Abstract Book

Session Info:	A02	Economic Assessment of Health Care and Health Promotion Programs	
Track	Evidence-Based Programs: Research, Translation, and Evaluation
Titles 
An Economic Analysis of a Childhood Obesity Intervention in Largely Hispanic Schools 
Submitter Name H. Shelton Brown								
Page 54
Racial Disparities in Hospitalizations and Its Costs Due to Chronic Disease in Arkansas     
Submitter Name Appathurai Balamurugan					
Page 90
The Cost Effectiveness of Treating the Metabolic Syndrome in the African American and General Population Joseph 
Submitter Name Tichawona Tasosa					
Page 98

Session Info:	A03	Promising Evaluation Approaches to Assessing the Impact of Community-Based Programs
Track	Evidence-Based Programs: Research, Translation, and Evaluation
Titles										
Adapting to Diversity at the U.S.-Mexico Border: Process and Outcomes of a Family-Based Diabetes Program	 
Submitter Name Nicolette I. Teufel-Shone	
Page 52
Evaluating Programs for Public Health Impact: Examples From the WISEWOMAN Program		
Submitter Name Julie Will			
Page 72
Factors Involved in the Utilization of PRC Research: A Multiple Case Study Approach		
Submitter Name Jeffery Chaichana Peterson	
Page 77

Session Info:   A04    Diabetes and End-Stage Renal Disease	
Track  Methods and Surveillance
Titles											
EndStage Renal Disease Due to Diabetes Among Southwestern American Indians, 19902001
Submitter Name Nilka Rios Burrows		
Page 194
Getting the Most Out of Vital Statistics Data: Diabetes- related Heart Disease Mortality in New Mexico 
Submitter Name Heidi Krapfl		
Page 196
The Incidence of End-stage Renal Disease, Georgia, 1999-2002
Submitter Name Karon G. Abe		
Page 219

Session Info:	A05	Using Data to Guide Community Partnership Efforts	
Track Partnerships
Abstract Titles	
Using Data to Build Community Partnerships: The Little  Project That Did!
Submitter Name Marilyn M. Gardner		
Page 46
Using Geographical Information Systems to Facilitate Community-based Public Health Planning of Diabetes Intervention Efforts
Submitter Name Daniel J. Kruger
Page 47	
Youth at Risk: A Status of Youth Behaviors in West Texas and Ciudad, Juarez, Mexico
Submitter Name Ann G. Pauli		
Page 49
	
Session Info:	B03	Community Experiences in Implementing Healthy Aging Evidence-Based Programs	
Track Evidence-Based Programs: Research, Translation, and Evaluation
Abstract Titles	 
Developing, Implementing and Disseminating Evidence-based Healthy Aging Programs in Community-based Organizations	
Submitter Name Nancy Whitelaw and Lynda Anderson  
Page 68
Implementing Evidence-based Programs to Support Healthy Aging: An Initiative for Community-based	
Submitter Name James LoGerfo		
Page 83
		
Session Info: B04 Improving School Health Using National and Local Tools	
Track Evidence-Based Programs: Research, Translation, and Evaluation
Abstract Titles	 
American Indian Children Walk for Health: Increasing 		
Submitter Name Donald B. Bishop		
Page 53	
Physical Activity by Daily Walking at School CDCs School Health Index: A Coordinated Approach to Improving School Health		
Submitter Name Anu Gupta			
Page 58
Effectiveness of the Massachusetts Partnership for Healthy Weight (MPHW) School-based Physical ActivityResearch, Translation, and and Nutrition Intervention (5-2-1 Go!)			
Submitter Name Daniel M. Finkelstein		
Page 70

Session Info:	B05	Arthritis and Multiple Sclerosis Data Sources	
Track Methods and Surveillance
Abstract Titles	 
Disparities in National Prevalence Estimates of Arthritis- Attributable Work Limitation		
Submitter Name Kristina A. Theis		
Page 191
Prevalence and Impact of Arthritis Among Utahs Hispanic/Latinos compared to Utahs Non-Hispanic/Latino Whites
Submitter Name Richard Clarke Bullough	
Page 208
Strategies for Surveillance of Autoimmune and Neurological Diseases
Submitter Name Dhelia Williamson		
Page 216
	
Session Info:	B06	Assessing Physical Activity in Populations
Track Methods and Surveillance
Abstract Titles	 
Elementary Students Dietary and Physical Activity Behaviors  Disparities by Grade and Gender		
Submitter Name Millie Naquin		
Page 193
Putting the Pieces Together: Lifestyle Physical Activity Among Hispanics Using Multiple Surveillance Systems
Submitter Name Sandra A. Ham		
Page 210
The Status of the States: Benchmark Scoring for the State Physical Activity Program	
Submitter Name Tammy M. Vehige		
Page 220
Session Info:	B07	The Art and Science of Developing Partnerships	
Track Partnerships	
Abstract Titles	 
Developing Sustainable Community-Based Chronic  Disease Prevention Models in NC
Submitter Name Margaret L. Sauer
Page 24
Moving From Advising to Partnering		
Submitter Name Anne Doolen
Page 32
Using Neighborhood-specific Clusters to Stimulate and Evaluate Behavioral Change: A Social Mobilization 
Campaign for Increasing Awareness of HIV/AIDS & Chronic Disease	
Submitter Name Bilal A. Salaam		
Page 38
	
Session Info:	B08	Partnerships for Promoting Physical Activity
Track Partnerships
Abstract Titles	
Extending Access to Physical Activity Programs for Persons With Arthritis Through Community Partnerships	
Submitter Name M. Jean Gearing		
Page 26
Implementing Diverse National Strategies to Address Health Disparities in Older Adults Through Physical Activity
Submitter Name Jason E. Lang		
Page 30	
PE2GO: A Program to Address Disparities in Youth Physical Activity Opportunities
Submitter Name Maurice "Bud" Martin	
Page 36
	
Session Info:	B09	Partnerships to Promote Child Health
Track Partnerships	
Abstract Titles	 
Child Participation in Snack and Meal Preparation Positively Affects Preference for Fruits and Vegetables		
Submitter Name Marilyn S. Nanney
Page 19
Lessons Learned From Engaging Schools and Underserved Youth in Physical Activity Promotion Research		
Submitter Name Nancy O'Hara-Tompkins	
Page 31	
Promoting Healthy Eating and Physical Activity Among Preschoolers in Low Socio-economic Communities In Pennsylvania 
Submitter Name Kevin Alvarnaz		
Page 37
	
Session Info:	B10	Implementing Plans of Care for Chronic Conditions in the School Setting	
Track Policy and Legal
Abstract Title
Diabetes Awareness, Training, and Action Program: North Carolinas Response to the Care of School Children With Diabetes Law
Submitter Name Paula Hudson Collins		
Page 229
	
Session Info:	B11	Influencing Social Determinants at the State and National Level	
Track Social Determinants
Abstract Title	 
Case Study Assessment of Hard to Reach Populations Perceptions of Medicare Rights and Protections
Submitter Name Margaret Gerteis		
Page 124

Health for All: Californias Strategic Approach to Eliminating Racial and Ethnic Health Disparities		
Submitter Name Larry Cohen and Leslie Mikkelsen     
Page 134
Predictors of Health Status for Disadvantaged Medicare Beneficiaries: Results of the Medicare Health Outcomes Survey  	
Submitter Name Beth Hartman Ellis		
Page 143
	
Session Info:	C01	Utilizing Social Marketing to Address Health Disparities	
Track Communication and Technology
Abstract Title	 
Application of Chronic Disease Self-Management Materials and Methods in a Rural Primary Care Setting		
Richard Crespo		
Page 154
Start Living Healthy: Using Social Marketing to Address Health Disparities		
Submitter Name Cynthia Cabot		
Page 171
VERB Campaign: Extending the Reach of a National Campaign to Ethnically Diverse Audiences			
Submitter Name Heidi Melancon and 	Rosemary Bretthauer Mueller	
Page 176

Session Info:	C02	Adopting Healthy Aging Programs in Diverse Settings	
Track Evidence-Based Programs: Research, Translation, and Evaluation
Abstract Titles	 
The 10 Keys to Healthy Aging: An Innovative Approach to Community Health		
Submitter Name Constance Bayles		
Page 51
Community-Based Arthritis Exercise Randomized Control Trials: Implementation in Diverse Populations	
Submitter Name Leigh F. Callahan		
Page 63
Eliminating Disparities in Communities of Color Through the Lifetime Fitness Program		
Submitter Name Susan J. Snyder		
Page 71

Session Info:	C03	Progress in Chronic Care Monitoring
Track Evidence-Based Programs: Research, Translation, and Evaluation
Abstract Titles 
Application of Chronic Disease Frameworks to Diabetes Care Within the Indian Health Care System
Submitter Name Kelly J. Acton	
Page  56
Creating a Medical Home for Asthma: Improving Care in Pediatric Clinics Serving Low-income Communities
Submitter Name Winston Liao	
Page  64
Evaluation and Quality Monitoring of Chronic Disease Education Programs: Brokerage System for Providers and Funders 
Submitter Name Richard H. Osborne		
Page 73

Session Info:	C04	Disease Management and Collaboratives: Innovative Methods and Effective Tools	
Track Health System Change
Abstract Titles	 
Six Health Organizations that Have Implemented Chronic  Disease Management Programs in Rural and Underserved Patient Populations
Submitter Name Jane Nelson Bolin		
Page 118
	
Strategies that Facilitate Statewide Collaboration and Impact Chronic Disease Disparities in Primary Health Care Settings
Submitter Name Janet Johnson Reaves		
Page 119
Using a Scoreboard to Improve Outcomes Among Disparate Populations		
Submitter Name Jo Anderson		
Page 120

Session Info:	C05	Chronic Disease in American Indians
Track Methods and Surveillance	
Abstract Titles	
Awareness of Cardiovascular Disease Risk in American Indians
Submitter Name Carrie S. Oser	
Page 182
Culturally Competent Surveillance Strategies: Working With American Indian and Alaska Native Populations
Submitter Name	Janis C. Weber		
Page 186
Etiology of Chronic Liver Disease Among American 	Indians, Phoenix, Arizona	
Submitter Name Stephanie Bialek		
Page 195
	
Session Info:	C06	
Hair Today, Health Tomorrow: Eliminating Health Disparities Through Partnerships With Beauty Salons
Track Partnerships
Abstract Titles	
Healthy Hair Starts With a Healthy Body: Lay Health 	Advisors Making a Difference Within Communities	
Submitter Name Jodi M. Burke		
Page 29
Not In Mama's Kitchen: Empowering Women of Color Against Secondhand Smoke		
Submitter Name Brenda Bell-Caffee and Tamika R. Walls
Page 33
Response, Reach, Results: The ShopTalk Breast Cancer Awareness Project			
Submitter Name Julie Lejeune		
Page 40

Session Info:	C07	An Interactive Workshop on How to Build Partnerships for Community-Based Participatory Research
Track Partnerships	
Abstract Title	 
Building and Maintaining Effective Community-based Participatory Research Partnerships: An Interactive Session
Based on Best Practices		
Submitter Name Sarena D. Seifer		
Page 16
	
Session Info:	C08	Utilizing Innovative Methods to Develop Interventions to Address Social Determinants of Health Disparities
Track Social Determinants
Abstract Title	 
Engaging Older Adults to Be More Active Where They Live: Audit Tool Development
Submitter Name Melissa K. Kealey		
Page 129
The Influence of Social, political, and Cultural Factors on Physical Activity Among African Americans
Submitter Name	Cheryl M. Kelly		
Page 147
What We See Depends on Where We Stand: Federal and Local Perspectives on Health Disparities	
Submitter Name Mary Kane		
Page 150
	
Session Info:	D04	Minority Womens Participation in Cancer Screening
Track Evidence-Based Programs: Research, Translation, and Evaluation	
Abstract Title	
National Breast and Cervical Cancer Early Detection Program: 1991-2002 National Report		
Submitter Name A. Blythe Ryerson		
Page 87
Taking Care of Yourself: Factors Influencing African  American Women's Participation in Breast Cancer		
Submitter Name Ellen Phillips-Angeles and Cobie Whitten   
Page 97
		
		
Session Info:	D05	National Strategies to Identify and Disseminate Evidenced-Based Programs
Track Evidence-Based Programs: Research, Translation, and Evaluation	
Abstract Title	
Challenges in Disseminating Evidence-Based Programs to Eliminate Disparities: A Multi-Issue Roadmap	
Submitter Name Cynthia Vinson		
Page 59
Selecting Best Practices for Disparities Interventions in the National Healthcare Disparities Reports		
Submitter Name Karen K. Ho		
Page 96
		
Session Info:	E03	Are Social Marketing Approaches Positively Changing Knowledge and Behavior?
Track Communication and Technology	
Abstract Title	
Huesos Fuertes, Familia Saludable (Strong Bones, Healthy Family): Improving Bone Health Among Latino	 
Submitter Name Nestor Martinez		
Page 163
Moving People to Move: Mid-point Results of the Walk the Ozarks to Wellness Project		
Submitter Name Nikki M. Caito		
Page 166
Reaching Spanish-speaking Hispanic Women to Prevent Birth Defects by Promoting Folic Acid	
Submitter Name Christine E. Prue		
Page 169
		
Session Info:	E04	Increasing Cancer Screening Rates Among Diverse Populations
Track Evidence-Based Programs: Research, Translation, and Evaluation
Abstract Title	
Colorectal Cancer Screening among Latinos From U.S. Cities Along the Texas-Mexico Border: A Qualitative 	 
Study		
Submitter Name Maria E. Fernandez		
Page 61
Colorectal Cancer Screening Among Minorities in Florida		
Submitter Name Zhaohui Fan		
Page 62
Increasing Colorectal Cancer Screening Rates Among African Americans: Varying Approaches in Community and Clinical Settings	
Submitter Name Selina A. Smith		
Page 84
		
Session Info:	E05	The Benefits of Culturally Competent Care  Three Diverse Examples	
Track Health System Change
Abstract Title	 
Investigating Unrecognized Risk of the Metabolic Syndrome in African-American Women: The Role of 
Psychological Factors		
Submitter Name Daphne P. Ferdinand		
Page 112
Out on the Prairie: Homophobia, Heterosexism, and Oblivious Disregard - Rural Health Hazards		
Submitter Name Sherri L Paxon		
Page 115
Public Health Villains or Good Guys: Do We Know the Difference?
Submitter Name Barbara A. Yamashita		
Page 116

Session Info: E06  Improving Health and Reducing Costs: Modeling Changes in Health Systems	
Track Health System Change
Abstract Title	 
Inequities in Access to "Best Medicines": Role of Public Health in Fight Against Health Disparities
Submitter Name Katharina A. Kovacs Burns	
Page 111
Keep ME Healthy: The Maine Youth Overweight Collaborative	
Submitter Name Joan Orr			
Page 113
Lessons Learned in Miami in Complex Care Delivery, Disease Management, and Navigation With Underserved 
Populations		
Submitter Name Margaret McLoughlin		
Page 114
	
Session Info:	E07	Minority Health Surveys and Minority Participation in Health Surveys
Track Methods and Surveillance	
Abstract Title	
Assessing Health Disparities: Results of the Oklahoma Minority Health Survey		
Submitter Name Janis E. Campbell		
Page 180
Race, Ethnicity, and Linguistic Isolation as Determinants of Participation in Public Health Surveillance Surveys	
Submitter Name Michael W. Link		
Page 211
	 
Session Info:	E08	Smoking Cessation Programs and State Smoking Reductions
Track Methods and Surveillance	
Abstract Title	
Socioeconomic Disparities in Smoking and Recent Quitting in Maine: Individual and Town Level Predictors
Submitter Name Nancy Sonnenfeld		
Page 213
Success Stories! California and New York Reduced Smoking and Health Disparities	
Submitter Name Bruce Leistikow		
Page 217
Trying to Quit: Low-income Smokers Access to Cessation Care in a Managed Care Environment	
Submitter Name Millicent Fleming-Moran	
Page 223

Session Info:	E09	Training Community Members as Health Workers to Reach the Underserved	
Track Partnerships	
Abstract Title	
A Community-based Partnership to Address Barriers to Physical Activity in an African American Community
Submitter Name Marcus Plescia		
Page 13
Developing a Rural Health Promotion Specialist Program to Provide Preventive Health Care to the Medically
Submitter Name Joy Maltese		
Page 22
Public Housing Residents Are Catalysts to Enhanced Public Health Promotion and Community Health Linkages
Submitter Name Erin E. Gray		
Page 38

Session Info:	E10	Culture Influences on Health	
Track Social Determinants	
Abstract Title	
Fruit and Vegetable Consumption Among African American Women: Do Cultural Characteristics Help Identify Sub-Groups With Greater and Lesser 
Submitter Name Ajlina Karamehic		
Page 132
Reducing the Risk of Obesity in Latino Children		
Submitter Name Andra Opalinski		
Page 145
The Use of Cultural Competency Training to Begin Chronic Disease Program Integration	
Submitter Name Eric Weiskopf		
Page 149
	
Session Info:	E11 Ways of Bringing About Change in Social Determinants of Health Inequities (Part One)
Track Social Determinants	 
Abstract Title	
Education and Negative Affect as Prospective Factors in Hypertension Disparities Between White and Black 
Submitter Name Bruce Stephen Jonas		
Page 128
Health Perceptions and Knowledge of Healthy Choices Among Adult Mexican Americans With Intellectual 
Disabilities		
Submitter Name Janine Jurkowski		
Page 136
Lessons Learned From the Field: Faith- Based Breast and Cervical Cancer Early Detection Project	
Submitter Name Elizabeth Calhoun		
Page 139
	
Session Info:	F01 Using Social Marketing Assessments to Drive Communication Campaigns Differently	
Track Communication and Technology
Abstract Title	
Changes of Fortune: Working With the Telenovela Industry to Communicate Health Messages About Diabetes  Submitter Name Betsy Rodriguez		
Page 155
Improved Targeting of Smokers With Cessation Messages: Insights From the HealthStyles and ConsumerStyles
Submitter Name David E. Nelson		
Page 164
The National Diabetes Education Program Partnership Network		
Submitter Name Jane Kelly			
Page 173
		
Session Info:	F02	Environmental Approaches to Assessing and Addressing Community Health Promotion	
Track Evidence-Based Programs: Research, Translation, and Evaluation	
Abstract Title	
An Investigation of the Environment and Diabetes Risk in Rural Communities		
Submitter Name Karrisa Weidinger		
Page 55
Project WOW: Implementing a Multi-level Walking Intervention in Rural Missouri		
Submitter Name Sarah L. Lovegreen		
Page 88
		
THRIVE: Toolkit for Health and Resilience in Vulnerable Environments	
Submitter Name Larry Cohen		
Page 99
		
Session Info:	F03	Guidelines and Compliance: Patient, Provider, or Just Poor Documentation?
Track Health System Change	
Abstract Title	
Adherence to Guidelines for Following Up Low-grade Pap Results by Age and Race or Ethnicity	
Submitter Name Vicki Benard		
Page 104
Compliance With Pediatric Asthma Guidelines in General Emergency Departments
Submitter Name Ellen A. Vasser		
Page 106
Improving Chronic Disease Outcomes in Correctional 		
Submitter Name Ronald Shansky		
Page 110
	
Session Info:	F04	Measuring Health Disparities
Track Methods and Surveillance	
Abstract Title	
Challenges to Measuring Health Care Disparities in the National Healthcare Disparities Report
Submitter Name Ernest Moy		
Page 185
Developing Unique Community-Based Infrastructure for Assessment to Identify, Monitor, and Assist Disparate 
Populations		
Submitter Name Alex Charleston		
Page 187
Measuring Population Health Disparities: The Wisconsin County Health Rankings
Submitter Name Angela M. Kempf		
Page 204
	
Session Info:	F05	Unique Partnerships for Early Disease Detection
Track Partnerships	
Abstract Title	 
From the Flying Deck, Get a Breast Check		
Submitter Name Selma J. Morris		
Page 12
An Effective Osteoporosis Education, Screening, Follow- Up, and Treatment Initiative in the Asian Community
Submitter Name David B. Bauer		
Page 15
Detecting Diabetes in East Harlem, New York through a "Food for Life" Festival
Submitter Name Carol Horowitz and Louise Square     
Page 21
		
Session Info:	F06	Ways of Bringing About Change in Social Determinants of Health Inequities (Part Two)
Track Social Determinants
Abstract Title	 
Gender Disparities in Physical Activity Participation Among Boston Youth
Submitter Name Alison M. El Ayadi		
Page 133
Health Inequities of Eastern North Carolina Native Americans: Comparisons with Latino Immigrants and African Americans	
Submitter Name Dothula Baron-Hall		
Page 135
Making a Difference in Our Own Lives: Pemiscot Male Mentoring Program
Submitter Name Alfonzo Branch		
Page 140
	
Session Info:	G04	Geographic Distribution of Chronic Disease
Track Methods and Surveillance	
Abstract Title	
Innovative Uses of Geographic Information Systems Technology to Reveal Health Disparity Burdens in Disadvantaged Communities		
Submitter Name Charles Marc Croner		
Page 202
State Cancer Profiles: A Data Portal for Comprehensive Cancer Control Planning		
Submitter Name Temeika L. Fairley		
Page 214
Temporal Changes in the Geographic Disparity of Heart Disease Mortality
Submitter Name	Michele Casper		
Page 218
	
Session Info:	G05	Women's Health	
Track Methods and Surveillance
Abstract Title	 
Making the Grade on Womens Health: A National and State-by-State Report Card		
Submitter Name Michelle Berlin		
Page 203
Using the Perinatal Periods of Risk (PPOR) Approach for Reducing Health Disparities in Feto-infant Mortality
Submitter Name Jennifer Skala		
Page 225
	
Session Info:	G06	Promoting Nutrition in Schools  Increasing Student Achievement Through Nutrition	
Track Policy and Legal	
Abstract Title	
Educating California School Board Members: Aligning Policies for Student Health and Achievement
Submitter Name Vicki Berends		
Page 230
The USDA Fresh Fruit and Vegetable Snack Program: Effective Policies Promoting Exciting Environments in 
Schools		
Submitter Name Tracy Fox			
Page 234
	

	Partnerships
From the Flying Deck, Get a Breast Check

Author: S.J. Morris

Objective:
To promote work site breast health for both women and men.

Setting: 
The worlds busiest airport, Hartsfield-Jackson Atlanta International, has over 44,000 employees. Breast Health Education is performed at the Grady Health Systems R.L. Brown Airport Health Center and on the concourses.

Method or Intervention:
The program was marketed from several vantage points: 1) Department of Aviation newsletter, 2) the principal investigator speaking at monthly concession meetings, and 3) Community Health Advisors disseminating pamphlets about the program on the numerous concourses within the airport. Community Health Advisors performed breast health education for airport employees/support staff. This included one-on-one and group education. Women/men were given free clinical breast examinations by volunteer health care providers (nurse practitioners, physician assistants, and doctors). Those employees that were uninsured or underinsured received free mammograms and follow-up from our partners.

Result or Outcome:
Multicultural employees/support personnel were able to receive free breast health services. We were able to use the E Factors for this program: 1) educate, 2) engage, 3) empower, 4) employ, and 5) evaluate a work site breast health program to include both women and men.

Conclusion or Significance:
To address the disparity in breast cancer mortality, this program included individuals from all multicultural groups. Through ongoing collaborative efforts, this program will continue and will be replicated nationally and internationally.

A Community-Based Partnership to Address Barriers to Physical Activity in an African American Community

Author: M. Plescia; M. Groblewski 

Objective:
To describe changes in physical activity behaviors resulting from a partnership between a community coalition, lay health advisors, and a local branch of the YMCA.

Setting: 
The Centers for Disease Control and Preventions Racial and Ethnic Approaches to Community Health (REACH 2010) project funds 37 communities to engage in participatory, community-based interventions to address racial and ethnic health disparities. This project targets a geographically defined, urban, medically underserved African American community of 18,892.

Method or Intervention:
The main focus of the project is to recruit, train, and support lay health advisors to promote health behavior change among community residents. A partnership with a local branch of the YMCA was designed to support the efforts of the lay health advisors and address existing barriers to participation in regular physical activity. Residents are encouraged to participate in community-based YMCA activities that occur in a range of settings and are funded by the REACH 2010 coalition. Evaluation methods include 1) a yearly random survey of community residents by telephone using Behavioral Risk Factor Surveillance System (BRFSS) questions on physical activity behaviors; 2) pretest and 2-year follow-up surveys by telephone of program participants to measure relative frequency of physical activity and current stage of change for physical activity behavior change; and 3) focus groups to determine motivational factors among community participants in the YMCA program.

Result or Outcome:
The project has maintained an average of 15 active lay health advisors working at least 10 hours a week in the community. In year 2 of the project, the percentage of adults in the focus community who indicated they did not meet physical activity recommendations decreased from 32.0% (95% CI, 28.6-35.5) at baseline to 24.4% (95% CI, 21.1-28.2). At 2-year follow-up of YMCA program participants, 56.6% indicated that they were exercising more than they did 2 years before, and the percentage who indicated Maintenance Stage of Change increased from 41.67% (95% CI, 37.31-46.03) to 54.24% (95% CI, 48.01-58.65). Focus group respondents identified intrapersonal factors such as improved self-efficacy and interpersonal factors such as social support and fellowship as aspects of the YMCA programs that helped motivate them to continue participation in the program.

Conclusion or Significance:
Partnership between a REACH 2010 community coalition and a local YMCA branch was instrumental in establishing and supporting a community lay health advisor program and addressing community barriers to physical activity. This multicomponent intervention resulted in significant physical activity behavior change at the individual and community level.

Addressing Multicultural Health Promotion Through Driving Wellness Programs

Author(s): N. Ceridwyn

Objective:
To share lessons learned for multicultural health education based on two pilot programs providing health promotion materials to older adults aged 55 and older in the Latino and Filipino communities.

Setting: 
Community-based informal ethnic service groups.

Method or Intervention:
With funding from a local community foundation, we trained local community members to conduct two 6-hour health promotion interactive classes around the theme of keeping the car key longer. Community facilitators were encouraged to modify their presentations to meet culturally appropriate learning modes. Facilitators conducted one class in Spanish for 22 older Latinos and one in English for 25 Filipino elders. We surveyed class participants after the intervention about their class experience and behavior changes that they planned to make.

Result or Outcome:
The Filipino group found learning about diet and alternative transportation the most important aspect of the class. In the follow-up, 70% had discussed driving wellness with family and friends and changed their driving habits, 18% investigated driver refresher courses, and 6% began using driving alternatives. Within the Latino population, the most important aspects were exercises, stress reduction, and strategies to maintain driving alertness. In the follow-up interviews, 83% had discussed the information with a friend or family, 33% took a driving refresher class, and 14% visited their eye doctor. Six months following the classes, the groups found funding to conduct four more classes. The Latino elders began monthly health information meetings. From the Filipino class, a nonprofit organization is now being formed to develop supplemental transportation. The programs created an awareness of health promotion and safety in communities that previously had not considered the issues and have motivated community members themselves to take action to advance health education and promotion.

Conclusion or Significance:
Key strategies in effectively conveying health messages to culturally diverse groups who are often underserved in receiving health education include 1) presenting appealing and personally relevant topics, 2) selecting and training culturally acceptable and trusted presenters, and 3) providing settings that allow for small-group interaction.

An Effective Osteoporosis Education, Screening, Follow-Up, and Treatment Initiative in the Asian Community

Author(s): D.B. Bauer

Objective:
To reduce the incidence of osteoporosis and osteoporosis-related fractures in the Asian community through a focused education and screening program.

Setting: 
One-day programs involving osteoporosis seminars and bone density testing in three separate Asian communities in Michigan, with subsequent follow-up and management.

Method or Intervention:
In collaboration with the University of Michigan School of Nursing, the Michigan Public Health Institute, and the Healthy Asian American Project, we provided lectures on osteoporosis to three separate Asian communities in Michigan. Evaluation of lecture effectiveness was monitored via pre-lecture and post-lecture questionnaires. All lectures were given with a live Mandarin-speaking interpreter, and all forms were translated into Chinese. A risk factor questionnaire was also distributed to ascertain the participants osteoporosis risk. Those found to be at risk subsequently had a central dual-energy x-ray absorptiometry (DXA) bone mineral density (BMD) test on the hip, performed on-site with a mobile GE Lunar central DXA table. Every individual tested had an on-site consultation on their scores. Of these individuals scanned by DXA, participants with a T-score of less than -1.5 were then referred to a practitioner for follow-up and initiation of therapy if indicated. Follow-up telephone calls were then made at 3 months and 6 months to assess participant progress with their practitioners recommendations. Further collaboration with Merck Pharmaceuticals, Inc. allowed free alendronate therapy to those in need of complimentary medication.

Result or Outcome:
A total of 143 Asian-Americans participated in the three programs by hearing the lecture, asking questions, and filling out all forms. Of these 143 participants, 101 Asians were deemed to be at-risk for osteoporosis and had subsequent hip BMD tests performed. Of these 101 people having bone density tests, 64 individuals were found to have a T-score of less than -1.5 and were then referred to a practitioner for follow-up. A total of 44 out of the 64 individuals who were referred to a practitioner actually obtained follow-up. Of these 44 who saw a practitioner, 36 individuals were started on osteoporosis therapy (i.e., alendronate, risidronate, calcitonin, raloxiphene).

Conclusion or Significance:
Focused programs combining education, on-site testing, and follow-up can effectively bring osteoporosis awareness, screening, and therapy to the Asian community, thereby reducing osteoporosis incidence and related fractures.

Building and Maintaining Effective Community-Based Participatory Research Partnerships: An Interactive Session Based on Best Practices

Author(s): S.D. Seifer; J.F. Kauper-Brown

Objective:
To address the continuing need for training and education for all partners that will enhance their capacity for community-based participatory research (CBPR) that addresses priority health issues from the community's perspective.

Setting: 
Partnerships between communities, universities, and public health agencies have become central to the national public health practice and research agenda.

Method or Intervention:
With funding from the Centers for Disease Control and Preventions Prevention Research Centers (PRCs) Program Office, through a cooperative agreement between the Association of Schools of Public Health and CDC, the Community-Institutional Partnerships for Prevention Research Group has identified characteristics of successful CBPR partnerships, factors that facilitate and impede success, and strategies for building the capacity of communities, public health agencies, and academic institutions to engage in CBPR. The Group comprises Community-Campus Partnerships for Health, PRCs, Urban Research Centers, Kellogg Community Health Scholars Program, American Public Health Association Caucus on Community-Based Public Health, CDCs PRC National Community Committee, and Wellesley Central Health Corporation.

Result or Outcome:
The Curriculum Training Module on Building and Maintaining Effective Community-Institutional Partnerships for Prevention Research translates the groups work into a series of short presentations using case studies and interactive exercises designed to trigger discussion and equip participants with strategies and tools for building and sustaining CBPR partnerships. The curriculum includes the following units: 1) What is CBPR and why should we do it? (defines CBPR and its principles, ethical issues, and when is CBPR not for you?); 2) Developing a CBPR partnership: Getting started (covers establishing operating norms and infrastructure, and determining levels of affiliation and participation); 3) Getting the work done (includes establishing processes for decision-making and resources allocation, and addressing concerns about expectations and accountability, which may change throughout the partnership life cycle, and ownership and dissemination); and (4) How to sustain a CBPR partnership (includes strategies for conflict resolution, appreciation, and celebration, and sustaining long-term funding for the partnership).

Conclusion or Significance:
This interactive skill-building workshop will use the curriculum units to guide participants in initiating, developing, and sustaining CBPR partnerships. To learn more about the group and the training curriculum, visit: http://depts.washington.edu/ccph/researchprojects.html#ExaminingCommunityPartnerships

Building Community Capacity for Healthy Eating Through the Use of Tailored Resources

Author: Q.J. Moore

Objective:
To provide community leaders with a helpful resource they can use to showcase the food service cookbook and market the good taste of healthful eating, nutrition, and health to family, friends, co-workers and other service volunteers.

Setting: 
Four metropolitan cities in Michigan with large populations of African Americans.

Method or Intervention:
A social marketing framework was used to design trainings utilizing the Healthy Food, Healthy Soul Leader Guide for the target population, primarily faith-based leaders. A total of six Healthy Food, Healthy Soul Leader trainings were conducted in various metropolitan, urban areas in the state. The training locations included the Detroit area (2), Southfield, Pontiac, Kalamazoo, and the Flint area community. Participants completed a survey containing questions on the cookbook and leaders guide, current eating practices, and perceived use of the resource.

Result or Outcome:
Approximately 200 individuals from a variety of agencies were trained on the use of the Healthy Food, Healthy Soul (HFHS) Leader Guide and accompanying food service cookbook. These individuals included volunteers, cooks/chefs, directors/program coordinators, paraprofessionals, health team staff,  and ministerial staff, and represented over 55 community agencies, including but not limited to faith-based institutions, shelters, soup kitchens and food pantries, Michigan State University Extension, senior centers, day care centers, Head Start, multiservice community centers, a number of southeast regional Salvation Army service centers, and restaurant staff. Overall, the trainings were quite successful and were enjoyed by participants, as evidenced by the positive feedback received on the workshop evaluations. There is apparently much support for this practical healthful eating information among African Americans. Most workshop attendees noted that they planned to share or use the Leaders Guide and food service cookbook in the future. The HFHS leader trainings provided participants with the tools to help market healthful eating and a taste of the message. This encouraged them to consider further dietary changes they and others can make to promote good health. Host agencies welcomed the workshop and were pleased that they did not have to contribute to its cost. A variety of methods were used to market the workshop to community agencies, including posters, handouts, word of mouth, and numerous calls directly to identified key agency staff.

Conclusion or Significance:
Training and education on healthy food can help to build capacity, create leaders, and improve health behaviors within African American agencies and communities.

Characteristics of a Successful Community Coalition

Author: H. Fuller

Objective:
To share identified factors that contribute to the development of a successful community coalition.

Setting: 
Coalition development is critical in effecting changes or building grassroots support for a particular area of interest in a community. Coalitions may be formed for a variety of reasons: to apply for funding to address a specific problem/need in the community, to pass a policy, etc. For a coalition to be successful, many factors must be addressed, including membership (recruitment and retention), leadership, organization, communication, strategic planning, and evaluation. Knowing which factors are key in determining the success of a coalition would greatly help coalition coordinators in Kansas to focus their efforts/limited resources when building a coalition.

Method or Intervention:
A coalition evaluation tool was developed and mailed to 40 community coalition coordinators across Kansas. To date, 26 completed surveys have been returned for a 65% response rate. The average number of members on the community coalitions surveyed is 28.16, with the smallest coalition having 6 members and the largest having 92. The average length of time the coalitions have been active is 7.76 years.

Result or Outcome:
According to the results of the survey, having common needs and shared goals is the most important factor in determining the success of a community coalition. Other important factors include dedicated staff to support the coalition, effective communication between partners, and funding to support the coalitions activities. The most common barriers to coalition development are time and membership recruitment. Lack of funding, lack of volunteer leadership, and dependence on paid staff are other barriers encountered while doing coalition work.

Conclusion or Significance:
Survey results will be shared with KDHE Outreach Coordinators in order to provide specific technical assistance to these community coalitions. Statewide and regional trainings may also be scheduled for designated areas of need in relation to coalition development.

Child Participation in Snack and Meal Preparation Positively Affects Preference for Fruits and Vegetables

Authors: M.S. Nanney; D. Haire-Joshu; M. Elliott

Objective:
To describe an innovative partnership to improve diet among at-risk children and promote child participation in snack and meal preparation as a strategy to increase fruit and vegetable intake.

Setting: 
Tutors and their students participating in structured mentoring programs across twenty community sites serving 6- to 10-year-old children (n=1048) in St. Louis, Missouri.

Method or Intervention:
Tutors collected baseline data as part of an interactive lesson plan called Healthy Me. Using colorful pictures, tutors asked their students to describe their preference for each fruit (n=12) and vegetable (n=12) (never tried, don't like, like, favorite) and indicate what they eat for after-school snacks and whether they participate in snack and meal preparation at home.

Result or Outcome:
There were no differences between the total number of fruits and vegetables (FV) described as likes/favorite for boys (MN = 15.02 FV) and girls (MN = 15.11 FV). African American children preferred more FV than white children (MN = 15.7 vs. 14.8 FV, P = .001). The majority of children (51%) indicated that they do not select FV for after-school snacks. Children who help with snacks and meals identify a higher number of FV as likes/favorite (F = 55.09, P = .000), are more likely to choose FV for after-school snacks (F = 13.03, P = .000), and indicate that they like trying new FV (F = 17.51, P = .000). There were no helping differences found by gender (t = 1.24, P = .215). Likelihood of helping was negatively affected by age (t = -3.37, P = .001) and being African American (t = .913, P = .000). Helping is described as setting the table (54%), getting ingredients (38%), washing food or stirring ingredients (37%), and putting food on the table (34%).

Conclusion or Significance:
Partnerships that integrate an evidence-based nutrition curriculum to promote cognitive and social development are innovative and promising in addressing health disparities. Practical at-home tips that encourage child participation in snack and meal preparation may positively affect fruit and vegetable intake. Identifying barriers to children helping prepare snacks and meals in African American families and age-appropriate helping tasks should be explored.

CommunityInstitutional Partnerships: Understanding Trust Among Partners

Authors: S. White; L.A. Anderson; E.C. Stewart; N. Dawkins; S. Kamin; D. Chervin

Objective:
The success of the Centers for Disease Control and Preventions Prevention Research Centers (PRCs) program depends on the ability of its partner groups to develop and maintain partnerships that are built on trust. Although trust is recognized as integral to partnering efforts, it is often viewed as an elusive concept. This study was conducted to explore PRC partners experiences with and opinions about trust in community, state, and academic partnerships.

Setting: 
The PRC Program, a network of academic health centers, partner communities, and public health practitioners, enables the CDC to fund research activities that promote community-based approaches to prevention research, build capacity for public health practice, and foster collaboration with communities. Through science, community involvement, and practical application, the overall goal of the program is to improve community health and eliminate health disparities.

Method or Intervention:
Six focus groups were conducted: two with community, two with state, and two with academic partner representatives. Focus group participants were diverse with respect to age of the PRC (i.e., 215 years), location of the PRC (i.e., rural or urban communities), and number of years working with the PRC (i.e., 6 months13 years). In each group, participants were asked to 1) identify characteristics of their PRC partners attitudes and behaviors that encouraged or discouraged trust and 2) discuss how trust is developed for partners (i.e., at the interpersonal level, organizational level, or both).

Result or Outcome:
From these groups, we learned that state, community, and academic partners have different opinions about trust in their PRC relationships and the functioning of their partnerships. Academic and state groups discussed functional and organizational issues, whereas community members discussed issues related to the interpersonal aspects of partnerships. Across the groups, participants agreed that building and maintaining trust primarily depends on the individual but organizational barriers exist that can result in a distrusting environment and poor working relationships.

Conclusion or Significance:
As a result of this study, a tool is being developed to help partners identify and build on their successes in establishing and sustaining trusting relationships. Aligning partners perceptions is necessary for appropriate functioning, the future of the partnerships, and reaching the ultimate goal of improving health and eliminating health disparities.

Detecting Diabetes in East Harlem, New York, Through a Food for Life Festival

Author: L. Square

Objective:
To find undiagnosed diabetes in East Harlem and to engage the community in nutrition education.

Setting: 
The largely black and Hispanic population of East Harlem, New York.

Method or Intervention:
Because East Harlem has one of the highest rates of diabetes prevalence in New York City, it was chosen as one of ten pilot sites nationally to participate in the Diabetes Detection Initiative sponsored by the Department of Health and Human Services (HHS). In component one of the initiative, sites were asked to mass-distribute a customized version of the American Diabetes Association (ADA) risk test. Despite an initial lack of enthusiasm, coalition health centers agreed to participate and have contact information placed on the back of the test so that individuals who scored high could come into their clinics for follow-up. Component two was designed and executed by community and coalition partners in accordance with their established priorities, focused on nutrition issues. In collaboration with local restaurants, state and local health departments, CDC, and HHS, a Food for Life Festival was held. Local restaurants were invited to prepare a healthy dish using only foods that could be found in the neighborhood. Nutritionists determined the nutritional value and cost, and the recipes were shared through distribution of a cookbook. Fifteen restaurants from the area participated, and taste tests of all the recipes were shared with residents. Attendees were asked to complete the ADA risk test and, if their risk was high, participate in follow-up fingerstick blood glucose testing. Nutrition education and information about physical activity was available.

Result or Outcome:
Although there is no evidence that any individuals sought follow-up testing at the participating clinics from use of the risk test during component one, the results were more promising for the Food for Life Festival. Over 1,000 people attended the event, and over 100 local volunteers provided assistance. Of the 380 people who were screened, 180 were determined to be high risk. Blood glucose screenings were performed on 141 individuals, and 34 tested abnormal. Of the 34 who tested abnormal, 18 later admitted theyd been previously diagnosed with diabetes. Follow-up is ongoing for a small number of individuals. A most positive result was that the restaurateurs indicated their interest in adding healthy food options to their menus.

Conclusion or Significance:
The coalition was able to mount a successful community event to raise awareness of dibetes risk factors, based on their knowledge that nutrition concerns are paramount in East Harlem.

Developing a Rural Health Promotion Specialist Program to Provide Preventive Health Care to the Medically Indigent

Authors: J. Maltese; C. Brewton 

Objective:
To convey a technique used to recruit and train individuals to help promote preventive health care in underserved rural areas.

Setting: 
Troup and Heard County communities located in rural West Georgia.

Method or Intervention:
District Four Public Health Chronic Disease Prevention Initiative took the REACH 2010 program designed for urban areas and implemented it in rural communities with minor modifications. The main area of focus in finding lay volunteers was the faith community but was also extended to private businesses such as laundromats and community centers. Volunteers were trained in blood pressure screenings, body mass index (BMI) measuring, diet counseling, exercise, and the available resources to support individuals screened. A resource library was established with supporting information that includes pamphlets and flip charts to help facilitate interaction with individuals at risk. Health Promotion Specialists collect and submit contact data for aggregate review to the District Health Services Chronic Disease Prevention staff.

Result or Outcome:
After a 1-day training was provided to 15 Health Promotion Specialists, 134 people were screened over a 3-month period. Ninety-eight percent of these individuals were African American, lived in rural areas of West Georgia, and were medically indigent or had limited access to health care. The data showed that 39% of the individuals screened were prehypertensive, and 37% were either in stage 1 or stage 2 hypertension for their systolic measurement. The BMI measurements showed that 34% were overweight and 40% were considered obese. That gives our data set a group of 76% at hypertensive risks that correlates to 74% that are overweight or obese. Several individuals who had Stage 2 hypertension admitted not taking medications as directed by their doctor. The Health Promotion Specialist was able to encourage these people to resume their medications and recorded a return to normal blood pressures after several weeks of taking medications on a regular basis.

Conclusion or Significance:
Having lay volunteers trained as Health Promotion Specialists in rural areas is critical in preventing stroke and heart attack, and reducing unnecessary emergency department visits in the absence of a health care provider. Individuals screened and counseled respond well to the advice given by people they know and trust in their churches, community centers, and local businesses. We currently have a waiting list for people to be trained and hope to expand this initiative to every community in our health district and, eventually, throughout the state of Georgia.

Developing Effective Partnerships Between Researchers and the Faith Community: Results from Pastor Focus Groups

Authors: M. Goldmon; N.C. Blakeney; B. Weathers; C. Corbie-Smith; J.T. Roberson; E. Eng; A. Ammerman; C. Washington; C. Blumenthal; A. Bunton; G. Smith; M. Rushing; C. Boyd

Objective:
To identify perceptions and lived experiences among African American pastors regarding participation in health disparities research in order to form effective partnerships with African American churches in North Carolina and apply the findings to inform a church-based participatory research approach to establishing a participant registry for health disparities research.

Setting: 
A 5-year research partnership between the University of North Carolina and the Shaw University School of Divinity to eliminate health disparities among African Americans in four designated priority regions in North Carolina. These regions were selected because they represent 1) higher population density of African Americans and predominantly African American churches; 2) major economic distress tiers; and 3) higher incidence and prevalence of diseases related to health disparities

Method or Intervention:
Four focus group interviews, one in each region, were conducted with 30 African American pastors. Pastors were initially contacted by letter from the Divinity School and followed with a personal phone call from a member of the Divinity School faculty. A focus group discussion guide explored pastors perceptions of and experiences with research, willingness to engage their congregations as study participants, and perceived barriers and facilitators to forming community-academic partnerships. All sessions were tape-ecorded and transcribed. Transcripts were analyzed using Atlas ti software to code and retrieve concepts represented in the data. Themes were generated from the extracted text and assigned the same code.

Result or Outcome:
Distrust of researchers was identified as a major barrier to participation. Pastors also expressed concerns about misuse of and lack of access to research results. Important facilitators to participation expressed by the pastors were honest communication regarding study objectives, increased awareness of research opportunities, and demonstration of a long-term commitment to the community by researchers. Also highlighted in this presentation are the participatory activities and structures developed by this research partnership to build the research capacity of Shaw University, recruit focus group participants, develop the discussion guide, design a protocol for establishing a participant registry, and determine procedures for reviewing and approving investigator access to the registry

Conclusion or Significance:
Effective partnerships between academia and the faith community should develop in the context of sustained, trusting relationships that offer faith leaders and their congregants substantive, tangible benefits to participation.

Developing Sustainable Community-Based Chronic Disease Prevention Models in North Carolina

Authors: L. Michener; M.L. Sauer; S.D. Yaggy

Objective:
To work at the cmmunity level with low-income, uninsured individuals to develop sustainable chronic disease/obesity prevention services.

Setting: 
Thirty-seven across North Carolina serving low-income populations. Community partners include health departments, schools, park and recreation departments, economic development offices, and other civic groups.

Method or Intervention:
Duke University Medical Centers Department of Community and Family Medicine administers programs for a variety of funding agencies seeking to decrease and prevent chronic disease and obesity. Increasing physical activity, improving nutrition and smoking cessation are central intervention strategies. The community is the heart of each project. Each project has been created using the strengths and knowledge of community partners to achieve long-term sustainability recognizing cultural and demographic differences. Projects are challenged to change the culture of chronic disease and obesity in their community from that of inevitability to prevention. Some are more successful than others, however, in each case, issues have arisen that are difficult to overcome. These issues are well documented in community-based participatory research literature; forging and sustaining partnerships, staffing, resource management, leadership, and the development of clear, action-oriented and measurable outcomes.

