Cultural competency training for public health students: integrating self, social, and global awareness into a master of public health curriculum.

Cultural competency training in public health, medicine, social work, nursing, dental medicine, and other health professions has been a topic of increasing interest and significance. Despite the now burgeoning literature that describes specific knowledge, attitudes, and skills that promote cultural "competence," fully defining this complex, multidimensional term and implementing activities to enhance it remain a challenge. We describe our experiences in introducing a mandatory, full-day workshop to incoming Master of Public Health students, called "Self, Social, and Global Awareness: Personal Capacity Building for Professional Education and Practice." The purpose of the program is to provide a meaningful, structured environment to explore issues of culture, power, privilege, and social justice, emphasizing the centrality of these issues in effective public health education and practice.

A cluster-based randomized controlled trial promoting community participation in arsenic mitigation efforts in Bangladesh.

OBJECTIVE: To reduce arsenic (As) exposure, we evaluated the effectiveness of training community members to perform water arsenic (WAs) testing and provide As education compared to sending representatives from outside communities to conduct these tasks. METHODS: We conducted a cluster based randomized controlled trial of 20 villages in Singair, Bangladesh. Fifty eligible respondents were randomly selected in each village. In 10 villages, a community member provided As education and WAs testing. In a second set of 10 villages an outside representative performed these tasks. RESULTS: Overall, 53% of respondents using As contaminated wells, relative to the Bangladesh As standard of 50 µg/L, at baseline switched after receiving the intervention. Further, when there was less than 60% arsenic contaminated wells in a village, the classification used by the Bangladeshi and UNICEF, 74% of study households in the community tester villages, and 72% of households in the outside tester villages reported switching to an As safe drinking water source. Switching was more common in the outside-tester (63%) versus community-tester villages (44%). However, after adjusting for the availability of arsenic safe drinking water sources, well switching did not differ significantly by type of As tester (Odds ratio = 0.86[95% confidence interval 0.42-1.77). At follow-up, among those using As contaminated wells who switched to safe wells, average urinary As concentrations significantly decreased. CONCLUSION: The overall intervention was effective in reducing As exposure provided there were As-safe drinking water sources available. However, there was not a significant difference observed in the ability of the community and outside testers to encourage study households to use As-safe water sources. The findings of this study suggest that As education and WAs testing programs provided by As testers, irrespective of their residence, could be used as an effective, low cost approach to reduce As exposure in many As-affected areas of Bangladesh.

Smoking cessation advantage among adult initiators: does it apply to black women?

INTRODUCTION: Smokers who initiate as adults are more likely to quit than those who initiate as adolescents. Black women are more likely than White women to initiate smoking in adulthood and are less likely to quit. There is a paucity of research examining whether the smoking cessation advantage among adult initiators applies to Black women. The study objective is to examine race differences in the effect of developmental stage of smoking initiation on number of years until cessation among Black and White women. METHODS: Data were extracted from the National Longitudinal Survey of Young Women, a national cohort of women between the ages of 49 and 61 years in 2003. The analytic sample comprised 1,008 White women and 271 Black women with a history of smoking. Survival analysis procedures were utilized to address the study objective. RESULTS: Racial disparities in smoking cessation were most evident among women who initiated smoking as adults. White young adult initiators had a 31% increased hazard of smoking cessation advantage (adjusted hazards ratio [HR]: 1.31, 95% CI: 1.04-1.65) over adolescent initiators, whereas Black young adult initiators had no smoking cessation advantage (adjusted HR: 0.85, CI: 95% 0.55-1.30) over adolescent initiators. CONCLUSIONS: Prior observations that smoking initiation in adulthood is associated with high rates of cessation do not apply to black women. To contribute to the reduction of disparities in women's cessation efforts to prevent initiation should target young adult women, particularly Black young adult women.

Identifying women at-risk for smoking resumption after pregnancy.

