information was provided to employers on supporting breastfeeding in the workplace. A subsample of mothers who received an electric pump on return to full-time work was compared with counterparts in a wait list control group. Mothers who received an electric pump as soon as requested did not request formula until 8.8 months on average, whereas those who did not receive an electric pump requested formula on average at 4.8 months (P < .0001). Mothers who received an electric pump when requested were 5.5 (95% CI 2.0-15.1) times as likely as mothers who did not receive an electric pump to not request formula at 6 months.

The effect of disease management on utilization of services by race/ethnicity: evidence from the Florida Medicaid program.

OBJECTIVE: To measure possible racial/ethnic differences in a Florida disease management (DM) program on utilization of selected healthcare services for 4 chronic illnesses. STUDY DESIGN: Pre-post comparison of utilization among 15,275 high-risk beneficiaries enrolled in DM in the Florida Medicaid program between October 2001 and October 2003. METHODS: Two-part regression analyses of the effect of DM on annualized inpatient days, emergency department (ED) visits, and outpatient visits, controlling for relevant covariates. Annualized rates were used to adjust for differences in length of program enrollment. RESULTS: Disease management patients in the postperiod had significantly lower annual rates of inpatient days, ED visits, and outpatient visits across most racial/ethnic groups. Disease management reduced utilization by a similar absolute amount in each racial/ethnic group. However, baseline disparities in utilization of inpatient days were not reduced by the DM program. CONCLUSIONS: Disease management has a similar effect across different racial/ethnic groups but may not ameliorate important baseline disparities. Evaluations of DM programs should account for baseline disparities in utilization and examine whether those disparities can be reduced through DM.

Impact of disease management on health care utilization: evidence from the "Florida: A Healthy State (FAHS)" Medicaid Program.

OBJECTIVE: To examine the impact of disease management on utilization of selected health care services. METHOD: Prospective observational population-based study comparing Florida Medicaid patients who elected to participate in disease management (DM, N=15,275) with a usual-care (UC, N=32,034) group who elected not to participate in the program. Patients had at least one of four chronic diseases (diabetes, asthma, congestive heart failure, and hypertension) and all received standard health care. DM participants received supplementary telephone health counseling by a managed care specialist. The data for this paper were collected between October 2001 and October 2004. RESULTS: Annual rates of inpatient hospital stays, inpatient days, emergency room (ER) visits, and outpatient (OP) visits, during and post intervention, were used as outcomes. Age, race, gender, comorbidities, severity indicators, geographic location and pre-intervention utilization were used as covariates. Compared to UC patients, DM patients had lower adjusted post intervention annualized rates of hospitalizations ranging from 0.07 to 0.38 stays, lower rates of hospital days ranging from 0.40 to 2.54 days, and lower rates of ER visits ranging from 0.10 to 0.91 visits per DM enrollee in all four chronic conditions. Most results were statistically significant at the 5% level, except for hypertension patients, where they were suggestive, though not significant. CONCLUSION: Disease management is effective in reducing potentially avoidable inpatient hospital stays and ER visits among patients with chronic illness.

Influence of contextual environment and community-based dental education on practice plans of graduating seniors.

This study investigated senior dental students' plans to provide care to underserved racial/ethnic minority populations. Three sets of determinants were analyzed: contextual environment, community-based dental education (CBDE), and student characteristics. We analyzed data from the ADEA Survey of Dental School Seniors and administrative data sources to construct contextual variables. Multivariable results show three contextual variables predicted practice plans: greater numbers of federally qualified health centers, higher percentages of underrepresented minorities, and attending a California Pipeline dental school. Regarding CBDE predictors, it was alarming to find seniors who viewed the cultural competency curriculum as inadequate and perceived themselves as less prepared to provide oral health care to diverse populations were also those most likely to serve minority patients. Significant student characteristics included racial/ethnic minority, female gender, older age, lower parent's income, and socially conscious orientation. The study provides evidence that contextual environment, CBDE, and student characteristics were significantly associated with plans to care for underserved patients. Findings suggest if the Pipeline initiative is successful in stimulating reform in U.S. dental schools, future students will develop greater awareness regarding critical access problems and the competencies required to effectively care for diverse populations. In the long term, addressing the problem of dental care access will require the creation of policy, financial, and structural interventions to motivate providers to care for the underserved.

Methods for improving regression analysis for skewed continuous or counted responses.

Standard inference procedures for regression analysis make assumptions that are rarely satisfied in practice. Adjustments must be made to insure the validity of statistical inference. These adjustments, known for many years, are used routinely by some health researchers but not by others. We review some of these methods and give an example of their use in a health services study for a continuous and a count outcome. For the continuous outcome, we describe re-transformation using the smear factor, accounting for missing cases via multiple imputation and attrition weights and improving results with bootstrap methods. For the count outcome, we describe zero inflated Poisson and negative binomial models and the two-part model to account for overabundance of zero values. Recent advances in computing and software development have produced user-friendly computer programs that enable the data analyst to improve prediction and inference based on regression analysis.