Result or Outcome:
The Department of Community and Family Medicine has developed a technical assistance partnership with each project. The partnership enables each community to formulate the priorities and essential ingredients necessary for the goals and activities of the project. The partnership with Duke enables the community to maintain control and direction of the project but receive the technical assistance to work through issues as they occur. The goal in each case is the development of a sustainable community-based model to prevent chronic disease and obesity.

Conclusion or Significance:
We will identify successful strategies, common mistakes and barriers, typical developmental stages in project maturity, program outcomes and the use of scorecards to benchmark progress, and features of successful and sustainable projects.

Development of a Partnership Enhancement Tool Kit

Authors: C.S. Soloe; A. Vance

Objective:
To describe the development of a tool kit that aims to convey information about developing, sustaining, and evaluating effective partnerships, with an emphasis on health disparities, to national cancer programs funded by the the Centers for Disease Control and Preventions Division of Cancer Prevention and Control.

Setting: 
CDCs National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Program Services Branch.

Method or Intervention:
One of the aims of the Division of Cancer Prevention and Controls Program Services Branch is to assess, plan, build, support, and evaluate collaborative relationships to implement integrated approaches to comprehensive cancer control, with a special emphasis on health disparities. Specifically, the Program Services Branchs Partnership and Collaboration Team provides technical assistance and expertise related to partnership and collaboration, serves as a focal point for partnerships, and provides a framework for building and sustaining key partnerships. To effectively meet this purpose, the Program Services Branch has developed a Partnership Enhancement Toolkit. This Toolkit is designed to help program consultants within the Program Services Branch guide their programs through the process of identifying partnership needs; assessing potential partners, especially those who have developed effective methods to eliminate cancer health disparities; developing and sustaining effective partnerships; and evaluating partnership efforts and outcomes. Rather than separate health disparities into an individual module, the issues related to health disparities are interspersed throughout the Toolkit. This compels Program Consultants to regularly reflect on health disparities as they provide technical assistance.

Result or Outcome:
A tool kit designed to help program consultants within the Program Services Branch work with their programs to identify partnership needs and develop, sustain, and evaluate partnership efforts. Health disparities issues as they relate to partnership identification, development, sustenance, and evaluation are incorporated as an integral part of the tool kit.

Conclusion or Significance:
This effort resulted in a tool designed to help foster effective partnerships among CDC-sponsored cancer programs.

Extending Access to Physical Activity Programs for Persons with Arthritis Through Community Partnerships

Author: M.J. Gearing

Objective:
To describe how community partnerships can be leveraged to develop sustainable physical activity programs for persons with arthritis.

Setting: 
Six counties in southeastern Georgia.

Method or Intervention:
In the third iteration of the Georgia Arthritis Programs community intervention, we successfully mobilized community partnerships organized through Georgias Chronic Disease Prevention Initiative (CDPI) to train facilitators and co-sponsor People with Arthritis Can Exercise (PACE) programs in six counties in southeastern Georgia. These six rural counties had never been served by the Arthritis FoundationGeorgia Chapter, and no PACE classes had ever been offered. The PACE Plus Program combined community awareness events coordinated by the CDPI Coordinator and the Arthritis FoundationGeorgia Chapter with PACE classes held at local senior centers, health care agencies, parks and recreation departments, retirement communities, and nonprofit fitness facilities. Staff were trained at no cost in exchange for offering the program to community members for free during the first 8-week class session. The Georgia Arthritis Program provided educational materials, Therabands, and pedometers to participants. Local media provided coverage at no cost for the program launch. Community physicians participated as guest speakers and referred patients to the program.

Result or Outcome:
The strong community coalitions established by the Chronic Disease Prevention Coordinator yielded more requests for training and more facilities willing to sponsor the program than originally anticipated. Forty-five individuals completed the PACE facilitator training. Nineteen facilities sponsored 27 PACE classes that enrolled 317 participants. Community awareness events attracted 260 participants. Twenty-three of the original 45 facilitators completed at least one 8-week class session and were certified by the Arthritis Foundation. Six facilities and ten facilitators immediately incorporated the PACE Program into their ongoing programs and services. Another ten facilities have indicated they will offer the program again this year in partnership with the health district. We will also hold a PACE Program train-the-trainer training, further ensuring the long-term sustainability of the PACE program in the Coastal Health District. The success of this pilot has led to the adoption of the CDPI-coordinated PACE Plus Program as our main strategy to extend access to physical activity programs to persons with arthritis in other rural, underserved areas of the state.

Conclusion or Significance:
The study describes how chronic disease-focused coalitions and health education strategies established a sustainable physical activity program for persons with arthritis.

Floridas Coordinated School Health Program: A World-Class School Health Learning Community

Authors: F. Johnson; A. Meeks

Objective:
To introduce participants to a resource system designed to provide optimum support and information to educators working with a wide variety of students.

Setting: 
Web-based learning community tailored to meet the needs of Florida educators, but available through the World Wide Web to any interested professional.

Method or Intervention:
The Coordinated School Health Program, a proven national model, focuses on improving both student health and academic achievement. In the past 10 years Floridas Coordinated School Health Program has provided support and facilitation for 16 school-based pilot projects. Data developed through these projects indicated a need for a highly responsive resource system to expand the CSHP to reach more than 6,000 schools in Florida, and take the CSHP Model to scale. Floridas demographics range from some of the largest urban school districts in the nation to some of the most rural, and include over 188 different languages and cultures. This presentation will use learning simulations to demonstrate how the learning community sytem was developed and how agencies, teachers, parents, and program administrators in the CSHP eight component disciplines access and use the system. Participants will be given a recipe book for the development of an interactive, state-based, online resource system.

Result or Outcome:
The World-Class School Health Learning Community has been under construction since February 2004 and will have preliminary information by the conference date.

Conclusion or Significance:
The presentation will include strategies others can use in the development and implementation of a Web-based program designed to provide comprehensive support to those professionals representing the CSHP's eight school-based components: Health Education; Physical Education; Nutrition Services; Health Services; Counseling, Psychological, and Social Services; Healthy School Environment; Staff Wellness; and Family and Community Involvement.

Harvesting Our Community: Mobilizing Community Support for Obesity Prevention Among African Americans in West Virginia

Authors: W.L. Moore; N. OHara-Tompkins

Objective:
Little information is available about the health behaviors and status of African Americans in West Virginia. Harvesting Our Community, an ongoing initiative, was designed to collect primary data about physical activity, nutrition, and overweight/obesity among West Virginian African Americans in order to mobilize community support to address overweight/obesity.

Setting: 
This project is occurring in three primarily African American unincorporated areas in West Virginia. The total population of the three communities is approximately 1,500.

Method or Intervention:
A Community Health Worker was hired by a consortium of African American churches to form and facilitate a Community Health Committee. The committee comprises about 10 active members. The Community Health Committee designed and conducted a mailed and key informant survey to collect information about physical activity, nutrition, and overweight/obesity. The community survey used many of the questions from the Behavioral Risk Factor Surveillance System (BRFSS). Data from the surveys were presented to the larger community during a Community Forum. The survey, which was preceded by a letter encouraging participation, was mailed to 527 households.

Result or Outcome:
Completed surveys were received from 69 households, indicating a 13% response rate. A large number of surveys were returned as undeliverable. Fifty-five percent of those who did return a survey were older (5170 years of age), reflecting the demographics of the communities. Survey results revealed that a high percentage of respondents were overweight (32.4%) or obese (28%) and that overweight and obesity was more prevalent among women, paralleling findings from national data on African Americans. Eighty-three percent of the respondents reported no leisure-time physical activity in the last month and only 1% reported eating 5 or more fruits and vegetables a day. Nineteen percent reported having enough food, but not always the kind they want to eat

Conclusion or Significance:
Although the low response rate limits the generalizability of the survey findings, the survey and accompanying Community Forum did provide an impetus for some members of the community to become concerned about overweight/obesity. This concern led to the submission of a state grant to create a community garden and provide educational sessions on healthy eating and physical activity. The garden will increase the availability of fruits and vegetables in the community and provide opportunities for physical activity for those who participate in working the garden. The grant was funded, and the garden is scheduled to break ground in early spring 2005.

Healthy Hair Starts with a Healthy Body: Lay Health Advisors Making a Difference within Communities

Authors: D.K. Beach; J. M. Burke

Objective:
Healthy Hair Starts with a Healthy Body is a diabetes, hypertension, and kidney failure program intended to reduce the disproportionate rates of those diseases among African Americans.

Setting: 
The program empowers hairstylists within their community by training them on diabetes, hypertension, and chronic kidney disease; local health care resources; and nutrition and physical activity.

Method or Intervention:
Through Healthy Hair, stylists are trained at an 8-hour workshop to function as lay health advisors with their clients, specifically urging them through health chats to adopt a prevention behavior or see a doctor to discuss their disease risks. Salon clients are specifically urged to improve their diet (decrease fat and cholesterol), increase physical activity (regular physical activity most days of the week), stop smoking, and seek physician assistance or take medication if already diagnosed. The foundation of the program is building upon a communitys strengths. The stylists enjoy long-term supportive relationships within the African American community in which they work. They, therefore, become the perfect delivery system for an important health message. Risk surveys, brochures, videos, and incentives provide vital campaign elements. Data is collected through a health chat form, which the stylists collect before and after the intervention, to determine the changes made by the client.

Result or Outcome:
Data analysis shows positive client benefit in various ways. One month post-intervention, 60% took a prevention step and/or talked with a doctor. Fifty percent took a prevention step (i.e., eating more nutritiously, increasing physical activity, or stopping smoking). Forty percent discussed their risks with a doctor or make an appointment to do so. A total of 163 clients have been newly diagnosed with hypertension or diabetes as a result of the program. Client surveys conducted 6 months after the intervention also note positive, long-lasting benefits. Stylists benefit as well: 87% made a positive prevention behavior change and improved business and organizational skills.

Conclusion or Significance:
Launched in Detroit in 1999, the Healthy Hair program has expanded to seven Michigan cities with the aid of the Michigan Department of Community Health, the Robert Wood Johnson Foundation, and United Way. In all, 33 campaigns have taken place in which 574 stylists have been trained and over 11,000 clients reached. The program has been featured in local, regional, and national publications including Roll Call, the publication of Capitol Hill, and Black Hairstyles and Trends.

Implementing Diverse National Strategies to Address Health Disparities in Older Adults Through Physical Activity

Authors: J.E. Lang; D.M. Lawry

Objective:
Several national examples involving multiple national, state, and local partners spearheaded by the Centers for Disease Control and Prevention (CDC) and the Administration on Aging (AoA) have been developed and implemented since 2001 to address the health needs of older adults through health promotion/disease prevention activities. This session will highlight three distinct examples of grants programs targeting older adults. Specifically, physical activity programs aimed at reducing health disparities for racial/ethnic minority groups of older adults were chosen.

Setting: 
Each national program seeks to reach older adults where they live and congregate. CDC and AoA are using their respective networks, including state and local health departments, state units and regional agencies on aging, to develop and implement the programs at the local level. Each state or local entity in turn has partnered with local community-based organizations, local health care providers, academic institutions, or nonprofit groups to enhance capacity and contribute specialized expertise in program evaluation, research methodology, and outreach. To reach racial/ethnic minority older adults, local activities have taken place at senior centers in minority neighborhoods, Indian reservations, and faith-based institutions.

Method or Intervention:
The presenters will share goals, objectives, interventions used, and outcomes for 1) the You Can! Campaign, a national awareness campaign focused on promoting physical activity and good nutrition; 2) the National Evidence-Based Disease Prevention Grants program; and 3) the SENIOR (State-Based Endeavors of Needed Interventions: Organized and Replicated) grants program. Each program emphasizes partnership and the use of evidence-based approaches.

Result or Outcome:
Each national program has been successful in recruiting and developing partnerships at the state and local level, which has enhanced the success of program development, marketing, and implementation. Culturally appropriate approaches to health promotion for older adults have increased enrollment among racial/ethnic minority older adults. Qualitative data from grantees suggest improvements in self-reported health status among older adults.

Conclusion or Significance:
These program examples demonstrate creative strategies to reach older adults, diverse partners who bring specialized expertise to the projects; and strategies for addressing the unique needs of older adults. The partnerships developed through the course of each program are a critical element to bringing the respective expertise and strengths of the public health and aging services networks together to address older adult health in an effective and comprehensive manner.

Lessons Learned from Engaging Schools and Underserved Youth in Physical Activity Promotion Research

Authors: N. OHara-Tompkins; J.A. Rye; S. Zizzi

Objective:
Rural populations experience significant health disparities. This paper describes an initiative that involved primarily rural underserved secondary level students in the development, implementation, and evaluation of school/community-based research projects designed to promote physical activity.

Setting: 
The West Virginia Health Sciences and Technology Academy (HSTA) is a university-school-community partnership that provides academic enrichment through summer institutes and after-school community-based clubs. Approximately 25% of participating high school students are African American, and almost half are financially disadvantaged. The community-based clubs, which are facilitated by teachers, provide research and service opportunities for HSTA students, where students attempt to make a difference in their communities.

Method or Intervention:
A Request for Proposals (RFP) process was used to solicit grant applications from HSTA clubs. Focus groups with teachers and students, workshops, and targeted technical assistance were used to move HSTA clubs through the various phases of the research process, from project conceptualization (including Institutional Review Board (IRB) approval) to design, data collection, data analysis, and dissemination of findings.

Result or Outcome:
Six physical activity promotion projects emerged from this process. Numerous community partners were involved, including an exercise physiologist, school and community nurses, and trails and walkable communities constituencies. Target populations included school faculty and staff, high school students, and sedentary women in the community. The projects sample sizes ranged from 20 to 100. Every club employed a one-group pre- and post-research design. Intervention strategies reflected a mix of individual and environmental (both physical and social environments) strategies. All the clubs used pedometers both for motivational and measurement purposes. The length of the interventions across projects ranged from 8 to 16 weeks. Multiple outcomes using both quantitative and qualitative measures were tracked, including psychosocial (physical activity barriers, self-efficacy, outcome expectations), step counts, and anthropometrical measures (body mass index, percentage body fat). Although most analyses were descriptive, students in several clubs used inferential statistics. More than 35 student presentations were made about these projects.

Conclusion or Significance:
Focus group findings from teachers revealed that this experience increased their students capacity and interest in conducting research and in careers in the health sciences. Challenges included lack of time after school to complete all activities, competing student activities, and delays due to the IRB process. Students also reported increased research skills and awareness of challenges associated with promoting physical activity in rural settings. These preliminary findings reinforce the importance of providing opportunities for underserved youth participation in rural health promotion.

Moving from Advising to Partnering

Authors: M. Campbell; S. Benedict; S. Brown; A. Doolen; C. Fisher-Borne; P. Gonzalez

Objective:
To convey lessons learned, strategies, and tactics that resulted in the development of more effective partnerships between a Community Advisory Committee and a university-based Prevention Research Center.

Setting: 
A community-based participatory research intervention addressing womens health issues in two rural counties in eastern North Carolina. Partners include the Center for Health Promotion and Disease Prevention at the University of North Carolina-Chapel Hill, Community Advisory Committee and three Community-Based Organizations (CBOs). The CBOs included the Migrant Benevolent Association, Tri-County Community Health Center and U-Care (Domestic Violence Program).

Method or Intervention:
Through a historic review and ongoing evaluation of the partnerships between the university, the Community Advisory Committee, and three community-based organizations, we have uncovered compelling information and lessons learned. We have tracked the relationship of these organizations from a traditional research intervention to one that is based on the principles of community-based participatory research (CBPR). The historical review and evaluation include in-depth interviews, surveys, focus groups, and an analysis of the relationship dynamics based on principles of CBPR with all partners. The design of all evaluation instruments and methods is a shared responsibility of all members of the partnership.

Result or Outcome:
The evaluation findings include evidence of increased leadership capacity in the CBOs; increased community competency in the members of the university research team; improved community-based, community-driven research design and implementation; and increased efficacy in addressing social determinants of health. Additional information includes the changing relationships within the partnership and the development of projects beyond the scope of the grant. We will discuss the application of these findings as they relate to CBPR and, in particular, the potential power in partnerships between universities and community organizations.

Conclusion or Significance:
The presentation discusses strategies that develop effective partnerships among organizations and universities, particularly those working in diverse and rural communities.

Not in Mama's Kitchen: Empowering Women of Color Against Secondhand Smoke

Authors: T.R. Walls; B.B. Caffee

Objective:
To increase awareness of the negative health effects of secondhand smoke among African American women and to reduce the incidence of secondhand smoke (SHS) in homes across Arkansas.

Setting: 
Statewide Secondhand Smoke initiative targeted toward African American women. According to the U.S. Census data, many African Americans live in female-headed households. Our message is directed to mothers, grandmothers, daughters, aunts, and sisters  eliminate SHS and its effects in the home.

Method or Intervention:
At the Event Kickoff, we presented the campaign to the media to gain their buy-in for additional promotion to the community through their vehicles. We provided Community Kits to our outreach partners so they had all the information they needed to successfully implement the Not in Mamas Kitchen program. This education-focused campaign was created to collaborate with faith-based communities, community-based organizations, coalitions, African American hair salons and beauty supply merchants, and the community at large to get commitment pledges signed by women to not allow smoking in their homes or cars.

Result or Outcome:
Not in Mamas Kitchen originated in California. Survey data revealed that 96% of respondents stated that they would continue to maintain a smoke-free home and car beyond the campaign. The campaign continues to receive requests from communities and states impacting the programs longevity well into the new millennium.

Conclusion or Significance:
Not in Mamas Kitchen communicates the dangerous health effects of secondhand smoke through a targeted, statewide grassroots effort.

Opportunities to Eliminate Health Disparities Through Partnerships in AAPI Cancer Survivorship

Authors: R. Bautista; A. Wong

Objective:
To discuss opportunities to eliminate health disparities through partnerships in Asian American and Pacific Islander (AAPI) cancer survivorship.

Setting: 
National network of cancer programs and advocates addressing AAPI cancer survivorship

Method or Intervention:
Starting September 2003, the Asian and Pacific Islander American Health Forum (APIAHF) was funded by the Centers for Disease Control and Prevention (CDC) to address the impact of cancer and survivorship in the AAPI population in the United States and the Pacific Island jurisdictions. As we enter the second year of a 5-year grant, we have made attempts to connect and coordinate AAPI cancer support groups and organizations to similar counterparts in addition to cancer programs in health departments through an organizational and individual-based network membership. Through regional partnerships with AAPI-serving organizations in Hawaii and Massachusetts, and national organizations such as APIAHF and the Association of Asian Pacific Health Care Organizations (AAPCHO), we have conducted four focus groups and convened two national cancer strategy exchange teleconferences to assess the needs of cancer programs; coordinate cancer support resources between cancer programs and AAPI community-based organizations, and solicit recommendations for the development of AAPI cancer survivorship programs and resources. The program will continue to assess these cancer programs needs through continued focus groups, key informant interviews, and teleconferences.

Result or Outcome:
Findings from the focus groups and key informant interviews indicated that health care providers need cross-cultural training on how to address cancer in the various AAPI communities; patients, survivors, and caregivers need help in navigating through the system once diagnosed with cancer; a dev cancer resource directory needs to be developed that will assist both programs and individuals in accessing AAPI cancer resources; and existing and future AAPI cancer support groups need guidelines to streamline delivery of support resources for their communities. Relationships between mainstream and AAPI-serving cancer programs need to be strengthened to pool resources, share knowledge, and develop strategies to best address cancer and survivorship and eliminate health disparities in the AAPI population.

Conclusion or Significance:
This program discusses strategies to help foster effective partnerships and develop opportunities to promote cancer support and survivorship activities in the AAPI community.

Partnering to Decrease Health Disparities Among Native American Women

Authors: G. Cross; S. Lamb

Objective:
Increase ethnic groups use of mammography through collaboration and partnerships.

Setting: 
Tribal health care facilities and county health departments in areas where Choctaw women reside.

Method or Intervention:
Outreach and education to bring Native Amerian Choctaw women in to have mammograms and have access to on-site mobile mammography unit.

Result or Outcome:
Increase of mammography use by Native American women. Seeing rarely and never screened women in clinic that were not present previous year.

Conclusion or Significance:
To decrease morbidity and mortality rates of Natvie American women. Areas to improve for 2005 include patient flow, other methods of outreach, and continued collaboration with Choctaw Nation.

PE2GO: A Program to Address Disparities in Youth Physical Activity Opportunities

Authors: M. Martin; S. Martin; E.R. Martin

Objective:
The purpose of this study was to investigate the effectiveness of the PE2GO pilot program.

Setting: 
Six school districts across the United States. Nike US Community Affairs partners with several organizations across the country to offer an array of programs to foster physical activity among youth through their influencers (parents, teachers, coaches) in underserved areas (e.g., Native American Boys and Girls Clubs, African American and Latino communities in Los Angeles). PE2GO, one of Nikes initiatives, is a self-contained physical education (PE) program that provides classroom teachers with the tools they need to lead developmentally appropriate, quality PE lessons in their 4th - and 5th-grade classrooms in inner-city schools.

Method or Intervention:
Experienced trainers from nonprofit Sports, Play, and Active Recreation for Kids (SPARK) PE staff conducted a 1-day training using a playbook created especially for the PE2GO program. Nike provided the curriculum and the necessary equipment. The initial training focused on themes one and two: building a foundation and disguising fitness. About 4 months later a second training focused on theme three: simplifying sports. The data collection for the evaluation of this program took place in three distinct phases: pre-intervention, mid-intervention, and post-intervention. Trained evaluation consultants independent from Nike or SPARK conducted all aspects of the data collection and analyses.

Result or Outcome:
Reported minutes of PE per week increased significantly from pre-intervention to mid-intervention (37 vs. 60 minutes, P < 0.05) and remained significantly higher than pre-intervention at the posttest (73 minutes). Satisfaction increased significantly from pre- to mid-intervention (P < 0.05) and remained elevated post-intervention. Four of the eight questions assessing barriers showed that barriers decreased significantly from pre- to mid-intervention (P < 0.05) and remained reduced post-intervention. Almost all administrators reported that they would support staff development (94%) and encourage staff to implement PE2GO (88%); over half said they would reward staff for implementing PE2GO with fidelity (56%). From the qualitative research, almost all responded that administrators have expressed support for the program, yet about half added that administrators have had little involvement.

Conclusion or Significance:
Classroom teachers were successfully trained and satisfied with the program and the effect it was having on their 4th- and 5th-grade students. Reported minutes of PE increased substantially. The PE2GO program holds promise in this day of declining opportunities for children to be active during their school hours, especially in schools with limited resources for PE specialists.

Promoting Healthy Eating and Physical Activity Among Preschoolers in Low Socioeconomic Communities in Pennsylvania

Author: V.C. Prabhakher

Objective:
To improve nutrition and physical activity among children in daycare settings in targeted communities through a focused public/private sector partnership.

Setting: 
Preschool programs in five Pennsylvania counties.

Method or Intervention:
In 2003, the Pennsylvania Department of Health (Department) convened multiple organizations as potential partners to promote healthy eating and physical activity in daycare centers. Partners included the Department of Education, the Department of Public Welfare, the Head Start Collaborative, the American Cancer Society, and the Pennsylvania Nutrition Education Network. The partners collaboratively reviewed model programs from other states and selected Color Me Healthy (CMH), a program developed by North Carolina. CMH is designed to reach limited-resource children aged 4 and 5. The partners selected five counties as pilot sites, based on cultural diversity, geographic representation, and health disparities. Resources shared by partners were human and financial, including payment for kits (Education, Public Welfare, Head Start), workshops (Department), training logistics (American Cancer Society, Family Literacy), and the time and expertise of all collaborating agencies.

Result or Outcome:
The CMH program was implemented in over 300 daycare, Head Start, and Family Literacy Centers across Pennsylvania, from February to June 2004. Three training workshops were held in each pilot county as a collaborative effort of the above organizations. The partnership helped achieve a common goal to promote healthy eating and physical activity. A majority of respondents indicated that they saw positive changes among children in terms of fruit and vegetable recognition and healthy eating. Over one-half of the respondents also indicated that childrens attitudes toward physical activity improved. The need for the agencies representatives to set aside their own organizational agendas for a focused program with interdisciplinary features was the major challenge.

Conclusion or Significance:
Effective partnerships between multiple and diverse agencies are integral to the success of public health programs. As a result of the collaborative approach used by Pennsylvania, the CMH program demonstrated positive behavior changes among the target audience and will be expanded to twelve new Pennsylvania counties in the fall of 2004. Continued partnerships between the state departments of education and health and other statewide agencies are essential for future success of the program.

Public Housing Residents Are Catalysts to Enhanced Public Health Promotion and Community Health Linkages

Authors: E.E. Gray; G. Douglas; R. Goodman; G. Davis

Objective:
To provide a program that trains public housing residents as Resident Health Advocates (RHAs) to increase prevention efforts and create linkages between the residents and the health resources available in their communities.

Setting: 
Boston public housing developments in urban Boston provide the setting for the Resident Health Advocate Training Program. This program is a part of the CDC-funded Partners in Health and Housing Prevention Research Center (PHH-PRC). The partnership includes Boston University School of Public Health (BUSPH), Boston Housing Authority (BHA), and Boston Public Health Commission (BPHC).

Method or Intervention:
Public housing residents are critical assets to their communities. The PHH-PRC partnership provides a health and skills-based training program for public housing residents. Residents attend a 10-week training program, where they learn about community-identified health issues as well as skills needed to effectively act as health resources in their community. Following the training, these residents are hired as employees of the Boston Housing Authority to serve in the role of Resident Health Advocates.

Result or Outcome:
RHAs were able to link their communities to health resources through many different avenues and have helped over 150 families in the first two years. The trained RHAs have held health fairs, were available through office hours, created walking groups, and developed networks with some community health centers. The knowledge and skills gained through the training, combined with their experience and health connections developed through the program, have provided some participants with full-time jobs after completion of their RHA position. The last 3 years have highlighted the importance of continuous quality improvement assessment to determine the curriculums relevancy and appropriateness. This is based on RHA responses during our training sessions, an outcome evaluation at the programs completion, and the real-life issues that the RHAs are experiencing in their public housing developments that informed curriculum quality improvement. Outcome lessons also include respecting the challenges that each PHH-PRC partner faces, and recognizing the fragile balance between competing academic and public service interests while continuously striving to deliver an effective and relevant curriculum.

Conclusion or Significance:
The RHA training program enhances education and promotes awareness about health in Bostons public housing communities through the residents themselves. The training of community members can be an effective method of promoting public health and preventing disease in a population in a defined population.

Reducing Health Disparities by Strengthening Clinical Competencies in Rare/Chronic Bleeding Disorders: The Tri-Regional Seminar

Authors: J.R. Baker; B.K. Riske

Objective:
To describe the development and impact of a tri-regional partnership to promote workforce development for clinicians who provide diagnosis and treatment services to persons with rare, chronic bleeding disorders.

Setting: 
Over 95 clinicians from 24 states in the three federal regions of the western U.S. who provide nursing, social work, and physical therapy prevention and treatment services to 20% of the nations hemophilia population.

Method or Intervention:
Over the past 10 years, we conducted near-annual advance practice clinical education seminars for hemophilia treatment center (HTC) clinicians in Regions VIII, IX, and X. The seminars are jointly funded via regional Centers for Disease Control and Prevention (CDC) and Maternal and Child Health Block (MCHB) grants and private foundations. Unique features of the seminar include planning by a rotating committee, lack of pharmaceutical industry sponsorship, nonmarket-driven invitation and content, small-group interaction, opportunities for professional networking, and interaction with State Health Department Title V leaders.

Result or Outcome:
Over 95% of the HTC clinicians attended each of the seminars. Pretest and posttest evaluations reveal improvements in clinical knowledge. Formal evaluations consistently rate these as the most highly valued advance practice clinical education seminar available for core nonphysician clinicians at U.S. HTCs.

Conclusion or Significance:
The tri-regional seminar is a cost-effective intervention for strengthening the clinical skills of isolated nurses, social workers, and physical therapy specialists in rare chronic bleeding disorder diagnosis and management. This intervention could be used to increase clinical competencies in the care of persons with other rare, chronic disorders.

Response, Reach, Results: The ShopTalk Breast Cancer Awareness Project

Author: J. Lejeune

Objective:
To increase awareness among women that mammograms save lives through early detection, that Medicare covers mammograms every 12 months, and that the state Breast and Cervical Cancer Screening Program (BCCSP) has resources to provide screening services for low-income and uninsured women.

Setting: 
The ShopTalk project was offered statewide in West Virginia through 500 beauty shops in 50 of 55 counties.

Method or Intervention:
The ShopTalk project included a specially designed kit of educational materials to start the breast cancer awareness conversation between stylists and customers. Kits were distributed in late April 2004 to tie in with Mothers Day. Kits included items for stylists to display (posters, counter cards) and items to distribute to customers (Mothers Day cards, womens health records, nail files). The State Barbers and Cosmetologists Licensing Board endorsed the project and mailed a participation letter to 2,800 licensed professionals. The State Breast and Cervical Cancer Screening Program, YWCA ENCOREplus Program, American Cancer Society, and Leukemia and Lymphoma Society provided resource materials and identified local volunteers. Cancer support groups, and faith-based and senior organizations hand-delivered kits to local participating shops. Statewide broadcast and print media promoted the project.

Result or Outcome:
Five hundred shops in 91% of counties participated, well above our original goal of 300 shops. Approximately 25,000 women received Mothers Day cards with the Mammograms Save Lives message. Over 100 community volunteers delivered kits to shops. Participating cancer information specialists reported connecting nearly 100 women with BCCSP services as a result of the program. Hundreds of shops are continuing to share preventive health information as Community Health Improvement Champions. A post-intervention evaluation of participating shops showed a high degree of success, including a 97% favorable rating for the program and distribution rates of intervention kit materials ranging from 72% (shared cancer information) to 97% (distribution of nail files with mammography message).

Conclusion or Significance:
ShopTalk is an effective intervention to increase awareness of the need for mammography among women. The project can easily be replicated in other states. Developing health information kits with specific directions on how to display and distribute items is an effective method of delivering preventive health messages. Barbers and cosmetologists are interested in sharing preventive health messages with their clients. Association leadership support (licensing board) is effective in encouraging member participation. Key partnerships are effective in identifying volunteer support. Grassroots volunteer and advocacy groups can be mobilized to distribute health information. Media are interested in local human interest stories about breast cancer awareness.

Retooling an Osteoporosis Prevention Program to Serve Low-Income Populations: A Practical Guide to Bone Health

Authors: D. Cyzman; J. Lyles 

Objective:
To modify an existing osteoporosis prevention program to address the needs of low-income consumers and to assess its effectiveness in a pilot test.

Setting: 
Selected sites in four Michigan counties served by Michigan State University Extension (MSUE) educators.

Method or Intervention:
Building on previously collected focus group data from consumers and educators, we surveyed eight MSUE educators to help identify barriers encountered delivering an educational prevention program to low-income constituents. They recommended content changes that placed more emphasis on practical information relating to food choices, nutrition, and physical activity. Registered dietitians and staff representing the Michigan Nutrition Network, United Dairy Industry, and the Michigan Department of Community Health developed new material. A statewide steering committee reviewed the resulting program, A Practical Guide to Bone Health, before a final field test. We conducted the program at four sites selected by MSUE educators who reach low-income populations. Participants completed pretests and posttests assessing basic knowledge and intent to change behavior. Educators documented program location, number of participants, and audience income level.

Result or Outcome:
Program. A Practical Guide to Bone Health was designed as a 45-minute presentation available in either a flip chart or Power Point format. The content emphasized physical activity, diet quality, and the importance of calcium and vitamin D. A shopping section guided consumers to better food choices. The program also encouraged change in diet and physical activities.
Pilot test. Four MSUE educators deployed the program at four MSUE sites, one urban, three rural. A total of 46 people attended. Participants were primarily between the ages of 18 and 44 (75%), white (93%), and female (79%); at 3 of 4 sites, participants were predominantly low-income. A total of 43 participants completed both the pretest and the posttest (93%). Of those who did not have perfect scores on the knowledge pretest, 73% increased their scores following the session. Prior to the program, 28% reported inadequate calcium intake and 30%, inadequate physical activity. At posttest, 50% of those with low calcium intake indicated intent to eat three or more servings of calcium-rich foods. Likewise, 62% of those with low activity levels reported intent to increase physical activity to at least 30 minutes three times a week. An additional 13% indicated intent to increase activity to 30 minutes five times a week.

Conclusion or Significance:
Collaboration resulted in an easy-to-use and effective osteoporosis prevention program directed toward the needs of low-income populations.

Screen Our SistersCommunity Agencies Collaborate to Provide Breast Cancer Screening to African American Women

Authors: C. Leon; A. Austell

Objective:
Using collaborative relationships to decrease the incidence of breast cancer deaths in an Africian American Community in Tulsa, Oklahoma.

Setting: 
Breast Cancer Screening and Mammography Services were provided in an African American community at various locations including churches, clinics, nutritional centers, and pharmacies.

Method or Intervention:
Several public and private agencies such as Oklahoma Foundation for Medical Quality, the Oklahoma BCCEDP Program, Tulsa Area Agency on Aging, Tulsa Project Woman, Hillcrest Chapman Breast Center, Oklahoma State University Take Charge Program, and community churches, community volunteers, and community health care professionals came together to provide Breast Cancer Screening for African American women at numberous locations between August 2004 and the end of October 2004. Outreach to the community included community-specific radio and TV announcements, community-specific newspaper articles, and widespread flyers, presentations, and meetings with community ministers.

Result or Outcome:
One of the outcomes was the establishment of the community group, Screen Our Sisters, that will remain ongoing to promote health for the African American women in the Tulsa, Oklahoma, community. Public and private groups that have not worked together for one targeted population came together and brainstormed with the community volunteers to plan this massive community intervention. Strenghts and limintations for this type of collaboration will be discussed. The resulting data from the interventions (currently in process) will be analyzed and presented.

Conclusion or Significance:
The number of deaths due to breast cancer can be reduced in a targeted population through networking and collaborating with public and private agencies, community volunteers, and faith-based organizations. Positive collaborative experiences can extend to other areas of health care and increase opportunites to intervene at a more extensive level.

Successfully Treating Chronic Conditions in Low-Income Elders: The Just for Us Program

Author(s): D. Kempe Jacobowitz Ames

Objective:
This study evaluates the capacity of the program Just for Us to treat chronic conditions in the residents of low-income housing units administered by the City of Durham Housing Authority, as measured by achievement of treatment goals for hypertension and diabetes.

Setting: 
Coordinated in-home primary-adjunct medical care, mental health services, and social work services are provided to patients in their homes at no cost to them.

Method or Intervention:
Continuing medical care is provided by midlevel practitioners through cooperation of Duke University Medical Center and Lincoln Community Medical Center, a federally qualified community health center, and The Durham Center, an area mental health agency. Visits are regularly scheduled in patients homes every 3 to 6 weeks by the nurse practitioners or physicians assistant.

Result or Outcome:
The average income of patients served by Just for Us is approximately $6000/year, and their average age is 70. Eighty-two percent are African American, and 84% of the patients have hypertension. According to the HEDIS goal of blood pressure less than or equal to 140/90, 83% of current hypertensive patients were at goal at their last appointment. Hypertensive patients receiving care from a single provider were more likely to achieve HEDIS standards for control of hypertension. Forty-two percent of the patients have diabetes. Diabetic patients with hypertension were more likely than nondiabetic patients to achieve the HEDIS goal, 88% versus 78% for the last blood pressure measured. Seventy percent of current diabetic patients met the American Diabetes Association (ADA) 2004 goal of a blood pressure less than 130/80; 84% of diabetic patients met the HEDIS goal of 9.5% glycosylated hemoglobin A1c; and 43% met the ADA 2004 goal of less than 7% glycosylated hemoglobin A1c.

Conclusion or Significance:
Just for Us meets recognized standards of care for diabetes and hypertension at high rates on several important measures in a population traditionally considered difficult to treat: poor, elderly, and majority African American. There are clinical and financial advantages in the combination of a leading medical center and a federally qualified community health center in providing a high-quality sustainable program for the management of chronic conditions. Just for Us demonstrates that continuing in home primary-adjunct care can meet important needs for chronic condition management among the elderly living independently in low-income housing.

The Use of Social Capital to Promote Physical Activity in Older Adults

Author: M.T. Brick

Objective:
To promote physical activity in older adults through the use of social capital.

Setting: 
Erie County, NY.

Method or Intervention:
The Older Adults Mobility and Socialization Program began as a series of guided walks that took place over a 15-month period. Participants were encouraged to develop or increase their physical activity through the program. The lead agency organized the guided walks throughout the park system within the city of Buffalo, New York, and the surrounding county. It used the existing social capital network in the project area to enlist senior centers, congregate meal sites, and others to mobilize their constituencies and participate in the walks. At each walk an educational forum was provided on a variety of health and wellness topics. The program emphasized social connectedness among participants by gathering bridging networks of people, or people of diverse backgrounds, to come together and stay together, in order to achieve a generalized reciprocity. Participants registered for the kickoff event and subsequently signed in at each walk thereafter. Pre- and post-evaluations were conducted to determine demographics, self-reported physical activity and health status, and overall satisfaction with the program.

Result or Outcome:
Participants returned on a weekly basis to participate in the walks. A total of 1,122 walkers registered for both of the spring series of walks, and 685 registered for the fall series. The winter walks, consisting of six indoor mall walks, saw 592 registrants. Participants were motivated to return with earned incentives such as stickers for their walking passports, sun visors, and waist packs. In post-evaluations, 82% of participants reported the program helped to increase their physical activity, 92% responded that they would continue walking after program completion, and 56% reported that they would consider forming or joining a walking group in their community. Participants were also as ked what they liked best about the program. Among the top ten responses were the friendliness of the group, meeting new people, having others to walk with, and peer companionship

Conclusion or Significance:
The program established an interactive social environment for physical activity. Based upon review of participant zip code data, 34% of suburban and rural participants took part in the spring series of walks throughout Buffalo city parks. Of the urban participants, 4% were from predominantly ethnic/ minority areas. The program provided access to areas supportive of physical activity (the city and county park system), eliminated barriers to physical activity such as transportation, and used the Healthy Community Model to support community inclusion and program implementation. Participants overwhelmingly responded to post-surveys that the program helped increase their physical activity level (n=1,998) and they would continue walking after the program ended (n=2,265).

Tobacco Prevention and Control in Utahs Ethnic/Minority Communities

Author: L. Larsen; H. Borski; J. Duncan

Objective:
Expand Utahs tobacco prevention and control efforts to identify and eliminate tobacco-related disparities in the African American, American Indian, Hispanic/Latino, and Pacific Islander communities.

Setting: 
Four ethnic community networks in Utah.

Method or Intervention:
In 2002, the Utah Tobacco Prevention and Control Program (TPCP) convened a diverse group of community representatives to develop a strategic plan to better address tobacco prevention and control among six identified populations disparately affected by tobacco use (African American, Hispanic/Latino, Asian/Pacific Islander, Native American, low socioeconomic status, and rural). Disparately affected populations were identified according to the Utah Behavioral Risk Factor Surveillance System (BRFSS) and access to services. Working Together to Bridge the Gap: A Strategic Plan to Identify and Eliminate Tobacco-Related Disparities in Utah was published in 2003. TPCP, in spring of 2004, issued a Request for Application (RFA) to carry out the plan in the African American, American Indian, Hispanic/Latino, and Pacific Islander communities.

Result or Outcome:
Four community groups received awards in summer of 2004 to accomplish activities in the five goal areas of the Plan: 1) data; 2) capacity building; 3) cultural competency; 4) policy; and 5) collaboration. Early successes will be described.

Conclusion or Significance:
Developing a strategic plan with community partners led to creation and funding of four ethnic networks and expanded TPCP efforts to underserved and vulnerable populations with a disparate tobacco-related burden.

Using Data to Build Community Partnerships: The Little Project That Did!

Authors: M.M. Gardner; E. Siddens

Objective:
To illustrate ways in which existing data sources can be culled and used to build partnerships to address health disparities related to issues of childhood overweight

Setting: 
Five counties in rural south-central Kentucky

Method or Intervention:
Community health practitioners discount or disregard national and statewide data that they view as not being reflective of their communities. If health problems are to be addressed effectively, community partners must understand the extent of the problem within their own community. Although national attention has focused on the problems of childhood overweight, little was being done at the local level to address this issue. In order to raise awareness among community partners and to develop and implement programs addressing this growing health concern, a project was undertaken to use existing data sources mandatory school health physicalsto document the extent of childhood overweight. Point-prevalence of childhood overweight was calculated among kindergarten and grade 6 students in five counties using NutStat. Analysis was shared with schools and community partners.

Result or Outcome:
Local prevalence exceeded prevalence at the national and statewide level. More than one-third of kindergarten students and close to one-half of 6th-graders were at or above the 85th percentile. Furthermore, the majority of these students67% of kindergartners and 61% of the 6th-graderswere at or above the 95th percentile. Once presented with these data, schools and community partners initiated actions to address this problem. Activities included formation of coalitions, changes in school lunch offerings and vending practices, education for training for teachers and physicians, and grant development.

Conclusion or Significance:
Local data are viewed as salient and therefore provide the impetus for action and the development of community partnerships.

Using Geographical Information Systems to Facilitate Community-Based Public Health Planning of Diabetes Intervention Efforts

Authors: D.J. Kruger; J.S. Brady; L. Shirey; E.Y. Lewis

Objective:
The survey was developed with three main objectives: To increase our understanding of health and social issues in Genesee County (Michigan) communities, to increase community awareness of the practical application of systematic information collection, and to increase community competence in survey design, conduct, and use.

Setting: 
The Prevention Research Center of Michigan (PRC/MI), with its central mission to expand and share knowledge and thereby strengthen the capacity of the community in order to improve the publics health, used community-based research principles to design and implement the Speak to Your Health! Community Survey. This survey, developed by the alliance of partners that comprise the PRC/MI in Genesee County, Michigan, focuses on community health and community concerns. This presentation will describe the use of community survey data to facilitate diabetes intervention efforts.

Method or Intervention:
The community survey asked 1,862 residents of Genesee County about their diet, physical activity, health status, and other health-related items and behaviors. The U.S. Department of Health and Human Services (HHS) is currently piloting the Diabetes Detection Initiative in 10 communities throughout the United States, including Flint, Michigan. The Diabetes Task Force of the Greater Flint Health Coalition, a PRC/MI partner, has taken the lead in implementing this initiative in Flint. Using community survey data along with HHS criteria for diabetes risk, we calculated and geographically mapped diabetes risk scores and compared these to diabetes screening rates.

Result or Outcome:
The comparison showed that areas where diabetes risk rates were high had relatively low diabetes screening rates, revealing geographic areas where intervention efforts may be needed most. This information has been instrumental in raising the awareness of the issue with community groups and members. Those involved in community-based diabetes intervention efforts have used this information in the development of activities to address diabetes, and especially the racial disparity in diabetes, in Genesee County.

Conclusion or Significance:
Through this survey, the PRC/MI has shown that quantitative data collection can be accomplished using the principles of community-based research. The information obtained from analyses of community survey results will be used to plan and evaluate future research and intervention efforts aimed at improving the health of Genesee County residents, especially those experiencing a disproportionate share of adverse outcomes.

Using Neighborhood-Specific Clusters to Stimulate and Evaluate Behavioral Change: A Social Mobilization Campaign for Increasing Awareness of HIV/AIDS and Chronic Disease

Authors: B.A. Salaam; W.R. DeShazer; T. Straughter; A. Lindsey

Objective:
Elements necessary to implement an effective HIV/AIDS and chronic disease awareness/prevention social mobilization campaign targeted through using specific clusters.

Setting: 
Phoenix, Arizona; Chicago, Illinois; Baltimore, Maryland; Detroit, Michigan; Jackson, Mississippi; and Brooklyn and Harlem, New York City.

Method or Intervention:
The C.A.R. Communities Accepting Responsibility campaign, a multicultural social mobilization campaign to promote knowledge and behavioral change as it relates to HIV/AIDS and chronic disease was designed during a 5-year demonstration project funded by the Centers for Disease Control and Prevention, 19992004. Many public health communication campaigns use only demographics, such as age or race, as the categories for dividing the population into segments and determining which segments of the population will be targeted. The C.A.R. campaign segments the population using a neighborhood stakeholder-specific system of geodemographic mobilization clusters, which are grouped by neighborhood ZIP codes, school districts, judicial districts, and data from consumers, marketing databases that include information on minority buying habits, and economic status, to obtain greater accuracy in targeting specific at-risk populations. This campaign strategy has been evaluated in 11 major cities participating in our demonstration project.

Result or Outcome:
Results indicate that members of targeted neighborhood-specific clusters are more likely than standard coalition participants of community-based or nongovernmental organizations not associated with targeted clusters to engage in the process of coming together to discuss high-risk behaviors. This campaign reaches targeted populations, as indicated by the C.A.R. initiative. Significant, positive behavioral changes were observed in all 11 cities participating in this campaign. Members of these neighborhood-specific cluster coalitions increased their emotional intelligence and behavioral patterns from pre- to post-campaign, proactively seeking information on HIV/AIDS, STDs, mental health, cardiovascular disease, diabetes, and substance abuse. Research showed that bringing the coalition process to the people as opposed to the community-based organization was directly responsible for this behavioral awareness leading to behavioral change.

Conclusion or Significance:
Data indicates that targeting by information empowerment leads to mobilization effectiveness. Data also indicates that neighborhood-specific clustering enables communication campaigns to reach persons at high risk of behaviors that lead to HIV/AIDS, STDs, substance abuse, mental health, cardiovascular disease, and diabetes, and motivates prompt proactive screening and testing. A geodemographic cross-sectional strategy leads to constant, accurate data collection in addition to telephone surveys and tracking calls through hotlines.

Youth at Risk: A Status of Youth Behaviors in West Texas and Ciudad Juarez, Mexico

Authors: A.G. Pauli; E. Mata

Objective:
Without adequate health care coverage or financial resources for the region, it became apparent that the mission of the Paso del Norte Health Foundation (PdNHF) needed to focus on health promotion and disease prevention primarily in the behavioral and environmental aspect of health. In order to identify scientific data to support the foundations grant program, surveys such as the Youth Risk Behavioral Surveillance (YRBS) System have been used.

Setting: 
The Paso del Norte Health Foundation was created from the sale of a not-for-profit hospital in El Paso, Texas, in 1995. The service area of the foundation is west Texas, southern New Mexico, and Ciudad Juarez, Mexico. The quality of health care in America has continued to increase, but disparities of care are caused by socioeconomic, racial, ethnic, and geographic factors. The Paso del Norte region is a prime example of these disparities.