While prevalence of smoking during pregnancy has declined over the past two decades, maintenance of cessation after pregnancy remains an important public health challenge, particularly for women of color. This article reports on methods for improving detection of women at risk for smoking resumption after pregnancy through the use of an evidence-based smoking assessment instrument. The instrument was adapted for use by lay health workers in a community-based maternal and infant health program. A total of 276 primarily low-income Black and Hispanic pregnant and postnatal women enrolled in the program were screened for tobacco use in an initial assessment. Of these, 190 were reassessed an average of 2.7 months later. Assessments included measures of current and past smoking and risk factors associated with relapse. Bivariate differences by smoking status were analyzed. Seventeen percent of participants who would be classified as non-smokers using less sensitive screening questions were identified as former smokers and at-risk for resuming smoking. Twenty-two percent of former smokers resumed smoking by reassessment. Smoking resumption among former smokers was associated with having a partner and household members who smoked. Identification of former smokers is critical in order to prevent resumption of smoking after pregnancy and promote long-term maternal smoking cessation. Brief assessment instruments administered at multiple points in time during the prenatal and postnatal periods are an effective means of improving detection of women at risk for smoking resumption. Former smokers should be included in prenatal and postnatal tobacco education and counseling services.

Translating public health knowledge into practice: development of a lay health advisor perinatal tobacco cessation program.

The value of lay health advisor (LHA) interventions as an effective approach toward ameliorating racial, ethnic and/socioeconomic health disparities has been noted by researchers and policy makers. Translating scientific knowledge to bring state-of-the-art health promotion/disease prevention innovation to underserved populations is critical for addressing these health disparities. This article examines the experiences of a community-academic partnership in designing, developing, and implementing an evidence-based, LHA-driven perinatal tobacco cessation program for low-income, predominately African American and Hispanic women. A multimethod process evaluation was conducted to analyze three essential domains of program implementation: (1) fit of the tobacco cessation program into the broader project context, (2) feasibility of program implementation, and (3) fidelity to program implementation protocols. Findings indicate that project partners have largely succeeded in integrating an evidence-based tobacco cessation program into a community-based maternal and infant health project. The successful implementation of this intervention appears to be attributable to the following two predominant factors: (1) the utilization of a scientifically validated tobacco cessation intervention model and (2) the emphasis on continuous LHA training and capacity development.

The $5 man: the underground economic response to a large cigarette tax increase in New York City.

OBJECTIVES: We examined the mechanisms by which living in a disadvantaged minority community influences smoking and illegal cigarette sale and purchasing behaviors after a large cigarette tax increase. METHODS: Data were collected from 14 focus groups (n=104) that were conducted during the spring of 2003 among Blacks aged 18 years and older living in New York City. RESULTS: A large tax increase led to what focus group participants described as a pervasive illegal cigarette market in a low-income minority community. Perceived pro-smoking community norms, a stressful social and economic environment, and the availability of illegal cigarettes worked together to reinforce smoking and undermine cessation. CONCLUSIONS: Although interest in quitting was high, bootleggers created an environment in which reduced-price cigarettes were easier to access than cessation services. This activity continues to undermine the public health goals of the tax increase.

Assessing the Public's Health.

Metrics are an important part of the assessment of public health. They include traditional measures of mortality and newly described summary measures to describe the disability engendered by diseases. Epidemiology has transformed the understanding of risk factors for disease; however, a holistic approach includes recognition of social determinants and the neighborhood and communities where the people most at risk reside.

Implementation of a Multimodal Mobile System for Point-of-Sale Surveillance: Lessons Learned From Case Studies in Washington, DC, and New York City.

BACKGROUND: In tobacco control and other fields, point-of-sale surveillance of the retail environment is critical for understanding industry marketing of products and informing public health practice. Innovations in mobile technology can improve existing, paper-based surveillance methods, yet few studies describe in detail how to operationalize the use of technology in public health surveillance. OBJECTIVE: The aims of this paper are to share implementation strategies and lessons learned from 2 tobacco, point-of-sale surveillance projects to inform and prepare public health researchers and practitioners to implement new mobile technologies in retail point-of-sale surveillance systems. METHODS: From 2011 to 2013, 2 point-of-sale surveillance pilot projects were conducted in Washington, DC, and New York, New York, to capture information about the tobacco retail environment and test the feasibility of a multimodal mobile data collection system, which included capabilities for audio or video recording data, electronic photographs, electronic location data, and a centralized back-end server and dashboard. We established a preimplementation field testing process for both projects, which involved a series of rapid and iterative tests to inform decisions and establish protocols around key components of the project. RESULTS: Important components of field testing included choosing a mobile phone that met project criteria, establishing an efficient workflow and accessible user interfaces for each component of the system, training and providing technical support to fieldworkers, and developing processes to integrate data from multiple sources into back-end systems that can be utilized in real-time. CONCLUSIONS: A well-planned implementation process is critical for successful use and performance of multimodal mobile surveillance systems. Guidelines for implementation include (1) the need to establish and allow time for an iterative testing framework for resolving technical and logistical challenges; (2) developing a streamlined workflow and user-friendly interfaces for data collection; (3) allowing for ongoing communication, feedback, and technology-related skill-building among all staff; and (4) supporting infrastructure for back-end data systems. Although mobile technologies are evolving rapidly, lessons learned from these case studies are essential for ensuring that the many benefits of new mobile systems for rapid point-of-sale surveillance are fully realized.