Method or Intervention:
The YRBS was administered to 943 secundaria students in Ciudad Juarez, Mexico, and 888 seventh- and eighth-graders in El Paso County. Students in randomly selected schools and classrooms were asked to participate. A consent form signed by the students parent or guardian was required for participation. The YRBS is most commonly implemented at the high school level, but the determination to focus on younger students was guided by the perception that early intervention is necessary to prevent the initiation of risky behaviors.

Result or Outcome:
The YRBS results illustrate the early initiation of high-risk behaviors, such as tobacco use, alcohol and other drug use, and sexual activity. Seventeen percent of El Paso and 14% of Juarez middle school students have had sexual intercourse, and a large percentage report having their first encounter at age 12 or under. In addition, the increased percentage of overweight students correlated to increased hours of television viewing. Middle school years were pinpointed as a critical time during which students exercised risky behaviors. The results indicated the importance of effective prevention measures at an early age.

Conclusion or Significance:
The study provided information to support planning, development, and evaluation of interventions for PdNHF and other agencies to address risky behaviors of youth with an emphasis on the middle school years as a crucial period of change.

Evidence-Based Programs: 
Research, Translation, and Evaluation 
The 10 Keys to Healthy Aging: An Innovative Approach to Community Health

Authors: C. Bayles; L.H. Kuller; A.B. Newman; C. Milas; K. McTigue; K. Winters

Objective:
The 10 Keys to Healthy Aging (10 Keys) program aims to reduce preventable risk factors in the aging population and to improve quality life expectancy, focusing on preventable diseases and disability.

Setting: 
The program was initiated in the at-risk, underserved community of McKeesport, Pennsylvania, an abandoned mill town on the Monongahela River.

Method or Intervention:
The Center for Healthy Aging (CHA) selected the 10 Keys on the basis of epidemiological, clinical, and laboratory studies. Working with governments and other organizations, the CHA has worked to promote healthy aging using community outreach and research. Community outreach included public speaking, health fairs, talent shows, dances, weekly radio shows, quarterly newsletters, and organized walks. The research project recruited a sample of 544 people (6.3% nonwhite), aged 65 and older. They were randomized into one of two interventions: an intensive healthy lifestyle with emphasis on control of hypertension and diabetes, or brief health education with referral to community partners. All research volunteers were assigned to a health counselor to help them adopt the 10 Keys. Health status was monitored at entry, 6 months, and one year.

Result or Outcome:
Community outreach activities were assessed by the involvement of community partners, number of invited public speaking engagements and health fairs requested by partners, success of CHA-sponsored community events, success of our radio show, and the popularity of our newsletters (participant data base). The research demonstration project included 217 men and 327 women whose mean age was 74.5 years (SD 5.6). Before intervention, the percentage of participants meeting the 10 Keys recommendations was 95% (combat depression); 86% (regulate fasting glucose <110 mg/dl); 55.5% colonoscopy and 85.5% mammography (participate in cancer screening); 68% (control systolic blood pressure); 54% (maintain LDL cholesterol <100 mg/dl for coronary disease and diabetes); 64% (obtain >2.5 hours physical activity per week); 70% pneumovax and 92% influenza vaccine (get regular immunizations); 79% (prevent bone loss and muscle weakness); 95.6% (no smoking); and 99.3% (maintain social contact).

Conclusion or Significance:
Healthy adults frequently did not undertake key behaviors linked with maintaining health. However, diverse community organizations and individuals showed interest in learning about and implementing the 10 Keys. Participation in preventive medical care was highest for osteoporosis and breast cancer screening. Colon cancer screening, cholesterol lowering, hypertension management, and physical activity are areas to target for improvement. Over time the role of the community campaign and the demonstration project will be assessed.
Adapting to Diversity at the U.S.Mexico Border: Process and Outcomes of a Family-Based Diabetes Program

Authors: N.I. Teufel-Shone; R. Drummond

Objective:
To describe how family support was promoted in a diabetes education program designed for low-income Hispanic families and how the program was adapted to the socioecological characteristics of two distinct border communities.

Setting: 
Two predominantly Hispanic (>90%) communities located in border counties, one characterized by a rural agricultural economy and the other linked to a large city on the Mexico side. Hispanic populations within these counties suffer rates of diabetes twice the rate reported among all U.S. races.

Method or Intervention:
To enhance the translation of research findings that family support and involvement are associated with greater patient compliance with recommended self-management strategies and behavior change within the household, a community-university team developed a 12-week family-based diabetes education program for delivery by promotoras (lay health workers) in Hispanic border communities. Program partners identified significant differences in promotoras experience with diabetes education and community outreach, and in the socioecological characteristics of the communities (e.g., access to transportation, safe walking areas, and interfamily familiarity). To allow for adaptation to social and regional differences, the curriculum content was standardized but the framework for program delivery, interactive activities, and supplemental materials was flexible. A 15-item pre- and post-questionnaire was used to assess program impact on diabetes knowledge, attitudes, beliefs, and behaviors.

Result or Outcome:
Addressing barriers such as access to transportation and social privacy in the rural community, promotoras implemented the program through individual home delivery with 35 families. Building on families interest and willingness to gather in a central location in the more urban community, promotoras implemented the program in group sessions with 37 families. Pretests and posttests (n=116) indicate a significant increase in family participation in physical activity and a trend toward greater family cohesion at both sites. Other outcomes vary by site. Greater changes were seen in knowledge of diabetes risk factors, dietary choices, and increased physical activity in the rural community with home delivery.

Conclusion or Significance:
Translating research findings that support the involvement of the family in diabetes education and prevention requires a socioecological approach that considers the variations with the local context in a seemingly homogenous population.

American Indian Children Walk for Health: Increasing Physical Activity by Daily Walking at School

Author(s): D.B. Bishop; G. Taylor; R. Mays; O. Beaulieu

Objective:
To assess the feasibility and initial effects of a school environmental and policy change for increasing physical activity in American Indian children.

Setting: 
A quasi-experimental design with two schools in the intervention condition and one school in the comparison condition on two neighboring Indian reservations in northern Minnesota (n=179 American Indian students).

Method or Intervention:
Daily walking program incorporating a 20- to 30-minute walk into the school day when students are in 3rd- and 4th-grade. Students in seven classrooms in two schools walk with their teachers daily. The intervention was collaboratively designed with partners from the local schools and tribal health community. Measures included student height, weight, skin-fold thickness, waist circumference, body mass index (BMI) and percent body fat; a student survey of attitudes and behaviors; and physical activity monitoring (using pedometers and CSA monitors). Assessment is done at baseline, midpoint (after one year), and follow up (after 2 years) of intervention. Process measures assess compliance with daily walking.

Result or Outcome:
Baseline data indicate that 64% of children had BMI scores above the 85th percentile; 47% were above the 95th percentile. Students spend the majority of the school day in sedentary activity. In the first year, students walked with their teachers 85% of the school days. Preliminary results from midpoint evaluation indicate children in the intervention schools have become significantly leaner (percent body fat) than children in the nonwalking comparison school.

Conclusion or Significance:
Full collaboration of community partners is essential for success. Programs to increase physical activity and reduce obesity among American Indian children are needed. A daily walking program, structured within the school day, appears to be a feasible and efficacious method for increasing physical activity and reducing percent body fat for this population of American Indian children.

An Economic Analysis of a Childhood Obesity Intervention in Largely Hispanic Schools

Author: H.S. Brown

Objective:
To assess the net benefit and cost-effectiveness of the Coordinated Approach to Child Health (CATCH) intervention program.

Setting: 
From 2000 to 2002, the El Paso Coordinated Approach to Child Health (CATCH) conducted a controlled trial of the CATCH program in El Paso schools.

Method or Intervention:
The goal of CATCH is to reduce the number of childhood obesity cases. Using NHANES I and NHANES follow-up data, we project forward the number of adult obesity cases for people aged 4065 years by estimating adult obesity probabilities conditional on childhood obesity. There are two economic measures. First, from a societal perspective on costs, cost-effectiveness ratios are estimated, revealing the intervention costs per quality-adjusted life years (QALYs) saved. QALYs are estimated using National Health Interview Survey data. Second, the net benefit of CATCH is estimated by comparing the present value of averted future costs with the cost of the CATCH intervention.

Result or Outcome:
The results show that CATCH is cost-effective and net-beneficial. Further, CATCH appears to be slightly more cost-effective and net-beneficial than Planet Health, an alternative intervention.

Conclusion or Significance:
The results show that CATCH is cost-effective and net-beneficial. School-based obesity interventions are a good investment in Hispanic communities.

An Investigation of the Environment and Diabetes Risk in Rural Communities

Authors: K. Weidinger; S. Lovegreen; M. Elliott; D. Haire-Joshu; J. McGill; R.C. Brownson

Objective:
To identify factors of the home and community environment that are associated with elevated gylcosylated hemoglobin A1c (HbA1c) levels among overweight, nondiabetic individuals.

Setting: 
Twelve rural communities of southeastern Missouri, Tennessee, and Arkansas.

Method or Intervention:
Random-digitdialed telephone survey data from 2003 on the perceived environment were combined with biological data on levels of adult participants who were overweight (BMI >25 kg/m2) and nondiabetic. Metabolic status was evaluated with a laboratory test for HbA1c, which is a marker of long-term blood sugar control and thus suggests a risk level for diabetes. The association between elevated HbA1c levels (>5.5%) and perceived environmental variables was estimated using logistic regression to control for age, gender, and education. Crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were calculated.

Result or Outcome:
Three hundred and thirty overweight persons (mn age = 51 years; 78% female; 97% white) participated in the clinical assessment. Participants, on average, ate fast food once-twice/week and were sedentary (watching TV, computer, reading, sitting) 3 hours/day. Those who reported more places to be physically active were more likely to meet physical activity recommendations (moderate or vigorous activity). An elevated HbA1c level was positively associated with feeling unsafe from traffic while walking or biking in the community (aOR=2.5, 95% CI 1.3-5.1). Other indicators of the environment were found to be positively associated with elevated HbA1c levels, although not statistically significant, such as unavailable facilities to be physically active, unpleasant aesthetics of the community, feeling unsafe from crime, and an increasing gradient of sedentary behavior and fast food consumption.

Conclusion or Significance:
Factors of the community environment, particularly safety from traffic, may be associated with elevated HbA1c levels in individuals living in rural communities.

Application of Chronic Disease Frameworks to Diabetes Care Within the Indian Health Care System

Authors: K.J. Acton; Y. Roubideaux; K. Moore; S.L. Valdez; T. Brown; S. Gilliland

Objective:
To evaluate the implementation of essential elements of diabetes care in the Indian Health Care System using the Chronic Care Model (CCM) and the Innovative Care for Chronic Conditions (ICCC) Framework.

Setting: 
Diabetes is an important chronic condition affecting American Indians and Alaska Natives (AIAN) and is a major public health concern for this population. The Indian Health Service (IHS) is a federally operated health care system that provides care to over 2 million people from more than 557 federally recognized tribes in 35 states, more than 100,000 of whom have a diagnosis of diabetes. The IHS Division of Diabetes Treatment and Prevention (DDTP) administers a comprehensive diabetes prevention and treatment program in Indian health programs that includes, through special legislation, the new Special Diabetes Program for Indians (SDPI) grants program to prevent and treat diabetes in AI/AN communities.

Method or Intervention:
We examined the elements of diabetes care provided by the DDTP using the Chronic Care Model (CCM) and the Innovative Care for Chronic Conditions (ICCC) framework. The IHS DDTP program elements were reviewed using the CCM assessment tool by an outside evaluator and by program staff. A separate outside evaluator also reviewed the IHS DDTP program elements by comparing program elements with the ICCC framework. Information on how the IHS DDTP program elements compared to these frameworks was reviewed and summarized. The quality of diabetes care (both process and outcome measures) were analyzed before and after the implementation of the SDPI.

Result or Outcome:
The IHS DDTP has successfully implemented the key elements of the CCM and ICCC framework, including elements of the policy, health care organization, community, and patient/family environments. Many of these elements have been in place for over a decade. This approach to diabetes care has been associated with improved outcomes in gylcosylated hemoglobin A1c (HbA1c), blood pressure, mean lipid values, and increased use of ACE inhibitors in AI/AN patients with type 2 diabetes.

Conclusion or Significance:
The DDTP utilizes many of the elements of the chronic care frameworks including establishing new and enhancing old partnerships, informing policy makers, creating new funding sources, developing practical mechanisms to involve communities to build capacity, providing evidence for the effectiveness of clinical approaches, and evaluating programs to improve the health care system and chronic care outcomes. The DDTP experience provides an illustration of the potential use of chronic care models for more effective prevention and treatment of chronic conditions.

Cardiovascular Risk Reduction and Health Empowerment Among African American Men: the AMEN Example from the Fulton County REACH 2010 Project

Author: T. Stephens

Objective:
To demonstrate the effectiveness of self-help empowerment programs designed to reduce racial and ethnic disparities in cardiovascular health.

Setting: 
The Atlanta Empowerment Zone/Renewal Community is a federally funded program that provides grants or loans to nonprofit or for-profit organizations to implement a broad range of human services, safety, housing, and economic development programs within target areas in the City of Atlanta. The City of Atlanta's Empowerment Zone is made up of 30 neighborhoods and has a poverty rate of 57.4% and a population of 50,000.

Method or Intervention:
Data was collected from study participants at two time points: baseline and follow-up upon program implementation and completion. Baseline and follow-up data were collected via survey instrumentation from 192 and 128 participants, respectively. The data collection instrument collected information on participants demographic characteristics, knowledge of cardiovascular disease (CVD) risk, and health practices regarding physical activity and dietary behavior. Chi-square and t tests were conducted to determine if there were significant associations between participants responses or differences between data collection periods.

Result or Outcome:
Study findings indicated significant changes in participants knowledge of best practices regarding the reduction of cholesterol in the blood (P<.005), saturated fat intake (P<.018), best ways to stop smoking (P<.014), and which types of cholesterol may help protect one against heart attack (P< .042). Program participants also reported positive dietary behavior practices regarding increased consumption of drinking fruit juices (P< .003), eating more fresh fruits and vegetables (P<.001), and reduction in consumption of fried potatoes, French fries, and potato chips (P< .005).

Conclusion or Significance:
The study presents data that supports gender-specific interventions designed to reduce CVD risk among African American men. Such interventions are effective if they engage men to be proactive in their own health care. Integrating CVD risk reduction efforts with other health service programs and organizations can assist in connecting marginalized clients with active prevention services offered by REACH partners.

CDCs School Health Index: A Coordinated Approach to Improving School Health

Author: A. Gupta

Objective:
To describe the purpose and structure of the CDCs School Health Index: A Self-Assessment and Planning Guide (SHI) and to illustrate how it is used to improve school health and safety programs and policies.

Setting: 
School health teams consisting of key stakeholders in school health (including community members, parents, students, administrators, and teachers).

Method or Intervention:
The SHI helps schools assess and improve their health and safety policies and programs in the context of a coordinated school health program. The SHI translates research-based guidelines developed by the CDC into the most critical standards of school health for unintentional injury and violence prevention, physical activity, healthy eating, and tobacco use prevention. The newest edition of the SHI, to be released in 2005, addresses asthma in addition to the areas previously included. The SHI uses a coordinated approach by engaging a school health team of diverse stakeholders to assess and improve school health and safety polices and programs. The SHI guides the team through a process to identify areas of improvement within the context of a coordinated school health program and develop an action plan to implement recommendations produced as a result of the assessment.

Result or Outcome:
The SHI is currently being implemented in at least 46 states, in Canada, and in Mexico. The presenter will describe significant ways in which it is being used, innovative strategies that agencies and organizations have used to promote the use of the SHI, and methods some agencies and organizations have used to increase the impact of the SHI on school health policies and programs.

Conclusion or Significance:
The SHI can be an effective tool to help schools strengthen and improve their health and safety programs and policies.

Challenges in Disseminating Evidence-Based Programs to Eliminate Disparities: A Multi-Issue Road Map

Authors: C. Vinson; J. Kerner; M. Kane; J. Draut

Objective:
Investigations conducted as core activities of Turning Research into Improved Outcomes (TRIO) at the National Cancer Institute (NCI), whose objectives are to link research and translation to dissemination to reduce the cancer burden.

Setting: 
National in scope.

Method or Intervention:
The Strategic Plan To Reduce Health Disparities seeks to understand the causes of health disparities in cancer and to develop effective interventions to eliminate these disparities. NCI worked with partners, including CDC, the American Cancer Society (ACS), and national research experts, to involve them in authoring detailed perspectives on the factors that cause or accompany disparities in cancer and connect the factors to dissemination models to identify dissemination mechanisms and barriers. In each investigation, participants responded to a key focus question. The concept mapping methodology was applied to analyze and present results. The five issues investigations included a multiregional initiative to identify and assess needs for cancer control; two on disparities in cervical and breast cancer; and two exploring how to eliminate disparities through a national research agenda. The sixth focused on the research/practice relationship and capacity to disseminate evidence-based program knowledge to areas of need. After all the projects completion, CSI and NCI aggregated five topic-centered projects results and surfaced areas of highest need. CSI created a map of dissemination strategies, linking them to the content derived from the aggregate national disparities needs map.

Result or Outcome:
Each topic-centered investigation resulted in a unique concept framework map, useful to its own audiences for planning and action. These were combined for aggregate analysis. The critical linkage is the connection of the national content with the map of research and practice partner capacity and responsibilities for dissemination.

Conclusion or Significance:
Major challenges exist for researchers and practitioners to partner successfully on eliminating disparities: information sharing, using dissemination strategies, collaborations, and nontraditional methods. Issues included lack of agreement on the requirements of research/practice partnership, and the trickle-down effect of partnership barriers. NCI and its partners are developing training on translating research into practice and creating partnerships. Concept mapping content was used to create the content for advanced partner training.

Cholesterol Screening and Awareness in Michigan

Author: M.L. Cook

Objective:
To investigate trends in cholesterol screening and awareness in Michigan, and to examine demographic and medical care associations that might contribute to the trends observed.

Setting: 
Michigan.

Method or Intervention:
The Michigan Behavioral Risk Factor Survey (BRFS) is an annual, statewide, random-digitdialed telephone survey of adults that is conducted as a part of the national Behavioral Risk Factor Surveillance System. Each year data are collected concerning a multitude of health risk behaviors, preventive health practices, and chronic conditions among Michigan adults. Since 1993, cholesterol screening and awareness questions have been asked every odd year.

Result or Outcome:
Since 1993, Michigan has had higher prevalence estimates in cholesterol screening and awareness than the median among participating states and U.S. territories. From 1993 to 1999 few differences in the prevalence of cholesterol screening and awareness had been found in Michigan. Between 1999 and 2001, though, there was an increase in the proportion who reported ever having their cholesterol checked (76.3% to 79.5%), which was followed by a increase in high cholesterol among those who had ever had their cholesterol checked from 2001 and 2003 (33.0% to 37.6%). The proportion who had ever been told that they had high cholesterol increased for both men and women between 2001 and 2003 (men: 35.4% to 41.3%, women: 31.0% to 34.5%); this prevalence rate also increased for whites (33.7% to 39.0%), but not for African Americans. Among those who had health care coverage, the prevalence of high cholesterol increased from 33.8% in 2001 to 38.5% in 2003, but the increase did not occur among those who did not have health care coverage. The prevalence of high cholesterol also increased among those who had at least one health care provider (34.7% to 38.8%).

Conclusion or Significance:
Since high cholesterol is a major risk factor for cardiovascular disease, it is important to monitor cholesterol screening and awareness among demographic groups and other groups that have high health disparities over time. Part of the trend increase in Michigan may have to do with the new high density lipid cholesterol (HDL-C) recommendation from the National Cholesterol Education Program in 2001 that reduced the amount of HDL-C found in the blood to <35mg/dl. HDL-C is only one major risk factor that modifies low density lipid cholesterol goals; others include hypertension and cigarette smoking, risk factors for which Michigan was ranked 18th and tied for 7th, respectively, in 2003.

Colorectal Cancer Screening Among Latinos from U.S. Cities Along the TexasMexico Border: A Qualitative Study

Authors: M. Fernandez; I. Torres; S. Vernon; T. Byrd; M. Hinjosa-Lindsey 

Objective:
The purpose of this study was to assess factors influencing colorectal cancer screening among low-income Hispanics living along the TexasMexico border. Colorectal cancer (CRC) is a leading cause of cancer death among Latinos, yet most are not receiving the recommended colorectal cancer screening (CRCS) tests, and little is known about the types of factors that may influence informed decision-making for CRCS among Latinos.

Setting: 
Four focus groups with low-income Latino men and women were conducted in January 2004 at each of three sites (Brownsville, El Paso, and Laredo).

Method or Intervention:
Demographic, psychosocial, and cultural factors potentially related to CRCS were addressed as well as general issues such as access to health care services, perceptions about the importance of preventive health care, and issues surrounding health care decision-making.

Result or Outcome:
Both women and men in this study reported a heavy reliance on home remedies, herbal remedies, and prescription drugs bought across the border, partially because of financial barriers and lack of insurance. Many participants in all groups reported feeling more satisfied with the care they received on the Mexican side of the border due to the lower cost of medications and office visits and perceptions that the care in Mexico was more efficient, flexible, thorough, always offered in Spanish, and humane. The participants knowledge, attitudes, and beliefs related to cancer reflected a combination of misconceptions and accuracies, and fatalistic and nonfatalistic attitudes. They often associated the word cancer with descriptors such as death, fear, pain, ugliness, sadness, and hopelessness. Most participants in this study knew very little about colorectal cancer and even less about CRCS. Many participants were confused about the differences between colorectal cancer and stomach cancer or prostate cancer. There was also a strong belief that untreated hemorrhoids and constipation were major causes of CRC. Individual-level barriers to CRCS suggested by participants included embarrassment; machismo; lack of knowledge and information; procrastination; fear of questioning physicians; fear of the actual screening procedures; and fear of receiving a diagnosis of cancer. Other barriers to CRCS identified by participants included lack of health insurance or financial resources, being undocumented, and transportation barriers.

Conclusion or Significance:
Results from these focus groups have provided much-needed initial information related to this area of Latino health and will provide guidance for the development of interventions to increase CRCS among low-income Hispanics along the TexasMexico border.

Colorectal Cancer Screening Among Minorities in Florida

Authors: Z. Fan; Y. Huang; C. Miller

Objective:
This study identifies racial disparities in colorectal cancer screening and its related factors among adults aged 50 years and older in Florida.

Setting: 
Receiving regular cancer screening plays a vital role in the early detection and treatment of cancer. Colorectal cancer can be detected through the use of screening methods such as blood stool tests and sigmoidoscopy.

Method or Intervention:
The prevalence of colorectal cancer screening among adults aged 50 years and older was analyzed using 2002 Florida County Behavioral Risk Factor Surveillance System (BRFSS) data. The prevalence was compared among racial/ethnic groups and among people with or without health insurance or health care providers.

Result or Outcome:
Substantial racial disparities in the prevalence of colorectal cancer screening were identified among adults aged 50 years and older in Florida. The prevalence of having a blood stool test in the past 2 years was lower among both non-Hispanic blacks (28.0%) and Hispanics (21.9%) than among non-Hispanic whites (36.2%). Similarly, the prevalence of ever having a sigmoidoscopy was lower among both non-Hispanic blacks (44.0%) and Hispanics (37.6%) than among their non-Hispanic white counterparts (56.2%). Among non-Hispanic blacks and Hispanics, the rates of having either health insurance or a personal health care provider were lower than among non-Hispanic whites. Compared to people with health insurance, those without health insurance had a lower prevalence of having a blood stool test (19.6% versus 35.0%) or sigmoidoscopy (31.1% versus 55.0%) in the past 2 years. Similarly, in comparison to people who had a personal health care provider, those who did not have a personal health care provider had a lower prevalence of having a blood stool test (18.0% versus 35.9%) or sigmoidoscopy (28.3% versus 56.5%) in the past 2 years.

Conclusion or Significance:
This study cites specific racial disparities in colorectal cancer screening in Florida. Efforts should be made to provide cancer screening to minorities and those who do not have health insurance or access to health care.

Community-Based Arthritis Exercise Randomized Control Trials: Implementation in Diverse Populations and Settings

Authors: L.F. Callahan; T. Mielenz; B. Schoster; K. Buysee; K. Rizzone

Objective:
To discuss the challenges, rewards, and lessons learned associated with conducting randomized community intervention trials of arthritis-specific exercise programs in diverse populations and locations.

Setting: 
Thirty-five class sites including churches, senior centers, community centers, and wellness clubs in urban and rural areas across a southern state. Site locations were 10 to 260 miles from the research center.

Method or Intervention:
Two physical activity intervention programs were evaluated in randomized control trials in people with arthritis by our research team; People with Arthritis Can Exercise (PACE) and Active Living Every Day (ALED). A total of 348 subjects in 18 community sites were enrolled in the PACE program, and 359 subjects were enrolled in 17 sites in the ALED program. Sites were selected in partnership with the state arthritis program and the Area Agencies on Aging. Both trials conducted baseline and follow-up assessments including self-report surveys (assessing functional outcomes, symptoms, pain, fatigue, and psychological status) and functional tests of performance (assessing mobility, strength, balance, and endurance) on the participants. In addition, information on health literacy and program satisfaction was obtained. The PACE intervention lasted 8 weeks; the ALED intervention continued for 20 weeks.

Result or Outcome:
Challenges included the following: determining the best time of year to deliver the intervention (avoiding holidays and extreme weather), training instructors, minority instructor and participant recruitment, recruitment of males, recruitment of low-literacy participants, last-minute study enrollment, assessment day staffing, logistics and travel, facility differences (lack of adequate space to conduct the assessments), randomization frustrations (including participant disappointment when randomized to the control group), fidelity of program delivery, managing instructors from a distance, course retention, instructor variation, incentives, and reimbursing multiple contractors through a public university system. The four most important rewards were community interactions, collaborations with the Arthritis Program and state public health programs, research team building and positive feedback from participants. Strategies for dealing with the challenges will be presented and will focus on recruitment, retention and reimbursement, scheduling and logistics, off-site supervision, and collaboration with community facilities and agencies.

Conclusion or Significance:
Community-based randomized trials offer many advantages, including a greater awareness of the benefits of arthritis-appropriate exercises among the communities involved. Approaching these and similar studies with an understanding of the challenges and potential strategies will serve to enhance the success of the intervention.

Creating a Medical Home for Asthma: Improving Care in Pediatric Clinics Serving Low-Income Communities

Authors: D. Evans; W.C. Liao; L.P. Boss; M. Pinkett-Heller; M.C.B. Winslow; C. Ramos-Bonoan; L. Davis

Objective:
To reduce health disparities by developing, evaluating, translating, and disseminating a program to improve quality of care for asthma in pediatric clinics.

Setting: 
Forty-five pediatric clinics serving low-income, minority communities in New York City.

Method or Intervention:
We conducted a controlled trial in 22 of the clinics to evaluate an intervention to improve quality of care for asthma, with funding from the National Heart, Lung, and Blood Institute (NHLBI). The intervention included five interactive training sessions for all clinic staff to screen patients for asthma, provide treatment according to NHLBI guidelines, and provide asthma education to families. A goal of the training was to improve patient-staff communications and staff-to-staff teamwork, thus creating a comfortable medical home for families trying to manage childhood asthma.

Result or Outcome:
Follow up over 2 years showed that, compared with controls, intervention clinic staff increased identification of clinic patients with asthma from 2.5% to 6.9% (P<.001); scheduled visits for asthma by 75% (P<.001); controller medications given to patients to 25% vs. 2% in controls (P<.001); and asthma education by physicians (P<.01) and nurses (P<.05). Emergency department (ED) visits decreased by the second year of follow up (P<.05), but urgent visits for asthma to the clinic increased (P<.01), suggesting families shifted urgent care visits from the ED to the clinic, a better use of health care resources. Following the trial, staff from intervention clinics delivered the program to staff of the remaining 23 clinics plus new hires, showing the program could be sustained within the organization. Subsequently, the Centers for Disease Control and Prevention (CDC) funded translation of this program from research into practice through a contract with RTI International. The translated materials for this program can be downloaded free of charge from the New York City Department of Health Web site (www.nyc.gov/html/doh/html/cmha/index.html) and include modules on getting started, conducting training, implementing the program after training, and evaluating program impact. Materials include videotapes, slide presentations, detailed guides for leading sessions, a handbook for program participants, screening forms and written treatment plans for patients, medical care protocols, and links to other resources.

Conclusion or Significance:
This project has developed a successful program to improve quality of care for asthma in pediatric clinics serving low-income communities, thus addressing a major cause of health disparities in asthma. Translated Web-based materials make this program available for use by other pediatric clinics.

Creating an Effective Multi-Session Nutrition and Physical Activity Intervention for Low-Income Rural and Urban Women

Authors: R.E. Litchfield; S.J. Ryan; J.D. Myers Geadelmann; J.F. Pendergast; K.K. Ullom

Objective:
To describe a process for creating targeted nutrition and physical activity interventions, and an effective nutrition and physical activity intervention created using the process.

Setting: 
A 15-site cardiovascular research study for low-income, underinsured and uninsured, rural and urban Iowa women aged 4064 years.

Method or Intervention:
A nine-member task force of Iowa State University Extension (ISUE) Nutrition and Health Field Specialists, the ISUE Communication Specialist, and Iowa Department of Public Health (IDPH) WISEWOMAN (Well-Integrated Screening and Evaluation for Women Across the Nation) staff met in person and via online chat room over a 6-month period and created a multi-session nutrition and physical activity intervention based on the Health Belief Model. The six steps in the development process were 1) review research literature to identify important intervention content and structure issues; 2) gather qualitative data from task force members based on their past experience working with the studys target audience; 3) examine target audience demographic data to determine potential size, education level, and socioeconomic status of the population; 4) survey a sample of potential participants to identify motivators and barriers to, and interest in, participating in the proposed intervention; 5) develop intervention curriculum; and 6) pilot test materials with groups demographically similar to the target audience. The intervention was designed to be fun, easy, and practical to hold participant attention, enhance skills for making and sustaining lifestyle change, and provide group support. Each of the 12 sessions is 75 to 90 minutes long and is conducted in a magazine format that includes a snack, main topic, physical activity, skill-building activity, behavior change discussion, incentive, goal-setting, and next session preview. Sessions are taught by ISUE Nutrition and Health Field Specialists. Participants begin by attending Session #1, which sets the foundation for understanding womens heart disease risks, then progress through the sessions in any order. Each participant receives a transportation stipend upon enrollment.

Result or Outcome:
Evaluations of the lifestyle sessions have been overwhelmingly positive. Barriers to participation include lack of transportation, time constraints, and the length and number of sessions; but session evaluations indicate that those who attend find the information presented worth the time and effort. Many session evaluations include requests for more information and indicate increased participant self-efficacy.

Conclusion or Significance:
The study demonstrates a successful process for partners developing effective interventions and describes an intervention that is well-accepted by its target population.

Culturally Competent Health Care Systems: Evidence-Based Reviews in the Guide to Community Preventive Services

Authors: T. Quinn; L.M. Anderson

Objective:
This presentation will provide information on an update of a Guide to Community Preventive Services systematic review of five interventions that have the potential to reduce health disparities by improving cultural competence in health care systems. The interventions under consideration are programs to recruit and retain health care system staff members who reflect the cultural diversity of the community served; use of interpreter services or bilingual providers for clients with limited English proficiency; cultural competency training for health care providers; use of linguistically and culturally appropriate health education materials; and culturally-specific health care settings. Effectiveness of these intervention approaches were evaluated based on three outcomes: 1)client satisfaction with care; 2)improvements in health status, and 3)provider referral patternsand client's use ofservices.

Setting: 
Health care systems.

Method or Intervention:
A systematic review of recent literatureJanuary 2001 to July 2004was performed using synonymous search terms and methodology from an earlier Community Guide of literature that found insufficient evidence to evaluate these programs. Based on titles and abstracts, 1,561 citations were assessed for inclusion dependent on if they were intervention studies reporting a relevant outcome. This process yielded 85 articles that were screened for research design and content. Of these, 34 have been selected for potential inclusion. Included studies will be dual-abstracted and, based on study quality, a best-evidence subset will be used to determine program effectiveness.

Result or Outcome:
The previous systematic review on this subject yielded too few studies to determine the effectiveness of these interventions. It is anticipated that this update will deliver more quantifiable evidence about this topic of significant health importance. Results will be presented to the Task Force on Community Preventive Services in February 2005.

Conclusion or Significance:
This update discusses interventions that potentially reduce racial and ethnic disparities in health care access and health outcomes.

Developing a Culturally Appropriate Spanish Version of Tips to Prevent Medical Errors

Authors: G. Alcala-Levy; S. Crelia; D. Miranda

Objective:
To create a culturally appropriate Spanish version of the Five Steps to Safer Health Care messages.

Setting: 
Several predominantly Spanish-speaking urban sites in the United States.

Method or Intervention:
The Five Steps to Safer Health Care messages, or Tips to Prevent Medical Errors, were developed by the U.S. Department of Health and Human Services to educate the general public about simple steps that can be taken to ensure safer health care. To ensure the messages could also be understood and used by the Spanish-speaking population in the United States, BearingPoint and the Centers for Medicare and Medicaid Services (CMS) conducted a study to determine the most appropriate way to develop and disseminate these messages to that population. Instead of directly translating the messages from English into Spanish, which has proven to be an ineffective way to communicate with this population, we employed a three-stage methodology of 1) translating the messages into Spanish, 2) back-translating the messages to ensure that the original meaning and intent were not compromised by the translation, and 3) conducting cognitive interviews with a diverse representation of Hispanics in the United States. Our research not only measured how well participants were able to comprehend the messages but also took into account cultural differences in communication styles, both between the Spanish speakers and their English-speaking counterparts, as well as between various groups of Spanish speakers. Research participants, therefore, included Spanish speakers with diverse backgrounds, including country of origin, length of time living in the United States, age, education, and income levels.

Result or Outcome:
The study found that some of the concepts of Patient Safety were not well understood or recognized by this population. We also found that cultural differences, particularly related to the patient-provider relationship, play an important role in the likelihood of this population using the messages. The study showed that modifying the messages to reflect these cultural differences would make Hispanics more likely to comply with them and would, furthermore, allow them to recognize the importance of the suggested actions and to understand that they have the right to carry them out. On the basis of these findings, we created a culturally appropriate Spanish version of the Five Steps to Safer Health Care messages.

Conclusion or Significance:
The study discusses strategies that may further increase consumer comprehension and the intended use of the Spanish version of Five Steps to Safer Health Care messages.

Developing, Implementing, and Disseminating Evidence-Based Healthy Aging Programs in Community-Based Organizations

Author: N. Whitelaw 

Objective:
To disseminate findings on the development, implementation, and dissemination of evidence-based healthy aging programs in community-based organizations.

Setting: 
Community-based organizations in Boston, Houston, Los Angeles, and Portland, including care management agencies, senior centers, and churches, with a total of 15 locations implementing one of the four evidence-based programs. These settings reached highly diverse participants including Latinos, African Americans, Native Americans, Chinese, and other nonEnglish-speaking populations.

Method or Intervention:
The National Council on the Aging (NCOA) conducted a 3-year national project to translate health promotion and disease management studies into evidence-based model programs that are feasible for local agencies to operate and are attractive to older adults. Expert review panels examined the evidence for effective interventions on a variety of prevention topics and recommended the development of model programs for diabetes self-management, nutrition, depression management, and physical activity. Four regional teams across the country translated each of the review panels recommended evidence-based interventions into model programs, two using a lay leader method, and two designed for implementation by care managers. Throughout the translations process, experts from CDC and academic institutions reviewed the programs to ensure fidelity.

Result or Outcome:
The RE-AIM framework is being used to characterize the results of this project. Each site succeeded in reaching diverse populations with risk factors relevant to the model program. Approximately 350 older adults were reached during the pilot period. Data gathered on the pilots suggests that the programs were effectiveimprovements in self-reported health status were reported, and satifaction levels were high. Of critical importance was the willingness and ability of various settings to adopt the program. Considerable attention was paid to maintaining fidelity to the proven intervention during the implementation phases. On-site reviews by outside experts confirmed that implementation was consistent with original studies. Maintenance is still being assessed, but 12 of the 15 pilot sites continue to offer these programs.

Conclusion or Significance:
The results of this project reinforce the belief that community-based organizations are highly capable of implementing evidence-based health promotion and disease management programs for older adults. Such programs can be incorporated into existing programming, providing excellent opportunities for organizations to expand their reach and quality of offerings. The four model programs are now offered as free toolkits, which guide organizations through the implementation of the programs.

Economic-Related Disparities in Child and Parent Fruit and Vegetable Intake and Body Mass Index

Authors: C. Mushi-Brunt; M.B. Elliott; D. Haire-Joshu

Objective:
To examine economic-associated disparities in physical and social environmental factors associated with fruit and vegetable consumption and weight status among preadolescent children and their parents.

Setting: 
This study was conducted as part of P.A.R.A.D.E, a community-based partnership between local mentoring/tutoring agencies and the Obesity Prevention Center at Saint Louis University.

Method or Intervention:
Child and parent fruit and vegetable intake and physical environmental data was collected from parents through a telephone survey. Subjective physical environmental variables included parental estimates of distance to grocery stores and fast food establishments as well as accessibility of fruits and vegetables in the home. A geographic information system (GIS) was developed to map street addresses of each parent/child dyad to provide objective data regarding availability and accessibility of grocery and fast food establishments. The monetary costs associated with fruit and vegetable purchase and consumption were also assessed and used for analysis. Independent samples t-test and logistic regression analysis techniques were performed.

Result or Outcome:
Child BMI (mean=20.6) was negatively associated with vegetable intake (r=-0.118, p

Conclusion or Significance:
These findings suggest opportunities for community-level interventions to reduce socioeconomic-related disparities in fruit and vegetable intake.

Effectiveness of the Massachusetts Partnership for Healthy Weight (MPHW) school-based physical activity and nutrition intervention (5-2-1 Go!)

Author(s): Daniel M. Finkelstein; Philip J. Troped; Karen E. Peterson; Maria Bettencourt; Solomon Mezgebu; Kathleen Grattan; Wee Lock Ooi; Maren S. Fragala; Jean L. Wiecha

Objective:
To present preliminary findings on the effectiveness of a school-based intervention model addressing individual and environmental influences on overweight and behavioral risk factors in middle school youth

Setting: 
Thirteen public and parochial schools from urban and suburban communities in Massachusetts (MA)

Method or Intervention:
This study examines the effectiveness of 5-2-1 Go!, an intervention comprising the interdisciplinary Planet Health classroom and physical education (PE) curriculum and CDC;s School Health Index (SHI). 5-2-1 Go! was implemented and evaluated as a pilot intervention of the MA Partnership for a Health Weight (MPHW), a CDC-funded collaboration between the Massachusetts Department of Public Health, the Harvard School of Public Health, and other community and university partners statewide. Using a group-randomized design, 16 middle schools were stratified by school type (public vs. parochial) and distribution of race/ethnicity and randomly assigned to intervention or control condition. Three schools elected not to participate in the study after randomization. We obtained height and weight and a self-administered survey of physical activity, screen time and dietary intake behaviors among a cohort of 6th and 7th grade students in 13 schools during the Fall 2002 and Spring 2004 and an interim survey in Spring 2003. SHI assessment data were collected at baseline and at a two-year follow-up in both intervention and control schools. Process evaluation data that documented the extent of the delivery of the intervention were collected from intervention school personnel after years 1 and 2. To assess effectiveness of the intervention, we will develop statistical models that account for clustering within schools and individual-level covariates.

Result or Outcome:
Among the 1839 students with complete baseline data, 34.4% (n=259) of students at intervention schools and 34.7% of students (n=377) from control schools were at-risk or overweight (BMI- 85th percentile for age and sex). Complete data for the three time points were collected on a cohort of 1622 students (88.2% of baseline sample). Longitudinal analyses are ongoing. Preliminary results on the effectiveness of the intervention model at reducing the prevalence of overweight and improving students physical activity, diet, and screen time behaviors will be presented.

Conclusion or Significance:
This meeting will represent the first national forum in which findings from the MPHWs 5-2-1 Go! pilot intervention will be presented. Results of effectiveness trials provide an essential evidence base for widespread dissemination and program sustainability by public health partners.

Eliminating Disparities in Communities of Color Through the Lifetime Fitness Program 

Author(s): Snyder, Susan; Belza, Basia

Objective:
To convey lessons learned about factors that contribute to sustainable and effective group fitness programs for older adults in ethnic communities.

Setting: 
Eleven ethnic community centers in central and western Washington.

Method or Intervention:
The University of Washington Health Promotion Research Center conducted focus groups with older adults from seven cultural groups (American Indian/Alaskan Native, African American, Chinese, Korean, Spanish-speaking Latinos, Filipinos, and Vietnamese) to generate ideas for programming that would increase the level of physical activity in these communities. After focus group results were compiled and published, an evidence-based group exercise program for older adultsthe Lifetime Fitness Program (LFP)was implemented in community sites where these groups also had a nutrition program. LFP is offered in hourly sessions two to three times a week and includes strength, endurance, balance, and flexibility exercises. Lifetime Fitness Program Testing of Function for each participant is conducted at enrollment and every 4 months thereafter.

Result or Outcome:
Focus group findings showed that both the key motivator and primary barrier for physical activity was related to health and chronic conditions. Ideal fitness program components that were common across the groups were programs that included peer support and instruction, were offered in locations close to where attendees lived, were offered in a center that was targeted to their ethnicity, and included several options for exercising, including doing it alone or in a group. Detailed results of these focus groups are published in the report titled Elder Perspectives on Physical Activity: A Multicultural Discussion. Preliminary data reported here include 226 LFP participants from 11 ethnic sites. Participants had at least one valid outcomes measure; only 27% (N=62) had 4-month follow-up data. At baseline, participants at ethnic sites compared to those at nonethnic sites were below normal limits in the Arm Curl (23% vs. 10% nonethnic), Up and Go (68% vs. 36%) and Chair Stands (30% vs. 21%). Average age of participants is 72.8 (SD + 72.8). Significant improvement was seen in chair stands and arm curl repetitions at ethnic sites at 4 months.

Conclusion or Significance:
Knowledge gained from these focus groups and from the implementation and evaluation of the LFP can inform future interventions to better reach ethnic minority communities. A policy that links senior nutrition sites serving minority communities to evidenced-based programs such as LFP may be an effective way to reduce health disparities.

Evaluating Programs for Public Health Impact : Examples from the WISEWOMAN Program

Author(s): Rosanne P Farris; Julie C. Will; Eric A Finkelstein; Olga A. Khavjou

Objective:
To promote the use of a broader program evaluation framework, using the RE-AIM model, that goes beyond the assessment of effectiveness to include a number of other important public health dimensions.

Setting: 
The RE-AIM model will be applied to the North Carolina WISEWOMAN project which is one of 15 projects funded by CDC. The WISEWOMAN program aims to remove health disparities by providing uninsured, low-income mid-life women with cardiovascular preventive health services.

Method or Intervention:
We used data from WISEWOMAN and the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to assess 14 WISEWOMAN sites in North Carolina for public health impact during 2001-2003. Each site was evaluated on the five dimensions of the RE-AIM model that Glasgow and colleagues have proposed as important contributors to public health impact. These dimensions are Reach, Effectiveness, Adoption, Implementation, and Maintenance.

Result or Outcome:
We found that each of the 5 dimensions showed significant variation across the 14 sites. On a measure of Reach, we found that the lowest performing site screened 8% of the target population compared with 50% in the highest performing site. On a measure of Implementation, we found that at the end of 1 year of participation, the lowest performing site re-screened 9% of the enrolled population compared with 64% in the highest performing site. We also discovered that many of the sites showed significant variation across the 5 dimensions. One fairly common example was that sites that showed substantial improvements in CVD risk factors over time (i.e. had a high score on Effectiveness) were often unable to bring in a high proportion of women for screening (i.e. had a low score on Reach).

Conclusion or Significance:
If we had conducted a traditional evaluation of WISEWOMAN that focused only on effectiveness as defined by risk factor reduction, we would have come to a very different conclusion about which sites work best. Its important for evaluators to examine programs using a broader model that assesses overall public health impact. If they become aware of the inherent tradeoffs between the various public health dimensions, they can more efficiently focus their quality improvement efforts and identify sites where best practices can be found.

Evaluation and Quality Monitoring of Chronic Disease Education Programsbrokerage system for providers and funders

Author(s): Richard H Osborne; Sandra Nolte

Objective:
To convey the structure, function and potential contribution of a National Quality & Monitoring system for self-management programs for people with chronic diseases that is being implemented in Australia. The system produces monitoring and performance data for use by course leaders, organisations reporting to key stakeholders (Master Trainers, CEOs, Policymakers) and facilitates KPIs and Benchmarks.

Setting: 
Quality and Monitoring system chronic disease education programs designed in partnership with course leaders, physicians, funders, policymakers (Commonwealth, State and Veteran Affairs) and consumers. It is applied to education programs run in the community, by government programs and is an outcomes questionnaire for researchers.

Method or Intervention:
The development of the system was informed by 29 interviews with key stakeholders, an Outcomes Hierarchy Program Logic workshop, two Concept Mapping workshops (involving policymakers, course leaders and participants, physicians and educators), national teleconference with Arthritis Foundations CEOs, two waves of application with over 900 individuals and a national workshop with Master Trainers.

Result or Outcome:
The system involves administering a purpose build questionnaire (HEI-Q) filled in by people with chronic diseases participating in self-management / education programs. Information is collated in a standardised Course Report and fed back to course leaders and managers in a timely fashion. The report incorporates 5 key elements all of which facilitate national benchmarking; (a) Overall course impact on individuals in the following domains (Positive and active engagement in life, Health behaviour change, Skill and technique acquisition, Constructive attitudes and approaches, Self monitoring and insight, Health service navigation, Social integration and support and Emotional wellbeing) (b) Participant-reported quality of course delivery (pre-vs-post assessments) (c) Summated course scores for individual course leaders (formatted to empower course leaders to deliver better courses), (d) Summated scores for course leaders trained by specific master trainers (designed to monitor Master Trainer and guide Course Leader Updates) (e) Summated overall program performance for managers, policymakers and Government funders presented in standardised formats against national norms.

Conclusion or Significance:
The HEI monitoring system is user-friendly, relevant, and psychometrically valid protocol for evaluation of health education programs for people with a broad range of chronic conditions. The HEI-Q appears to be ideal for quality monitoring and research, with the capacity to empower course leaders and facilitate accountability. The output of the system is a highly endorsed by course leaders through to policymakers and will support identification of chronic disease education delivery excellence and provide clear data for implementing and monitoring quality assurance programs.

Evaluation Strategies for Qu Sabrosa Vida: A Culturally Targeted Community-based Nutrition Intervention, El Paso, TX

Author(s): R. Sue Day; Alison D. Gernand; Whitney Smith

Objective:
To describe the process evaluation strategies used in the community and with individuals to determine the five year success of Qu Sabrosa Vida (QSV), a culturally sensitive, community-based nutrition intervention for Mexican-Americans.

Setting: 
The predominantly low-income, Mexican American population of the Paso del Norte Region of Texas, New Mexico and Juarez, Mexico with high prevalence of obesity and diabetes.

Method or Intervention:
A baseline nutrition survey conducted prior to the intervention revealed few residents knew nutrition recommendations, most were in the earliest Stages of Change from the Transtheoretical Model, and most were not eating foods that followed recommendations. Intervention development and implementation is guided by the community using focus groups and evaluation forms of participants providing both qualitative and quantitative information. Process evaluation provides air time, language, and coverage areas of the media campaign with television and radio ads; demographics, referral source, and location of hotline callers; demographic information is collected for distribution of printed education brochures; participant, instructor, and agency evaluations are collected from nutrition courses taught by the community; and participant evaluations are ascertained from reunions for those who have already taken the course.

Result or Outcome:
Four hundred and six members of the community participated in focus groups to guide development and help evaluate the intervention components. Over 12,000 Paso del Norte residents have been directly impacted by QSV. Over 7500 residents have participated in nutrition courses and reunions taught in 173 different community sites and 5 worksites in the region. More than 1700 TV commercials and 750 radio commercials were aired. Printed media in the community has been monitored and evaluated for exposure to nutrition information. A total of 4394 people called the QSV hotline and received health promotion materials as a measure of exposure to media. Process evaluations indicated participants plans to change behaviors to meet nutrition and exercise recommendations. Evaluation also showed the target population was reached. Increase in participation has continued over the years from momentum that is the result of the guidance from the ongoing process evaluations providing successful diffusion of the QSV program in the community.

Conclusion or Significance:
A culturally sensitive intervention for Mexican-Americans was developed by research and community involvement to affect knowledge and behavior change. Process evaluation materials guide continued efforts and indicate that residents plan to change behavior toward healthy living.

Evidence of Effectiveness: A Summary of State Tobacco Control Program Evaluation Literature

Author(s): Nicole M. Kuiper; David E Nelson; Michael W Schooley

Objective:
To collect and summarize evidence from peer-reviewed and fugitive literature on the effectiveness of state tobacco control programs to inform decision-making in program planning, implementation, and evaluation.

Setting: 
Despite billions in Master Settlement Funds and increased state tobacco excise tax revenues, many state tobacco control programs have lost funds and several states have experienced adverse changes in key outcomes. While evidence supporting the effectiveness of state programs exists, a summary of key evaluation studies containing critical findings were not readily available in a manner that could be distributed.

Method or Intervention:
We identified key evaluation studies and recent major review articles. We used Medline to identify newly published findings. For the fugitive literature, we selected state reports that were on-hand or were accessible on the Internet. We created summaries of each article and tables that detailed the major outcomes measures in the individual evaluation studies: mortality, prevalence, consumption, cessation and secondhand smoke policies. We elicited internal and external feedback on the content and format of the summary.

Result or Outcome:
Key findings reflect that continuous, long-term, and multi-faceted program funding produces the greatest declines in key outcomes (e.g., consumption, prevalence, and mortality). We summarized 47 studies, including 3 review articles, 30 peer-reviewed evaluation studies, and 14 state reports or independent evaluations. Many studies contained more than one type of outcome measure. The distribution of outcome categories was: mortality (3 studies), prevalence (29 studies), consumption (20 studies), cessation (8 studies), and secondhand smoke policies (8 studies).

Conclusion or Significance:
This summary is an important new tool to help states demonstrate that comprehensive tobacco control programs are effective in reducing key indicators of tobacco use. Evidence reinforces and supports reviews conducted by the Institute of Medicine, the Task Force for Community Preventive Services, and others. This summary has been published on CDC/OSHs Sustaining States website at http://www.cdc.gov/tobacco/sustainingstates/index.htm. We plan to update with newly published literature on an annual basis.

Factors Associated with Tooth Loss Among Mississippi Adults

Author(s): Lei Zhang; Nicholas Mosac; William D. Johnson; Victor D. Sutton; Daniel Bender

Objective:
To investigate the impact of diabetes, coronary hear disease (CHD), along with age, gender, race, and household income on tooth loss among Mississippi adults.

Setting: 
One of the Healthy People 2010 objectives for improving health is to increase the proportion of adults who have never had a permanent tooth extracted because of dental caries or periodontal disease. Tooth loss has a significant impact on quality of life and contributes to poor nutrition and ultimately chronic disease. The identification of subgroups who have a propensity to experience tooth loss may provide clues that help health educators and policy makers further increase the proportion of adults who have never had a permanent tooth extracted. The study proposal has been evaluated and results will be sent to the Governors Oral Health Task Force, which is developing the Mississippi Oral Health State Plan.

Method or Intervention:
A total of 4,085 Mississippi adults aged 18 years or older participated in the 2002 Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is a telephone survey used to generate state specific estimates relative to public health related issues. We used a logistic regression analysis to investigate the impact of diabetes, CHD, along with age, gender, race, and household income on tooth loss among Mississippi adults. SUDAAN 9.0 was used to analyze the complex sample survey.

Result or Outcome:
People with diabetes were 69% more likely to have had one or more permanent teeth extracted than their counterparts. People with CHD were 4.5 times more likely to have had one or more permanent teeth extracted than their counterparts. Age (p = 0.0002), race (p = 0.0035), and household income (p = 0.0411) were statistically significant predictors of the tooth loss.

Conclusion or Significance:
Diabetes and CHD were important factors associated with tooth loss. Significant health disparities also exist regarding age, race, and household income on tooth loss among Mississippi adults. Older African Americans with lower household income were significantly more likely to have had one or more permanent teeth extracted because of dental caries or periodontal disease. Special dental care should be provided to people with such conditions, especially those with early-staged diabetes or /and CHD.

Factors Involved in the Utilization of PRC Research: A Multiple Case Study Approach

Author(s): Hood Nancy; Jeffery Peterson; Sally M. Davis; Leslie Cunningham-Sabo

Objective:
To identify key factors in the process through which prevention research findings are utilized by public health professionals and agencies, the communities of study, and other systems.

Setting: 
Six Prevention Research Centers (PRCs) addressing health disparities in diverse populations.

Method or Intervention:
This qualitative, two-component study followed Yins multiple case study approach utilizing in-depth, semi-structured interviews and a standardized interview protocol. For one component, we conducted six case studies of research utilization in community-based programs in which PRCs were involved. Thirty-five interviews were conducted with PRC staff and community partners involved with these examples. For the second component of this study, we conducted twelve interviews with a purposive sample of six PRC directors and six of their community partners and analyzed secondary documents for evidence of dissemination of research findings from each of the six PRCs. Research questions for both study components focused on describing dissemination activities being conducted by PRCs, types of information and products being disseminated by PRCs, examples of use of the information and products disseminated by PRCs, and facilitating and inhibiting factors for dissemination and use. Data were analyzed separately for the two study components using state-of-the-art NVivo qualitative data analysis software, and an inductive approach that relied on consensus coding of emergent themes and patterns. Data were then synthesized to arrive at common findings and implications from the study components.

Result or Outcome:
Results suggested that PRCs and their community partners are involved in multiple levels of dissemination and multiple types of research utilization but that they often hold different perspectives about the dissemination process. PRCs dissemination activities are not frequently evaluated therefore many questions remain about how people use the information and products that are disseminated. A variety of facilitating and inhibiting factors for dissemination activities and subsequent use will be presented. Recommendations include increasing communication and collaboration among PRCs and between PRCs and community partners, building capacity for dissemination among PRCs, and increasing the funding and resources available for dissemination and evaluation of such activities.

Conclusion or Significance:
This study suggests several practical implications for improving the utilization of prevention research to address health disparities in diverse community settings and the role of PRCs and their community partners in this process. Areas for future research will also be identified.

Health Risks and Conditions among American Indians in North Carolina

Author(s): Ziya Gizlice; Sara Huston

Objective:
Objectives: North Carolina has the eighth largest American Indian population among all states. American Indians have high death rates for a number of specific causes of death. However, there has not been comprehensive statewide information available regarding North Carolina American Indian health risks. The objective of this study is to examine health risks and conditions among adult North Carolina American Indians in comparison to whites and African Americans and to provide baseline data for health indicators among American Indians.

Setting: 
Data: The 2002-2003 North Carolina Behavioral Risk Factor Surveillance System (BRFSS) data.

Method or Intervention:
Methods: Unadjusted and age-adjusted percentages and adjusted odds ratios were calculated using weighted BRFSS data for 20 selected health indicators from five major areas: chronic conditions, risk factors, access to care, preventive behavior, and quality of life.

Result or Outcome:
Results: Seventeen of the 20 age-adjusted health indicators examined in this study showed a significant health disparity between American Indians and whites: diabetes (14.1% vs. 6.8%), high blood pressure (40.2% vs. 26.6%), asthma (16.4% vs. 11.1%), arthritis (36.3% vs. 29.1%), obesity (33.2% vs. 20.9%), did not get recommended level of physical activity (71.0% vs. 59.0%), no leisure time physical activity (32.4% vs. 23.7%), consumption of less than 5 servings of fruits and vegetables/day (80.3% vs.74.8%), no flu shot in the last year (73.0% vs. 66.1%), no current health insurance (19.2% vs. 13.4%), not being able to see a doctor due to cost (29.4% vs. 12.4%), no personal doctor (21.8% vs. 16.4%), fair or poor health (25.9% vs. 17.5%), disability (38.5% vs. 24.9%), 14+ poor mental health days/month (13.9% vs. 8.8%), 14+ poor physical health days /month (14.2% vs. 9.7%), and 14+ activity-limited days/month (11.6% vs. 5.7%). These differences persisted even after controlling for socio-demographic characteristics.

Conclusion or Significance:
Conclusions: North Carolina American Indians adults have significantly higher rates of chronic conditions and risk factors, less access to health care, and lower quality of life compared to whites and similar rates to those of African Americans. To eliminate health disparities between American Indians and whites and improve the quality of life among American Indians (Healthy People 2010 goals), North Carolina needs to target health promotion and disease control programs to the American Indian population. The prevalence estimates provided in this study can serve as baseline information for designing and evaluating these programs.

Healthier than you think: Disparities among adults with disabilities in primary care

Author(s): Suzanne McDermott

Objective:
A health disparity group is people with disabilities, as described in Chapter 6 of Healthy People 2010. A retrospective cohort study was used to identify similarities and differences in the prevalence and incidence of health conditions, between 2,084 patients without disability and 1,449 patients with disability. This research will support an evidence based approach to improve program decisions related to elimination of health disparities based on disability status.

Setting: 
The research was done in two University affiliated primary care practices, one rural and one urban in the midlands of South Carolina.

Method or Intervention:
A record review included data for over nine years for patients with disability and 6.7 years for those without disability. The disability group included individuals with sensory impairments (n=117), developmental disabilities (n=692), trauma-related impairments (n=155) and psychiatric impairments ( n=485).

Result or Outcome:
The only two conditions with increased risk, for all groups with disabilities, were dementia and epilepsy. Only patients with psychiatric disabilities had more conditions with increased risk compared to patients without disability. Thus, for patients with sensory, developmental, and traumatic disability there were more conditions where the risk was the same as for patients without disabilities, than conditions where there was increased risk for individuals with disabilities. Each of the disability groups had some increased risk for other conditions but these varied among the groups.

Conclusion or Significance:
Physicians should be able to accommodate many patients with disability since they have similar risk for a number of common health conditions, compared to patients without disability. There are many similarities and a smaller number of differences in the prevalence and incidence of health conditions.

Immigration and Health: Is immigration to the United States detrimental for health?

Author(s): Jimi Huh

Objective:
The aim of this study is to investigate the relative effects of nativity, ethnicity, immigration processes, and acculturation level, on physical health with specific respect to Asian and Hispanic immigrant populations. Given the paucity of research on the differential health outcomes of Asian and Hispanic immigrant groups, an important purpose of this research is to clarify the nature of healthy immigrant effect and nativity effect by taking such immigration-related factors into consideration: e.g., acculturation, nativity, subgroup differences, and health-related behaviors, as well as sociodemographic characteristics.

Setting: 
Fifty thousand and three hundred twenty two individuals in the United States with non-Hispanic white, non-Hispanic Asian, and Hispanic ethnic background are included in this study.

Method or Intervention:
The Sample Adult Files from National Health Interview Survey (NHIS) for 2000 and 2001 were used. The individuals who satisfied the ethnic background described above were then divided into foreign-born and U.S.-born groups based on their reported place of birth. Multinomial logistic regression was used for the analysis of specific diagnoses and Poisson regression was used for the analysis of total number of diagnoses in relation to key variables.

Result or Outcome:
After controlling for age, sex and other physical/sociodemographic characteristics, it was found that foreign-born Asians, foreign-born Hispanics and U.S.-born Hispanics were less likely to report their health being Excellent-Very good relative to Good than U.S.-born whites (odds ratios: .72, .83, and .82, respectively). When individual diagnoses (i.e., hypertension, cardiac conditions, asthma, cancer and diabetes) were examined, it was found that foreign-born individuals, regardless of their ethnicity, exhibited less health problems than U.S.-born whites. However, some inconsistent patterns were observed. Specifically, both foreign-born and U.S.-born Hispanics showed significantly greater odds ratios for diabetes (1.24 and 2.19, respectively) and foreign-born Asians showed a similar level of prevalence as that of U.S.-born whites, though not statistically significant. (The analysis of the total number of diagnoses in relation to key variables is being currently conducted and the result will be available soon.) Implications for health service for minority immigrant groups are discussed.

Conclusion or Significance:
It appears that how better health is measured or defined does have a significant effect on research findings of immigrant groups. Thus, the healthy immigrant effect, an often-drawn conclusion in studies using mortality data, must be evaluated. Birthplace and acculturation level must be considered when one attempts to examine the relationship between immigration and health.

Impact of Chronic Disease Self-Management Programs: A national community-based transition study

Author(s): H Richard Osborne; Barb Newell

Objective:
Although self-management programs are popular and highly endorsed in a variety of settings, little community-based real world impact data exist. This study examines programs across Australia and New Zealand. We compared the specific Arthritis Self-management Course (ASMC) with the generic Chronic Disease Self-management Program (CDSMP) in people with arthritis. Finally, the effectiveness of peer educators versus health professionals was examined.

Setting: 
Community-based attendees of the ASMC/CDSMP (Stanford Model) and Osteoporosis Education and Self-Management Programs.

Method or Intervention:
Questionnaires were completed prior to and 2 months after attendance. Questionnaires included SF-36 (range 0100), Assessment of Quality of Life (AQoL) instrument (death (0.0)full health (1.0)) and Kessler Psychological Distress scale (K10; 1050). Recruitment was through course leaders in their natural environment with passive mail follow-up (opt in). 468 individuals completed baseline and 267 provided follow-ups. No substantial differences were found between those who did and did not complete follow-ups.

Result or Outcome:
Improvement in the health status for all programs was demonstrated in 7 of 8 SF-36 scales (General Healthno change). The largest improvements were Role Physical (mean improvement 9.1, p

Conclusion or Significance:
Overall, the program resulted in small to medium improvements in well-being in several areas. Courses led by two peers produced somewhat greater improvement than those led by health professionals. Finally, both the arthritis-specific and the generic course delivered a similar effect for people with arthritis. The short term effects of the program in the community are over and above usual care in people with chronic diseases. The modest improvements suggest the program has had an effective transition from the research setting to the community.

Implementing Evidence-Based Guidelines For Managing Chronic Obstructive Pulmonary Disease (Copd) In Rural Primary Care Practices

Author(s): Ronald Deprez; Jean Mellett; Gregory Merriman; John Branscombe; James Haley

Objective:
The objective of the Project is to maximize the length and quality of life for patients with COPD and satisfy patient and caregiver needs while maintaining or decreasing the cost of care. This will be achieved by implementing a system-wide model of care that focuses on improving interactions between patients and providers using evidence-based COPD guidelines.

Setting: 
Horizon Health Services Presque Isle Aroostook County, Maine

Method or Intervention:
A variation of the Institute for Healthcare Improvement (IHI) collaborative model was used to guide implementation of this project. The COPD evidence-based changes were based on the GOLD guidelines developed by the Global Initiative for Chronic Obstructive Lung Disease. The model addresses practice issues, patient barriers and community support systems in the health care improvement process. An advisory committee consisting of primary practice physicians, pulmonologists, researchers and change managers was convened to select evidence-based guidelines for diagnosis and management of COPD and adapted them to meet the specific needs and capacity of the rural practices recruited for the study. Baseline measures of office practice were established through patient records review by staff of the Institute for Medical Improvement (EMH). Each physician practice identifed a specific population of COPD patients that could be monitored during the duration of the Collaborative. A patient registry was developed during the Collaborative to document and track results of interventions. Participating practices were open to changing actions and systems in order to improve clinical management and office efficiency. Participating organizations capitalized on the learning and improvement by coaching senior leaders in participating organizations to develop a system for spreading the practice redesign to other locations/ offices/clinics.

Result or Outcome:
Results demonstrated that the health care providers have accepted and implemented the guidelines as part of routine practice. Practice outcomes improved significantly from pre- to post intervention based on practice gap analysis and patient chart review.

Conclusion or Significance:
1.Rural physician practices are motivated to adopt evidence-based guidelines in their practices, given the appropriate support for change. 2.In busy practices, external support to assist with process transition is crucial. 3.In the rural setting, adoption of evidence-based guidelines does improve patient care.

Implementing Evidence-based Programs to Support Healthy Aging: An Initiative for Community-based Organizations

Author(s): Nancy Whitelaw

Objective:
To present and discuss lessons learned after one year of a 3-year Administration on Aging Initiative to implement evidence-based prevention programs for older adults.

Setting: 
Over 50 diverse community-based organizations serving highly heterogeneous older adult populations, as well as the National Resource Center on Prevention at the National Council on the Aging.

Method or Intervention:
In 2003, Assistant Secretary for Aging, Josefina Carbonell announced that the Administration on Aging (AoA) would launch an initiative to increase older peoples access to programs that have proven to be effective in reducing their risk of disease, disability, and injury. The 3-year project is demonstrating how results from rigorous research conducted through the NIH, CDC, and others can be effectively translated into community practice through aging services provider organizations. The interventions being implemented throughout the country are focused on disease self-management, falls prevention, nutrition, physical activity, and medication management. Local partners are drawn from public health, health care, aging services, and academe; the latter are overseeing in-depth evaluation to assess fidelity and outcomes.

Result or Outcome:
The first year of this evidence-based prevention initiative has brought challenges and great progress. With assistance from the National Resource Center, AoA, and a number of expert consultants including members of the CDCs Healthy Aging Research Network of the Prevention Research Centers, the twelve programs have been launched and are reaching hundreds of older adults. Although maintaining fidelity to the original research has been difficult at times, in general the organizations are finding the structure of the programs to be helpful, and many of the older adult participants appreciate the fact that these programs have been proven to work.

Conclusion or Significance:
Although still in progress, the evidence-based prevention initiative has brought awareness about the importance of evidence-based programming to the aging services network. Programs to support and promote healthy aging are continuing to progress  learning and overcoming barriers. Evidence-based programs provide community-based organizations with opportunities to expand their programming and reach out to older adults with programs that have proven to be effective. Our current assessment is that these programs have the potential to positively impact community-level risk factor rates among older adults, especially those in hard-to-reach populations.

Increasing Colorectal Cancer Screening Rates among African Americans: Varying approaches in community and clinical settings

Author(s): Charlye D. Majett; Selina A. Smith; Ernest Alema-Mensah; Lee Caplan; Daniel Blumenthal

Objective:
To increase colorectal cancer screening rates among African Americans. The purpose of the study to examine three methods of education and their effects on (1) the knowledge, attitudes and beliefs among African Americans regarding CRC screening and (2) whether reducing the financial barrier will increase screening rates in African Americans.

Setting: 
This project is being implemented in community and clinic settings.

Method or Intervention:
Sample selection: We are actively recruiting 500 African Americans (age 50 plus) into a randomized study with a control group and three intervention groups: one-on-one education, small group education, and financial incentives (assistance with out-of-pocket screening expenses and transportation). Each group is being provided a different level of educational materials. Measures and/or techniques: Questionnaires were designed to determine knowledge, attitudes and beliefs as well as psychosocial parameters. Data for psychosocial information has been extracted from the Rosenberg Self Esteem, Perceived Stress & Social Support Evaluation questionnaires. Screening outcome is being observed through an impact survey which is given three months after the last intervention session.

Result or Outcome:
Results: Preliminary results suggest a greater increase in the knowledge level of the one-on-one group compared to the other groups. The impact on screening is inconclusive, as results from the impact survey have not been determined for all pStudy on-goingQuantitative analysis: Tests are done using the intention-to-treat principle. The chi-square test for categorical data and t-test for continuous data are used to test for the comparability of the dependent variables between groups. articipants.

Conclusion or Significance:
Implications: If the preliminary results are borne out, the study will provide relatively simple educational models that can be utilized by health educators and health care systems to increase screening rates among African Americans. Additionally, this study will identify and define a strategy for increasing participation in intervention trials among the African American population.

Linking Real Data to a Program Assessment and Feedback Model in State Tobacco Prevention and Control Programs

Author(s): Gail G. Sneden; Amy Gottlieb-Nudd; Nell H Gottlieb

Objective:
Although the Health Communication Feedback Cycle is frequently referenced, the steps for moving between or within the sections of the model in a public health environment are rarely explained. We describe the mangement process by which the Texas Tobacco Consortium implemented the stage of assessing effectiveness and making refinements and expanded it to include a program assessment feedback model.

Setting: 
The vision was to create a supportive learning environment where researchers and practitioners alike could systematically and efficiently collect, review and integrate research findings into an on-going program development cycle.

Method or Intervention:
Management tools were developed to take the group through five stages of the expanded program assessment feedback model: (1) formulate research questions using logic models to identify key evaluation instruments; (2) format data displays from multiple data sources to address research questions; (3) use a facilitated group process complete with outcome and process agendas to present and review research findings; (4) prepare group, not individual researcher, recommendations; and (5) involve local partners to move recommendations into practice.

Result or Outcome:
A common vision between academic, state and community partners, a facilitated group process, and the advent of a web-based reporting system linked to locally collected program activity data have made the translatation of research to practice a reality. The management process allowed us to sift through a large volume of data. The web-based reporting system provided timely access to local data and process indicators that, when linked to logic models, provided actionable items for program improvement. Active and ongoing partnerships between researchers and state and local practitioners created the conditions for implementation of the recommendations. The program assessment feedback model and resulting program changes - including revisions to program materials and target audiences - for a community cessation campaign will be described.

Conclusion or Significance:
The process of moving through the assessment feedback cycle provided a systematic approach to translate research into practice. Lessons learned in the proving ground of a state tobacco settlement offer insights for creating data-based programs in other population-based public health promotion programs.

Mexican American Veterans' Stroke Risk Profiles: Implications for Expanding Culturally Responsive Best Clinical Practices

Author(s): Carol M. Baldwin; Mary Z. Mays; Iris R. Bell

Objective:
To profile stroke risk factors in Mexican American veterans that will inform culturally responsive promotion strategies and best clinical practices.

Setting: 
The Southern Arizona VA Health Care System (SAVAHCS) in Tucson, Arizona.

Method or Intervention:
Mexican American (n = 106) and Non-Hispanic White (n = 118) male military veterans, who received their primary care at the SAVAHCS were recruited by flyers posted in SAVAHCS primary care clinics and local Mexican American neighborhood centers and clinics, and by referrals from primary care providers. The Stroke Risk Assessment Form used in this study was created and validated for the prediction of stroke using the Framingham cohort (Wolf et al., 1991). Risk factor profiles included age, systolic blood pressure, antihypertensive therapy, diabetes mellitus, cigarette smoking, prior cardiovascular disease, atrial fibrillation, and left ventricular hypertrophy by electrocardiogram. Medical history was verified by record review. Stroke risk was estimated on the basis of the risk factors in the profile related to the average risk of stroke for persons of the same age and sex (men ages 54 to 86). Current height, weight, and blood pressure were obtained using a standard clinical protocol. Ethnicity was defined with an acculturation scale validated for health care use. Chi-square was used for nominal variables and ANOVA was used for interval variables.

Result or Outcome:
Mexican Americans (33%) were significantly more likely to have a history of physician-diagnosed diabetes compared to Non-Hispanic White (17.8%) veterans (OR = 2.3; CI = 1.2 - 4.2). The groups did not differ significantly in age (M = 68.1, SD = 7.9), systolic blood pressure (M = 133.5, SD = 17.4), smoking, antihypertensive medication use, or other variables that comprised the stroke risk profile.

Conclusion or Significance:
Higher rates of diabetes in Mexican American compared to Non-Hispanic White veterans replicate stroke risk findings in their civilian counterparts. There is a literature that suggests Mexican Americans high rates of diabetes put them at greater risk for lacunar and hemorrhagic strokes. Application of this brief validated profile into clinical practice can provide a basis for identifying patterns of stroke risk between and among ethnic groups, inform public health promotion strategies that are culturally relevant, and support culturally responsive best clinical practices.

National Breast and Cervical Cancer Early Detection Program: 1991 2002 National Report

Author(s): A. Blythe Ryerson; Vicki Benard; Anne C. Major

Objective:
To summarize CDCs report on the first eleven years of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and demonstrate the continued momentum and commitment of federal and state governments to cancer screening programs that work to close the gap in health disparities, improve early detection rates, and reduce the morbidity and mortality of breast and cervical cancers.

Setting: 
Many deaths from breast and cervical cancers could be avoided by increasing screening rates among women at risk. However, both mammography and Papanicolaou (Pap) tests are underused by women who have less than a high school education, are older, live below the poverty level, or are members of certain racial and ethnic minority groups. The NBCCEDP is a nationwide, comprehensive public health program that helps low-income, uninsured women 18 64 years of age from priority populations gain access to screening services for the early detection of breast and cervical cancers.

Method or Intervention:
The report summarizes the structure, history, screening participation, clinical outcomes and future direction of the NBCCEDP from 1991 through 2002. We calculated the distributions of screening results and final diagnoses, diagnostic follow up rates, cancer detection rates and positive predictive values of abnormal screening results by age, race, ethnicity, and screening round.

Result or Outcome:
From 1991-2002 the NBCCEDP provided over 4 million breast and cervical cancer screening and diagnostic tests to almost 1.75 million low-income, uninsured women. In this time period, 1,175,759 women received 2,038,118 mammograms, and 1,329,523 women have received 2,305,936 Pap tests through the NBCCEDP. Through these screenings, 9,956 cases of breast cancer, 12,187 cases of precancerous cervical lesions, and 832 cases of invasive cervical cancer were diagnosed.

Conclusion or Significance:
The CDCs NBCCEDP is one of the largest efforts in chronic disease prevention and control ever undertaken by an agency of the federal government. The success of the program has contributed to the growing focus of state health agencies on chronic disease prevention and control. The NBCCEDP will continue working  through research, partnerships, and grantee organizations  to increase the utilization of breast and cervical cancer early detection and treatment service among low-income and uninsured women, to develop strategies for improving rescreening rates among women enrolled in the program, and to implement public education and outreach strategies capable of reaching women who have rarely or never been screened.

Project WOW: Implementing a multi-level walking intervention in rural Missouri

Author(s): Sarah L. Lovegreen; Laura Hagood; Ross C. Brownson; Debra Haire-Joshu; Janet McGill

Objective:
To describe the development and implementation a multi-year community-based research program promoting physical activity, specifically walking, in rural Missouri.

Setting: 
Six rural communities in southeast Missouri characterized by low-income levels and high rates of overweight and obese individuals. Control communities are selected from neighboring states.

Method or Intervention:
In July 2003, a regional steering committee was formed to promote physical activity and walking trail use. The committee was comprised of active community members with representatives from the state health department and academia. Using a menu of evidence-based approaches (e.g., Guide to Community Preventive Services) and ideas from community members, interventions at the individual, interpersonal and community level have been implemented simultaneously to increase physical activity for reduced risk of overweight/obesity and type 2 diabetes. All activities are selected and guided by the steering committee. Program reach and effectiveness is evaluated through program enrollment in tailored newsletters, modified event logs and a telephone survey.

Result or Outcome:
Formation of the steering committee has resulted in over 1100 individuals enrolled to receive tailored newsletters encouraging walking behavior. These newsletters include individualized walking reports based on actual time spent walking at the local walking trail and messages focused on physical activity. Over 20 events have taken place in the past year reaching over 8000 community members. Events included fun walks, physician trainings, educational seminars and demonstrations, and health fairs. In addition, walking clubs have been formed and all communities participated in a statewide physical activity challenge and media campaign. Characteristics of a successful steering committee include dedication, planning, creativity, broader community buy-in, and partnership with existing community programs. Successful programs have been developed based on simultaneous community need and interest. Preliminary year one findings of the telephone survey indicate that 50% of residents are aware of Project WOW with 66% actively participating in at least one aspect of the program.

Conclusion or Significance:
Successful formation and functioning of the community steering committee has facilitated the implementation of interventions at all levels  individual, interpersonal and community. Partnerships through existing community programs and newly developed relationships promote walking and weight control for prevention of obesity and type 2 diabetes.

Promoting Healthy Lifestyles for People with Disabilities: Project Description and Research Results

Author(s): Nasreen Abdullah; Willi Horner-Johnson; Justin Weisser; Charles Drum

Objective:
To describe health disparities facing people with disabilities and discuss results from the Healthy Lifestyles Evaluation Project, which measures the effectiveness of the Healthy Lifestyles for People with Disabilities curriculum.

Setting: 
Ten 2-day workshops for people with various disabilities in Oregon communities. Workshops are conducted in collaboration with local Centers for Independent Living, and utilize the Healthy Lifestyles curriculum. Recognizing that people with disabilities are more susceptible to poor health and preventable secondary conditions and that traditional health promotion programs do not meet the needs of people with disabilities, the Healthy Lifestyles curriculum was developed to focus specifically on health promotion for people with disabilities. The curriculum takes a holistic approach to health, addressing connections among physical, social, emotional, spiritual health, and health through meaningful activities. During workshops, the participants obtain health information, and experience healthy activities such as yoga and non-impact aerobics, both tailored for people with disabilities. At the end of the workshop, participants identify two achievable goals, which are followed through in monthly support groups for 6-9 months.

Method or Intervention:
The project uses a delayed intervention comparison design in which participants are divided into two groups after completing baseline measures. One group (the intervention group) participates in a Healthy Lifestyles workshop within a few weeks and completes measures again at 3, 6 and 9 months after the workshop. The other group (the delayed intervention group) waits 3-4 months before participating in a workshop (to allow a control period comparison) and completes additional data collection immediately before the workshop, and at 3 and 6 months after the workshop. The Health Promoting Lifestyles Profile (HPLP) II is used for pre- and post workshop data collection to evaluate the impact of the curriculum on health behaviors and health-related attitudes.

Result or Outcome:
Preliminary data from 8 out of 10 workshops (N=89) show that intervention groups make significant gains in HPLP II scores from baseline to their first post-workshop measurement point, while the delayed intervention group shows no significant change between baseline and their pre-workshop measurement point. For both intervention group and delayed intervention group participants, at all post-workshop data collection points, HPLP II scores are significantly higher than pre-workshop HPLP II scores. Improvements are significant at the p

Conclusion or Significance:
Findings from the Healthy Lifestyles Evaluation Project indicate that people with disabilities who participate in Healthy Lifestyles workshops exhibit improvements in health behaviors and health-related attitudes. These improvements are sustained through the post-workshop follow-up period.

Racial Disparities in hospitalizations and its costs due to chronic disease in Arkansas

Author(s): Appathurai Balamurugan; Sue Ellen Peglow

Objective:
To determine whether disparities exist in hospital discharge rate, length of stay in the hospital and hospitalization costs due to chronic disease in Arkansas, among different racial groups.

Setting: 
The hospital in-patient information for Arkansas residents was obtained for the year 2003 from the Arkansas Hospital discharge data system.

Method or Intervention:
The hospital discharge rate, mean length of stay and mean hospitalization charges were calculated for chronic diseases like Ischemic Heart disease, Cancer, Stroke, Chronic Obstructive Pulmonary disease and Diabetes, which comprise the leading causes of death in Arkansas. The above variables for the major racial groups, namely Blacks and Whites were compared to determine disparities that exist between them. ICD-9 codes were used to abstract the hospital discharge data for the year 2003.

Result or Outcome:
The age-adjusted hospitalization rates due to Cancer, Stroke and Diabetes were significantly higher among blacks (Cancer - 706.21, CI 678.06  735.23; Stroke - 414.99, CI 392.63  438.29; Diabetes - 451.75, CI 429.60  474.74) compared to whites (Cancer - 554.80, CI 545.54  564.18; Stroke - 311.22, CI 304.49  318.07; Diabetes - 167.66, CI 162.44  173.00). The age- adjusted hospitalization rate due to Ischemic heart disease (IHD) and Chronic obstructive pulmonary disease (COPD) were significantly higher among whites (IHD - 790.18, CI 779.30  801.17; COPD - 427.95, CI 419.85  436.17) compared to blacks (IHD - 629.03, CI 601.67  657.31; COPD -375.64, CI 355.65  396.47). The mean hospitalization charges due to Stroke were significantly higher among blacks ($20036.44, CI 18269.68  21803.2) compared to whites ($17548.49, CI 17035.94  18061.03). The mean hospitalization charges due to Ischemic Heart disease (IHD) and Diabetes were significantly higher among whites (IHD - $29249.02, CI 28792.16  29705.88; Diabetes -$13440, CI 12713.69  14166.31) compared to blacks (IHD - $25710.9, CI 24494.32  26927.48; Diabetes -$11506.15, CI 10737.27  12275.02). The mean length of stay (in days) due to Stroke was significantly higher among blacks (7.57, CI 7.13-8) compared to whites (6.27, CI 6.11-6.43). The mean length of stay (in days) due to chronic obstructive pulmonary disease was higher among whites (4.52, CI 4.45-4.59) compared to blacks (3.88, CI 3.56-4.2).

Conclusion or Significance:
Disproportionate burden of disease exists among certain racial groups. It is compounded by limited access to health care and is reflected in hospitalization rate and its costs. New strategies to improve access to care and health care delivery would be key in eliminating health disparities.

Reach and effectiveness of CD-ROM intervention to increase informed decision making for prostate cancer screening

Author(s): Lori A. Crane; Judy Mouchawar; Jessica Bondy; Mondi Mason; Melanie Stopponi; Peter Raich; Paul H Barrett; Edward M Swartz; Steven S. Coughlin; Vicki Tosher; Yarborough Mark

Objective:
To test the reach and effectiveness of a CD-ROM to promote informed decision-making for prostate cancer screening.

Setting: 
Prostate cancer affects over 200,000 American men each year, disproportionately affecting African American men. Most medical organizations recommend that men make informed personal decisions about prostate cancer screening, because of medical uncertainty about the benefits and risks. This study utilized direct mail to distribute a CD-ROM about the risks and potential benefits of screening to Colorado men age 50-79. Men residing in African American neighborhoods were over-sampled.

Method or Intervention:
9000 men drawn from purchased lists of community residents and the enrollment of a large MCO were randomly assigned either to be sent the CD-ROM by mail, or to a no-intervention, usual care control group. Use of the CD-ROM, knowledge of prostate cancer screening, decisional conflict about screening, and realistic expectations about the likelihood of developing and dying of prostate cancer were assessed in a telephone interview 3-6 months after the CD-ROM mailing.

Result or Outcome:
Preliminary results are available for the first 1304 follow-up interviews (interim response rate = 26%). Reach: Of 554 men randomized to receive the CD-ROM, 227 (41%) reported receiving the CD-ROM, and 78 (14%) used it in a computer. Users of the CD-ROM had higher education, higher income, higher levels of computer usage, and were more likely to have had a PSA test compared to non-users. Effectiveness: In an intention to treat analysis, prostate cancer knowledge was slightly higher in the intervention group (mean score 6.5 vs. 6.2 on a 13 point scale; p=0.002); there were no differences between study groups in decisional conflict or realistic expectations. However, comparing those who did and did not use the CD-ROM using multiple regression analysis and controlling for age, race, education, income, insurance status, previous prostate cancer screening, and computer usage, use of the CD-ROM was significantly associated with higher prostate cancer related knowledge, lower decisional conflict, and more realistic expectations about risk of dying from prostate cancer (all p

Conclusion or Significance:
Studies examining the reach of educational interventions face methodological difficulties in testing effectiveness among users, due to low rates of usage and self-selection biases. We found that use of the CD-ROM was associated with lower levels of decisional conflict, and higher levels of knowledge and realistic expectations related to prostate cancer screening. This low-cost intervention can be distributed to vast numbers of men. While only a portion will use it, users appear to benefit.

Regional/Racial Prevalence of Metabolic Syndrome: The MSM Regional Assessment Health Surveillance Study (RAHSS), 20032004

Author(s): Jones, Dennis; Arroyo, Cassandra; Liu, Yong; Din-Dzietham, Rebecca; Davis, Sharon

Objective:
To examine regional and racial variations in the prevalence of the metabolic syndrome in Georgia.

Setting: 
Fulton, Bulloch, Candler, Evans, and Jenkins counties of Georgia.

Method or Intervention:
Random-digitdialing data followed by examination data were obtained from 319 African American and white men and women aged 19 years and over from 2002 through 2003. Metabolic syndrome (MetS) was defined by ATP III criteria. Correlates included race (African American vs. non-Hispanic white), gender, education level, age, and region (urban vs. rural). Univariate and multiple regression model were fit to assess the interaction between region and race, and the association with correlates setting nominal P-value at 0.05 for main effect and 0.10 for interaction. SUDAAN was used to account for the complex design and obtain correct variance and county-representative estimates.

Result or Outcome:
The MetS overall prevalence was 21.2%. Unadjusted prevalence of MetS was significantly higher (P<0.0001) in urban area (21.4%) vs. rural area (19.6%), among African Americans (31.1%) vs. non-Hispanic whites (9.6%), and among women (22.2%) vs. men (19.9%). There was a significant interaction between region and race (P<0.0001), so separate models were estimated for African Americans and non-Hispanic whites. For African Americans, MetS was 2.47 (95% CI 2.23-2.73) times more prevalent among those living in urban vs. rural and 0.48 (0.46-0.50) times less prevalent among men vs. women. Prevalence of MetS was also 1.48 (1.40-1.56) times higher among those with less than 12 years of education and 0.68 (0.65-0.72) times lower among those with 12 years of education vs. those with more than 12 years. Among non-Hispanic whites, prevalence of MetS was 0.34 (0.32-0.37) times less prevalent among those living in the urban area, 6.13 (5.60-6.71) times more prevalent among men, and 7.9 (7.12-8.68) and 4.6 (3.82-5.66) times more prevalent among those with 12 years of education and those with less than 12 years of education, respectively.

Conclusion or Significance:
The study suggests that African Americans living in the urban area of Georgia have a higher prevalence of metabolic syndrome than their white counterparts. National prevalence rate estimates for metabolic syndrome suggest that whites, in general, have higher prevalence of metabolic syndrome. A more comprehensive database is needed to further explore this interaction between race and region to target more specific groups for intervention.

Response Shift: The Measurable and Desired Outcome of Chronic Disease Self-Management Programs that Violates Pre- vs. Post-Assessment

Author(s): Hawkins, Melanie; Osbourne, Richard

Objective:
Self-management programs are traditionally evaluated through pre/post intervention questionnaires, which assume that participants answer questions from the same perspective before and after the program. Self-management programs are designed not only to empower participants and improve participant knowledge, but also to provide existential insights into their health and abilities to self-manage. Systematic reviews of the outcomes from self-management interventions that use self-appraisal outcomes identify small to no effects. This study aims to determine if changes in internal values or perspectives (termed a response shift) occur in participants and if response shift is measurable with a paper-based questionnaire.

Setting: 
Community-based self-management programs in Australia.

Method or Intervention:
A retrospective pretest questionnaire, the HEI-Q-Perspective Questionnaire, was developed specifically to measure potential benefits of self-management programs. Cognitive interviews elicited spontaneous statements about the reasons for paper-based answers across the eight items. Sensitivity, specificity, and overall accuracy of the questionnaire were calculated using the interview as the gold standard. Response shift can be negative (i.e., after the course participants reported they now realise that, before the course, they were worse than they thought they were), positive (i.e., participants now realise they were better than they thought they were), and neutral (no change).

Result or Outcome:
In-depth interviews (n=39) and mailed questionnaires (n=132) reflected that a true response shift occurred in about half the questionnaire items. Of these, 33% were negative response shift, 18% were positive response shift, and about 32% had no response shift. The presence or absence of response shift could not be determined in about 17% of cases. Substantial concordance between interview and questionnaire were observed (average overall accuracy 0.79), indicating the questionnaire effectively identified response shift. A positive or negative response shift was found to have profound effects on patient-reported outcomeseven large positive or large negative program effects revealed in interview could be concealed in an individuals pre/post score. This clearly demonstrates that response shift can violate classic outcome assessment of self-management programs.

Conclusion or Significance:
Response shift occurred in about half of the participants. This suggests that classic outcome assessment (pretest vs. posttest) in many individuals is flawed. Response shift is a valued outcome of courses but has not been formally measured. The strong concordance between the questionnaire and cognitive interviews indicates the HEI-Q-Perspective can detect response shift. This new questionnaire will assist researchers and program evaluators to better estimate the impact of self-management programs and to understand the role of response shift in this and other settings.

School based/school linked Dental Sealant Programs in Selected States

Author(s): Sherry Williams; S. Rene Lavinghouze

Objective:
Dental sealants are a primary mechanism of preventing dental decay in vulnerable populations less likely to receive private dental care. The objective of this study was to assess status of school based/school linked dental sealant programs in states funded by a CDC cooperative agreement to build an oral health infrastructure.

Setting: 
Schools targeted for sealant programs based on children participating in the free and reduced lunch programs in 12 states and one territory.

Method or Intervention:
States/territories funded by CDC cooperative agreement were surveyed for the presence of school-based/school-linked dental sealant programs. Assessment elements included: longevity and scope of program, personnel and funding, schools and grades targeted, evaluation tools, and developed protocols for sealant placement. Some of the baseline data efforts included number served and retention rates, cost data, and the 2002 Oral Health needs assessment.

Result or Outcome:
Nine states and one territory indicated they had a program ranging from 2 to 18 years (mean 10.4 years). Five states conducted their programs with other oral health activities such as referrals, class education, case management, preventive services and dental screenings. Four states implement their sealant program once a year and in some cases twice a year, and one had contracts with county health departments, hospitals, and health centers for ongoing year-round efforts. Most programs primarily target children in elementary school, but some included middle schools. All programs targeted schools with at least 50% of children in Free and Reduced Lunch (FRL) programs. These programs reached between 10 - 100% of their eligible FRL population with an average of 41.6%. Factors identified that contributed to program strengths included: diverse funding, commitment from contractors to provide data, having a state sealant coordinator, surveillance, and community partnerships. Factors identified that inhibit programs success included: partners not focusing enough on reporting and evaluation, collaborating across state/community or public/private entities, no follow up with the child, no referral mechanism, geographic distance, no state dental director, and no standing orders from dentists for dental hygienists to administer sealants.

Conclusion or Significance:
Most states funded by CDC to develop their oral health infrastructure do have a dental sealant program. The implementation of these programs varied from state to state and appears to reach 41.6% of children requiring dental sealants. These findings will help to facilitate issues raised and addressed by the CDC expert sealant panel that was convened to establish guidelines for sealants placed in school based/linked settings.

Seattle - Rapid Assessment of Physical Activity (RAPA): Preliminary Validation of a New Clinical Tool

Author(s): Tari D. Topolski; Marsha B. Patrick; Donald L. Patrick; Barbara Williams; Julie Walwick; James P LoGerfo

Objective:
Development and validation of a short, easily scored assessment tool to screen and monitor level of physical activity of older adults ages 50 years and older in a clinical setting.

Setting: 
Although the benefits of exercise have been well demonstrated, many health care professionals often do not recommend exercise to older and/or low-income patients. Physicians report lack of time during the office visit as one of the most common barriers to discussing physical activity.

Method or Intervention:
A systematic review of the literature, a survey of geriatricians, an expert panel, and focus groups with older adults were conducted in the development of the Seattle-RAPA. These procedures resulted in a 9 item instrument that was refined through a cognitive debrief process with 12 participants who were asked to think out loud as they answered the questionnaire. A sample of 68 older adults, mean age=73.6 (range 52-92), most of whom were regular exercisers (60%), was used in a convergent validity analysis. Three self report measures of physical activity, the Community Healthy Activities Model Program for Seniors (CHAMPS), the Behavioral Risk Factor Surveillance System (BRFSS) physical activity questions and the Patient-centered Assessment and Counseling for Exercise (PACE) were fielded with the Seattle-RAPA to for the convergent validity analysis. The caloric expenditure measure of the CHAMPS was used to measure criterion validity.

Result or Outcome:
The RAPA highly correlated with the BRFSS (r=0.72) and the PACE (r=0.62). It was also positively correlated with the CHAMPS(r=0.39), which was similar to the correlation of the PACE (r=0.43) and the BRFSS (r=0.38) with the CHAMPS. In comparison to the CHAMPS, the Seattle-RAPA showed better specificity (61%), sensitivity (84%), positive predictive value (66%), and negative predictive value (81%) than the PACE or the BRFSS. The flexibility question of the Seattle-RAPA had similar values on these statistics. The statistics for the strength training question were in the 90% range. The CHAMPS was used to calculate caloric expenditure for the week. A t-test on mean caloric expenditure showed significant differences between those who reported inadequate physical activity and those who met the guidelines for moderate or vigorous activity with the RAPA outperforming either the PACE or the BRFSS questions.

Conclusion or Significance:
The Seattle-RAPA is a very promising measure for use in clinical practice.

Selecting Best Practices for Disparities Interventions in the National Healthcare Disparities Reports

Author(s): Karen K. Ho; Ernest Moy

Objective:
To identify potential best practices for eliminating health disparities to include in the National Healthcare Disparities Report (NHDR).