Approaches to increase arsenic awareness in Bangladesh: an evaluation of an arsenic education program.

The objective of this study was to design and evaluate a household-level arsenic education and well water arsenic testing intervention to increase arsenic awareness in Bangladesh. The authors randomly selected 1,000 study respondents located in 20 villages in Singair, Bangladesh. The main outcome was the change in knowledge of arsenic from baseline to follow-up 4 to 6 months after the household received the intervention. This was assessed through a pre- and postintervention quiz concerning knowledge of arsenic. Respondents were between 18 and 102 years of age, with an average age of 37 years; 99.9% were female. The knowledge of arsenic quiz scores for study participants were significantly higher at follow-up compared with baseline. The intervention was effective in increasing awareness of the safe uses of arsenic-contaminated water and dispelling the misconception that boiling water removes arsenic. At follow-up, nearly all respondents were able to correctly identify the meaning of a red (contaminated) and green (arsenic safe) well relative to arsenic (99%). The educational program also significantly increased the proportion of respondents who were able to correctly identify the health implications of arsenic exposure. However, the intervention was not effective in dispelling the misconceptions in the population that arsenicosis is contagious and that illnesses such as cholera, diarrhea, and vomiting could be caused by arsenic. Further research is needed to develop effective communication strategies to dispel these misconceptions. This study demonstrates that a household-level arsenic educational program can be used to significantly increase arsenic awareness in Bangladesh.

Types of dental fear as barriers to dental care among African American adults with oral health symptoms in Harlem.

To examine the types of dental fear experienced by African American adults and the role of these fears in the utilization of dental care, in-depth interviews were conducted with a street-intercept sample of 118 African Americans living in Harlem, New York City, who had experienced at least one oral health symptom in the past six months. Despite their oral symptoms, participants delayed or avoided dental care (often for years) due to a variety of dental fears, including fears of: 1) pain from needles; 2) the dental drill; 3) having teeth extracted; 4) contracting an illness (e.g., HIV/AIDS) from unsanitary instruments; 5) X-rays; 6) receiving poor quality care or mistreatment. These findings provide insights into the situations that provoke fears about dental treatment among African Americans and suggest strategies to address these fears in order to remove these barriers and increase the utilization of dental care by African American adults.

Computer use, internet access, and online health searching among Harlem adults.

PURPOSE: Computer use, Internet access, and online searching for health information were assessed toward enhancing Internet use for health promotion. DESIGN: Cross-sectional random digit dial landline phone survey. SETTING: Eight zip codes that comprised Central Harlem/Hamilton Heights and East Harlem in New York City. SUBJECTS: Adults 18 years and older (N=646). MEASURES: Demographic characteristics, computer use, Internet access, and online searching for health information. ANALYSIS: Frequencies for categorical variables and means and standard deviations for continuous variables were calculated and compared with analogous findings reported in national surveys from similar time periods. RESULTS: Among Harlem adults, ever computer use and current Internet use were 77% and 52%, respectively. High-speed home Internet connections were somewhat lower for Harlem adults than for U.S. adults overall (43% vs. 68%). Current Internet users in Harlem were more likely to be younger, white vs. black or Hispanic, better educated, and in better self-reported health than non-current users (p<.01). Of those who reported searching online for health information, 74% sought information on medical problems and thought that information found on the Internet affected the way they eat (47%) or exercise (44%). CONCLUSIONS: Many Harlem adults currently use the Internet to search for health information. High-speed connections and culturally relevant materials may facilitate health information searching for underserved groups.

A stroke preparedness RCT in a multi-ethnic cohort: design and methods.