Setting: 
The NHDR provides an assessment of disparities in health care among racial, ethnic, and socioeconomic groups in the general U.S. population and among priority populations. In recognition of the importance of translating research into practice, the NHDR will highlight selected programs and interventions that have been successful at reducing healthcare disparities. This will inform users of the report on how the information in the reports can be used in real solutions to eliminating health disparities.

Method or Intervention:
Based on this preliminary study, a database has been created to summarize interventions that are believed to be potential promising practices. Several sources of information were used. - The American Public Health Associations Community Solutions to Health Disparities database - The National Association of County and City Health Officials Model Practices Database - CDC Office of Minority Health - Foundations including The California Endowment, The Commonwealth Fund, The Kaiser Family Foundation, The Robert Wood Johnson Foundation, and The W.K. Kellogg Foundation. A preliminary review of the interventions assessed project strategy and objectives. Interventions that emphasized community-based and targeted health services delivery and behavior change, as well as strong cross-cutting collaborations and partnerships were selected to be included in the database.

Result or Outcome:
- Access is important. Programs or interventions targeting specific racial or ethnic populations, in particular, have shown some success at reducing cultural and linguistic barriers. - Health literacy interventions may require further development. Preliminary assessment of interventions found these interventions to have less well-defined objectives and strategies. - Some disease condition-specific interventions are more developed than others. In general, heart disease, cancer and diabetes initiatives have received more support. - Partnership with local service providers is important. Local initiatives remain an important source of health services for individuals.

Conclusion or Significance:
Identifying best practices is a challenge. There are numerous ways to conduct program evaluations and measure success. However, for the purposes of the NHDR, we need to link measures of access and quality from the report to existing intervention objectives in communities. This preliminary study and creation of our best practices database is the first step in identifying possible best practices to include in the NHDR. Further study is needed to determine specific parameters to define best practices for disparities interventions and how the NHDR can be utilized by program staff to measure progress in reducing health disparities.

Taking Care of Yourself: Factors Influencing African American Women's Partcipation in Breast Cancer Screening

Author(s): Ellen Phillips-Angeles; Cobie Whitten; Fran Marcus Lewis; Dan Taber

Objective:
African-American women have more late stage diagnoses and higher mortality rates from breast cancer compared to white women in Washington State. The Washington Breast and Cervical Health Programs (WBCHP) goal is to reduce breast and cervical cancer morbidity and mortality among uninsured women with limited incomes. The literature describes barriers to mammogram screening for African-American women who decided to have the screening. This study is the first to identify barriers and beliefs of women who decided not to have a mammogram. The study was designed to discover why, despite gold standard outreach, some African-American women decided not to have a mammogram.

Setting: 
This is a population-based study of African-American women reached through WBCHP outreach who did not have a mammogram. Trained interviewers conducted face-to-face interviews with 43 women using 13 open-ended, pre-established questions.

Method or Intervention:
Qualitative data analysis was used. Interviews were audiotaped, transcribed verbatim, and verified. Data were processed using methods described by Glaser and Strauss: establish units of analysis, group by core category and develop explanatory theory. The womens actual words are preserved at each step.

Result or Outcome:
Interviewees offered rich personal text describing beliefs about breast cancer and mammography that formed the bases for their decisions to not be screened, even when offered free services. Beliefs fell into five categories: fears about screening, models of understanding personal risk for breast cancer, beliefs about benefits of early screening, equating breast cancer with loss, and personal and societal mistrust of physicians and medical treatment.

Conclusion or Significance:
Findings will be used to develop new outreach messages and training for health care providers so they can provide more effective services.

The Cost Effectiveness of Treating the Metabolic Syndrome in the African American and General Population

Author(s): Joseph Tichawona Tasosa; John S. McAlearney; Richard Schuster

Objective:
To assess the cost effectiveness of early treatment of Metabolic Syndrome (MS) risk factors (hyperlipidemia, diabetes and hypertension) in the African American and general population. To compare the cost-effectiveness of early treatment of MS risk factors in the African American and general population.

Setting: 
African American population and the general population in the United States.

Method or Intervention:
A cost effectiveness analysis was carried out using a Markov decision model to compare early treatment and late treatment of MS risk factors in African Americans and the general population. The main outcome measure was the incremental cost per Quality Adjusted Life Year (QALY).

Result or Outcome:
With the exception of early treatment of hyperlipidemia in African Americans ($187,462/QALY), early treatment of individual MS risk factors at age 30 was found to be cost effective (< $ 27,000/QALY) for both African Americans and the general population. The incremental cost of treating hyperlipidemia, diabetes and hypertension simultaneously in African Americans and the general population at age 30 was $53,140/QALY and $63,926/QALY respectively. With the exception of treatment of hyperlipidemia, early treatment strategies targeted at African Americans were found to be more cost effective than those targeted towards the general population. Sensitivity analyses indicated that age and cost of treatment were the most influential factors in the model. The cost effectiveness of early treatment of MS risk factors in blacks and the general population compares favorably with similar health care interventions.

Conclusion or Significance:
Early treatment of MS risk factors saves lives in a cost effective manner. The study supports a growing body of literature that indicates the cost effectiveness of providing preventive services to apparently healthy individuals. Our study also shows that disparate access to quality health care makes African Americans especially susceptible to the adverse effects of MS. We show that reducing these racial disparities by providing early treatment is cost effective.

THRIVE: Toolkit for Health and Resilience in Vulnerable Environments

Author(s): Rachel Davis; Danice Cook; Larry Cohen

Objective:
To provide an overview of how community factors can negatively impact health and safety outcomes in low-income communities and communities of color. This presentation will also provide examples of how community-level data on the community factors can guide community members and practitioners in formulating programs and policies that will reduce health disparities.

Setting: 
Developed for the Federal Office of Minority Health, THRIVE (Toolkit for Health and Resilience In Vulnerable Environments), a community resilience assessment tool, was piloted in Lordsburg, New Mexico with Hidalgo Medical Services (rural site), Del Paso Heights, Sacramento, CA with the Mutual Assistance Network (suburban site), and in East Harlem, New York with the New York City Health Department District Public Health Offices (urban site). The purpose of piloting THRIVE was to determine its applicability and utility. The THRIVE toolkit highlights the communtiy conditions that hold the most promise for reducing health disparities in low-income communities and communities of color.

Method or Intervention:
Prevention Institute utilized a five-part methodology in the development and testing of the Toolkit for Health in Resilience in Vulnerable Environments (THRIVE). This methodology included an environmental scan to determine the relationship between health and environmental factors, the formation of a national Expert Panel, the development of the THRIVE assessment tool, the pilot testing of this tool in three communities around the country, and the development of a set of preliminary guidelines.

Result or Outcome:
THRIVE contributes to a broad vision about community health, challenges traditional thinking about health promotion, organizes difficult concepts and enables systematic planning, has rural and urban applicability, has utility for practitioners and community members, and is a good tool for strategic planning at community and organizational levels. Several pilot sites instituted Farmers Markets within months of the pilot.

Conclusion or Significance:
THRIVE provides a framework for identifying and addressing community conditions that can improve health outcomes and close the health gap. The framework translates research into a conceptual model that people can understand and into a tool that enables people to identify specific factors and concrete actions that will make a difference in communities.

Health System Change

A Public Health Approach for the Prevention of Blindness Within States

Authors: D. Gohdes; R.T. Bunner; J. Todd; B.A. Larsen; C.M. Maylahn; A. Balamurugan

Objective:
To assess current state efforts to prevent blindness, knowledge about the prevalence of preventable eye disease, and potential data sources to describe the prevalence of eye disease. Recommendations for further action by public health agencies and entities will be developed.

Setting: 
Seven states selected to be representative of typical state health departments.

Method or Intervention:
Site visits were made to seven states to assess efforts of the public and private sector to prevent vision loss and blindness. State health departments hosted the visit. States were selected on the basis of U.S. region, size of the state and its population over 65 years, percent of the population below the poverty level, ethnic and racial distribution, estimated prevalence rates of vision impairment and blindness, and access to eye care. The site visit protocol included assessment of current programs at the state and local levels, state vision health planning, state policies/rules/regulations related to vision screening and care, program funding, local community vision services, state and local surveillance data, and future plans.

Result or Outcome:
Site visits were held in Arizona, Arkansas, Florida, Georgia, Maine, New Mexico, and Ohio. Site visit participants included representatives from state chronic disease programs, diabetes prevention and control programs, and aging and child health programs; Medicaid and Medicare agencies; vocational rehabilitation agencies; private organizations such as the Lions Clubs and Prevent Blindness America Affiliates; Veterans Administration Medical Centers; Indian Health Service; and professional associations representing optometrists and ophthalmologists. Though the level of vision preservation services varied by state, most screening services provided were for children, and rehabilitation services targeted vocational rehabilitation. Additional notable findings included a lack of population-based eye disease data, public awareness, statewide vision planning, coordination of existing services, standards for vision screening, physician referral to diagnostic and rehabilitation services; and underutilization of rehabilitation services to promote independent living. Most site visit participants were pleased to be invited to describe their role in vision preservation and eager to collaborate to improve the current system in their state.

Conclusion or Significance:
As the population ages, the number of Americans with visual impairment is expected to double. Priority populations that suffer disproportionately from such diseases as diabetes and glaucoma will bear the burden of this development. Currently, the public health system is ill-equipped to deal with this situation. The challenge is for public health practitioners to advocate for a federal priority for public health vision conservation to support the state role in vision preservation. Potential public health roles in preventing age-related eye disease will be discussed.

Abnormal Mammogram Follow-Up Among African American Women: Do Community Lay Health Advocates Make a Difference?

Authors: S. Crump; M. Shipp; S.J. Morris; G. McCray; S. Johnson-Thorne; L. Caplan; J. Okoli; D. Blumenthal

Objective:
Breast cancer is the leading cancer in American women and the second leading cause of cancer mortality. Early detection is our major weapon against breast cancer. Although mammography rates have risen substantially, success may be offset by low follow-up rates in women with abnormal mammograms, especially among African American women. Lack of follow-up for abnormal mammograms delays diagnosis and treatment of breast cancer, and contributes to breast cancer mortality. Therefore, this lack of follow-up might contribute to the increased mortality in black women compared with white women with breast cancer. Community Lay Health Advocates (CLHA), trusted community members serving as a linkage between the health care system and the community, may be instrumental in encouraging compliance with follow-up for abnormal mammograms. The purpose of this study was to evaluate the effectiveness of a CLHA intervention in promoting compliance with follow-up among African American women with an abnormal mammogram.

Setting: 
An inner-city, comprehensive breast center serving low-income women in Atlanta, Georgia.

Method or Intervention:
A pilot study was conducted in 20022003, including women aged 25 years and older with abnormal mammograms classified "suspicious abnormality" or "highly suggestive of malignancy." Fifty-four weeks of the study were randomized into two groups: 27 CLHA intervention weeks and 27 usual care weeks. Women in the intervention group were encouraged and assisted by CLHAs to comply with FNA/core biopsy recommendations by answering the womens questions, providing reminder phone calls, and assisting them on their appointment days. Medical record abstraction ascertained whether women complied with their follow-up appointments, and the dates and reasons for the follow-up appointments.

Result or Outcome:
Intervention group women were significantly more likely than usual care group women to keep their first follow-up appointment for their abnormal mammogram (95.8% vs. 77.1%, P<0.05).

Conclusion or Significance:
These findings suggest that CLHAs are effective in promoting compliance with follow-up recommendations for abnormal mammograms among African American women. By answering their questions, allaying their fears, providing friendly support, and navigating them through the health care system, they can serve as an important resource in reducing the racial disparity in breast cancer mortality by ensuring timely breast cancer diagnosis and treatment.

Access to Primary Care for NonMedicaid-Insured: The Advantage Program Survey

Authors: E.J. Nehl; M. Fleming-Moran; J. Gibson; M. Garland

Objective:
The purposes of this study were to 1) determine the perceptions of primary care access among the program users, 2) examine whether these perceptions vary by demographic characteristics, and 3) explore if a clients length of time in program increases the perception of access to care.

Setting: 
Federally funded community care clinics are coordinated by a state university medical school in a midwestern urban setting. The client population is predominantly minority, Medicaid/Medicare, and/or working-poor patients. Advantage Program clients as a study population meet 200% or less of federal poverty guidelines, but are not Medicaid-eligible.

Method or Intervention:
Computer-assisted telephone interviewing (CATI) surveys were administered in English or Spanish to 731 Advantage enrollees, representing 317 new clients (<1 year), 281 one-year clients, and 133 third-year clients. In addition to typical demographic questions, this study measured 1) organizational access (patients perceived ability to access their doctor/office); 2) visit-based continuity (how often patients are able to see their doctor); and 3) integration (patients assessment of their doctors ability to coordinate their care). All Primary Care Access Scales (PCAS) scores were then normalized to 100 points, and appropriate ANOVA analyses were conducted.

Result or Outcome:
Study findings indicate that the overall PCAS scores for the Advantage population were comparable with those of earlier Tufts study populations of white health care users with higher incomes and more education. Analysis of organizational access [(n=203) mean score: 55.51 (27.83)] found that race (P<.05), education (P<.01), and employment (P<.05) were significant predictors of satisfaction. For integration (n=81) and visit-based continuity (n=176), only employment status was a significant covariate of satisfaction (P<.05). These results suggest that persons who work have a harder time accessing the Advantage Program. Interestingly, time in the Advantage Program did not influence PCAS scores.

Conclusion or Significance:
Many federally funded hospitals and clinics attempt to address the needs of underserved populations. This study indicates that a principal concern of underserved persons, even those with safety net insurance coverage, is the flexibility of primary care offices, especially for those who are employed. Efforts should be made to improve accessibility and enhance the health care experience of the working poor.

Adherence to Guidelines for Following up Low-Grade Pap Test Results by Age and Race or Ethnicity

Authors: V. Benard; H. Lawson; C. Eheman; C. Anderson; W. Helsel 

Objective:
To determine if low-income and uninsured women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) with Papanicolaou (Pap) test abnormalities of atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesions (LSIL) were followed by the recommended interim guidelines for management of abnormal cervical cytology.

Setting: 
NBCCEDP women with a low-grade abnormality Pap test result (ASCUS or LSIL) followed by a second low-grade abnormality during the time period July 1991 through September 2000.

Method or Intervention:
For this study period, the National Cancer Institute (NCI) recommended guideline for women with a Pap result of ASCUS or LSIL was follow-up by Pap tests repeated every 4 to 6 months for 2 years. If a second ASCUS or LSIL report occurred, the patient should have been considered for colposcopic evaluation. We analyzed data from 10,004 NBCCEDP women with a low-grade abnormality Pap test result (ASCUS or LSIL) followed by a second low-grade abnormality.

Result or Outcome:
Using recommended guidelines, 44% of women in the NBCCEDP were followed appropriately with a colposcopy following two low-grade abnormalities. Younger women (under 30) were more likely to receive a colposcopy following two low-grade abnormalities, and older women (over 60) were more likely to receive a third Pap test. Hispanic or Latino women were more likely to receive a colposcopy after two low-grade abnormalities, and American Indian or Alaska Native women were more likely to receive a third Pap test than women of the other racial/ethnic groups.

Conclusion or Significance:
Less than half of the women studied were followed by the recommended guidelines. Factors such as age and race/ethnicity influence the appropriate follow-up of a woman with cytological abnormalities. From this study, we are not able to determine if these differences occur at the patient or provider level. However, the national program is working with state, territorial, and tribal programs to further investigate the issue and recommend intervention to improve the level of follow-up.

An Alternative to Identifying and Engaging the Underserved, Out-of-Care, HIV High-Risk Population

Authors: E. Khan Hadi; S. Jaar-Marzouka; T. Hiemke; L. Cardinale

Objective:
To assess the effectiveness of a mobile screening and referral program to the medically underserved, high-risk, and difficult-to-reach population of Dutchess County.

Setting: 
By U.S. Census 2000 population estimates, whites comprise 80% of the Dutchess County population; African Americans, 9.3%; and Hispanics, 6.4%. However, African Americans are 15 times more likely to have HIV than whites; Hispanics are almost 11 times more likely to have HIV than whites. The outreach van targets two low-income neighborhoods with the greatest burden of HIV disease at nontraditional service hours and high-risk venues.

Method or Intervention:
Mobile van outreach workers surveyed each individual screened, and results were reviewed to assess the needs of the HIV-positive out-of-care clients. Outreach service forms and screening forms were analyzed to quantify the number of clients served. Lastly, follow-up phone calls to designated service providers verified whether clients referred made medical visits.

Result or Outcome:
In 2003, the outreach van screened 179 individuals, identified 35 (19.5%) HIV-positive individuals, and linked 22 (62.8%) individuals to primary care. Among the identified HIV-positive individuals, outreach workers linked 17 (77.3%) African Americans and 5 (22.7%) Hispanics to primary care. There are 657 estimated HIV/AIDS-positive individuals out of care in Dutchess County. The outreach van linked 5.3% of these individuals to care. Some of the challenges this program faces include the need to contact high volumes of people to identify the individuals with HIV infection and the safety of the outreach staff and security of the van in high-risk neighborhoods. The success of the program can be attributed to the following factors: 1) basic primary care services are brought to the client; 2) the outreach van is staffed with racially diverse peers, outreach workers, and a nurse; 3) the program does not label the van as an HIV-care provider only: it provides various other low-threshold screenings, education, and support services; and 4) over time, trusted community leaders began to refer others in the community to use the van services.

Conclusion or Significance:
This initial evaluation indicates that mobile van outreach program is successful in keeping the minority, out-of-care population in underserved neighborhoods engaged in primary care. In addition, the outreach van provides an opportunity for surveillance of the HIV and the general health status of high-risk communities, and increases access to primary care through unique partnerships among service providers.

Compliance with Pediatric Asthma Guidelines in General Emergency Departments

Authors: E.A. Vasser; J.C. Welch; F. Qureshi; S. Goldblatt; J.D. Mason; M.L. Lawson; D.J. Isaacman

Objective:
To explore National Heart, Lung, and Blood Institute (NHLBI) Pediatric Asthma Guideline usage in general emergency departments (EDs) with the plan of fostering guideline adherence and thereby improving quality of care.

Setting: 
Four general EDs (two urban and two rural).

Method or Intervention:
Medical records (MR) from pediatric asthma visits in four general EDs between 9/01/02 and 2/28/03 were reviewed. Data collection was designed to reflect 1997 NHLBI asthma guidelines. To assess patient outcomes and parents perception of the ED visit, telephone surveys were administered to a convenience sample of families included from each site. Results were presented to an asthma management team at each site so they could design interventions to improve the delivery of pediatric asthma care and adherence to asthma guidelines.

Result or Outcome:
Of the 489 subjects included across all sites, 76% were African American and 52% make use of Medicaid or other public insurance. Of those patients who received three or more beta2-agonist treatments, 45% received the first three in 1 hour. Of those who were treated with more than one beta2-agonist inhalation, 81% received oral steroids in the ED, and 96% of these were discharged on oral steroids. Of those discharged, 87% were given a prescription for albuterol. Two percent of patients were admitted or transferred to another facility. Of the 57 phone surveys administered, 98% reported their childs asthma symptoms were better than when seen in the ED, and 76% reported the child had returned to normal activity. Of those discharged, 88% reported receiving verbal discharge instructions versus 81% with MR documentation of the same. A total of 89% of subjects reported receiving instructions on avoiding triggers, whereas 34% had documentation of these instructions in their MR. In addition, although 14% of charts had documentation of metered-dose inhaler use instruction, 71% of parents reported receiving these instructions.

Conclusion or Significance:
Although there appears to be significant room for improvement in NHLBI pediatric asthma guideline compliance, it is thought this issue is primarily one of poor documentation rather than inadequate care. Follow-up data collection to measure the effectiveness of interventions to improve the delivery of pediatric asthma care begins October 2004.

Economic Impact of Coronary Heart Disease in South Carolina

Authors: P. Joshi; S. Jackson

Objective:
To evaluate the economic burden of coronary heart disease (CHD) in South Carolina, as indicated by the morbidity statistics.

Setting: 
Hospital discharge data from South Carolina hospitals

Method or Intervention:
Hospital discharge data generated by the Office of Research and Statistics was used to assess the costs related to CHD in South Carolina. The data was categorized by race (white and nonwhite) and by service provider groups (Commercial/HMO, Medicare, Medicaid, and Self-Pay). Other variables that were generated by the hospital discharge data included number of discharges, total cost, and average cost for each discharge for all categories.

Result or Outcome:
The total cost for CHD discharges in the state was about $1.2 billion in 2002. Of this amount, about $768 million was spent through Medicaid and Medicare combined. It was noted that the total cost for all discharges under the Self-Pay category was $69 million. Furthermore, on average, nonwhites were 64% more likely to belong to the Self-Pay category than were whites.

Conclusion or Significance:
Studies have consistently shown that nonwhites are more likely to have lower socioeconomic levels than whites. They are also more likely to have increased risk factors for CHD. As the rate of uninsured is higher, CHD accounts for a greater economic burden among nonwhites, as shown by this studys results. Results also indicate a greater need for providing interventions to reduce health risks for uninsured and underserved populations.

Ethnic Disparities in the Control of Glycemia, Blood Pressure, and LDL-Cholesterol

Authors: J.K. Kirk; R. A. Bell; A.G. Bertoni; T. A. Arcury; S.A. Quandt; D.C. Goff; V.K.M. Narayan

Objective:
To review an in-depth search performed from 1993 to 2003 examining ethnic disparities in the quality of diabetes care among U.S. adults.

Setting: 
Data sources included PubMed, Web of Science, Cumulative Index to Nursing and Allied Health, Cochrane Library, Combined Health Information Database, and Education Resources Information Center.

Method or Intervention:
Reviewers performed a comprehensive search for literature and studies related to diabetes and ethnic disparities in quality of care. Using a reproducible search strategy, reviewers used a standardized abstraction form and graded articles for publication source and content. Data on glycemia, blood pressure, and LDL cholesterol were extracted.

Result or Outcome:
A total of 390 studies were reviewed. Data was organized by study author, date of publication, sample size, study population, description of study site, and control measure. A total of 77 studies were found that contained control measures for diabetes. For glycemia data from studies including a minority population (n=33), all of the reported literature showed mean glycosylated hemoglobin (HbA1c) values to be greater than or equal to 8%. Glycemia data from studies (n=25) that included a minority population and compared it with a non-Hispanic white population indicated that there were five studies with >1% difference in HbA1c among the ethnic minority group. The proportion of patients with high-risk glycemia (>9.5%) for HbA1c ranged from 27.1% to 63.8%. Blood pressure data from single studies involving an ethnic minority group showed that among 23 studies, the percentage of uncontrolled hypertension ranged form 34% to 69%. There were also 23 studies for blood pressure evaluated in minority populations that included comparison with a non-Hispanic white cohort. For African Americans, 35% to 67% did not have blood pressure controlled and for Hispanics, eight studies indicated poor control (34% to 73% with uncotrolled blood pressure). LDL-cholesterol data was reported from 16 studies that revealed poor control regardless of ethnicity; the LDL-cholesterol concentration range reported was between 100mg/dl to 146 mg/dl. However, the majority of studies (8 of 11) reported a greater proportion of non-Hispanic whites had suboptimal control of LDL-cholesterol than African Americans and Hispanics.

Conclusion or Significance:
Ehtnic minorities had poorer outcomes of care than non-Hispanic whites for glycemia and blood pressure. Disparities were most pronounced for glycemia and most studies showed blood pressure to be poorly controlled among ethnic minorities. These findings suggest that additional efforts are needed to promote quality of care among minority populations woth diabetes.

Health Care Utilization Following Negative Experiences in Primary Health Care Settings

Authors: J.W. Lee; A.K. Matthews; C. Manfredi; T.P. Johnson; E.A. Jacobs

Objective:
To examine the negative experiences of primary care patients in health care settings and the impact of the negative experience on patterns of subsequent health care utilization.

Setting: 
Three primary care centers or clinics in a large Midwestern city serving three diverse patient populations. Site 1 was a large private medical center, Site 2 was a public hospital, and Site 3 was a primary care clinic serving predominantly lesbian, gay, bisexual, and transgendered patients.

Method or Intervention:
We conducted a retrospective survey study from 2001 to 2003 at each of the three sites (N=400) funded by a NIH/NCI Research Supplement for Underrepresented Minorities (#R01 CA77525-02S1). All participants were recruited and surveyed at their treatment site. Consent for this study was oral, and participants received a small monetary incentive for their participation. The self-administered survey assessed patient satisfaction with health care services, satisfaction with the quality of medical care and quality of relationship with provider, types of medical interactions, prevalence of previous negative experiences in health care settings, and patterns of subsequent health care utilization.

Result or Outcome:
Study findings indicate that, on average, patients were very satisfied with their health care services and providers. However, nearly 25% of the sample reported previous negative experiences in health care settings. Patients reported a variety of health care utilization patterns following a negative experience in a health care setting. Sixty-five percent reported they decided not to follow provider advice, 58% stayed with the same provider but trusted him or her less, 52% stopped going for medical treatment as often as required, 50% did not return for their next medical appointment, 46% did not go for medical treatment the next time they were ill, and 37% stopped going for medical treatment entirely. We discuss the potential impact of these patterns of health care utilization on the management of chronic disease.

Conclusion or Significance:
Patients may report reduced health care utilization following negative experiences in health care settings. These patterns of health care utilization may have an impact on the management of some types of chronic disease.

Improving Chronic Disease Outcomes in Correctional Health Care Programs

Authors: R. Shansky; R.S. Chavez; E. Harrison

Objective:
To develop an effective chronic disease outcome measurement program for prison health care systems that will result in improved patient care.

Setting: 
Two large U.S. state prison systems having disproportionately minority populations of 80,000 inmates and an average length of institutionalization of over 2 years.

Method or Intervention:
As part of the quality improvement initiative for prison health care and using the recommendations in a report to Congress funded by the Centers for Disease Control and Prevention and the Department of Justice, we expanded upon nationally recognized chronic disease clinical guidelines by 1) describing strategies to overcoming barriers to their implementation commonly found in correctional settings and 2) developing a simple measurement tool that health care providers could use in assessing and improving patient care. Using customized clinic encounter forms, chronic disease patient care data were entered into a database and tracked over time. These data were analyzed and summarized, and reported to the prison systems for the purposes of quality improvement. The reports included information on patient improvement, provider adherence to clinical guidelines, and comparisons among institutions and state systems.

Result or Outcome:
Nearly 40,000 patient encounters were recorded for asthma, diabetes, hypertension, HIV, or seizure control. Variability among providers in adhering to clinical guidelines was identified. Using this information, one prison system was able to improve physician performance in assessing disease control by reducing the error rate from 30% to 15%. However, the quality of provider care is also influenced by factors beyond the scope of this project, such as staff turnover rates. Supervisors and system administrators found the quality improvement tools helpful to their work, as did many of the patient care providers. The project is still in the process of determining improvement in the number of patients in good control; preliminary data are encouraging, and conclusions should be available by the end of 2004.

Conclusion or Significance:
The project has led to improved chronic disease care and quality improvement programs in two state prison systems.

Inequities in Access to Best Medicines: Role of Public Health in the Fight Against Health Disparities

Author: K.A. Kovacs Burns

Objective:
To discuss possible strategies for public healths role in influencing policy decisions and health system inadequacies, leading to inequities in access to drugs and other best medicines needed by people with chronic illness who are trying to prevent complications.

Setting: 
Both Canada and the United States are in the midst of internal federal versus provincial/state battles regarding drug coverage, access, and choice issues, which affect millions of people living with chronic disease.

Method or Intervention:
This project consists of a comparative literature and news review of Canadian and American health care systems and public policies that specifically focus on addressing drug choices, coverage, and other access. Both countries discuss the need for cost containment of their health care expenditures, particularly around drug coverage. People with chronic illness often end up paying the price for their drugs and treatment. If drugs are not accessible or covered adequately, the cost can be much greater in terms of quality of life as well as hospitalization and treatments. Public health is an important link that must be made with people with chronic illness to ensure that they have access to the care and treatment they need without other, more severe consequences. Key words have been targeted in the literature and news reviews, in both the published articles and unpublished reports. These key words include health care/Medicare policies and coverage federally and provincially/state side; drug coverage plans; costs of plans; chronic illness costs of treatment and drugs; public health role in system; cross-border Internet pharmacy and impact; and others as they arise from the literature reviews.

Result or Outcome:
The literature has been summarized for similarities and differences between the two countries regarding health care and drug management. The impact of the cross-border Internet pharmacies is also part of the review and discussion. Based on the literature, the critical analysis and discussion provides the inequities leading to health disparities, and possible strategies for public health to play a key role in influencing policy decisions and health system inadequacies.

Conclusion or Significance:
Public health, in concert with patient groups, can take a lead role in influencing change in the health system and public health policies to prevent inequities and health disparities.

Investigating Unrecognized Risk of the Metabolic Syndrome in African American Women: The Role of Psychological Factors

Authors: D.P. Ferdinand; S. Nwachukwu; C. Taylor

Objective:
To determine associations between psychological factors of self-concept, self-efficacy, and stress, and the metabolic syndrome in obese African American women

Setting: 
Community-based clinical sites and African American womens organizations in the deep South region of the United States.

Method or Intervention:
Using a multi-correlational design, we recruited 110 African-American women to participate in the study. Participants completed four psychological questionnaires, along with anthropometric and physiologic measures. Fasting blood samples were obtained and analyzed in addition to high sensitivity C-reactive protein (hsC-RP) to examine for the metabolic syndrome factors. Multiple regression analysis was performed to analyze data. Innovative incentives were designed to remove three barriers of access to care: costs, transportation, and explanation of test results.

Result or Outcome:
Body weight measures ranged from 161 lbs to 329 lbs (standard deviation [SD]=37.4) and BMI 3056.5 (SD=5.6). Participants who reported positive physical self-concept demonstrated at least three of the five factors for the metabolic syndrome (P<0.0001). Self-efficacy for eating habits, and perceived stress were statistically significant (P<0.0001) in women with increasing BMI. The metabolic syndrome was identified in 23 African American women who were unaware of their at risk status. Review of laboratory test results increased womens awareness of their risk for diabetes and cardiovascular disease.

Conclusion or Significance:
Perceived satisfaction with physical size in obese AfricanAmerican women may influence how they seek behaviors to decrease their risk for diabetes and cardiovascular disease (CVD). Participants reported that convenient access to diagnostic laboratory tests at no cost was a major incentive for participation in the research study. Understanding obese African American womens perceptions may assist health care providers with developing culturally tailored interventions to decrease CVD health disparities. Weight reduction programs should include components that assess participants for the metabolic syndrome. Public health practitioners may improve earlier identification and treatment of women who are at risk for diabetes and the metabolic syndrome by targeting obese African American women with personalized health education, hs-C-RP assessment, and social support.

Keeping ME Healthy:The Maine Youth Overweight Collaborative

Authors: M. Polacsek; J. Orr; L. Letourneau; V. Rogers; R. Holmberg

Objective:
The Maine Center for Public Health (MCPH), in partnership with the Maine Academy of Pediatrics (MAAP), and the Maine Harvard Prevention Research Center (MHPRC), has established the Maine Youth Overweight Collaborative, pioneering work to improve care and outcomes for youth who are at risk for overweight and those already overweight. Our Collaborative addresses the documented need for provider intervention tools and practice protocols in this area. Youth overweight disproportionately affects lower-income and minority youth.

Setting: 
Using the Breakthrough Series Collaborative model developed by the Institute for Healthcare Improvement (IHI), the MCPH has brought together clinical experts, primary care practices, and community partners to develop local expertise and shared goals among clinical practice teams in order to improve management of youth overweight and decrease youth overweight within the state. Our partnership, for the first time, applies this model to the problem of youth overweight in Maine.

Method or Intervention:
The Collaborative is focusing on improving systems in primary care practices to assess the problem of youth overweight, improving control of key behavioral and clinical risk factors, and improving use of self-management support strategies by clinician teams and patients. This innovative collaborative model works to improve the quality of care through the application of evidence-based interventions tailored to individuals, and utilizing community, family, and other system resources to accomplish health outcomes. Access to quality services is positively impacted for practices serving largely disadvantaged youth. With its emphasis on system change, the Collaborative serves as a model for all disease prevention and treatment, where health care systems foster improved outcomes for populations, eliminating disparities, and improving health for all.

Result or Outcome:
Specific changes in office practice being promoted include 1) patient self-management support; 2) improving the design of the delivery system; 3) the use of standard tools to improve clinical decision-making; 4) the establishment of appropriate clinical information systems; and 5) the development of relationships between health care organizations and their community partners in order to help patients and providers access community resources and support policies that promote improved outcomes.

Conclusion or Significance:
The prevalence of childhood risk for overweight and overweight is increasing at an alarming rate in the United States, especially among subpopulations and economically disadvantaged children. The potential future health care costs associated with pediatric overweight and its comorbidities are staggering. It is incumbent on the pediatric community to take a leadership role in prevention and early recognition and treatment of pediatric obesity.

Lessons Learned in Miami in Complex Care Delivery, Disease Management, and Navigation with Underserved Populations

Authors: K.L. Reiss; M. McLoughlin

Objective:
To convey lessons learned from 3 years of a coordinated program of disease management and health navigators in a community with high numbers of uninsured, underserved populations.

Setting: 
The Community Access Program (CAP) of Miami-Dade County, Florida, is a consortium of over 20 organizations that plan, advocate for, or deliver health services to uninsured and underinsured populations. Miami-Dade County is one of the most culturally and economically diverse metropolitan areas in the United States. More than half of the population is foreign-born, and more than two-thirds of the population does not speak English at home.

Method or Intervention:
For the past 3 years, with funding from the Health Resources and Services Administration (HRSA), the consortium of members of the Community Access Program of Miami-Dade County has developed innovative solutions with two overarching goals: 1) to increase the number of individuals with health insurance and 2) to increase the use of primary care and preventive services among the uninsured (thus reducing inappropriate emergency room use). To achieve its goals, the consortium includes a disease management initiative that focuses on diabetes, congestive heart failure, and Axis I Behavior Disorders, and culturally sensitive health navigators to assist populations in appropriate understanding and utilization of complex systems of care and funding. Our external evaluators with the University of Florida have assisted in the evaluation of this project. Disease management (DM) is based on the premise that a small percentage of very sick patients consume large amounts of health care resources. DM should cut down on expensive visits to emergency rooms, minimize inpatient hospital stays, and prevent complications. The net effect of DM should be cost savings and better quality of life for patients. Our preliminary evaluation suggests that DM programs represent operationally relevant, innovative practices to help participants identify and document specific operational DM best practices; identify importance and challenge using accepted standards of care; and provide recommendations for practice in other community programs for the uninsured. These practices include meeting patients where they can meet, being flexible with respect to meeting times, accommodating those with jobs, making multiple phone calls to remind patients about medical appointments and medications, and using materials in multiple languages with simple pictures.

Result or Outcome:
From the first 2 years of the DM program, $1,432,606 in costs have been avoided from decreases in emergency room utilizations, crisis stabilizations, and hospitalizations.

Conclusion or Significance:
Designing and implementing disease management for uninsured populations result in cost savings, but present unique challenges.

Out on the Prairie: Homophobia, Heterosexism, and Oblivious DisregardRural Health Hazards

Author: S.L. Paxon

Objective:
Health disparities for the lesbian, gay, bisexual, and transgender (LGBT) populations are a controversial topic, especially in rural and conservative settings. Documented disparities include higher risks due to unique factors such as sexual behavior or anti-gay prejudice. Other disparities fall into conditions and chronic diseases that occur with greater prevalence in the LGBT population. Still another category of disparity exists in the lack of culturally competent health care. Training for health care providers and community workers in LGBT health disparities is one objective, which includes identifying the barriers and solutions to quality care. The second objective is accomplishing buy-in from health care professionals, which is essential in reducing LGBT health disparities.

Setting: 
LGBT persons willing to complete the health services survey and health care groups willing to provide LGBT health disparities training to staff members in North Dakota.

Method or Intervention:
The LGBT North Dakota Health Services Survey is an eight-question tool to gather information regarding the experiences of LGBT individuals with North Dakotas health care systems. Participants were asked to describe whether they are open with health care providers regarding their sexual orientation or gender identity, the reactions of providers, and any institutional bias. Survey participants were primarily from central North Dakota. The survey was completed by a small convenience and snowball sample of the LGBT population.

Result or Outcome:
The survey results confirmed that these North Dakota LGBT individuals face the same health disparities described in the literature for other areas in the United States. North Dakota lesbians, gay men, bisexual individuals, and transgender people are reluctant to reveal their sexual orientation or gender identity to health care providers, even to the point of lying or omitting information that might out them. They admit to sometimes avoiding health care settings because of unease with the provider or health system. Their comments suggest that health care institutions are not perceived as being friendly to the LGBT population.

Conclusion or Significance:
Health disparities for the LGBT population exist, and homophobia, heterosexism, and oblivious disregard impact the issue both for the patient and the provider. Training is needed to heighten awareness of health disparities before solutions can be implemented. As in many regions, North Dakotans are more likely to buy-in to information, training, or recommendations if there is a link to state residents. Though the survey sample size was small, this snapshot view of health services for LGBT individuals in North Dakota adds validity to provider training sessions.

Public Health Villains or Good Guys: Do We Know the Difference?

Author: B.A. Yamashita

Objective:
To improve the cultural competence of public health department systems and ensure that they include community input from the at-risk populations they serve.

Setting: 
Examination of epidemiological data on the chronic disease burden in Hawaii clearly demonstrates consistent and increasing health disparities, particularly among Native Hawaiians, Filipinos, those with low incomes or education and those in rural areas (e.g., neighbor islands). Furthermore, for Native Hawaiians, high morbidity and mortality rates have persisted long term. Similarly, risk behaviors, obesity, access to health care, disability, and preventive practices differ across all subpopulations.

Method or Intervention:
Feedback from a series of focus group discussions with representatives from Native Hawaiian, Filipino and rural communities in Hawaii suggest that changes are needed in the methodology of prevention programs, health research, and evaluation.

Result or Outcome:
Any health program, research, or evaluation being conducted for colonized indigenous peoples throughout the Pacific, should use a model centered on their values. Such culturally appropriate methodologies need to be respectful of diverse communities, engage communities at all points in the process, and let the communities themselves take the lead.

Conclusion or Significance:
Community engagement can become a mechanism for empowering communities themselves and for developing needed leadership capacity in such marginalized communities.

Racial Differences in Factors that Influence Survival with Oral Cancer in Georgia: 19782001

Authors: R. Krishna; J. Liff; A. Chen; P. Eke; V. Robison

Objective:
The purpose of this study was to examine the racial differences in distribution of risk factors associated with oral cancer survival in Georgia (19782001).

Setting: 
Studies have shown that the 5-year survival rate for people with oral cancers is much lower in blacks than whites. According to the Surveillance, Epidemiology and End Result (SEER) program, the national 5-year survival rate for people with cancers of the oral cavity and pharynx from 1992 to 1997 was 36.1% for blacks and 59.7% for whites.

Method or Intervention:
Data from 1,503 whites and 531 blacks with oral cancers in five urban and 10 rural counties of Georgia from 1978 to 2001 were analyzed. Data were collected by the Georgia Center for Cancer Statistics (GCCS), a population-based cancer registry affiliated with the SEER program. Racial disparities in stage at diagnosis, grade of cancer, sex, age, socioeconomic status, rural/urban residence, and type of treatment were examined.

Result or Outcome:
Compared with whites, blacks were twice as likely (odds ratio [OR] = 2.5, 95% confidence interval [CI], 2.0-3.0) to die during the 5-year follow-up time. Compared with whites older than 70 years of age, blacks were 2.2 (95% CI, 1.6-3.1) times more likely to be diagnosed at 6170 years of age, 3.7 (95% CI, 2.7-5.1) times more likely to be diagnosed at 5160 years of age, and 4.8 (95% CI, 3.4-6.7) times more likely to be diagnosed at less than 50 years of age. Compared with whites who were mostly diagnosed at the localized stage of the disease, blacks were 3.0 (95% CI, 2.4-3.8) times more likely to be diagnosed at the regional stage and 4.8 (95% CI, 3.4-6.7) times more likely to be diagnosed after distant metastasis. Blacks were also more likely to have grade 2 (OR = 3.0, 95% CI, 2.3-3.9) and grade 3 (OR = 2.2, 95% CI, 1.6-3.1) cancers. Consequently, blacks were more likely to have received radiation (OR = 3.1, CI, 2.2-4.3) or both radiation and surgery (OR = 2.3, 95% CI, 1.7-2.9). Whites were more likely to have received surgery only.

Conclusion or Significance:
In Georgia, oral cancers in black patients were diagnosed at a much younger age, at a more advanced stage and higher grade of disease, and were treated with other than cancer-directed surgery only. These disparities highlight both a challenge to further understand the reasons and an opportunity to reduce racial disparities in survival rates of patients with oral cancers.

Six Health Organizations that Have Implemented Chronic Disease Management Programs in Rural and Underserved Patient Populations

Authors: J. Nelson Bolin; L.D. Gamm; B. Kash

Objective:
To investigate and evaluate chronic disease management (DM) programs offered by health plans serving primarily rural and underserved patient populations; and determine whether there are observable clinical and financial outcomes associated with the chronic disease management programs offered to these populations.

Setting: 
Six health organizations, in six states, serving rural or uninsured patients with chronic diseases.

Method or Intervention:
Data was gathered from three primary sources: 1) on-site interviews with chronic disease management leaders; 2) self-administered mail survey of DM leaders and providers; and 3) patient-level outcomes data from three DM programs. A summary of diabetes DM financial outcomes for a single managed-care organizations DM program was provided.

Result or Outcome:
Study findings indicate that the six health organizations are successfully carrying out DM in rural and underserved areas using a variety of innovative and collaborative methods. These organizations have achieved clinical and financial success while employing the chronic disease management model in a variety of rural populations, including uninsured and Medicare-eligible populations. Clinical indicators, such as reduced HbA1c, LDL levels, blood pressure, and urine micro-protein, supported the efficacy of the chronic disease management in the plans providing patient-level data. Significant financial savings were demonstrated in one plan, including reduced hospital inpatient days, in-patient charges, outpatient services, and ER visits. Total per-member per-year savings in 2002 were 17%.

Conclusion or Significance:
Health organizations are successfully carrying out DM in rural and underserved patient populations with both clinical and financial success. These health plans are employing the chronic disease management model in a variety of populations, while employing innovating patient care strategies and collaborative models.

Strategies that Facilitate Statewide Collaboration and Impact Chronic Disease Disparities in Primary Health Care Settings

Authors: J. Johnson Reaves; M. Wolf; D. Porterfield

Objective:
To describe successful partnering efforts and strategies of the North Carolina Chronic Disease Management Collaborative that state health departments may adopt to impact the quality of health care for disparate populations.

Setting: 
Three state organizations (the state health department, the Community Health Center Association, and the Quality Improvement Organization), professional schools, health plans, professional associations, and 21 primary care practice settings serving underserved populations.

Method or Intervention:
In 2004, the North Carolina Diabetes Prevention and Control Program (DPCP) and the North Carolina Community Health Center Association expanded the Diabetes Collaborative begun in 2003 to a Chronic Disease Management Collaborative (CDMC) targeting diabetes and cardiovascular disease. New partners joined the statewide effort including the North Carolina Heart Disease and Stroke Prevention Program (HDSP) in the state health department as well as Medical Review of North Carolina, the states Quality Improvement Organization. Future partners include professional schools, managed care organizations, and professional associations. Built on successful national models from the Institute of Health Care Improvement, Improving Chronic Illness Care and the Health Disparities Collaboratives, North Carolina recruited 21 primary health care settings serving disparate populations for participation. The CDMC began in the summer of 2004 with prework activities, and the first Learning Session was held in August 2004. Initially, the project was supported by a Robert Wood Johnson Foundation grant. Currently, a local charitable trust and DPCP and HDSP funds from the Centers for Disease Control and Prevention support the effort. Scholarships are also provided to teams from Medical Review of North Carolina, local health departments receiving HDSP funding as lead counties in a region, and the DPCP.

Result or Outcome:
Materials and tools including a Memorandum of Understanding, contractual agreements, formal communication policies and procedures, an oversight committee, and a business plan were developed to facilitate collaboration, clearly delineate the roles and responsibilities of each partner, aid in decision-making and plan for sustainability and spread. A partnership with one of our four schools of medicine has also been developed, and residents are currently participating as a team in the CDMC.

Conclusion or Significance:
Outcomes from year 1 of the Diabetes Collaborative suggest positive changes in the processes of care, including foot and eye exams, flu and pneumococcal vaccines, and average HbA1C and blood pressure levels.

Using a Scoreboard to Improve Outcomes Among Disparate Populations

Author: L.A. Brenneke

Objective:
To share the concept of creating and using a scoreboard report as a quality improvement and communication tool within federally qualified health centers (FQHC).

Setting: 
A partnership with the Missouri Diabetes Prevention and Control Program (MDPCP), the Missouri Primary Care Association (MPCA), and ten Missouri FQHCs participating in Health Disparities Collaborative work.

Method or Intervention:
Through a contract with the MPCA, the MDPCP collects monthly summary registry data from FQHCs participating in the National Health Disparities Collaborative on diabetes and cardiovascular disease. From the monthly registry reports, MDPCP creates a quarterly scoreboard report. The scoreboard report provides a summary report of an individual FQHCs progress in achieving Health Resources and Services Administration (HRSA) and Centers for Disease Control and Prevention (CDC) goals, along with a comparison of aggregate goal achievement by all Missouri FQHCs. The scoreboard report is distributed to various levels within FQHCs through the MPCA, including a quarterly meeting of the FQHC Executive Directors.

Result or Outcome:
The scoreboard serves as a quality improvement tool by serving several functions:  it 1) targets areas for improvement cycles;  2) identifies successful centers in implementing best practices so they can be a resource to others; 3) provides a peer-pressure effect; and 4) serves as a communication tool allowing all individuals within an organization to see how their organization is performing.

Conclusion or Significance:
The scoreboard is a quality improvement tool that aids FQHCs in improving the quality of chronic disease care to ultimately reduce and eliminate health disparities.

Social Determinants of Health Inequities

Aspirin Use as a Preventive Measure for CVD Among African Americans and Whites in Georgia

Authors: P.T. Baltrus; G. Baldwin; S.K. Davis

Objective:
Research has shown aspirin to be highly effective as both a primary and secondary prevention treatment for cardiovascular outcomes, including myocardial infarction (MI) and stroke. The U.S. Preventive Service Task Force and the American Heart Association recommend aspirin for men over age 40 and postmenopausal women. Since African Americans suffer from a greater risk of cardiovascular disease (CVD) than whites, aspirin use may provide a relatively inexpensive way to reduce health disparities. This study is an analysis of the factors that influence the use of aspirin as a primary preventive treatment for CVD.

Setting: 
Data from the Regional Assessment Health Survelliance Study (RAHSS), a survey of a representative sample of African American and white adults residing in six counties in Georgia, were used. The study population (n = 651) was men aged 40 and over and women aged 60 and over with no previously diagnosed CVD.

Method or Intervention:
Race, gender, education, income, insurance status, urban/rural residence, having a regular physician, obesity, smoking status, and diagnosed high cholesterol and blood pressure were examined as predictors of aspirin use. Chi-square tests and logistic regression were the statistical methods used.

Result or Outcome:
Chi-square univariate anlayses showed that race, education, smoking status, high blood pressure, and high cholesterol were significantly related to aspirin use. A multivariate logistic model adjusted for all predictor variables revealed that whites are 72% (odds ratio [OR] = 1.72, 95% confidence interval [CI] = 1.13-2.61) more likely than African Americans to use aspirin as a preventive treatment for CVD,  and those without a high school education are 45% (OR = 0.55, 95% CI = 0.31-0.96) less likely to use aspirin as a preventive treatment for CVD.

Conclusion or Significance:
African Americans and the less educated are less likely to use aspirin as a preventive measure independent of their insurance status, access to health care, and health status. Reasons for this disparity in aspirin use as a CVD preventive measure should be further investigated.

Attitudes Toward Pap and HPV Testing and Health Surveys in an Appalachian Community

Authors: C. Hopenhayn; A. Christian; R.A. Fletcher; M.K. Anglin

Objective:
To assess the knowledge and attitudes of women in an Appalachian community toward Papanicolaou (Pap) and human papillomavirus (HPV) testing, as well as the types of health surveys likely to yield higher response rates.

Setting: 
In spite of the high potential for prevention of cervical cancer through appropriately timed Pap smears, and possibly in combination with HPV testing, incidence rates remain high in areas of Appalachia. This warrants the need and the potential for increased and novel prevention strategies. The Behavioral Risk Factor Surveillance System (BRFSS) estimates Pap test usage, but it is uncertain if this represents the actual testing prevalence in underserved areas of Appalachia, such as eastern Kentucky, due to the nature of the survey (household telephone ownership, types of questions, and low response rates).

Method or Intervention:
Through active interaction with community groups in an Appalachian county with high rates of cervical cancer incidence (about twice as high as the estimated United States as a whole), two sets of representative key informants were identified and interviewed. In total, 16 semi-structured, in-person interviews were conducted with 7 community leaders and 9 health care professionals regarding health care access in general and Pap testing in the region, perceived barriers to Pap testing, BRFSS administration and questions, and HPV knowledge and perception of testing. In addition, two focus groups were conducted: one with women recently screened for cervical cancer and one with women who were never or not recently screened.

Result or Outcome:
On the basis of preliminary analysis, some of the salient findings from the interviews include very limited knowledge about HPV and its relationship to cervical cancer among community leaders or perceived knowledge among women in general (yet there was potential interest in self-testing approaches); knowledge about Pap testing; and mixed opinions on the methods used by the BRFSS and other options that would increase participation in a community-based womens health survey.

Conclusion or Significance:
The results of this study will shed light on methods in which Pap testing could be better assessed in a rural, underserved area of the Appalachian region, the perceptions of access to Pap tests and follow-up of abnormal results, and the feasibility of conducting a pilot about HPV testing in this community.
Case Study Assessment of Hard-to-Reach Populations Perceptions of Medicare Rights and Protections

Authors: M. Gerteis; A.M. Ward; S. Crelia; J. Gerteis; L. Blatt; C. Chang

Objective:
To explore 1) how isolated, vulnerable, and minority populations of Medicare beneficiaries perceive their rights and protections under Medicare; 2) their experiences exercising those rights; 3) how their perceptions and experiences differ from those of Medicare beneficiaries in general; and 4) how vulnerable populations access information about Medicare rights and protections.

Setting: 
Dayton, Ohio; Eugene, Oregon; Olympia, Washington; Sarasota, Florida; Springfield, Massachusetts; and Tucson, Arizona.

Method or Intervention:
Case studies in six communities, using five principal methods of data collection: 1) Medicare diaries; 
2) one-on-one in-depth interviews; 3) participant observation; 4) focus groups; and 5) key informant interviews. Specific Medicare beneficiary populations targeted included 1) the general Medicare population; 2) those belonging to racial, ethnic, and linguistic minorities, including African Americans, non-English-speaking Hispanics (Mexicans and Puerto Ricans), and non-English-speaking Asians (Vietnamese, Koreans, and Chinese); 3) low-income beneficiaries; 4) frail elders and disabled beneficiaries; and 5) rural and geographically isolated beneficiaries.

Result or Outcome:
Most beneficiaries within the general Medicare population understood very little about their rights and protections under Medicare. Although general understanding was limited, there were marked variations in knowledge levels and willingness to take action. Those most knowledgeable and most assertive often had past experience advocating on behalf of a parent or spouse. However, circumstances and experiences within each of the targeted hard-to-reach populations varied in unanticipated ways. Some disabled beneficiaries were among those most knowledgeable about Medicare, while those unable to advocate for themselves often had an identifiable support person to advocate for them. Low-income beneficiaries were often well established in networks of community support, as were non-English-speaking Hispanic and Asian beneficiaries. Social isolation appeared to be more of a risk factor than other characteristics of any given population.

Conclusion or Significance:
Findings do not support prior assumptions that people with limited financial resources, ethnic minorities, frail or vulnerable elders, the disabled, and isolated linguistic minorities or rural populations are at greater risk than others in the Medicare population regarding understanding or asserting their basic rights and protections under Medicare. Overall understanding of Medicare rights and protections appears limited even among the general Medicare population. Research suggests that risk has more to do with not being connected to systems of support than with characteristics such as poverty, ethnicity, language, disability, or frailty.

Chronic Stress, Clinical Depression, and Blood Pressure in Clinically Diagnosed Hypertensive African American Women

Author: C. Bienemy

Objective:
The purpose of this research study was to explore relationships between chronic stress, clinical depression, and blood pressure in clinically diagnosed hypertensive African American women. A secondary aim of the study was to examine the moderator effects of social support and spiritual well-being in relationships between chronic stress, clinical depression, and blood pressure among hypertensive African American women.

Setting: 
Community-based settings in the Southeastern region of the United States, which included churches, womens groups, beauty parlors, and community centers and community activities.

Method or Intervention:
A multi-correlational research design was used to test hypotheses addressing relationships between chronic stress, clinical depression, blood pressure, social support, and spiritual well-being in 167 African American women. An interdisciplinary theoretical framework representing three health-related disciplines (psychology, nursing, and social work) was used to guide the development and implementation of the current study. Pearsons product moment correlation analysis was used to test hypotheses regarding relationships between variables, and moderator multiple regression analysis was used to test hypotheses, which focused on testing the moderator effects of social support and spiritual well-being.

Result or Outcome:
Five of the ten hypotheses that were tested were fully supported, and four were partially supported. Significant relationships were found to exist between chronic stress as measured by the African American Womens Stress Scale (Modified) and blood pressure, whereas no significant relationships were found between chronic stress as measured by the Perceived Stress Scale and blood pressure. All measures of chronic stress in the sample population were significantly correlated with clinical depression as measured by the Beck Depression Inventory FastScreen for Medical Patients. Social support and spiritual well-being were found to significantly moderate relationships between chronic stress, blood pressure, and clinical depression.

Conclusion or Significance:
The study findings have implications for nursing education and research. The expanded use of interdisciplinary conceptual models that emphasize gender, culture, spirituality, and social support in nursing education programs could be beneficial in both undergraduate and graduate nursing programs. Additionally, the development of more culturally specific prevention or intervention programs that address both the physiological and psychological health care needs of hypertensive African American women may lead to better clinical outcomes for this vulnerable population.

Colorectal Cancer Screening in Washington State: Predictors of Current Screening and Explanations for No Screening

Authors: P. Hannon; J. Harris; D. Martin; J. VanEenwyk; D. Bowen

Objective:
To identify predictors of current colorectal cancer screening in Washington State and to examine participants reasons for not being screened.

Setting: 
2002 Behavioral Risk Factor Surveillance SystemWashington State.

Method or Intervention:
We analyzed data from the 2002 Behavioral Risk Factor Surveillance System for Washington State residents aged 50 years and older (N = 2,109). Current colorectal cancer screening was defined as fecal occult blood test (FOBT) within the past year and/or sigmoidoscopy or colonoscopy within the past 5 years. Participants who did not have current FOBT or current endoscopy were asked the primary reason for lacking screening.

Result or Outcome:
Overall, current colorectal cancer screening was reported by 51.9% of the sample (FOBT by 25.8%; endoscopy by 42.8%). Univariate analyses showed that several demographic characteristics were significantly associated (P<.05) with screening status, including white race, age 65 years or older, annual income over $75,000, and having a college degree. In a multivariate analysis adjusting for the above characteristics and other likely confounding variables (sex, marital status), participants were more likely (P<.01) to have current screening if they possessed health insurance (54.2% vs. 16.8% for uninsured participants) and had discussed colorectal cancer screening with a health care provider (67.3% vs. 33.4% for participants who had never discussed screening with a health care provider). Participants were also more likely to report current screening if they lived in a large town or urban area (53.0% vs. 42.7% for participants living in small towns/rural areas; P<.05). The majority of participants without current screening cited lack of awareness as the primary reason for not being screened (53.0% for FOBT; 46.9% for endoscopy). An additional group of participants stated their physicians had not recommended screening (24.8% for FOBT; 33.3% for endoscopy). Relatively few participants said they were not willing to be screened (20.4% for FOBT; 18.1% for endoscopy) or cited lack of access (1.8% each for FOBT and endoscopy).

Conclusion or Significance:
Our results indicate that nearly half of age-appropriate Washington State residents lack current colorectal cancer screening. Awareness of colorectal cancer screening, particularly via speaking with a health care provider, was an important predictor of screening. These findings are consistent with published reports based on National Health Interview Survey data. Interventions should be developed to increase awareness of and physician recommendations for colorectal cancer screening, particularly to disadvantaged patient populations.

Differential Effects of Active Living on Quality of Life at Various Levels of Income

Authors: J.J. Peterson; J.B. Lowe; N.A. Peterson; K.F. Janz

Objective:
This study used a moderator model to examine the effects of active living on the physical components of health-related quality of life (i.e., overall physical, physical functioning, and ability to fulfill physical role).

Setting: 
The study participants were a randomly selected sample of rural residents (n = 407) from the Midwestern United States.

Method or Intervention:
The method employed was an observational study.

Result or Outcome:
Results showed that active living had a greater impact on health-related quality of life for those reporting lower income. The magnitude of effect of active living on the overall physical component for the low-income group was more than twice the effect on the high-income group. For physical functioning, the magnitude of effect of active living for the low-income group was greater than three times the effect for the high-income group.

Conclusion or Significance:
Although active living behaviors have been demonstrated to be less prevalent among those of low socioeconomic status, this group may have the most to gain from these activities. Findings highlight the need for increased and specifically targeted promotion of active living interventions. Implications of the study and directions for health promotion practice are presented.

Education and Negative Affect as Prospective Factors in Hypertension Disparities Between White and Black Women

Authors: B.S. Jonas; S.M. Williams; J.F. Lando

Objective:
1) To test the hypothesis that education and negative affect are prospectively associated with hypertension incidence among white and black women; 2) to investigate whether risk disparities in hypertension incidence for negative affect would persist after stratification by education and race; and 3) to investigate whether the inclusion of change in body mass index (BMI) as a time-dependent covariate has an effect on the patterns of risk and disparities.

Setting: 
The first National Health and Nutrition Examination Survey (NHANES I) is a national probability sample of the United States. The NHANES I Epidemiologic Follow-up Study (NHEFS) is a longitudinal study of the participants in NHANES I. A population-based cohort of 1,852 initially normotensive and chronic disease-free women in NHANES I was tracked in NHEFS through four follow-up waves (22 years maximum).

Method or Intervention:
Negative affect was defined as combined symptoms of depression and anxiety categorized as elevated compared with non-elevated (reference group). Education was categorized as low (<12 years) compared with high (12+ years = reference group). Hypertension was defined as doctor-reported hypertension or high blood pressure at one or more follow-up waves. The association between hypertension and baseline education and negative affect among white and black women was analyzed using Cox proportional hazards regression adjusting for baseline age, race, smoking status, alcohol use, diastolic and systolic blood pressure, BMI, and change in BMI. Additional models were stratified by race and education.

Result or Outcome:
Objective 1: Race (black women compared with white women as the reference group: relative risk [RR] = 1.51; 95% confidence interval [CI], 1.14-1.99), low education (RR = 1.24; 95% CI, 1.03-1.50), and elevated negative affect (RR = 1.65; 95% CI, 1.37-1.99) were all associated with hypertension incidence. Objective 2: Elevated negative affect was associated with hypertension incidence for white women (RR = 1.54; 95% CI, 1.27-1.88) and for black women (RR = 3.76; 95% CI, 1.75-8.11). Elevated negative affect was further associated with hypertension incidence for white women with high education (RR = 1.45; 95% CI, 1.14-1.84), white women with low education (RR = 1.61; 95% CI, 1.12-2.31), black women with high education (RR = 2.81; 95% CI, 0.81-9.73) and black women with low education (RR = 4.43; 95% CI, 1.61-11.77). Objective 3: Although change in BMI was independently associated with hypertension incidence, its model inclusion had little effect on patterns of risk and disparities observed for education and negative affect.

Conclusion or Significance:
Womens hypertension incidence risk disparities were independently observed for blacks, low education, and elevated negative affect. Risk disparities were particularly pronounced for black women with low education and elevated negative affect.

Engaging Older Adults to Be More Active Where They Live: Audit Tool Development

Authors:    J. Kruger; M. Kealey; R. Hunter; S. Ivey, W. Satariano; C. Bayles; L. Brennan Ramirez; L. Bryant; C. Johnson; C. Lee; D. Levinger; K. McTigue; G. Moni; A. Vernez Moudon; D. Pluto; T. Prohaska; C. Sible; S. Tindal; S. Wilcox; K. Winters; K. Williams

Objective:
Because of an increase in the prevalence of chronic diseases and an aging population, older adults are at highest risk for poor health. Health disparities by age and socioeconomic status have been shown to exist for many physical activity outcomes and may be explained in part by differences in the built environment in which older adults live, work, and play. Partners of the Environmental Workgroup of the CDC Healthy Aging Research Network (HAN) have designed and piloted an instrument that focuses on the relationship between the built environment and physical activity in older adults.

Setting: 
Neighborhoods in seven diverse U.S. communities served by HAN: Alamosa, Colorado; Berkeley, California; Chicago, Illinois; Columbia, South Carolina; Hendersonville, North Carolina; McKeesport, Pennsylvania; and Seattle, Washington.

Method or Intervention:
An environmental audit instrument, developed to be sensitive to issues of importance to older adults, was designed to assess street-scale factors associated with physical activity across multiple settings. Audit items included land use, destinations, sidewalk and intersection conditions, amenities such as benches, social disorder such as litter, and the types of activities that people are seen engaging in. In the pilot study, 1530 street segments were audited by two or more trained researchers at each of the seven HAN sites. In addition to the audit, qualitative semi-structured interviews were conducted to identify additional items of importance to adults aged 65 years or older.

Result or Outcome:
Interrater reliability among the trained researchers was examined. Researchers across the seven HAN sites examined differences in neighborhood segments audited to determine the distribution of study variables, such as presence of sidewalks and crosswalks. A summary of the qualitative findings from interviews with older adults will be discussed. In addition, recommendations for environmental audit instrumentation as an assessment tool for research about physical activity with older adults will be presented.

Conclusion or Significance:
This study describes the development of an audit instrument and findings from combined research efforts across seven sites to discuss the perceived and actual environment where older adults live.

Environmental Correlates of Physical Activity in a Rural Population with Diabetes

Authors: A.D. Deshpande; E.A. Baker; S.L. Lovegreen; R.C. Brownson

Objective:
To determine the relationship between physical and social environment attributes and levels of physical activity in a population-based sample of rural residents with diabetes.

Setting: 
Cross-sectional telephone survey data from rural communities of Arkansas, southeastern Missouri, and Tennessee was used.

Method or Intervention:
No intervention was tested in this study.

Result or Outcome:
A total of 278 (11%) persons with diabetes were identified. Almost 37% of this group reported no leisure-time physical activity. People with diabetes who reported regular physical activity were more likely to report better general health status, normal body mass index (BMI), and no physical impairment. After adjustment, regular activity was positively associated with use of 3 or more facilities for exercise (population odds ratio [POR] 14.3, 95% confidence interval [CI] 3.0-67.3) in the past 30 days, the availability of many places to walk to nearby (POR 2.3, 95% CI 1.1-4.8), the availability of shoulders on streets (POR 2.4, 95% CI 1.3-4.5), often walking to nearby places (POR 4.1, 95% CI 2.0-8.3) and rating the community for physical activity as generally pleasant (POR 2.3, 95% CI 1.1-4.8). Additionally, the regular activity group was more likely to report that their physician had helped them make a plan to increase physical activity (POR 2.8, 95% CI 1.3-5.8) and followed up with them on their plan (POR 2.2, 95% CI 1.1-4.4). Social environment variables were not associated with physical activity after adjustment.

Conclusion or Significance:
Physical inactivity is a significant problem for rural residents with diabetes. We have identified aspects of the social and physical environment that are positively associated with physical activity.

Factors that Lead to Depression Among Black Men: A Systematic Review of the Literature from 1984 to 2004

Authors: D.C. Watkins; B.L. Green; B.M. Rivers

Objective:
This review examines two decades of literature that address factors that contribute to depression among African American men.

Setting: 
Articles published in peer-reviewed journals between 1984 and 2004 were systematically reviewed (n =  22), screened for eligibility (n = 17), and analyzed based on whether the results suggested depressive factors (n = 9).

Method or Intervention:
All studies used psychosocial instruments to measure their samples. Major depression resulted from age, socioeconomic status, employment status, social isolation, economic exclusion, health status, stressful life events, sociodemographic factors, and psychosocial factors.

Result or Outcome:
Studies suggested that psychosocial coping, family structure, and racism (or rather, the black mans acceptance in white America) were the main factors that lead to depression among African American men.

Conclusion or Significance:
The findings raise important concerns about the need for more research on depression in African American men and the coping strategies African American men execute in what they consider to be an oppressive society.

Fruit and Vegetable Consumption Among African American Women: Do Cultural Characteristics Help Identify Subgroups With Greater and Lesser Consumption?

Authors: A. Karamehi; A.C. Booker; A. Deshpande; M.W. Kreuter

Objective:
This study explored whether and how four cultural variablescollectivism, racial pride, religiosity, and time orientationcontribute to identifying subgroups of African American women who differ in their level of daily fruit and vegetable (FV) consumption.

Setting: 
In a sample of 1,620 African American women from urban public health centers in St. Louis, Missouri, and Durham, North Carolina, we examined associations between daily FV consumption and cultural, psychosocial, health status, and demographic variables.

Method or Intervention:
A classification-tree analysis identified 16 distinct groups that were homogenous with respect to FV consumption.

Result or Outcome:
These groups ranged in size from 24 to 372 members, with mean FV consumption ranging from 2.1 to 5.7 servings per day. Results indicated that psychosocial and cultural characteristics distinguished subgroups of African American women who ate significantly different numbers of FV servings per day.

Conclusion or Significance:
This study adds to a growing body of literature suggesting the importance of cultural variables in influencing health behaviors.

Gender Disparities in Physical Activity Participation Among Boston Youth

Authors: A.M. El Ayadi; S.L. Gortmaker; C. Hannon; J.L. Wiecha

Objective:
To examine gender disparities in barriers to physical activity participation among Boston youth.

Setting: 
Insufficient levels of physical activity contribute to the current epidemic of childhood obesity. Prior research has established that girls lag behind boys in physical activity participation. Data on barriers to participation are sparse but essential to inform intervention.

Method or Intervention:
Play Across Boston surveyed 421 young people aged 1018 years from public middle and high schools, community centers, middle school after-school programs, and Boys & Girls Clubs of America to explore perceptions of individual and environmental factors influencing their physical activity, sedentary behavior, and dietary patterns. This evaluation is part of a larger community-based research effort in Boston, funded by the Centers for Disease Control and Prevention, to document available sport and physical activity programs and facilities; understand how community resources affect youth participation in physical activities and sports; identify potential solutions for gaps in programming, resources, and barriers to participation; and monitor youth access to and participation in sports and physical activities.

Result or Outcome:
Our study validated substantial gender disparities in meeting recommended levels of vigorous activity levels and sports team participation. Among Boston youth, girls face larger numbers of barriers to physical activity participation than their male counterparts. Girls cited a higher mean number of barriers as sometimes or always prohibiting them from participating (3.75 vs. 2.67). Additionally, significantly higher proportions of girls indicated that certain barriers always or sometimes prevent them from participating in physical activity, including perceptions of low self-efficacy, program availability, and safety issues. Girls responded more frequently than boys that not feeling skilled enough (38% vs. 22%), not having fun (43% vs. 29%), a lack of program availability near their homes (41% vs. 27%) and schools (40% vs. 28%), inconvenient locations (43% vs. 31%), and safety concerns around home (35% vs. 26%) and on public transportation (40% vs. 27%) affected their participation in sports and physical activity. Higher proportions of girls also felt that certain physical activity sites were not within walking distance of their homes, including basketball courts (13% vs. 5%), YMCAs (65% vs. 44%), and pools (33% vs. 21%). Regression modeling controlling for clustering, age group, race/ethnic group, and barriers confirmed the gender disparity in physical activity.

Conclusion or Significance:
This study highlights areas contributing to gender disparities in Boston youth participation in sports and physical activities, and can guide efforts into improving opportunities for Boston girls.

Health for All: Californias Strategic Approach to Eliminating Racial and Ethnic Health Disparities

Authors: R. Davis; L. Cohen; L. Mikkelsen; M. Aboelata

Objective:
This presentation will provide an overview of Health for All: Californias Strategic Approach to Eliminating Racial and Ethnic Disparities in Health, a description of the community clusters and factors that contribute to or reduce disparities, their role in closing the health gap, and implications for next steps.

Setting: 
The Approach delineates how the resources of diverse governmental and private institutions can be aligned to work with communities to make significant progress toward eliminating health disparities in California. The Approach also addresses how the relationship of place, ethnicity, and poverty leads to the greatest disparities in health. This presentation will shed light on the community conditions that hold promise for reducing health disparities in low-income communities of color by delineating factors that can contribute to or prevent health disparities.

Method or Intervention:
The community factors are based on an iterative process consisting of a scan of peer-reviewed literature, relevant reports, and interviews with practitioners and academics, and an analysis including brainstorming, clustering of concepts and information, and a search for supporting evidence. The literature scan began with medical conditions and searched for information that linked them with social, behavioral, and environmental elements. The review also focused on the relationship of community factors to California Priority Medical Concerns and Healthy People 2010 Leading Health Indicators. On the basis of the findings, the authors identified a set of 20 community factors that could be linked to medical issues through research. The factors clustered into the following areas: built environment, social capital, services and institutions, and structural factors.

Result or Outcome:
The Approach makes a significant contribution to the public health field in several ways. First, it emphasizes not only addressing disparities in access to and quality of care but also and equally the need to prevent the development of disease and injury by fostering healthy behaviors, community environments, and institutional support of good health outcomes. Second, the Approach delineated critical pathways from root factors of disparities to behavioral and environmental factors and medical services. Third, it delineates specific community environmental factors that can be addressed to close the health gap and improve health. Fourth, it establishes the need for broad-based involvement and identifies key sectors that can make significant contributions.

Conclusion or Significance:
The campaign provides an understanding of how and why morbidity and mortality disproportionately affect communities of color and how to use what is known to develop appropriate and effective efforts within these communities.

Health Inequities of Eastern North Carolina Native Americans: Comparisons with Latino Immigrants and African Americans

Authors: D. Baron-Hall; S.L. Edwards; M. Revels

Objective:
To improve the health status of American Indians in eastern North Carolina through increasing access to culturally sensitive health care; empowering Indian communities to provide adequate health care; developing a culturally appropriate plan of personal health care; promoting healthy lifestyle living; and establishing a current database on the health status of Native Americans in eastern North Carolina.

Setting: 
Indian Health Outreach Project established in five state-recognized tribes in collaboration with community health centers, the North Carolina Office of Minority Health, Migrant Benevolent Services, Inc., the Commission on Indian Affairs, universities, and other related state and nonprofit health programs in North Carolina.

Method or Intervention:
The Eastern North Carolina American Indian Rural Health Outreach Project has been established in all five tribes. Health outreach workers have been identified; a health survey has been designed; tribal health councils have been formed; key health issues have been identified; and culturally appropriate health programs have been structured for each tribal community. This project was conceived in response to the overwhelming need for access to adequate, affordable, culturally appropriate health care for American Indians in rural North Carolina and the failure of most state and local preventive health programs to target the health needs of North Carolina American Indians as an underserved population. Its focus is physical, mental, emotional, and spiritual health. Special emphasis is placed on chronic diseases as well as depression, HIV/STDs, and alcohol/substance use/abuse. The University of North Carolina at Pembroke, a school initially founded for Indian students in the Lumbee community in eastern North Carolina, has agreed to store and maintain data gathered from this project to be available for future studies and provision of services. The databases used for this study are the Behavioral Risk Factor Surveillance System (BRFSS) and the Native American Interfaith Ministry HIV/STD Survey, incorporated by the Director of the School of Social Work at the University of North Carolina-Pembroke, who is also the Project Evaluator.

Result or Outcome:
We are finding that Eastern North Carolina Indians report similar health disparities as other tribes in the United Stateshigher percentages of poor or fair health, no health coverage, high rates of diabetes, problem smoking, lack of exercise, and generally poorer health than that of most other ethnic groups in the region, including African Americans and Latinos.

Conclusion or Significance:
Culturally appropriate health education, care, and services can decrease, and in some cases, alleviate health disparities among Indians and other specific ethnic groups in rural communities.

Health Perceptions and Knowledge of Healthy Choices Among Adult Mexican Americans with Intellectual Disabilities

Author: J. Jurkowski

Objective:
To share research exploring health perceptions and knowledge of healthy choices for preventing chronic diseases among Latino adults with intellectual disabilities (ID) who participate in programs at a community agency in Chicago.

Setting: 
Community agency serving predominantly Latinos with disabilities in Chicago

Method or Intervention:
Focus groups were conducted in Spanish and English with predominantly Mexican American men and women with ID to explore health conceptualization, perceptions, and priorities for guiding health promotion efforts at the community. The groups were guided by theory and conducted in collaboration with the agency.

Result or Outcome:
Mexican Americans with ID who participated in the focus groups have some understanding of nutritious foods and the importance of physical activity. However, none reported regularly making healthy food choices. Few expressed enjoyment of traditional exercise, except when training for Special Olympics. Most preferred outdoor, social, and interactive activities such as dancing and playing ball outside. They believe they have control over their health, but God and their family play a significant role in helping them maintain or improve health. Social relationships with friends, family, and staff are central for feeling content. Being active and engaged with work, people, or recreational activities is important, and they expressed sadness about how being ill prevented them from engaging in these activities.

Conclusion or Significance:
Health promotion programs that may include Latino adults with ID should not only focus on knowledge of healthy choices but also teach concrete strategies for behavior change. Physical activity programs that are social and recreational such as dancing or event-focused may be more effective. Family and agency staff should also be targeted for health promotion programs as they influence healthy choices.

Improved Physical Environment Can Improve Quality of Life

Authors: S.L. Penchishen; K. Wenrich

Objective:
To increase physical activity, decrease obesity, and improve pedestrian safety through changing the environment to decrease vehicular traffic congestion, fatalities, and injuries, and increase the safety of pedestrians within a community that ultimately improves health, wellness, and quality of life.

Setting: 
Liberty High school campus in Bethlehem, Pennsylvania.

Method or Intervention:
Decreasing the risk of injuries and fatalities involving pedestrians while increasing physical activity, health, and wellness, and improving quality of life. Students were not utilizing the designated crosswalks around the school and motor vehicles were not yielding to pedestrians in the crosswalks. Lack of designated crosswalks also increased the risk for injuries and pedestrian fatalities. Traffic congestion and traffic flow was a concern around the school. Pedestrians did not use the crosswalks because of the congestion, increasing the conflict between pedestrians and motor vehicles. Due to this conflict, students were driven to school instead of walking, which increased traffic in an already congested area. In a pre-survey, about 1 in 125 (20%) students used the crosswalks, and about 2 of every 4 vehicles (50%) yielded to a pedestrian in the crosswalk. Through a collaborative effort, crosswalks were painted, mandatory Code of Conduct classes were conducted, and pedestrian warnings were distributed. The Health Bureau kept track of the offenders and forwarded a list to the District Justice. A number of citations were issued to motorists/pedestrians. After a 2-week warning period, police conducted ongoing enforcement for both pedestrians and motor vehicles.

Result or Outcome:
During the 2-week warning period, more students were walking to school and using the crosswalks. About 45 of 500 students (11%) did not use the crosswalks during the 2-week warning period. After the warning period, approximately 650 of the students (100%) are crossing in the crosswalks. The initial problem was the perception that pedestrians were in conflict with the motor vehicles; however, after the program was implemented, it was found that about half the motor vehicles were in conflict with the pedestrians.

Conclusion or Significance:
Through increasing the safety of pedestrians and motor vehicles and decreasing injuries and fatalities through modifying the environment, students were enabled  to safely walk to school, thus increasing physical activity and improving health, wellness, and quality of life.

Is Food Insecurity a Price of Smoking Among the Poor?

Author: B. Armour 

Objective:
To estimate the share of income that families spend on cigarettes and to determine the association between food insecurity, smoking, and poverty.

Setting: 
Retrospective study using data from the 2001 Panel Study of Income Dynamics. Cigarette smoking prevalence is higher among adults living below the poverty level. The opportunity cost of smoking (the goods and services smokers forgo to purchase cigarettes) will be proportionately higher among poor families than nonpoor families because a larger share of their income will go toward the purchase of cigarettes. No study has documented what these opportunity costs might be. This study shows an association between food insecurity and the share of income spent on cigarettes. Evidence supporting this association suggests that state-sponsored smoking cessation programs targeting poor smokers may have an added benefit of reducing food insecurity.

Method or Intervention:
The Panel Study of Income Dynamics is a nationally representative longitudinal study of U.S. families. The study collected economic, health, and social behavior data on 7,406 families. This information was used to identify smokers and families that were food-insecure, and to determine the share of families income spent on cigarettes. T-tests and chi-square tests were used to assess univariate differences between continuous and categorical variables. Multivariate logistic regression models were used to assess the association between food insecurity, smoking, and poverty.

Result or Outcome:
Approximately 7.6% of families lived in poverty, 6.1% were food-insecure, and 26.1% had at least one family member that smoked in 2001. Poor families were more likely to have a family member that smoked cigarettes than nonpoor families (33.3% vs. 22.5%; P<.01). The share of income spent on cigarettes was significantly higher for poor families than nonpoor families (12.0% vs. 2.0%; P<0.01). Results from the multivariate logistic regression analysis revealed that the odds of being food-insecure increased as share of income spent on cigarettes increased (adjusted odds ratio: 1.72; 95% CI [1.66- 1.79]).

Conclusion or Significance:
Having an average annual income of $8,624 and average annual cigarette expenditures of $857, poor families with a family member who smokes spend a large share of their income on cigarettes. This study suggests that, in addition to the adverse health consequences linked to smoking, poor families may also pay a price in terms of their food insecurity.

Lessons Learned from the Field: Faith-Based Breast and Cervical Cancer Early Detection Project

Authors: E. Calhoun; N. Berrios; G. Birkby

Objective:
To offer lessons learned that affect the implementation of a faith-based breast and cervical cancer early detection program for low-income minority women.

Setting: 
Faith-based health education intervention coupled with linkage to breast and cervical cancer screening services in nine African American and eight Latino churches in the Chicago metropolitan area.

Method or Intervention:
In Phase I, we conducted 6-month follow-up surveys followed by debriefing focus groups among 17 participating churches. In an effort to better understand differences in screening behavior between our two study populations, we conducted 17 focus groups during Phase II for breast/cervical cancer screeners and nonscreeners. The evaluation process assessed the opinions and perceptions of African American and Latina women related to their knowledge and health beliefs about chronic diseases. The study also gathered demographic data such as insurance status and education level to learn if these factors impact screening behaviors.

Result or Outcome:
Six-month follow-up surveys revealed that 72.5% of African American women who participated in the program had a mammogram within the past year, and 66.8% received a Papanicolaou (Pap) test. Figures for Latina women show that 45.3% had mammograms and 52.6% received Pap tests as a result of the intervention. However, nonparticipants were less likely to have accessed screening services. For example, only 64.8% of African American women (nonparticipants) reported having had a mammogram within the last year. Percentage differences between participants (44.9%) and nonparticipants (43.4%) were not that striking for Latina women. Debriefing focus groups revealed that regular screeners typically had histories of breast abnormalities as well as a history of breast/cervical cancer in their family. Furthermore, the presence of friendly personnel and good technicians at clinics were important factors in encouraging screening. Phase II screening focus groups highlighted different experiences and perceptions between screeners and nonscreeners. Education level does not necessarily positively correlate with screening behavior. Women who screen tend to be more connected with their health. Findings show a relationship between entering the health care system for any reason at all and becoming a consistent screener. Nonscreeners then are less likely to have ever entered or accessed health care.

Conclusion or Significance:
Overall, an important lesson learned was that the African American women were less likely to get a referral through the program because they had insurance; they also reported higher levels of education. For Latina women, the free mammograms and low-cost Pap tests are compelling incentives for screening.

Making a Difference in Our Own Lives: Pemiscot Male Mentoring Program

Authors: A. Branch; V. Motton; K. Frye; F. Motton; E.A. Baker

Objective:
To decrease health disparities by assisting men in obtaining the education and skills necessary to acquire work (including providing health education to young people at after-school programs) and building on the community capacity to create meaningful changes in their own communities.

Setting: 
The Pemiscot County Male Mentoring Program (PCMMP) serves the specific needs of African American men living in an economically depressed community in rural southeast Missouri.

Method or Intervention:
The PCMMP was developed as part of a community-based participatory action research project. Through a community assessment process, community members identified education as one of the most important underlying social determinants of health in the community, particularly for men. Therefore, the program was developed on the basis of social learning theory and a review of the specific factors influencing the health of men in our community. The community concluded that improving the well-being of men and using them as role models for young people was the best way to improve the attitudes and health of young people and adults. The program used an existing Fatherhood First program to recruit participants. Evaluation methods include tracking of the partnership and factors related to completion of the general equivalency diploma (GED) program.

Result or Outcome:
As a result of our efforts, the number of men who have entered GED programs and obtained GEDs has increased, as have the collaborative efforts of groups beyond those traditionally affiliated with public health initiatives, and grants have been written to provide the opportunity for more specific health-related training and certification.

Conclusion or Significance:
Education is one of the most important underlying social determinants of health in our communities, yet few health practitioners see it as within their purview to intervene in this area. The PCMMP is an important example of how community members can participate in defining the underlying factors affecting their community and work toward effective solutions.

Maternal Diabetes and Perinatal Outcomes

Authors: R.E. Gainor; C. Pollard; C. Fitch

Objective:
This research was completed to test the hypothesis that West Virginia women with maternal diabetes would experience more negative perinatal outcomes than those women who did not have maternal diabetes. A secondary hypothesis tested stated that West Virginia women with pre-gestational (pre-existing type 1 or type 2) diabetes would experience more negative perinatal outcomes than West Virginia women with gestational diabetes.

Setting: 
Births to Medicaid mothers in West Virginia during the years of 2001 and 2002.

Method or Intervention:
This study was a population-based ex post facto research design with secondary data analysis. Data were analyzed for the years 2001 and 2002 on all babies born to mothers enrolled in the West Virginia Medicaid program. Data for those two years were analyzed using three different databases including West Virginia Vital Statistics, the West Virginia Birth Score Project, and West Virginia Medicaid Claims. There were a total of 14, 583 births included in the population. The population was split into two groups according to the presence of diabetes in the mother. This was determined using ICD-9 codes for diabetes in the Medicaid Claims data. The diabetic group consisted of 853 women; the nondiabetic group consisted of 13,750 women. The diabetic group was divided into those women with pre-gestational diabetes and those women with gestational diabetes. The pre-gestational group consisted of 396 women, and the gestational group consisted of 457 women.

Result or Outcome:
Study findings indicated significant associations between the presence of diabetes in the mothers and several negative perinatal outcomes including macrosomia (26.85% vs. 19.54%, P<.0001), preterm delivery (18.77% vs. 10.80%, P<.0001) and less than optimal 1-minute Apgar scores (8.79% vs. 5.63%, P = .0001). Also, pre-gestational diabetes was shown to be significantly associated with more negative perinatal outcomes than was gestational diabetes. These perinatal outcomes included macrosomia (31.31% vs. 22.98%, P<.0061), preterm birth (24.49% vs. 13.85%, P<.0001), less than optimal Apgar scores (4.04% vs. 1.09%, P = .0056), occurrence of complications of labor and/or delivery (7.58% vs. 3.94%, P = .0215) and occurrence of congenital anomalies (1.01% vs. 0%, P = .0461).

Conclusion or Significance:
This study demonstrates associations between maternal diabetes and negative perinatal outcomes in the Medicaid population of West Virginia. A prospective-longitudinal study may be planned in the future to further support these findings.

Obesity and Income Are Associated with Low Priority for Fruit and Vegetable Consumption

Authors: S.R. Bobra; M.S. Nanney; M. Elliot; D. Haire-Joshu

Objective:
To identify factors that impact priorities to engage in obesity prevention behaviors in African American populations.

Setting: 
Parents (n = 388) of girls (mean age = 8.36 years) who attended a summer mentoring program in urban St. Louis, Missouri.

Method or Intervention:
A telephone survey was administered to parents of African American girls enrolled in a mentoring program to examine the factors associated with reporting low priorities for physical activity (PA) and fruit and vegetable (FV) consumption. Independent sample t-tests were used to analyze the impact of parental body mass index (BMI) upon PA and FV priorities. Chi-square analyses were employed to examine the differences in socioeconomic status and parental priorities for PA and FV. Lastly, the link between parental BMI levels and child BMI levels was examined.

Result or Outcome:
No significant differences were found between parents who identified being physically active as a low priority (17.3%) versus a medium or high priority for income (chi-square = .013, P = .456) or parental BMI levels (30.51 vs. 29.80, t = -.640, P = .523. Significant differences were found between parents for whom consuming FV is a low priority (13.6%) versus a medium or high priority. Low FV priority is associated with having a higher average BMI (32.36 vs. 29.54, t =  2.335, P = .020), income less than $15,000 a year (chi-square =  22.007, P = .000) and also being less likely to consume three or more servings of fruits and vegetables (odds ratio [OR] = .174, P = .018). Parental BMI is positively associated with the child being at risk of overweight compared with normal weight (OR  =  1.786, P = .004). Every 10-point increase in parental BMI leads to a 1.786 times greater chance of having a child that is at risk of overweight (85th<95th percentile) or is overweight (95th percentile and higher). Parents who are obese are more likely to have children who are overweight or at risk of overweight compared with normal or overweight parents (OR = 1.91, P = .024).

Conclusion or Significance:
This study indicates that income and parental BMI predict low priority for consumption of FV but not for PA. These findings suggest that emphasis should be placed on increasing the priority that low-income families place on consuming FV. The link between parent and child weight reinforces the importance of intervening at the family level to modify dietary patterns developed at young ages.

Predictors of Health Status for Disadvantaged Medicare Beneficiaries: Results of the Medicare Health Outcomes Survey

Author: B.H. Ellis

Objective:
To examine predictors of physical health outcomes during a 2-year interval for African American, Hispanic, Asian, American Indian/Alaskan Native, and other race/multiracial Medicare + Choice beneficiaries compared with white Medicare + Choice beneficiaries.

Setting: 
Beginning in 1998 and continuing annually, a Medicare Health Outcomes Survey baseline cohort is created from a random sample of 1,000 members from Medicare + Choice (managed care) organizations in the United States. The same beneficiaries are then surveyed again 2 years later. Cohort II baseline data were collected in 1999, and follow-up data were collected in 2001. Cohort III baseline data were collected in 2000 , and follow-up data were collected in 2002.

Method or Intervention:
We analyzed predictors of health status between baseline and 2-year follow-up for African American (N = 21,768), Hispanic (N = 18,456), Asian (N = 5,864), American Indian/Alaskan Native (N = 1,782), and other race/multiracial (N = 4,304) managed care beneficiaries (white, N = 287,830 was the reference group). Approximately 16,000 beneficiaries were deceased during the time interval but were incorporated in the regression modeling; thus, the bias that results from analysis on survivors was eliminated in this study. A logistic regression model was used to estimate the probability of being healthy at follow-up (the deceased were assigned a value of zero). Multiple regression was then used to predict the probability of health at follow-up.

Result or Outcome:
The results indicated that racial/ethnic background was not the strongest predictor of poor health at follow-up. Poor beneficiaries (household income of less than $10,000 a year) and those who had a low educational level (8th grade or less) were more likely to have poor health at follow-up. Other significant predictors of poor physical health status at follow-up included beneficiaries with a positive depression screen, smokers, proxy respondents, and those with comorbid chronic conditions.

Conclusion or Significance:
The National Healthcare Disparities Report indicates that low-income families of any race are in poorer health than wealthier Americans. The results of the current research confirm this finding. Disparities in health status exist in Medicare managed care. In this population, disadvantaged Medicare managed care beneficiaries are those with low income and a low educational level. Disease management programs and managed care plans should target these beneficiaries through health literacy programs. Depressed beneficiaries, smokers, and beneficiaries with multiple chronic conditions should also be targeted by plans for preventive care. The Medicare Health Outcomes Survey data are available to researchers on the Web at www.cms.hhs.gov/surveys/hos.

Reducing Disability, Income, and Racial/Ethnic Disparities: How Much Will Health Indicators Improve?

Authors: N. Wilber; K.M. Clements; M. Mitra

Objective:
To explore the effect of reducing racial/ethnic, income, and disability disparities on selected Healthy People 2010 (HP2010) indicators.

Setting: 
State of Massachusetts from 1998 to 2002.

Method or Intervention:
Data are from the Massachusetts Behavioral Risk Factor Surveillance System (BRFSS), a random-digit-dial telephone survey of adults aged 1864 years, weighted and adjusted for age. Disparities analyzed were income adjusted for household size (150% poverty level), race/ethnicity (white/black/Hispanic), and disability status (with/without disability). Health indicators were fair/poor health (overall health indicator), feeling sad 15+ days in the past month (mental health indicator), and obesity (body mass index [BMI] 30+, physical health indicator). In addition to odds ratios (OR), population attributable risks (PARs) were calculated to account for the prevalence of higher risk groups in the overall population. PARs estimate the improvement in the indicator if higher risk race/ethnicity, income, or disability groups have the same risk as lower risk groups.

Result or Outcome:
Having a disability was most strongly associated with fair/poor health (OR = 10.6, 95% CI 9.2-12.2), followed by low income (OR = 5.3, 95% confidence interval [CI] 4.6-6.1) and Hispanic ethnicity (OR = 4.3, 95% CI 3.7-4.9). Associations of disability status, income, and Hispanic ethnicity with feeling sad 15+ days in the past month showed a weaker but similar pattern (OR = 7.4, 95% CI 6.3-8.7; OR = 3.5, 95% CI 3.0-4.1; OR = 1.9, 95% CI 1.62.3, respectively). Disability status (OR = 2.0, 95% CI 1.7-2.2), black race (OR = 1.9, 95% CI 1.6-2.2), Hispanic ethnicity (OR = 1.4, 95% CI 1.3-1.7) and low income level (OR = 1.4, 95% CI 1.1-1.6) were associated with obesity. Eliminating excess risk associated with having a disability most improves the three indicators (assuming independence of the disparities). For fair/poor health, the PAR for disability was 61%, followed by 42% for low income, and 21% for Hispanic ethnicity. The PARs for sad 15+ days showed a similar pattern (51%, 30% and 7%, respectively). Likewise, the PARs for obesity were 14%, 6%, and 4% for the three groups. With certain exceptions (especially for obesity), PARs calculated for risk and disease factors (e.g., high cholesterol, no physical activity, diabetes, smoking) were lower than those for the disparities highlighted above.

Conclusion or Significance:
Substantial improvement in overall HP2010 indicators in Massachusetts will require strategies that improve the health of persons with disabilities, Hispanics, blacks, and low-income people. PAR analysis may help focus efforts in other states. Data support inclusion of a disability focus, functionally defined as in the BRFSS, in health promotion partnerships addressing this and other disparities.

Reducing the Risk of Obesity in Latino Children

Author: A. Opalinski

Objective:
To understand the cultural beliefs and practices of Latino families regarding causes of childhood obesity.

Setting: 
The setting for this study included three Midwestern metropolitan U.S. cities, each with a stable Latino community.

Method or Intervention:
Using standard ethnographic methods of data collection, semi-structured interviews were conducted. Eleven Latino mothers with children ranging from ages 311 living in the same household were interviewed. Field notes derived from participant observations during interviews were recorded. In addition, field notes from observations at local fast-food restaurants and playgrounds in these predominantly Latino communities were recorded. Data were analyzed using qualitative analytic strategies. Dialogue from the interviews and text from the field notes were examined for semantic relationships of cultural practices of diet and activity as well as cultural beliefs of causes of childhood obesity. Interview text was analyzed and hand-coded. Salient codes were aggregated into categories of mothers cultural descriptions. This is a report of a broader population, and beginning saturation of this preliminary data was achieved in nine to ten interviews.

Result or Outcome:
Study findings revealed cultural ways of food preparation to be fat-laden and include few fresh fruits and vegetables. Physical activity was described only in relation to extracurricular activities with no school or family involvement for increasing physical activity of children. However, financial strain of extracurricular physical activities often prohibited families from providing this type of activity. Cultural beliefs about causes of childhood obesity were stated as too big portion sizes and overfeeding, yet observations revealed continual food-pushing practices between Latino parents and children.