BACKGROUND: Tissue plasminogen activator (tPA), the only approved treatment for acute ischemic stroke (IS), is significantly underutilized likely due to poor lay information about stroke as an emergency. In order to improve outcomes in acute IS, it is critical to raise awareness and recognition of stroke symptoms particularly among minority populations. This manuscript describes the application of a stroke preparedness behavioral intervention and includes baseline information in a multi-ethnic population of stroke and transient ischemic attack (TIA) survivors. METHODS: In the Stroke Warning Information and Faster Treatment Study (SWIFT), we prospectively identified, and randomized IS and TIA patients to determine efficacy of a culturally tailored interactive stroke preparedness strategy. Data collected at baseline included acute stroke parameters, stroke knowledge, severity, social resources and vascular risk assessment. RESULTS: Of the 736 enrolled to date, 76% were IS and 24% TIA events. The cohort was 51% female: 45% Hispanic, 26% White and 25% Black. Over 75% reported hypertension, 36% diabetes, and 16% cardiac disease. Mean time from onset to emergency department (ED) arrival was 46h (median 13h) differing significantly between Whites (mean 52h, median 11h) and Blacks (mean 52h, median 17h) versus Hispanics (mean 39h, median 11h). Knowledge that a stroke occurs in the brain differed significantly by between Whites (85%), Blacks (64%), Hispanics (66%, p<0.000). CONCLUSIONS: Disparities remain in both action and knowledge surrounding acute stroke. Use of written information has not proven an effective means of changing health behaviors. We propose an interactive culturally tailored intervention to address behavioral change in acute stroke.

Making the connections: community capacity for tobacco control in an urban African American community.

Developing community capacity to improve health is a cornerstone of community-based public health. The concept of community capacity reflects numerous facets and dimensions of community life and can have different meanings in different contexts. This paper explores how members of one community identify and interpret key aspects of their community's capacity to limit the availability and use of tobacco products. Particular attention is given to examining the interrelationship between various dimensions of community capacity in order to better understand the processes by which communities are able to mobilize for social change. The study is based on qualitative analysis of 19 in-depth interviews with key informants representing a variety of community sectors in Harlem, New York City. Findings indicate that the community is viewed as rich in human and social resources. A strong sense of community identity and connectedness underlies this reserve and serves as a catalyst for action.

African American women and smoking: starting later.

It is commonly accepted that adolescence is the period for initiation into smoking and other tobacco use behaviors. However, evidence is increasing that the set of presumptions about adolescent onset of tobacco use may not be true for all cultural or subpopulation groups. Secondary analysis of data from the 2000 National Health Interview Survey (NHIS) was used to examine ethnic differences in smoking patterns among African American and White women. Results showed a striking racial/ethnic difference in age of onset; African American women initiate smoking later than White women at each age group. Prevention interventions need to continue beyond adolescence well into the adult years, especially for African American women. Late onset for these women represents an often missed window of opportunity for prevention.

Access to health services in an urban community: does source of care make a difference?

The importance of having a usual source of medical care is well established. Few studies, however, examine whether there are differences in health care utilization associated with the type of site used and whether having a primary clinician is more important than site in influencing utilization. The aim of this study was to examine these issues and assess the relative importance of usual source of care characteristics in determining access to a variety of health services. The study was based on a cross-sectional survey of a household probability sample of 695 adults from Central Harlem in New York City. Outcomes examined included use of hospitals as the regular source of care compared with other types of providers, having a usual clinician, receipt of various preventive health services, and illness-related utilization. Multiple logistic regression analysis indicated that men and people of lower socioeconomic status were significantly (P

Lack of oral health care for adults in Harlem: a hidden crisis.

OBJECTIVES: Profound and growing disparities exist in oral health among certain US populations. We sought here to determine the prevalence of oral health complaints among Harlem adults by measures of social class, as well as their access to oral health care. METHODS: A population-based survey of adults in Central Harlem was conducted from 1992 to 1994. Two questions on oral health were included: whether participants had experienced problems with their teeth or gums during the past 12 months and, if so, whether they had seen a dentist. RESULTS: Of 50 health conditions queried about, problems with teeth or gums were the chief complaint among participants (30%). Those more likely to report oral health problems than other participants had annual household incomes of less than $9000 (36%), were unemployed (34%), and lacked health insurance (34%). The privately insured were almost twice as likely to have seen a dentist for oral health problems (87%) than were the uninsured (48%). CONCLUSIONS: There is an urgent need to provide oral health services for adults in Harlem. Integrating oral health into comprehensive primary care is one promising mechanism.