Conclusion or Significance:
Results suggest that continued education must focus on diet, healthy food preparation within cultural ways of cooking, and family/community involvement in physical activity. Strategies that are culturally appropriate as well as appropriate to the acculturation level must be tested with this population. These data were collected from mothers with a relatively high acculturation level. Further investigation is needed in those families with lower acculturation levels; the cultural beliefs and behaviors may be different in these families. In addition, these results suggest the need for increased community involvment to assist Latino families with physical activities for their children. Interventions within schools and communities may be most effective in providing consistent, low-cost physical activity to these children.

The California 5 A Day Be Active Pilot Project: A State and Local Perspective

Authors: J. Micheletti; G. Sisneros; C. Bogan; S. Jackson; L. Cleveland; M. Oppen

Objective:
In the summer of 2002, three pilot planning projects in three communities were initiated in order to develop social marketing campaigns. These campaigns incorporate physical activity within nutrition educationbased interventions using the social-ecological model. The pilot programs are led by the Cancer Prevention and Nutrition Section (CPNS) of the California Department of Health Services and funded by the U.S. Department of Agriculture (USDA). The pilot projects target low-income white, African American, and Latina mothers of school-aged children in California. Very few existing programs address these populations.

Setting: 
Three organizations in Oakland, Los Angeles, and Riverside, California: The YWCA of Oakland, Weingart YMCA in Los Angeles, and Riverside County Nutrition Services in Riverside.

Method or Intervention:
After months of initial formative research, three organizations in Oakland, Los Angeles, and Riverside, California, worked with CPNS and other partners in an ongoing process to build physical activity integration resource centers in their communities for low-income women with children. All three projects incorporated walking components, linked with existing community nutrition education programs, and had citywide launch events and a variety of activities specific to the community. The first phase of the project was in July of 2002 through December 2003. A second phase of funding began in January 2004 to expand the projects to a regional level. The second phase of funding will conclude in March 2005. Jim Sallis Exercise Confidence and Social Support surveys were administered in English and Spanish beginning in August 2004.

Result or Outcome:
This joint presentation will feature both a state-level and a local-level coordinator to provide multiple perspectives. The presenters will 1) give feedback about the unique planning process used; 2) share sample community plans; 3) discuss program evaluation ideas, strategies, and results (Exercise Confidence and Social Support survey results will be available by March 2005); and 4) share successes and lessons learned.

Conclusion or Significance:
These pilot projects demonstrate the successes and challenges of working with low-income white, African American, and Latina populations to increase physical activity and access to fruits and vegetables.

The Influence of Social, Political, and Cultural Factors on Physical Activity Among African Americans

Authors: C.M. Kelly; B. Baker; E. Barnidge; J. Strayhorn

Objective:
To explore the influence of social, political, physical. and cultural factors on physical activity among African Americans using structured focus group techniques.

Setting: 
Current research indicates that physical activity rates as well as many associated disease rates vary by race/ethnicity. A national study also indicates that physical activity rates vary by income status: adults with incomes below the poverty level are three times as likely to be physically inactive as adults in the highest income group. Given the importance of physical activity and its strong association with various chronic diseases, it is imperative that we understand better the combined effects of race, gender, and income so we can develop effective interventions that highlight the multiple factors influencing physical activity.

Method or Intervention:
Structured focus groups were conducted with a stratified random sample of African American men and women from high- and low-income groups. Participants were asked to list challenges to participating in physical activity specific to their race and gender as well as to their geographic location. Transcripts of the focus groups were then analyzed using deductive focused coding techniques.

Result or Outcome:
The four subgroups identified some similar as well as unique challenges to participating in physical activity, including lack of safety, decreased neighborhood cohesion, physical environment, generational lifestyle changes, lack of facilities, motivation, transportation systems, financial issues, and social norms.

Conclusion or Significance:
Interventions developed to increase physical activity need to take into consideration these various contextual barriers rather than individual barriers alone. In addition, it appears that the importance of these barriers varies by both gender and income, suggesting that different interventions may be necessary to increase physical activity for various subgroups.

The Use of Arizona BRFSS Data to Estimate Health Disparities in Hispanics

Authors: M.D. Lebowitz; M. McGorray; J. Chong

Objective:
To estimate disparities in the prevalence of diabetes, general health status, and associated risk factors between Hispanics and non-Hispanics living in Arizona, and the relationship between the risk factors and disease status.

Setting: 
Arizona, 19922001.

Method or Intervention:
We analyzed 10 years of Arizona BRFSS data (19922001) to estimate the prevalence of diabetes, general health status, and selected risk factors, and the relationship of the risk factors for diabetes to Hispanics and non-Hispanics. The relevance of residence on the United StatesMexico border was examined. Secular trends were analyzed for health-related variables as well. Variables with significant secular trends were corrected and then included in the multiple logistic regression analysis. 
Result or Outcome:
Diabetes increased over time and general health decreased over time, more so in Hispanics, but the increases were not statistically significant. The age- and sex-adjusted odds ratios showed that Hispanics were more than one and a half times more likely to be obese than non-Hispanics, more than twice as likely to be told that they have diabetes, half as likely to engage in recommended levels of physical activity, and three times less likely to report that they feel in good or excellent health. However, they were less likely to report being current smokers than non-Hispanics. Being overweight was related to diabetes prevalence in both ethnic groups, and socioeconomic status contributed somewhat to predicting diabetes as well. Individuals in border counties as a whole were less likely to report excellent or good health or to engage in the recommended levels of physical activity.

Conclusion or Significance:
Arizona Hispanics suffer from a higher prevalence of diabetes, poorer health status, and risk factors related to both than non-Hispanics, regardless of whether they live on the border. Disease and risk factors are increasing over time. Even aggregating 10 years of data does not provide a sufficient sample to allow regional estimation of minority populations.

The Use of Cultural Competency Training to Begin Chronic Disease Program Integration

Authors: E. Weiskopf; E. Bradt; M. Casey

Objective:
Provide participants with a template for a replicable one-day training in cultural competency that can be used for local and state partners as a first step in eliminating disparities. Participants will also learn how chronic disease programs can collaborate on training efforts.

Setting: 
Trainings have been provided to local health departments, hospitals, and other program contractors and partners at 10 locations across New York State. The training focuses on the influence of culture on our own decisions and perceptions, as well as those of the people we interact with and serve. Local panelists drawn from cultural groups represented in the training location discuss their health perceptions and beliefs.

Method or Intervention:
Chronic Disease Prevention and Control Programs, working as an integrated team, developed a one-day curriculum called Pack Your Bags: Essentials for the Road to Cultural Competency. The program uses staff from the following programs to conduct the trainings: cardiovascular health, diabetes, cancer services, and injury prevention.

Result or Outcome:
Over 600 individuals have been trained in the last 2 years. The demand for the training is so great that a train-the-trainer program is now being developed.

Conclusion or Significance:
Before changes in health disparities are achieved, public health practitioners need to understand how culture influences not only the populations they serve, but themselves as well.

What We See Depends on Where We Stand: Federal and Local Perspectives on Health Disparities

Authors: M. Kane; V.K. Hogan; B. Burt

Objective:
As Phase I in the "Roadmap to Eliminate Health Disparities, the objectives of the conceptual framework developed through this initiative were to provide a common conceptual framework, co-contributed by federal and local communities of interest, to inform and guide the successful implementation of the road map and to enforce community action as a critical tool for change.

Setting: 
1) Centers for Disease Control and 2) the Jackson, Mississippi, community

Method or Intervention:
As the groundlaying activity in the Kellogg Foundation-supported Roadmap to Eliminate Health Disparities, two investigations were conducted. Using a mixed-methods stakeholder-based inquiry and examination model called concept mapping, researchers invited national level personnel from the Centers for Disease Control and Prevention and partners to respond to the prompt: A specific thing that causes African Americans to get sick more often and die sooner is. Community members representing many communities of interest in Jackson, Mississippi, were asked the same question, through community action planning and engagement. Two conceptual frameworks were developed on the basis of input from each community of interest. Each group interpreted the results and derived a detailed framework from their own data. Researchers reviewed the similarities of content and value prioritization between the two groups using the graphical and report output from the process.

Result or Outcome:
Both maps, and the resulting interpretations and presentations, surfaced the serious social construct barriers to eliminating disparities and provided guidance on health practice issues related to the community context. The results of the double initiative were integrated to inform the public health agenda on planning for effective programs to challenge disparities, and as the foundation of a key conference held in Jackson to inform the road map and inaugurate the community steering committee.

Conclusion or Significance:
The two maps also served as the agenda for an intensive review of existing knowledge and research on the topics identified as highest priority. Findings reinforced the belief that chronic illness and early death are strongly linked to institutional, social, and economic factors that must be recognized and addressed, along with better quality of and access to prevention and treatment.

Communications and Technology

A Pilot Study of the Use of Theater in Nutrition Education for Low-Income African American Children

Authors: C.J. Jackson; R.M. Mullis

Objective:
To pilot test a culturally appropriate theater production, Lil Red Ridin Thru Da Hood, in order to determine if theater is an effective way of conveying messages about healthy eating and physical activity to low-income African American children in school-based settings.

Setting: 
Four low-income predominantly African American urban public schools in the Southeastern region of the United States.

Method or Intervention:
A culturally appropriate theater production, Lil Red Ridin Thru Da Hood, was developed specifically to address the barriers that low-income African American children may encounter while trying to adopt a healthy lifestyle. Study findings were evaluated using pretest/posttest measures from an adaptation of a previously validated instrument. Pretests/posttests measured student knowledge, choices, intentions, and behaviors related to eating healthy foods and increasing physical activity. The study sample included 3rd- and 4th-grade students attending four elementary schools in a large, urban public school system (N = 298). Ninety-five percent of the participants were African American. All students were administered a pretest, engaged in an activity, and were given a posttest approximately 3 weeks after the pretest. Students at two schools (intervention group) attended a performance of Lil Red Ridin Thru Da Hood and completed school-to-home activities to reinforce the messages conveyed in the play. Students at the remaining two schools (control group) participated in a readers theater activity that included no nutrition or physical activity information, and did not complete any follow-up activities.

Result or Outcome:
One hundred percent of students reported that they enjoyed the play. One hundred percent of teachers gave the show a rating of Excellent and reported that the play effectively conveyed health and nutrition messages for this population. Much of the data related to student knowledge, choices, intentions, and behaviors did not indicate statistically significant results. There were, however, significant differences in students physical activity choices (P<.029) and physical activity recall (P<.003).

Conclusion or Significance:
Both student and teacher acceptance of the use of a culturally appropriate theater production in nutrition education suggest that this innovative educational approach is a viable medium for introducing nutrition and physical activity messages to low-income African American children in school-based settings. Further research, however, is needed to create interventions that will keep students engaged in nutrition and physical activity education, and potentially will yield behavioral changes.

Analysis of Disparities in Client Satisfaction Between Spanish- and English-Speaking Women Enrolled in the Utah Cancer Control Program 

Authors: K. Rowley; M. Arce-Larreta; S. Wagstaff; A. Bowler

Objective:
The Utah Cancer Control Program (UCCP), a program of the Centers for Disease Control and Prevention (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) offers free breast and cervical cancer screening to medically underserved women.

Setting: 
To identify disparities between English- and Spanish-speaking clients and to develop a more effective strategic plan for cancer prevention programs and policies to reduce disparities among the Spanish- and English-speaking clients as a means to reduce breast and cervical cancer mortality in the Utah population as a whole.

Method or Intervention:
Random sampling for two of Utahs largest districts and complete sampling of the remaining nine rural districts was done in August 2004 to assess clients satisfaction with screening and follow-up services. The survey was sent to every client in both English and Spanish so each client had the option to respond in their native language. Incentives were offered for responding. Of the 3,000 deliverable surveys sent out, 1,086 were completed, for a return rate of 36.2%.

Result or Outcome:
Of the 1,086 surveys returned, 211 (19.4%) completed the Spanish-language version, and 867 (80.6%) completed the English-language version. Thirty-four percent of Spanish-speaking clients (SSC) received a breast referral to see a surgeon because an abnormality was found on clinical breast examination, compared with 7.5% of English-speaking clients (ESC). A majority of the respondents (92.1% of SSC and 94.1% of ESC) were highly satisfied or satisfied with the services provided by the surgeon. More SSC (21.3%) than ESC (6.0%) received a pelvic referral due to an abnormal Pap smear or pelvic examination to see a gynecologist. More SSC (95.6%) than ESC (89.0%) were satisfied or highly satisfied with services provided by the gynecologist. The overall quality of medical care was rated excellent to very good by 98% of SSC and 99% of ESC.

Conclusion or Significance:
It appears that SSC had more abnormalities found and were referred more often to see a provider. More abnormalities for breast and cervical cancer were found among the SSC than the ESC. A high proportion of SSC and ESC reported satisfaction with services provided by the surgeon and gynecologist. Both rated the overall medical care received through our program extremely high.

Application of Chronic Disease Self-Management Materials and Methods in a Rural Primary Care Setting

Authors: R. Crespo; S. Plogger

Objective:
The objectives of this presentation are to describe the development and application of self-management materials and methods that are congruent with the transtheoretical model of behavior change into a rural primary care setting and to present findings on the efficacy of the model in promoting self-management among patients with chronic diseases.

Setting: 
Rural primary care centers and churches associated with the Partnership of African American Churches.

Method or Intervention:
The research team created a communications plan that is congruent with each stage of change in the transtheoretical model and tailored the information to rural, underserved Appalachian culture. On the basis of data from the clinics surveillance system and focus group surveys, the team adopted three key communications messages: balance your plate, choose to move, and kick the habit. Thus for example, posters on balance your plate address the pre-contemplation stage and a readiness to change questionnaire is used to communicate with people who are at the contemplation stage. For the action and maintenance stages, the team has implemented Stanford Universitys Chronic Disease Self-Management Program to help patients acquire and practice self-management skills. The highly participatory course is held once a week for 2 hours for 6 weeks. During the course, mutual support and success builds the participants confidence in managing their health and maintaining active and fulfilling lives. The course and materials are offered to health center patients, other community members, and congregation members associated with the Partnership of African American Churches. Many of the rural health centers patients and church members are low-income people who have not previously received support for behavior change.

Result or Outcome:
Data will be presented on the proportion of patients who commit to a self-management behavior and the number and percentage who continue after 6 months. The patient population will be from the health centers and the African American churches in the community. Additionally, focus groups findings will be presented on the integration of patient self-management into the clinics system of care. On the basis of these findings, the presenter will make recommendations for integrating self-management into rural, underserved health centers and churches in the community.

Conclusion or Significance:
Chronic disease self-management is crucial for behavior change to occur. The self-management materials and methods presented will provide a system for integrating self-management into a rural health center and African American churches.

Changes of Fortune: Working with the Telenovela Industry to Communicate Health Messages About Diabetes

Authors: J. Kelly; B. Rodriguez

Objective:
The age-adjusted prevalence of type 2 diabetes among Hispanic/Latino Americans is 1.9 times the prevalence among non-Hispanic whites. Higher rates of diabetes complications (nephropathy, retinopathy, and peripheral vascular disease) have been documented in studies of Mexican Americans compared with non-Hispanic whites. Formative research identifies many barriers to healthful behaviors that could contribute to diabetes prevention and control among Hispanic/Latino Americans. We hypothesized that an effective venue for communication with this health disparities group could be telenovelas: Spanish-language serial dramas that typically focus on emotional human interactions, similar in many ways to soap operas. Telenovelas are among the most widely watched programs among the Hispanic/Latino viewers.

Setting: 
Telenovela Summit in Barcelona, Spain.

Method or Intervention:
We reviewed qualitative data on Hispanic/Latino Americans knowledge, attitudes, and behaviors regarding diabetes prevention and control. We summarized this information in a series of behavioral tables and presented them to telenovela industry consultants in spring 2004. With their guidance, we developed a package of materials describing the emotional and behavioral impact of diabetes and the medical facts of potential complications. These materials were presented in October 2004 at the second annual Telenovela Summit in Barcelona, Spain.

Result or Outcome:
The high prevalence of diabetes suggests that a realistic depiction of characters with diabetes offers verisimilitude and multiple dramatic opportunities for the changes of fortune typical of telenovelas. Suggested character development included emotional turmoil around hopes, fears, and vulnerabilities highlighted by living with diabetes; interactions with the health care system; reactions to the insidious nature of chronic disease; struggles with unfamiliar symptoms; attitudes, beliefs, and behaviors that adversely affect outcomes; possible disrupted relationships (family, workplace expectations); crises demanding decisions at an emotional crossroads; and transformation of challenges into successes. We offered sample case stories in which behaviors around food, physical activity, diabetes self-care, and interactions with the medical system could be modeled through characters in a telenovela.

Conclusion or Significance:
The presenter will discuss this behavior modeling as a new approach for communicating health messages. The focus on patient empowerment, stages of change, and resolution of emotional conflicts expressed as denial, anger, and depression is predicated on the idea that the target audience will remember a characters actions and emotions in a story and seek to emulate or avoid those behaviors in himself. The speaker will present feedback to this approach received from participants at the Telenovela Summit. Possible methodology for process and impact evaluation if these themes are incorporated into telenovelas will be discussed.

Characteristics of Internet Use and Health Locus of Control of Seniors with Arthritis

Authors: P. York; S. Koelling; K. Park; J. Geppert

Objective:
To improve Internet health communications through identifying characteristics of Internet use among seniors (aged 65+ years) with arthritis, compared with younger adults (aged <65 years).

Setting: 
Participants in the Arthritis Foundation (AF) North Central Chapter programs.

Method or Intervention:
A survey was mailed to 1,767 participants in AF programs regarding Internet use, desired sources and types of arthritis information, type of arthritis, and multidimensional health locus of control. A total of 760 surveys (43%) were returned.

Result or Outcome:
Seniors were five times less likely to use the Internet than younger adults (15% compared with 48%). Information accessed by seniors did not differ significantly from that accessed by younger adults for the topic areas of general arthritis (81% vs. 84%), medications (57% vs. 67%), coping methods (35% vs. 48%), and medical equipment (11% vs. 17%). Younger adults were twice as likely to request information on alternative treatments; 25% of seniors and 37% of younger adults requested this information. The proportion of adults accessing information about their specific arthritis condition differed by diagnosis and age. Of those with osteoarthritis, 86% of seniors and 41% of younger adults (P<0.01) sought condition-specific information. Of those with rheumatoid arthritis, no differences between age groups were found: 32% of seniors and 38% of younger adults sought information. Younger adults with fibromyalgia (45%) were significantly (P<0.01) more likely to access condition-specific information than older adults (18%). Although younger adults were more likely (P<0.01) to access online chat rooms and support groups than seniors (0% seniors vs. 10% younger adults), 31% of seniors and 26% of younger adult Internet users said they would like to use chat rooms in the future. E-mail support groups and online education programs were utilized by less than 10% of both age groups. However, 20% of older adults and 32% of younger adults said they would like to use e-mail support groups, and 63% of seniors and 73% of younger adults would like to use online education programs in the future. Multidimensional health locus of control did not differ by Internet use for either age group, although seniors had higher internal, chance, and doctor MHLQ scores than younger adults (P<0.01).

Conclusion or Significance:
Although seniors are less likely to use the Internet than younger adults, seniors are a growing population of Internet users. Web page designs need to be inclusive of the needs for all age groups.

Communication and Partnership Strategies for Reaching Rural Hispanic Populations

Authors: S.K. Stoffels; L.G. Powell

Objective:
The objectives of La Buena Salud (Idaho Hispanic Wellness Initiative) are fourfold: 1) to educate students and practitioners in an interdisciplinary approach to culturally appropriate wellness care; 2) to deliver wellness services to rural Hispanic families in nontraditional home and community-based settings. 3) to increase the number of Hispanic students entering the health professions; and 4) to increase retention of culturally sensitive rural health care practitioners.

Setting: 
La Buena Salud, the Idaho Hispanic Wellness Initiative, provides mobile wellness and screening services in three rural Hispanic farmworker communities in southwest Idaho: Chula Vista Housing Authority in Wilder, Marsing Housing Authority in Marsing, and Farmway Village in Caldwell, Idaho.

Method or Intervention:
Interdisciplinary teams of health care students and faculty provide a variety of wellness services using a mobile screening unit leased from the local Lions Club. Teams provide services weekly in each of the communities throughout the course of the semester. Services include health screenings, measurement of blood pressure, height/weight, body mass index, cholesterol and glucose levels, and vision and hearing assessments. Referrals are provided to local providers as needed.  Follow-up visits are made as needed.  Culturally and linguistically appropriate health education is provided on an ongoing basis. Health promotion activities for adults and children are provided weekly. In addition to direct and referred services, La Buena Salud students contact local schools and make presentations to middle and high school students to encourage them to consider a career in health care.

Result or Outcome:
Screening data reveals disparities in the areas of obesity, high cholesterol, high blood pressure, vision and hearing limitations, lack of health insurance, literacy issues, and transportation issues. Satisfaction data documents appreciation for types of services and availability of services.

Conclusion or Significance:
Presentation will include discussion of the various strategies employed to reach the Hispanic farmworker population, including completing community assessments prior to project implementation, using many local community partners for project implementation support and guidance, providing free services in the farmworker communities to improve access, utilizing Hispanic bilingual nurse team leaders, incorporating students from the Department of Modern Languages to serve as medical interpreters, emphasizing culturally sensitive care, and involving health care students who are motivated to work with diverse cultures. Discussion will also include sustainability issues in serving minority populations such as future plans to support the development of Hispanic community coalitions and introducing promotoras/cultural brokers to sustain project efforts in wellness and prevention.

Conducting a Successful Through With Chew Week

Author: S. Bagdonas

Objective:
To convey strategies for developing partnerships, media campaigns, and awareness of chew tobacco interventions by conducting a Through With Chew week.

Setting: 
This statewide program targeted Wyomings small and rural population, which has a disproportionately high rate of chew tobacco usethe second highest in the country (Behavioral Risk Factor Surveillance System [BRFSS], Adult Tobacco Survey [ATS], 2003).

Method or Intervention:
Few states have tobacco programs specifically focused on chew/spit tobacco use. Originally conceived by the American Academy of Otolaryngology, Through With Chew (TWC) Week (including a Great American Spit Out Day) provides an excellent opportunity to address this problem, shifting the focus of tobacco use and intervention to a broader picture. Although TWC week lasts only 7 days, it can serve as a launch pad for year-round activities. Sadly, the lack of state or national groups conducting a TWC Week mirrors the general lack of programming and attention focusing on chew tobaccoat the local, state, and national levels. Funding sources and baseline data are also scarce. Wyoming successfully conducted a TWC week in February 2003, educating the public about the extent of chew use in Wyoming and its costly health implications for all citizens, conducting surveys to establish baseline data on current levels of prevention and intervention, partnering with health care providers to promote quitting, counteradvertising the tobacco industry, and determining adaptations necessary for American Indian populations. Wyoming developed a comprehensive statewide plan including tool kits, media kits, and quit spit kits for use by local program managers. Extensive media coverage included newspaper and pizza box ads, television coverage, and presentations by Gruen Von Behren, a 25-year-old man severely marred by oral cancer. Additional guerrilla advertising can be conducted in barbershops, rodeo and fairgrounds, little league fields, bowling alleys, and agriculture shops and publications.

Result or Outcome:
Follow-up surveys to Tobacco Free Wyoming Communities and the dental community indicated increased interventions by 58% of dental offices, a threefold increase in Quitline and QuitNet response volumes by chew tobacco users, testimonials, and audience evaluations at the Gruen presentations.

Conclusion or Significance:
Wyomings campaign, including lessons learned and tangible tools for success, can be easily replicated in other states and communities.

Designing Effective Health Messages for Ethnically Diverse Audiences: Overcoming an Environment of Distrust

Authors: A.L. Friedman; H. Shepeard; D. Anderson

Objective:
This research was conducted with the ultimate goal of developing effective health messages for the prevention of sexually transmitted diseases (STDs) and their complications in high-risk, minority populations.

Setting: 
Certain STDs can lead to chronic and life-threatening conditions, if left untreated. Complications from syphilis (e.g., heart disease, dementia, congenital syphilis in offspring) and human papillomavirus (HPV) infection (e.g., cervical cancer) disproportionately affect minority populations in the United States.

Method or Intervention:
In 2001, the Centers for Disease Control and Prevention (CDC) conducted key informant interviews in nine U.S. counties with high syphilis morbidity. Interviewees were identified change agents, including opinion leaders, community-based organization representatives, and health care providers (N = 238). Between 2001 and 2003, CDC conducted a total of 43 exploratory focus groups with general and at-risk audiences (N = 381) across 10 U.S. sites, which were selected based on high rates of cervical cancer mortality and syphilis prevalence. Participants were segmented by gender (male/female) and race (white, African American, Hispanic), among other variables. This qualitative research assessed participants STD-related knowledge, attitudes, and beliefs, with a focus on syphilis and HPV, as well as their communication preferences and perceived barriers to effective communication. Interpretive analyses were conducted on qualitative data.

Result or Outcome:
Similar to members of the general population, participants in the African American and Hispanic focus groups knew very little about syphilis or HPV. Upon learning about HPV, participants became suspicious of the public health and government agencies silence on it, given the apparent prevalence, invisible nature, and potential consequences of this STD. In discussing both syphilis and HPV, African American groups, in particular, voiced distrust of the health system and government agencies, referencing the Tuskegee Trial and suspected government conspiracies regarding HIV. This distrust was echoed by change agents in African American communities, who noted that it would serve as a barrier to effective communication around syphilis.

Conclusion or Significance:
Distrust of public health authorities can have serious implications for the acceptance of prevention, screening, and treatment messages for these STDs and their complications. In light of past mistakes in federal public health research and beliefs in government conspiracies, public health authorities must be exceptionally cautious when communicating to ethnically diverse audiences about often asymptomatic or unrecognized STDs with potentially deadly consequences. Recommendations are made for developing messages that effectively reach diverse audiences, without causing undue panic, defensive reactions, or instilling further distrust of health authorities in minority populations.

Developing a Web-Based Health Care Decision Support Tool for Adults with Arthritis

Authors: M.B. Waterman; S. Prows; K. Meyers

Objective:
The purpose of this presentation is to 1) discuss the collaboration between the Arthritis Foundation and FACCT to develop and implement a tool that enables consumers to hold the system accountable for quality and to act as partners in improving their own health, and 2) demonstrate the tools utility.

Setting: 
People with osteoarthritis. 

Method or Intervention: There is a growing desire among consumers to have information about clinical guidelines and quality indicators. To meet this need, the Arthritis Foundation collaborated with FACCT (Foundation for Accountability) to translate the arthritis performance indicators into a user-friendly format that enables consumers to hold the system accountable for quality and to act as partners in improving their own health. Together, the Arthritis Foundation and FACCT developed an online interactive quality assessment and coaching tool for people with osteoarthritis. BRFSS data from 2002 showed that 49 million people had doctor-diagnosed arthritis. Although increasingly effective treatment is available for arthritis, the delivery of care is often suboptimal. As the number one cause of disability, quality care and proper management of arthritis is critical to improving lives. Evidence-based performance indicators related to arthritis were recently developed. These measures established standards for care and create a powerful tool for focusing on key components of arthritis care. The tool helps people understand what quality health care is and how to get it. 

Result or Outcome:
The arthritis-specific COMPAREYOURCARETM (CYC), developed by leading scientific experts, presents users with a series of short topical quizzes and gives them personalized feedback. Specifically, it offers consumers 1) the ability to rate the quality of care provided by their provider; 2) a comparison of regional and national benchmarks of their quality of care; 3) coaching information on communicating and partnering with providers; and 4) self-care and disease management information and tips. Additionally, users receive specific information on areas where their care is unusually good or poor, and tips on how to get better care in each area.

Conclusion or Significance:
The tool encourages users to take charge of their health care and work with their doctor to get the best care possible.

Exploring Racial and Ethnic Differences to Reduce Childrens Television Viewing to Prevent Childhood Overweight/Obesity

Authors: A. Filomeno; L. Rojas-Smith; A. Jordan; J.C. Hersey; J. McDivitt; A. Branner; C. Heitzler

Objective:
To report qualitative research findings that explore differences among white, black, and Hispanic families incentives and barriers to reducing childrens television viewing to prevent childhood overweight.

Setting: 
Three U.S. cities: Chicago, Richmond, and Philadelphia.

Method or Intervention:
In fall 2003 and winter 2004, 180 parent/child pairs participated in focused interviews. Equal numbers of groups were conducted with white, African American, and Hispanic families. Children (aged 6 to 13 years) were interviewed separately from adults.

Result or Outcome:
Results of this research will describe individual, familial, and community factors that shape childrens television viewing. The presentation will describe ethnic and racial differences in childrens access to, use of, and feelings about television and other media; parents beliefs about the effects of media use on children; key points of confusion and concern expressed by children and parents with regard to reducing TV time; practices parents use to limit television time; and barriers and motivations to change current behavior in both children and parents.

Conclusion or Significance:
Nearly 9 million American children today are overweight, a figure that has tripled since 1980. Recent studies suggest that childrens heavy television viewing may be contributing to the rise in childhood overweight. The results will identify promising strategies specifically for white, African American, and Hispanic families to reduce TV time that might ultimately impact childhood overweight/obesity.

Healthy Food, Healthy Soul: Campaign: Promoting Healthy Eating and Physical Activity to African American Men

Author: Q.J. Moore

Objective:
To promote physical activity and healthy eating to low-income African American men through a tailored social marketing campaign.

Setting: 
Churches and faith-based organizations in Detroit and Southeast Michigan.

Method or Intervention:
Qualitative research methods were used to determine the appropriate design of a social marketing campaign. CDC (CDCynergy) and HHS (Making Healthy Communication Programs Work) materials were used for planning purposes. Health resource material and program strategies were tested with the target audience and tailored. The project utilized both mass communication and interpersonal strategies. A local organization (Institute for Black Family Development) with strong relationships and ties to church and faith-based networks was used to recruit organizations, support project activities, organize and provide training on health issues and provide ongoing technical support to the churches engaged and involved in the campaign. Popular mass media sources were also selected to promote the availability of materials, programs, and services to the target audience.

Result or Outcome:
Focus groups indicated a campaign promoting support and encouragement to families with men serving as head of households. As a result, the test message Healthy Food, Healthy Soul: Men, Theyre Counting On You! was selected as the campaign title. Thirteen churches and faith-based organizations were involved in the project and provided trainings on healthy eating, physical activity, and cooking to over 500 men in the target group. Materials were provided at 23 other churches within the city as well as through select partnerships at local health systems and national health advocacy groups working with faith-based communities. During the 6-month campaign, over 4,000 African American men in Detroit and Southeast Michigan received educational materials. Materials tested and provided to the target audience included a brochure on eating 5 to 9 fruits and vegetables each day, a consumer magazine on healthy eating and physical activity and a Healthy Food, Healthy Soul cookbook. Support of the church and faith-based audiences was supported through strong partnerships and organizational buy-in by leadership (i.e., pastors, ministers).

Conclusion or Significance:
Creative partnerships can be beneficial in promoting a tailored social marketing campaign to a select, hard-to-reach population.

Huesos Fuertes, Familia Saludable (Strong Bones, Healthy Family): Improving Bone Health Among Latino Mothers

Author: N. Martinez

Objective:
To share a social marketing project aimed at increasing behaviors that promote bone health among Spanish-speaking Latino women and their families as a way to improve health and reduce the risk of osteoporosis.

Setting: 
California Project LEAN (CPL) implemented and evaluated the Huesos Fuertes, Familia Saludable (Strong Bones, Healthy Family) intervention in four Latino dominant communities in California.

Method or Intervention:
Huesos Fuertes, Familia Saludable promotes the consumption of an additional 8-ounce serving of 1% milk each day among Latino women. The belief is that the Latino mothers are the gatekeepers for their familys health, thus serving as a role model and educator to shape positive nutritional habits of all family members. A social marketing approach was used to develop, implement, and evaluate this project. This approach included extensive formative research, the development of a social marketing plan, development and testing of educational materials, and a pilot project intervention. The intervention elements include an educational component that utilizes trained community health workers (promotores de salud) to lead educational sessions on osteoporosis, consumption of calcium-rich foods, and the importance of physical activity. The intervention also utilizes paid Spanish language media, including radio commercials, taste-tests of low-fat milk at grocery stores, and community outreach through participation in various local community events.

Result or Outcome:
The evaluation included pre- and post-surveys of the target audience, and matched pre- and post-surveys of promotora class participants. Promotora participants completed a survey before and after a 4-week series of classes. There was no significant difference in amount of milk consumed after the campaign among participants exposed to the marketing-only intervention. However, a significant difference was seen in the type of milk consumed at posttest. Significant differences were noted in the amount of milk that class participants reported consuming after participating in the promotora class and being exposed to the marketing campaign (1.55 cups pretest vs. 2.37 cups posttest). The distribution of the type of milk consumed by individuals who responded yes to questions which asked about amount of milk consumed also differed significantly. The consumption of 1% milk increased by 57.0% and the consumption of whole milk dropped by 35.3% at posttest.

Conclusion or Significance:
It appears that the Huesos Fuertes, Familia Saludable combined marketing and promotora intervention has a significant impact on increasing the amount and type of milk consumed by Latino women.

Improved Targeting of Smokers with Cessation Messages: Insights from the HealthStyles and ConsumerStyles Surveys

Authors: D.E. Nelson; M. Gallogly; M. Barry; D. McGoldrick

Objective:
Smoking cessation is a major component of tobacco control efforts in public health. Evidence strongly suggests that many cessation aids are effective, such as nicotine replacement products, prescription medications, and counseling. Appropriately targeting and reaching smokers through different communication channels with cessation messages, especially for those most interested in quitting, is a challenge.

Setting: 
Nationally representative survey of adults aged >18 years.

Method or Intervention:
Data were analyzed using 20022003 HealthStyles and ConsumerStyles proprietary consumer databases (n = 15,310). Smoking prevalence was examined by different measures of radio and television use (time of day, genres, TV stations, specific programs); newspaper, magazine and Internet use; and leisure activities, spectator sports, and specific stored shopped in the past 3 months. Additional analyses restricted to current smokers only (N = 2,857) were conducted for these same measures by level of confidence in quitting and plans to quit in the next 6 months.

Result or Outcome:
In general, cigarette smokers were more likely than nonsmokers to be heavier users of television and radio but were less likely to read newspapers or use the Internet. Smoking prevalence exceeded 30% among listeners to alternative/progressive rock or hard rock radio genres; viewers of Cinemax, TNN, Comedy Central, The Movie Channel, and SCI FI channel; and viewers of The Simpsons, King of the Hill, or That 70s Show. Smoking prevalence exceeded 30% among readers of the National Enquirer, Hot Rod, Outdoor Life, and Vogue magazines; and fans of car racing, wrestling, and boxing. More than 40% of all smokers shopped at Wal-Mart, K-Mart, Dollar General, Family Dollar, and Home Depot stores in the past 3 months. A statistically significant association was found in the higher percentage of adult smokers who were both highly confident in being able to quit and who planned to quit in the next 6 months for persons who listened to all-news, religious/gospel, or rhythm and blues radio genres; who watched the BET channel; who read Cosmopolitan, Parents, or People magazine; who sought travel information on the Internet; or who were major league baseball fans.

Conclusion or Significance:
We found differences between smokers and nonsmokers, as well as among smokers themselves, by confidence and plans to quit, by exposure to different communication channels. This information can provide insights into how best to plan and reach smokers with cessation messages, and suggests the possibility of new partners to consider for collaboration. Further analyses are under way to examine communication channel exposure and use among smokers by age group, race/ethnicity, and gender.

Knowledge, Beliefs, and Stage of Adoption Toward Colorectal Cancer Screening Among Chinese Work Site Population

Author: Su-I Hou

Objective:
Asia has one of the lowest colorectal cancer (CRC) screening rates using fecal occult blood test (FOBT). This study assessed CRC screening knowledge, psychosocial beliefs towards cancer screening in general, and stage of FOBT adoption among a Chinese work site population.

Setting: 
Participants (aged 40 and older) were recruited from 10 work sites in Taiwan (2002).

Method or Intervention:
A single-group pretest and posttest design was used. Baseline survey on the theory-based cancer screening beliefs (including perceived pros, cons, and susceptibility measured by Cancer Screening Belief Inventory [CSBI]), knowledge, and stage of adoption toward FOBT were assessed and analyzed (n = 375).

Result or Outcome:
The mean age of the participants was 48.18 (standard deviation [SD] = 8.79), and 58.8% were males. Stage of adoption among participants showed that 45.2% of them had never heard about FOBT (unaware). Of those who had heard about it, 12.9% never had the test and reported no intention to have one (pre-contemplators), 13.8% were contemplators (never, but has intention), 17.6% were in relapse stage (ever, but overdue for repeat testing), and 10.5% were in relapse risk /maintenance stages (on schedule). Participants in late stages of behavior adoption tended to be older and more educated (p

Conclusion or Significance:
Data showed that a large proportion of the Chinese participants were either unaware of FOBT or still in pre-contemplation stage. Results suggests that in addition to age and education, higher scores of knowledge on colorectal cancer and its screening, and lower perceived cons or barriers towards cancer screening in general are significant in predicting FOBT adoption among the participating Chinese work site participants. The study has implications for communication messages and strategies that target screening-related knowledge and beliefs to promote cancer screening at Chinese work sites.

Moving People to Move: Midpoint Results of the Walk the Ozarks to Wellness Project

Authors: N. Caito; M. Elliott; S. Lovegreen; P. Klump; M.W. Kreuter; R. Brownson

Objective:
To use tailored newsletters to increase walking among low-income, overweight, rural Missourians who are overweight and have diabetes or are at risk.

Setting: 
Six rural underserved communities in Missouris Ozark region.

Method or Intervention:
We are in the process of conducting a 5-year longitudinal study of walking in the Ozark region of Missouri. Participants enrolled in the project at community health events sponsored by health organizations and community steering committees. Participants received newsletters for 2 years. For the first year, participants received newsletters every month. In the second year, participants received newsletter every other month. Newsletter messages were written based on the surveys participants filled out at baseline and at month 9. Topics addressed in the first nine newsletters included motivation, health history and discussions with doctors, self-efficacy, and barriers. Additional newsletters included topics about social support and physical activity level.

Result or Outcome:
To date, 1,065 participants have enrolled in the program in nine separate groups. We have received midpoint (T2) surveys from 153 participants in the first group. Paired t-test analyses show significant improvement at T2 in those who reported no walking and no moderate activities at baseline, in both days per week and minutes per week (P < 0.001). Of those who marked having no place to exercise as a barrier at baseline, 81% no longer had this barrier at T2. McNemar tests show significant improvement at T2 in those who had not talked to their doctors about healthy eating, exercise, and losing weight at baseline (P <0.001, P = 0.029, P <0.001, respectively). Stages of change analyses show advancement in those who were in the pre-contemplation and contemplation stages; overall, 69% in precontemplation and 67% in contemplation moved forward.

Conclusion or Significance:
These results show the preliminary impact of a tailored intervention in a high-priority population. Tailored interventions such as this are most effective in 1) moving participants forward in the initial stages of change; 2) increasing awareness about the importance of talking with ones doctor about leading a healthy lifestyle; and 3) decreasing perceived barriers.

Promoting Healthy Behavior Among Older Adults: A Consumer Research Approach

Author: N.S. Bryant

Objective:
The danger of pneumococcal infection to the older population is well-documented, with half of all pneumococcal-related deaths occurring among people aged 65 and older. Despite the serious risks and consequences and various immunization efforts for older adults, many do not take advantage of pneumococcal immunizations. This study created a health information brochure to encourage older consumers to talk with their medical providers about obtaining a pneumococcal vaccine

Setting: 
Variety of residential and community settings including a continuing care/retirement community, low-income congregate housing facilities, and senior centers in the D.C. metro area and Missouri. A national survey of aging services professionals.

Method or Intervention:
The research was divided into three phases: 1) message testing, 2) brochure testing, and 3) dissemination and format. The message testing consisted of six focus groups to determine which statements would best motivate older adults to receive a pneumococcal vaccination and convey the idea that the vaccines are safe, effective, and important. The focus groups were conducted with seniors aged 65 years and older who had not received a pneumococcal vaccine within the last 5 years. The brochure-testing research included 12 triads with older consumers to test two draft brochures. The mail survey evaluated the most effective methods for consumer education materials.

Result or Outcome:
Focus groups findings showed that consumers were confused about pneumococcal disease and the vaccination. The most compelling themes were those reflecting the serious nature of the illness, and participants favored images showing a diverse group of healthy elders. Consumers preferred a brochure offering general wellness information and using a softer tone about the seriousness of pneumococcal infection and its consequences. Participants preferred messages that are simple, concise, use large fonts, and have contrasting colors. They stressed that materials should come from trusted sources, such as physicians, and state and national government agencies.

Conclusion or Significance:
This study created a brochure that has been consumer-tested and is sensitive to the reading and comprehension limitations of many seniors (the brochure is written at a 7th-grade level). The study discusses recommendations for consumer health education materials: 1) materials should include knowledge and action-step messages; 2) we must employ multiple methods when delivering health promotion and disease prevention messages to older adults; and 3) physicians represent a critical point of access for the current older cohort to preventive health measures such as immunizations and other screenings.

Race and Income Differences in Community Attitudes About Diabetes and Organ Donation

Authors: A.D. Waterman; R. Whitlock; A.C. Barrett

Objective:
Compared with whites, African Americans and Hispanics are 1.5 times more likely to have diabetes and 3 times more likely to have kidney disease. This study examined how attitudes about diabetes and organ donation varied by race and income to determine whether improved health education for minorities is needed.

Setting: 
A total of 1,416 African Americans (30%), Hispanics (10%), and whites (60%) residing in Missouri.

Method or Intervention:
Using random-digit-dialing and oversampling areas with African American and Hispanic households, we conducted a telephone survey measuring respondents demographics and agreement with attitudinal statements about diabetes and organ donation. We estimated two logistic regression models with adjustment for disproportionate sampling using data weights comparing 1) African Americans with whites and 2) Hispanics with whites to understand differences due to race, income (<$25,000 or ?$25,000 yearly income), and their interaction.

Result or Outcome:
Respondents were primarily female (59%), with an average age of 45 years (standard deviation [SD] = 17.9) and modal annual household income between $25,000 and $50,000 (38%). Diabetes Attitudes. Compared with other respondents, Hispanics with incomes ?$25,000 were less likely to agree that diabetics should not smoke (odds ratio [OR] = 0.14, confidence interval [CI] = 0.04, 0.42). Compared to people with ?$25,000 yearly income, respondents with incomes <$25,000 were less likely to agree that: diet and blood sugar control (OR=0.14, CI=0.05, 0.42), weight control (OR=0.21, CI=0.10, 0.44), regular exercise (OR=0.32, CI=0.13, 0.81), and not smoking (OR=0.59, CI=0.36, 0.98) were important in caring for diabetes.
Organ Donation. Compared with others, African Americans (OR=0.36, CI=0.26, 0.51), respondents with incomes Health Education Needed. Compared with whites, African Americans (OR = 2.21, CI = 1.18, 4.14) and Hispanics with incomes ?$25,000 (6.61, CI = 1.52, 28.79) were more likely to agree that education about diabetes is needed in their community. Hispanics with incomes ?$25,000 (OR = 0.17, CI = 0.07, 0.41) were less likely to agree that there is enough diabetes information in schools compared with other respondents.

Conclusion or Significance:
Insufficient health education for racial minorities and respondents with lower incomes about diabetes and kidney disease may explain their confusion about key diabetic health care concepts and low interest in organ donation. To reduce health disparities, tailored health education correcting diabetes misinformation and emphasizing the importance of organ donation needs to be made accessible to these communities.

Reaching Spanish-Speaking Hispanic Women to Prevent Birth Defects by Promoting Folic Acid Consumption

Authors: C.E. Prue; A. Flores; H. Carter; A. Nair

Objective:
To increase folic acid awareness, knowledge, and consumption among Spanish-speaking Hispanic women between the ages of 18 and 35 years for the prevention of neural tube birth defects.

Setting: 
Eight U.S. cities with high proportions of Spanish-speaking Hispanic women were selected for this evaluation: Two markets received the intervention and six markets served as comparison markets (they were monitored for folic acid promotion activities, but did not receive the intervention).

Method or Intervention:
Intensive communication campaigns composed of paid media and interpersonal outreach efforts by local promotoras were conducted in two intervention markets during 2001/2002 and 2002/2003. Television and radio airtime was purchased to broadcast a Spanish-language public service announcement produced by the Centers for Disease Control and Prevention (CDC), and local community outreach was conducted. The paid media campaign ran from September 2001 through December 2001, and from November 2002 through January 2003. At baseline and after each intervention period, telephone surveys were conducted in the two intervention markets and six comparison markets with Spanish-speaking Hispanic women between the ages of 18 and 35. Measures of campaign implementation, exposure, and effects were collected through an extensive process evaluation and by telephone surveys assessing important campaign indicators: folic acid awareness, knowledge, and consumption.

Result or Outcome:
Over the two campaign periods, preliminary results indicate an increase in folic acid awareness, knowledge, and consumption among Spanish-speaking Hispanic women in the intervention markets as compared with Spanish-speaking Hispanic women in comparison markets.

Conclusion or Significance:
This evaluation provides evidence that a combination of health communication tactics (paid media plus interpersonal outreach) can influence womens folic acid awareness, knowledge, and consumption. The need for folic acid educational interventions aimed at Spanish-speaking Hispanic women is critical since they are at an increased risk for neural tube defect-affected pregnancies and births. This birth defect not only impacts individuals and families on an emotional and financial level but also has strong implications for areas such as insurance, medical care, and special education costs.

Reducing Dental Sealant Disparities in School-Aged Children Through Better Targeting of Informational Campaigns

Authors: K. Jones; S. Griffi; R. Moonesinghe; F. Jaramillo 

Objective:
To investigate whether disparities in receipt of dental sealants among school-aged children are linked to caregivers knowledge of the preventive purpose of sealants; these lessons may be used to better target oral health informational campaigns.

Setting: 
Data: 2003 ConsumerStyles, HealthStyles, and Recontact marketing surveys (collectively, HS); National Health and Nutrition Examination Survey 19992000 (NHANES).

Method or Intervention:
Using NHANES data, we estimated sealant prevalence among 6- to 17-year-olds who had at least one tooth eligible for a sealant. Using HS data and logistic regression, we identified the explanatory factors (main effects model) associated with knowledge of sealants among caregivers of children <18 years old. We stratified both the HS data regarding sealant knowledge and the NHANES data regarding sealant prevalence by race/ethnicity and income (whether >= or <200% of federal poverty line), the significant explanatory factors (P <0.05) common to both data sets.

Result or Outcome:
Over the full study sample, sealant knowledge was 62.5% and sealant prevalence was 31%. Caregivers race/ethnicity, age, marital status, education, income, and gender were significant predictors of their sealant knowledge. Both sealant knowledge and prevalence were positively associated with income level. Among higher-income families, 71% of caregivers exhibited sealant knowledge compared with 47% of their low-income counterparts; 42% of higher-income children had sealants compared with 22% of their low-income counterparts. Among higher-income families, sealant prevalence among children was positively associated with caregiver knowledge (r = 0.973). Both knowledge and prevalence were highest among non-Hispanic whites in this group, 78% and 49%, respectively; these values were lowest among non-Hispanic blacks, 41% and 22%, respectively. Among low-income families, there was no association between caregiver knowledge and sealant prevalence.

Conclusion or Significance:
Current sealant prevalence is well below the Healthy People 2010 objective of 50%. We found disparities in both knowledge and prevalence of sealants by race/ethnicity and income. The positive association between sealant knowledge and prevalence for higher-income families is consistent with the economic principle that demand for sealants increases with knowledge of their benefit. The lack of an association between sealant prevalence and knowledge among low-income families may reflect higher levels of public provision of sealants to this group. This suggests that informational campaigns could increase demand for sealants in both income groups. Additionally, efficient targetingtargeting groups with the lowest demonstrated knowledgeshould also help eliminate disparities. This information is useful to the CDC-funded oral health coalitions in many states in their efforts to promote oral health and eliminate oral health disparities.

Start Living Healthy: Using Social Marketing to Address Health Disparities

Authors: C. Cabot; L.S.L. Takeuchi

Objective:
To share lessons about a mass media campaign targeted to a multiethnic population.

Setting: 
Hawaii is the most ethnically diverse state, having over 75% of the population coming from ethnic minority groups. Although residents of Hawaii enjoy the nations longest life span, large ethnic disparities exist among the population, especially in Native Hawaiian and Filipino populations. A mass media campaign entitled Start.Living.Healthy.(SLH) was created to promote increased physical activity, improved nutrition, and reduced tobacco use among Hawaiis multiethnic population. Advertising was created for Hawaiis multiethnic community and used surface and deep structure tailoring in television, print, and radio ads.

Method or Intervention:
The first stage of the SLH campaign ran from January 2002 to June 2003 and was promoted primarily through advertisements on television, radio, a Web site, in movie theaters, and in community events. Gross Rating Points (GRP) were collected for television and radio ads. Web site exposure was measured through Web site hits and unique visitors. Three cross-sectional surveys of Hawaiis adult population (n = 1,200 per survey) using random-digit-dialing procedures were conducted every 6 months to assess campaign awareness.

Result or Outcome:
Total GRP for the entire duration of the campaign was 10, 084 for television and 17,854 for radio. The SLH Web site received over 51,000 hits during the first stage of the campaign. Data was analyzed by ethnicity, income, and education level. Campaign recognition rates were high among all ethnic groups (white [63.2%], Filipino [65.4%], Hawaiian [67.0%], and Japanese [59.3%]), with no significant differences. Also, no significant differences were found between campaign recognition and levels of education and income. However, a nonsignificant trend indicated that people with higher education and income tended to be slightly more aware of the campaign. Media channels were also evaluated, though no significant differences were found between recognition by media channels and ethnicity, education, or income.

Conclusion or Significance:
Results of the first phase of the Start.Living.Healthy. campaign indicate high brand recognition and campaign awareness among all ethnic, income, and education groups. Although mass media appears to be an effective way to reach disparate populations, further research is needed to assess the effectiveness of media messages in changing knowledge, attitudes, and behaviors in these populations.

The National Business Group on Healths Racial and Ethnic Health Disparities Initiative

Author: R. Finch

Objective:
The Health Disparities Initiative provides information to large employers about the impact of documented health disparities on the ability to provide quality health care services; provides practical solutions to employers on how to plan and purchase appropriate health care for a workforce that is increasingly diverse; and represents the private purchaser perspective to researchers and policy makers working in this area and serves as a link between the business and public health communities.

Setting: 
Employers and their workplaces.

Method or Intervention:
The Business Group conducted three major research projects in the Initiative: 1) A National Employer Survey conducted by telephone of 1,505 benefits and human resources executives to assess awareness, existing health strategies and programs, sources of information, and potential barriers to action around disparities; 2) a Cardiovascular Disease (CVD) Pilot Project at three member companiesKellogg, Texas Instruments, and Coca-Colato survey employees to assess both CVD risk and health care experiences in relation to race/ethnicity; and 3) the Business Case for reducing racial and ethnic health disparities in the workplace.

Result or Outcome:
1) The Employer Survey found that almost half of executives interviewed had not heard of health disparities in the past year (45%). Furthermore, more than 60% believed that racial/ethnic minority groups with health insurance received the same diagnostic and treatment services as their white counterparts. Most (80%) agreed that differences in the quality of health care exist because of health insurance status, education, and lifestyle, and 47% stated that the issue was not a problem at their company. 2) In contrast to national statistics, the Pilot Project found that racial and ethnic minority employees at the three companies had better CVD risk profiles and more positive health care experiences than white employees. 3) The Business Case outlined the major research about racial/ethnic health disparities for an employer audience. It also profiled several member companies, programs, and other available best strategies to tackle this issue in the workplace.

Conclusion or Significance:
Several large employers, such as those who participated in the Pilot Project, are pioneers in addressing and managing the issue of health disparities in their workforce by being proactive. Nationally, although large employers recognize the sensitivity and complexity of the issue, they do not yet understand its full effect on their workforces.

The National Diabetes Education Program Partnership Network

Authors: J. Kelly; S. Harper

Objective:
The National Diabetes Education Program (NDEP), a joint initiative of the Centers for Disease Control and Prevention and the National Institute of Diabetes and Digestive and Kidney Diseases, is a network involving over 200 private and public partners invested in reducing the burden of diabetes.

Setting: 
A key component of NDEP is the focus on health disparities populations. Working through four health disparities work groups (African American, American Indian/Alaska Native, Asian American/Pacific Islander and Hispanic/Latino), the NDEP has created innovative products for diabetes prevention and control. Supported by formative research and pilot testing, each NDEP work group tailors the three main NDEP campaigns (Take Control; Be Smart About Your Heart  Know Your ABCs; and Small Steps, Big Rewards, Prevent Type 2 Diabetes) to its specific audience.

Method or Intervention:
Through its partnership network, NDEP has greatly increased the reach of these materials. For example, in response to formative research in the Hispanic/Latino population and with the guidance of the NDEP Hispanic/Latino workgroup, the NDEP created a music CD, Movimiento Por Su Vida, in 2003 to promote physical activity through dancing. Focus groups research emphasized that dance is a culturally appropriate form of physical activity embraced by many minority groups.

Result or Outcome:
Movimiento has since been adopted by our partner the American Diabetes Association for use at their venues. The Pan American Health Organization (PAHO) uses Movimiento for multiple programs at the U.S.Mexico border, including the training of promotoras. In another example, the NDEP multicultural primary diabetes prevention campaign Small Steps, Big Rewards has been adapted from a general audience approach to targeting specific populations with the guidance of the four ethnic minority work groups. Materials are now available in Spanish and 15 Asian/Pacific Islander languages. NDEP also supports through cooperative agreements six national minority organizations to reach out to health disparity populations through trusted venues. This additional outreach has been synergistic with the mission of these organizations and has resulted in further translation of NDEP materials into four additional languages.

Conclusion or Significance:
The NDEP relies heavily on partner input for evaluation. The NDEP partner survey results describing the use of NDEP materials (broken down by state diabetes prevention and control programs and other NDEP partners) will be presented as well as process and impact measures gathered by national surveys. The breadth of NDEP materials on the three main NDEP campaign messages will be presented.

Understanding the Unique Information Needs of Diverse Population Groups in the United States

Authors: S. Crelia; A. Ward; G. Alcala-Levy

Objective:
To identify special information needs of diverse populations in the United States, including racial and ethnic minorities, and low-income and less educated populations, through cognitive research and materials testing.

Setting: 
Multiple locations throughout the United States.

Method or Intervention:
Over the past several years we have been providing ongoing technical assistance to the Centers for Medicare and Medicaid (CMS) in better understanding the unique information needs of and particular barriers facing the diverse Medicare (persons over 65 and disabled) and Medicaid (low-income) populations in the United States. We have conducted extensive cognitive research, including hundreds of in-depth interviews, focus groups, and dyads with Medicare and Medicaid beneficiaries and their intermediaries. Our research has included not only the general Medicare and Medicaid populations but has been particularly focused on the more vulnerable groups, including Hispanics, American Indians and Alaskan Natives (AI/ANs), African Americans, Asian Americans, the less educated, people with disabilities, the uninsured, and the homeless. Our research has focused on testing, evaluating, and revising various forms of communication materials targeting these populations, including print materials, videos, and Web sites that require these audiences to comprehend and navigate potentially complex concepts or text.

Result or Outcome:
Our research has helped Medicare to improve the readability of most English-language Medicare documents and has identified unique information needs as well as linguistic and cultural needs that should be taken into account when developing and designing materials, messages, and communication strategies targeting the more vulnerable populations. For example, those with limited English-speaking proficiency often do not feel comfortable asking their health providers questions, not only because of language barriers but because they may not consider it culturally appropriate; Hispanics tend to understand materials better when they are created in Spanish rather than directly translated; Hispanics also tend to rely on informal networks, such as family and friends, and identify more with messages that emphasize benefits to family rather than the individual; Many AI/ANs still follow an oral tradition and prefer verbal communication over written; AI/AN elders have an average of 6th-grade education level, making comprehension of complex or lengthy materials difficult; and low-income beneficiaries tend to be passive information seekers and often wait for information to be given to them.

Conclusion or Significance:
The research addresses unique information needs of the diverse Medicare population in the United States and identifies potential communications strategies to best reach these groups.

Validity and Reproducibility Testing of a Web-Based Food Frequency Questionnaire Among Urban African-American Preadolescents

Authors: K.G. Lane; R.M. Mullis; P. Fleming

Objective:
To test the validity and reproducibility of a culturally specific Web-based food frequency questionnaire among urban African American preadolescents.

Setting: 
Four predominantly African-American public schools in a low-income urban area.

Method or Intervention:
A Web-based food frequency questionnaire was developed that contained digital photographs of foods that preadolescent children in these schools commonly reported consuming. The questionnaire measured number of servings of each food item or beverage during the previous week. The Web-based food frequency questionnaire and 24-hour dietary recalls were administered to 130 4th-graders in four schools on two consecutive Saturdays at each school. The questionnaires were administered on four laptops with local IIS servers. Three 24-hour dietary recall interviews were conducted: one each Saturday and one during the school week. Most of the data collection was conducted outside of school hours to decrease interruption of classroom time. A school bus was provided on Saturdays to transport the children. To measure reproducibility, Pearson coefficient correlations were used to compare reported intake of food items on the food frequency questionnaire at Time 1 and Time 2. The validity of the instrument was measured by using Pearson coefficient correlations to compare the reported intake of food items on the second food frequency questionnaire to the summed intake of the items reported during the three 24-hour dietary recall interviews.

Result or Outcome:
The questionnaire had poor validity (r = 0.06 to 0.42) as compared to the three 24-hour dietary recalls. However, the questionnaire had moderate reproducibility correlations (r = 0.45 to 0.72) between the two administrations. Verbal feedback from the children suggested that the children preferred the food frequency questionnaire to the dietary recall interviews.

Conclusion or Significance:
Despite the inclusion of culturally appropriate foods and beverages as well as positive feedback from the children, the food frequency questionnaire performed similarly to published research of traditional food frequency questionnaires with preadolescent populations. The Web-based food frequency questionnaire demonstrated only moderate reproducibility when administered on two occasions one week apart. The questionnaire demonstrated poor validity as compared with the validation standard of 24-hour recalls. In addition, access to the students during school hours, availability of school computers after hours, and consistent Internet access were challenges in collecting the dietary data. These results suggest that additional research is needed to determine creative strategies for data collection and to further refine existing methods if accurate dietary intake reporting of urban, low-income African American children is to be achieved.

VERB Campaign: Extending the Reach of a National Campaign to Ethnically Diverse Audiences

Authors: R. Bretthauer-Mueller; H. Melancon

Objective:
The mission of the Centers for Disease Control and Prevention (CDC) campaign VERB.TM Its what you do. is to increase and maintain physical activity among tweens.

Setting: 
National social marketing campaign with ethnic market overlays.

Method or Intervention:
VERB reaches all  tweens (9- to 13-year-olds) across the nation with messages designed to get them up and moving. To ensure that all segments of the multicultural audiences are reached by the campaign, CDC worked with four multicultural advertising/marketing agencies to supplement and complement the general market communication with culturally relevant messages and executions through appropriate channels. The campaigns culturally relevant efforts extend a personal invitation to Native American, African American, Asian American, and Hispanic/Latino tweens to take part in what the VERB brand has to offer. These culturally and linguistically relevant efforts also help to fill in the gaps inherent in general market communication channels that reach tweens, as well as those that reach parents and other adult influencers. The culturally relevant VERB executions expand campaign messages, reach, impact, and effectiveness.

Result or Outcome:
To reach ethnic audiences, the four multicultural agencies have produced a marketing mix that includes television, radio, out-of-home, and print advertising; in-school promotions; viral marketing; events; and public relations. As is the standard for the VERB campaign, these products were developed on the basis of extensive formative and message-testing research. The culturally relevant products are also strongly rooted in the VERB brand strategy to maintain synergy with the general market efforts, which is critical to a seamless campaign.

Conclusion or Significance:
The campaigns national longitudinal evaluation indicates that 63% of African American tweens and 70% of Hispanic/Latino tweens are aware of the VERB brand, exceeding the campaigns goal of 50% awareness. A special survey was administered in-language with Asian languagespeaking parents of tweens living in the Los Angeles area. The results indicate that the parents surveyed were more aware of VERB than any other parental ethnic group.

Methods and Surveillance

Age- and Race-Specific Distribution of Prostate-Specific Antigen Among U.S. Men, 20012002

Authors: M. Saraiya; B. Kottiri; S. Leadbetter; T. Thompson; D. Blackman; M. McKenna; F. Stallings

Objective:
We describe age- and race-specific distributions of prostate-specific antigen (PSA) and free/total PSA ratio in a nationally representative sample of U.S. men aged 40 years and older.

Setting: 
Prostate cancer incidence and mortality is higher among non-Hispanic black men than among non-Hispanic white men. Serum prostate-specific antigen (PSA) and the ratio of free/total PSA are used to screen men for prostate cancer. However, national population-based age- and race-specific distributions of PSA levels and national estimates of number of men with varying PSA levels have not been available.

Method or Intervention:
We analyzed data from the 20012002 National Health and Nutrition Examination Survey (NHANES), a cross-sectional survey of a nationally representative sample of the noninstitutionalized civilian U.S. population. Participants in this study were limited to men aged 40 years and older without previously diagnosed prostate cancer (n = 1,320). Weighted analyses were done overall and within three racial/ethnic groups (non-Hispanic whites, non-Hispanic blacks, or Mexican-Americans) to project the results to the entire U.S. population of men aged 40 years and older.

Result or Outcome:
An estimated 3.4 million or 6.1 % [95% confidence interval [CI] (4.9%, 7.5%)] of U.S. men aged 40 years and older had a PSA >4.0 ng/ml. Serum PSA levels rose with age for all three racial/ethnic groups. Free/total PSA remained constant across ages for non-Hispanic whites and Mexican-Americans but not for non-Hispanic blacks. The ratio of free/total PSA decreased as serum PSA increased.

Conclusion or Significance:
These data support the use of age-specific differences for PSA and suggest race-specific differences for free/total PSA. This information may help guide prostate cancer public health policy and screening practices.

Age-Adjusted per Capita Charges as an Indicator to Identify Racial/Ethnic Disparities in Hospitalization Expenditures

Authors: Y. Li; A. Malone

Objective:
1) To examine the effect of age-adjustment to per capita hospitalization charges from heart disease and stroke and 2) to utilize age-adjusted per capita charges as an indicator of disparities in hospitalization expenditure among racial/ethnic groups.

Setting: 
2002 Tennessee Hospital Discharge Data, which included hospitalization records from all hospitals licensed by the Tennessee Department of Health. Hospitalizations for non-Tennessee residents were excluded from the study.

Method or Intervention:
Per capita charges for heart disease and stroke inpatient hospitalization were analyzed and age-adjusted to 2000 U.S. standard population using the direct method applied to 10-year age groups. Age-specific, crude, and age-adjusted per capita charges were reported for inpatient hospitalizations with heart disease or stroke as the principal diagnosis.

Result or Outcome:
In 2002, Tennesseans spent a total of $2.6 billion in hospitalizations for heart disease and stroke. The overall crude and age-adjusted per capita charges were $375 and $369, respectively, for heart disease, and $68 and $68, respectively, for stroke. When age-specific per capita charges for stroke were compared between major racial/ethnic groups, African Americans charges were higher than whites for all age groups (P<0.01). Age-adjusted per capita charges for stroke were 121% higher for African Americans ($126) than for whites ($57) while the crude per capita charges indicated that charges for African Americans were only 48% higher in African Americans ($91) than for whites ($48). For heart disease, African Americans also had higher per capita charges for all age groups and the differences were statistically significant (P <0.01). The age-adjusted per capita charges identified such disparities by showing that per capita charges were 36.1% higher for African Americans ($461) than for whites ($339). In contrast, the crude per capita charges indicated the opposite: 9.3% lower for African Americans ($335) than for whites ($369). In summary, the above referenced results showed that age-adjusted per capita charges differed from the crude per capita charges slightly for Tennessee overall and substantially for minority groups.

Conclusion or Significance:
The differences between crude and age-adjusted per capita charges for heart disease and stroke hospitalizations could vary slightly or substantially depending on the subgroups being reviewed. When comparing hospitalization expenditures between different racial/ethnic groups, age-adjusted per capita charges are more reliable indicators than crude per capita charges. Therefore, age-adjusted per capita charges should be used to identify possible disparities and to quantify the magnitude of the identified disparities.

Assessing Health Disparities: Results of the Oklahoma Minority Health Survey

Authors: J.E. Campbell; C.G. Tutor; P. Li; H.R. Comstock; A. Bliss

Objective:
To illustrate how a telephone survey was used to collect data on health status, risky behaviors, racism, preventive care, and sexual assault among racial/ethnic minority populations.

Setting: 
A telephone health survey was conducted among racial/ethnic minority populations in Oklahoma.

Method or Intervention:
A survey was implemented among racial/ethnic minority adult populations in order to obtain a larger sample from these groups than the standard Behavioral Risk Factor Surveillance System (BRFSS). The interview tool consisted of questions from the 2003 Oklahoma BRFSS as well as questions from national surveys pertaining to areas such as racism, discrimination and trust, language and ethnicity, and sexual assault.

Result or Outcome:
By September 2004, 4,098 nonwhite Oklahoma adults were surveyed. Preliminary results indicate disparities in health status, behavioral risk factors, and preventive health care among racial/ethnic subgroups. American Indians had the highest rates of diabetes (14.5%) and obesity (body mass index [BMI] ?30; 33%); African Americans had the highest rates of high blood pressure (36%) and overweight (BMI ?25; 67%). Hispanics had the lowest rates of having health insurance (48%), having had their cholesterol checked in the past 5 years (50%), and, among those with diabetes, of having had a dilated eye exam (49%) and having had their hemoglobin A1C levels checked in the past year (56%). In addition, Hispanic women aged 40 and older had the highest rate of not having had a mammogram in the past 2 years (41%), and American Indian women had the highest rate of poor mental health (34%). When compared with the Oklahoma 2003 standard BRFSS, the rates of some indicators among racial/ethnic groups agreed with our survey whereas others did not, suggesting that this larger sample may provide better estimates. Additional data from the racism/trust and sexual assault modules revealed that approximately 15% of those surveyed reported that they had been judged unfairly or treated with disrespect by a health care provider in the past 2 years and that women who were sexually assaulted were less likely to have had a mammogram in the past 2 years than those who had not been assaulted.

Conclusion or Significance:
A statewide Minority Health Survey can be successfully implemented, providing critical evidence-based data on racial/ethnic disparities regarding health status, access to care, and behavioral risk factors. Additional information regarding perceived racism and trust in the health care setting and the impact of sexual assault on necessary screenings can be ascertained from this type of survey.

Associations of Diabetes and Family History Among Adult NHANES Participants 19992002

Author: A.M. Annis

Objective:
To examine the strength and effect of having a family history of diabetes on the prevalence of self-reported, previously diagnosed diabetes among adult NHANES participants during 19992002.

Setting: 
NHANES is a continuous, national, population-based survey conducted by the National Center for Health Statistics (NCHS). The target population for the survey is the civilian, noninstitutionalized U.S. population. Information is obtained from households via in-home interviews and physical health examinations. After removing personal identifiers, NCHS releases survey data online in public use data files.

Method or Intervention:
For this study, data from 10,283 NHANES participants aged 20 years and older were obtained from the NCHS public use data files and used to compare demographic and risk factors among self-reported diabetics with those of nondiabetics. Independent variables, such as sex, race/ethnicity, age, body mass index, annual family income, and poverty income ratio, were examined in relation to the association between family history and diabetes.

Result or Outcome:
After extrapolating the survey data to the general U.S. adult population, the crude prevalence of diabetes among individuals who had a first-degree relative with diabetes was estimated to be 14.3%, compared with only 3.2% among individuals who did not have a first-degree relative with diabetes. Prevalence of diabetes also increased with level of parental history, from 4.2% among individuals with neither parent having diabetes, 12.3% among individuals having one parent with diabetes, and 25.4% among people having both parents with diabetes. People with diabetes who had first- or second-degree relatives with diabetes were found to have a mean age of diagnosis 6 years younger than diabetics without a family history (45.5 years vs. 51.5 years).

Conclusion or Significance:
This study represents one method of extracting genomic information from existing data sources. Family history of diabetes was shown to be a significant predictor in diabetes prevalence in the adult U.S. population. Family history of chronic disease is a valuable measure of risk because it represents the interaction between environmental, behavioral, and genetic factors. The utilization of a family history assessment can be crucial for the prevention, early detection, and treatment of diabetes. Findings support current American Diabetes Associations recommendations that include family history as one of the criteria for screening.

Awareness of Cardiovascular Disease Risk in American Indians

Authors: C. Oser; L. Blades; C. Strasheim; S. Helgerson; D. Gohdes; T. Harwell

Objective:
Although cardiovascular disease (CVD) has become the leading cause of death in American Indians, little is known about how Indian communities perceive their risk.

Setting: 
Adult American Indians living on or near Montanas seven Indian reservations.

Method or Intervention:
In 2003, a telephone survey was conducted in American Indians living on or near the seven reservations in Montana. Respondents were asked about awareness of heart disease risk, history of CVD (heart attack, angina, or stroke), and risk factors.

Result or Outcome:
The prevalence of CVD and risk factors among men and women aged 45 years and older (N = 516) was high: CVD (26% for men and 15% for women), diabetes (24% and 26%), high blood pressure (48% and 46%), high cholesterol (34% and 40%), smoking (28% and 33%), and obesity (37% vs. 46%). Men with a history of certain medical conditions were more likely to be aware of their risk for heart disease than men without these conditions: CVD (87% vs. 46%), high blood pressure (70% vs. 44%), high cholesterol (71% vs. 53%), and obesity (67% vs. 52%). The same was true of women, but the ranking was different: (98% vs. 58%), diabetes (74% vs. 60%), high blood pressure (73% vs. 56%), high cholesterol (72% vs. 60%), and obesity (74% vs. 55%). Neither men nor women associated smoking with their own risk for heart disease.

Conclusion or Significance:
The prevalence of CVD risk factors was alarmingly high in this population. Awareness of risk for heart disease was associated with most modifiable CVD risk factors, except smoking.

Barriers to Physical Activity Among Women in a Rural, Medically Underserved Population

Authors: T.A. Osuji; S.L. Lovegreen; R.C. Brownson; M.B. Elliott

Objective:
To assess the relationship between personal, social, and environmental barriers to physical activity and meeting public health recommendations for moderate physical activity in a sample of rural women.

Setting: 
Data was obtained from a random-digitdialed telephone survey of 2,510 residents of rural Southeastern Missouri, Tennessee, and Arkansas.

Method or Intervention:
Analyses were conducted using logistic regression to calculate prevalence odds ratios (OR) and 95% confidence intervals (CI).

Result or Outcome:
After adjusting for age and income, women who did not meet recommendations for moderate physical activity were more likely to identify personal/psychosocial barriers, such as lack of time (OR 1.4, 95% CI 1.1-1.7), lack of energy (OR 1.8, 95% CI 1.5-2.2), no motivation (OR 1.8, 95% CI 1.5-2.2), disinterest in exercise (OR 1.7, 95% CI 1.4-2.1), being too tired to exercise (OR 1.8, 95% CI 1.4-2.2), fear of injury (OR 1.5, 95% CI 1.2-1.9), and having no one to exercise with (1.3, 95% CI 1.08-1.7). There was evidence of a dose-response relationship between the number of barriers identified and meeting moderate physical activity recommendations among women in this sample. Annual household income was associated with differences concerning barriers and meeting physical activity recommendations. Women with annual household incomes of $25,000 or more who did not meet moderate physical activity recommendations were more likely to report lack of motivation (OR 2.5, 95% CI 1.9-3.2) and disinterest in exercise (OR 2.0, 95% CI 1.6-2.7) as barriers to physical activity than women with lower incomes (OR 1.3, 95% CI 0.9-1.7; and OR 1.4, 95% CI 1.03-1.9), respectively. The dose-response relationship related to the number of barriers was present in women with higher incomes, but not in women with household incomes less than $25,000.

Conclusion or Significance:
The results of this study yield important information that may be used to tailor theoretically based programs to promote physical activity to the specific needs of women in rural populations.

Binge Drinking in the United States: Sociodemographic Disparities

Authors: E.E. Sullivent; T. Naimi; R.D. Brewer; J.W. Miller; C.A. Okoro

Objective:
To assess disparities in binge drinking (prevalence, frequency, number of drinks consumed, preferred beverage) by race/ethnicity, education, and income.

Setting: 
Binge drinking (consuming five or more drinks on one occasion) generally results in acute impairment and is responsible for more than half of the 75,000 alcohol-attributable deaths in the United States. However, studies have not adequately characterized differences in binge drinking by race, ethnicity, education, and income. Knowledge of these differences could help guide prevention programs.

Method or Intervention:
We analyzed 2003 Behavioral Risk Factor Surveillance System (BRFSS) data from all states to determine the prevalence and frequency of past-month binge drinking and 2003 data from a new BRFSS binge drinking module used by 13 states to assess the average number of drinks per binge episode and alcohol beverage preferences among binge drinkers.

Result or Outcome:
The prevalence of binge drinking was highest among Hispanics (17.3%) and whites (16.2%), and lowest among blacks (10.6%). Among binge drinkers, however, the frequency of binge drinking was highest in blacks (4.8 episodes) and lowest in Hispanics (3.8 episodes). The number of drinks per binge episode was 9.1 in Hispanics, 8.3 in blacks, and 7.8 in whites. Beer was the most common beverage among Hispanic (81.8%); white (74.7%); and black (64.2%) binge drinkers, followed by liquor (blacks 27.0%; whites 16.5%; and Hispanics 14.3%). Wine was the least common beverage type (<10% across all racial/ethnic groups). Respondents with higher incomes and those with a high school education or greater had the highest prevalence of binge drinking. Binge drinkers with lower incomes and education, however, binged more frequently, consumed more drinks per episode, and were more likely to drink beer than those with a higher income or education.

Conclusion or Significance:
Binge drinking is more prevalent among whites and those with higher incomes. However, racial and ethnic minorities and those with lower incomes and educational levels tend to binge drink more frequently, consume more drinks per binge drinking episode, and to drink beer. Effective interventions to reduce binge drinking, including increasing alcohol excise taxes and restrictions on physical access to alcohol, should be adopted to reduce the overall prevalence of binge drinking as well as the frequency and intensity of binge drinking among racial and ethnic minorities and other vulnerable populations.

Challenges to Measuring Health Care Disparities in the National Healthcare Disparities Report: Disparities in Data

Authors: E. Moy; I. Arispe; J. Holmes

Objective:
To assess the ability of extant national data sets to measure health care disparities in access, use, and quality for different racial and ethnic groups, based on our experiences in developing the congressionally mandated National Healthcare Disparities Report (NHDR).

Setting: 
The Agency for Healthcare Research and Quality reports on differences in access and use of health care services by various U.S. populations.

Method or Intervention:
For each of the health care measures included in the NHDR, the ability of national data sources to provide information for different groups was examined. We focused on groups specified by 1997 Office of Management and Budget (OMB) Standards:
 	Racial minorities: Single-race blacks, Asians, Native Hawaiians and Other Pacific Islanders (NHOPI), and American Indians and Alaska Natives (AI/AN), and multiple-race individuals
 	Ethnic minorities: Hispanics
Measurement challenges were categorized as issues of
 	Collection, if data for a particular group were not collected and usable.
 	Estimation, if data for a group were collected but suppressed because of small cell size or large relative standard error.
 	Power, if data for a group were collected and adequate to generate estimates but lacked sufficient power to detect relative differences compared with comparison groups of 10% with P <0.05.

Result or Outcome:
For almost every NHDR measure, measurement challenges limited our ability to assess disparities for at least one group. Major measurement challenges varied among groups. Collection issues prevented assessments of disparities for NHOPI and for multiple-race individuals for over 60% of NHDR measures. Estimation issues prevented an assessment of disparities for AI/AN for almost half of measures. Issues of statistical power were common among Asians, NHOPI, AI/AN, and multiple-race individuals. Measures that focus on subsets of the general populations (i.e., women, children, the elderly) were particularly vulnerable to measurement challenges.

Conclusion or Significance:
The goal of reducing disparities in health care is dependent upon our capacity to measure and track differences in care. For some racial and ethnic minority groups, extant national data are sufficient for assessing many areas of disparity. However, for smaller groups, challenges related to data collection, estimation, and power severely limit our ability to assess disparities. These disparities in data must be addressed to allow design of interventions that reduce disparities in care for all minority groups rather than just the larger groups.

Culturally Competent Surveillance Strategies: Working with American Indian and Alaska Native Populations

Authors: J.C. Weber; L. Reano; A. Easton

Objective:
Available national surveillance data suggest that AI/AN populations have the highest tobacco use rates (41.8%) among minority populations, and anecdotal evidence suggests that use is as high as 75% among certain segments of the AI/AN populations. These data are typically gathered through state adult tobacco surveys and reflect only a small representation of AI/AN participants. In many cases, the small sample sizes of AI/ANs in state surveillance databases render the data statistically unreliable. The data that are available suggest the existence of disparities when compared with data for either the general U.S. population or other priority populations. In addition, the surveillance data that are available fail to provide tribal/village-specific data regarding rates of tobacco use among AI/AN populations. The purpose of this project was to initiate a process by which tribal-specific (AI) and village-specific (AN) tobacco surveillance data could be gathered, thus enabling tribes to address the public health problem and policy issues.

Setting: 
Service areas covered by six Tribal Support Centers for Tobacco Programs (TSC) funded by the Centers for Disease Control and Prevention (CDC) that serve American Indian and Alaska Native tribes/villages.

Method or Intervention:
Tribal Support Centers staff, CDC, and contractors worked together to establish a methodology that was not only scientifically rigorous but culturally competent. Cultural traditions, taboos, methods of communications and the like were respected and melded into methodological strategies that employed focus groups, cognitive interviews, statistically sound sampling design, and survey fielding. Consensus was employed in order to effect agreement on methods that respected tribal sovereignty, cultural realities, and scientific rigor.

Result or Outcome:
We found that 1) public health efforts differ significantly across tribes/villages regarding tobacco control and prevention; 2) significant cultural differences exist between and among American Indian and Alaska Native tribes and villages; 3) employing native surveyors is key to tribal/village buy-in; and 4) data ownership and control is vitally important to tribes/villages.

Conclusion or Significance:
The cutting-edge process used in this project of melding scientifically rigorous methods with cultural appropriateness is a model for success in surveillance efforts with priority populations.

Developing Unique Community-Based Infrastructure for Assessment to Identify, Monitor, and Assist Disparate Populations

Authors: A. Charleston

Objective:
Provide examples of innovative approaches to community health assessment and data use, and demonstrate their potential impact on health disparities.

Setting: 
State/local public health.

Method or Intervention:
The Assessment Initiative is a cooperative program between the Centers for Disease Control and Prevention (CDC) and state health departments that supports the development of systems and methods that improve the way data are used to inform public health decisions and policy. The program has two primary focus areas: data dissemination systems and community health assessment practice. Now in its third 5-year funding cycle, the Assessment Initiative serves as a test-bed for the development or modification of practical assessment resources and approaches. This session will discuss Assessment Initiative work in four states, providing examples of innovative approaches to community health assessment and data use, and demonstrating their potential impact on issues associated with health disparities.

Result or Outcome:
New Mexico: As one of two states with no majority racial/ethnic group, New Mexico faces some unusual challenges in improving the health status of its population. New Mexicos Assessment Initiative project targets both community health councils and Indian tribes, and has developed practical methods and tools to improve the quality and scope of community health assessment through more systematic evaluation, coordination, and training. Florida: Floridas project, Comprehensive Assessment, Strategic Success (COMPASS), has established a model for impacting health disparities through community-based action. In Hardee County, Florida, where the Hispanic proportion of the population is twice that for the state, the county health department effectively gathered public health partners and used tools developed though COMPASS to design a comprehensive plan for community health assessment. In Citrus County, diverse community partners were mobilized to plan improvements in access to care and channels for communicating health information. Utah: Utahs Assessment Initiative continues to evaluate and make improvements to the states Indicator-Based Information System for Public Health (IBIS-PH), which provides the data needed to identify at-risk populations. Data made accessible through IBIS-PH have provided the impetus to design programs educating physicians on emergency care for strokes, successfully obtain grant funding in support of a statewide campaign for colorectal screening, and develop a statewide action plan to reduce teen pregnancy. Washington: A partnership between the Seattle-based Urban Indian Health Institute (UIHI) and Public HealthSeattle & King County provided much needed data to identify and address health disparities experienced by urban American Indians/Alaska Natives (AI/AN). UIHI adapted Seattle/King Countys VistaPHw software for analysis of vital statistics and census data. Data were summarized in a national report documenting the severe health disparities affecting AI/AN people.

Conclusion or Significance:
Methods/tools developed through the Assessment Initiative can be adapted and applied in other state or local health department settings.

Development of a User-Friendly Audit Tool for Assessing the Activity-Friendliness of Neighborhood Environments

Authors: C.M. Hoehner; L.K. Brennan Ramirez; R.C. Brownson

Objective:
Neighborhood audit tools can be used to target areas for community intervention and evaluate progress in eliminating disparities related to environmental barriers and facilitators of physical activity. Many audit tools exist, yet few have been rigorously tested. This presentation describes a systematic approach for refining existing audit tools to develop a shorter, user-friendly tool designed for use by community members and public health practitioners.

Setting: 
Lower and higher income areas of St. Louis, Missouri, (representing a low-walkable city) and Savannah, Georgia, (representing a high-walkable city) covering 4.5 square miles in total area.

Method or Intervention:
Two versions of an audit instrument were created: a researcher-oriented analytic tool (with Likert-scale and ordinal response choices) and a user-friendly checklist tool (with dichotomous response choices). Both audit tools included 27 individual questions (some with multiple parts) to assess the following community domains: land use environment, transportation environment, recreational facilities and amenities, aesthetics, social environment, and signage. Audits were conducted between March and June 2003 by six trained researchers in all of the study areas and by five community members in the lower income study areas only. Interrater reliability was tested between two trained researchers and also between researchers and community members, using the one-way model intraclass correlation coefficient and kappa statistic. Associations were examined between audit-derived environmental measures and both transportation and recreational physical activity behavior of residents in the study areas. In addition, verbal and written feedback regarding the tools was collected from researchers and practitioners from other organizations with field experience using these or similar tools.

Result or Outcome:
The process and results of applying and weighting criteria to refine the existing tools, resulting in a shorter (~10 items), user-friendly audit tool, will be presented. The audit items were evaluated on the basis of six factors: 1) interrater reliability between two trained researchers; 2) interrater reliability between trained researchers and community members; 3) agreement between checklist and analytic audit tools; 4) significant and/or strong associations between checklist and analytic audit-derived measures and physical activity behavior; 5) input from researchers and practitioners with field experience using the tool(s); and 6) evidence from the scientific literature.

Conclusion or Significance:
This user-friendly audit tool provides a means for community members and public health practitioners to evaluate the activity-friendliness of neighborhood environmentsan important aspect of program planning, evaluation, and raising awareness among community members. Additional studies are needed to test the reliability of this tool across different community settings.

Disparities in Ambulatory CareSensitive Conditions Among Adults in Georgia

Authors: M. Wu; K. Mertz; K. Powell; S. Thompson

Objective:
To examine hospitalization rates for the three most common chronic ambulatory caresensitive conditions (ACSC) among adults in Georgia for evidence of disparities by race, sex, or income.

Setting: 
ACSC are medical conditions for which timely and appropriate outpatient or ambulatory care can reduce the risk of hospitalization. Higher rates of ACSC hospitalization for a population subgroup or geographic area may indicate limited access or inappropriate primary care.

Method or Intervention:
Hospital discharge data from nonfederal acute care hospitals in Georgia were analyzed using SAS software. Due to the differences in the types of diagnoses in children and adults, analysis was limited to persons aged 18 years and older with any one of the three most common chronic ACSC as principal diagnosis: congestive heart failure (CHF), asthma, and diabetes. Age-adjusted hospitalization rates for the three conditions were calculated by race (white, black), sex, and median county income. Counties were grouped into quartiles according to median income; the lowest income quartile was compared with the highest income quartile. Because ACSC hospitalization rates can be affected by the prevalence of ACSC, data from the Behavioral Risk Factor Surveillance System (BRFSS) were used to compare prevalence among different demographic groups.

Result or Outcome:
In 2001 in Georgia, 49,190 adult patients were hospitalized with a principal diagnosis of CHF, asthma, or diabetes, accounting for 5.2% of total hospitalizations that year. Blacks and residents of lowest income counties had significantly more hospitalizations for the three major ACSC than their respective counterparts, to a greater extent than would be expected from difference in prevalence. For example, blacks are 1.2 times more likely to have asthma than whites, but they are 3 times more likely to be hospitalized for asthma than whites. People living in the lowest median income counties are 1.2 times more likely to have asthma than those living in the highest median income counties; however, they are twice as likely to be hospitalized for asthma as people living in the highest median income counties.

Conclusion or Significance:
Racial and income disparities in ACSC hospitalization rates may reflect access barriers to ambulatory care in Georgia.

Disparities in Colorectal, Breast, and Cervical Cancers: Incidence, Mortality, and Stages at Diagnosis in 19812001

Authors: Y. Huang; T. Hylton

Objective:
To identify disparities in incidence of and mortality related to colorectal, female breast and cervical cancers, and related risk factors in Florida.

Setting: 
Florida Cancer Registry, a population-based statewide central registry.

Method or Intervention:
Florida cancer registry data were analyzed for incidence, mortality and stages of colorectal, female breast and cervical cancer in 19812001. Stages of cancer were defined as later stages (regional and distant) and early stages (in situ and local). Patients of races other than black or white were excluded due to small numbers. Race, sex, age, health insurance, and year of diagnosis were included in multivariate analysis of stage of cancer.

Result or Outcome:
A total of 438,533 cases and 132,902 deaths due to colorectal, breast, and cervical cancer in 19812001 were included in the analysis. Blacks had mortality rates from these cancers 26.8%85.7% higher than that among whites in 2001, even though blacks had a breast cancer incidence 27% lower than that for whites. Percentage of cancers diagnosed at later stages was higher among blacks than among whites for colorectal (67.6% vs. 62.1%), cervical (61.3% vs. 46.8%), and breast (48.5% vs. 32.3%) cancers in 2001. More blacks than whites either did not have medical insurance (3.6% vs. 1.1 %) or were Medicaid recipients (4.1% vs. 0.9%). Compared to people with private insurance, Medicaid recipients or people without any health insurance had higher percentages of cancer diagnosed at later stages. Blacks were 24%, 40%, and 71% more likely than whites to be diagnosed at later stages for colorectal, cervical, and breast cancer, respectively, controlling for sex, age, and health insurance.

Conclusion or Significance:
Blacks have disproportionally high mortality rates for colorectal, breast, and cervical cancers than whites. High mortality rates of these cancers among blacks are associated with high percentage of cancers diagnosed at later stages. Efforts should be made to improve cancer screenings for early diagnosis among blacks.

Disparities in National Prevalence Estimates of Arthritis-Attributable Work Limitation

Authors: K.A. Theis; J.M. Hootman; C.G. Helmick; L. Murphy; E. Yelin

Objective:
Work limitation is an important measure of arthritis impact. This study estimates national arthritis-attributable work limitation (AAWL) among those aged 1864 years with doctor-diagnosed arthritis (DRDX) and examines associated factors such as demographics, comorbidities, and access to care.

Setting: 
The Sample Adult Core of the 2002 National Health Interview Survey, an in-person survey of the adult (>18 years and over) civilian, noninstitutionalized, household population of the United States.

Method or Intervention:
We restricted our analysis to those between the ages of 18 and 64 who did not respond by proxy. DRDX was defined as a yes to:the question Have you EVER been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia? AAWL among those with DRDX was defined as a yes to the following question: In this next question we are referring to work for pay. Do arthritis or joint symptoms now affect whether you work, the type of work you do, or the amount of work you do? All analyses were conducted among persons with DRDX. We estimated prevalence of AAWL; sociodemographics and other factors were also compared among those with and without AAWL, using regression models. Survey data were analyzed in SUDAAN to account for the complex sample design.

Result or Outcome:
A total of 15.7% (26.7 million people) of the U.S. population between ages 18 and 64 report DRDX. Among those with DRDX, 30.6% (8.2 million people) report AAWL (4.8% of the U.S. population aged 1864). AAWL rates increased significantly with older age. Age-adjusted rates of AAWL were significantly higher for females, non-Hispanic blacks, and those with lower education and income but were significantly lower among Hispanics. Preliminary multivariate analyses suggest greater AAWL is associated with being divorced/widowed/separated, obesity, lack of physical activity, the number of comorbid conditions, other functional limitations, and poor emotional and self-rated health.

Conclusion or Significance:
AAWL is highly prevalent, affecting 8.2 million Americans. Disparities in AAWL by gender, race/ethnicity, education, and income suggest the need for more targeted research to better understand the natural history of AAWL and work-specific factors likely to result in AAWL. Public health interventions specifically directed at AAWL, particularly work site accommodations and accommodations directed at populations bearing the greatest burden, may be effective in countering AAWL.

Disparities in Premature Death from Stroke Among Adults in the United States

Author(s): C.D. Harris; C. Ayala; J.B. Croft

Objective:
An earlier onset of stroke is evident in African American populations; however, little is known about the burden of early stroke in other racial and ethnic groups.

Setting: 
We assessed racial and ethnic differences in the proportion of premature deaths (i.e., those occurring at ages <65 years) among all adult stroke decedents.

Method or Intervention:
Stroke was defined by ICD-10 codes I60-I69 reported on death certificates collected by the National Vital Statistics System for 19992001. We defined ICD-10 codes I60I62 as hemorrhagic stroke and ICD-10 code I63 as cerebral infarction.

Result or Outcome:
During 1999-2001, there was an aggregated total of 498,565 stroke deaths among adults; 61.4% were women. Overall, 11.5% of stroke deaths in adults occurred at ages <65 years. However, the proportion of premature deaths among all adult stroke decedents was 9.2% in whites, 27.3% in African Americans, 26.4% in American Indian/Alaska Natives, 21.3% in Asian/Pacific Islanders, and 25.6% in Hispanics of any race. Among adults, premature death was observed in 9.2% of 41,205 cerebral infarctions and 31.5% of 98,668 hemorrhagic strokes. Among decedents with cerebral infarction, the proportion of premature deaths was 7.6% in whites, 20.5% in African Americans, 25.4% in American Indian/Alaska Natives, 17.2% in Asian/Pacific Islanders, and 18.4% in Hispanics of any race. Among those with hemorrhagic stroke, the proportion of premature deaths was 26.2% in whites, 59.2% in African Americans, 54.2% in American Indian/Alaska Natives, 59.8% in Asian/Pacific Islanders, and 52.3% in Hispanics of any race.

Conclusion or Significance:
Premature deaths contribute to health disparities in stroke outcomes among adults. These findings suggest an earlier onset that may be associated with greater prevalence of risk factors. Greater risk factor prevention and control efforts at younger ages are needed to decrease the burden of stroke in minority populations and eliminate health disparities in U.S. residents.

Elementary Students Dietary and Physical Activity Behaviors: Disparities by Grade and Gender

Authors: M. Naquin; D. Cole; E. Walkwitz; J. Kelly

Objective:
To describe the dietary and physical activity behaviors of students in grades 14, examine the differences in these behaviors by gender and grade level, and use findings to make recommendations about interventions to prevent obesity.

Setting: 
Students in a laboratory school (public grade school within a university) in grades 14.

Method or Intervention:
We examined childrens health practices that are often associated with being overweight or obese, including physical inactivity and poor dietary behaviors. Seventy-six students were confidentially weighed and their heights were measured to determine body mass index (BMI). Subjects answered questions about their eating and physical activity by two methods: one-on-one interviews using open-ended questions and completing written questions. In the latter method, food models were used to indicate serving sizes.

Result or Outcome:
Students ranged in age from 6 to 11 years, with a mean age of 8. There were approximately the same number of males and females (39, 37 respectively). BMIs of students ranged from 14 to 33, with a mean of 18. Overall, 26% of the students reported eating at least two servings of fruit daily, and 37% indicated that they ate at least three servings of vegetables daily. About one-third said that they rode their bike, and 46% watched TV or played video games daily. By grade level, students in the combined grades of 1 and 2 were more likely to have consumed diet drinks and sweetened drinks than students in grades 3 and 4 (f=6.2, P<.02; f=6.3, P<.01). Further, students in the lower grades were less likely to have eaten two servings of fruit daily compared to those students in grades 3 and 4 (f=6.4, P<.01). By gender, girls were less likely to watch TV and play video games than boys (f=4.3, P<.05).

Conclusion or Significance:
Results indicate the need for early interventions to promote healthy physical activity levels and dietary behaviors starting in first grade. Such interventions should be continued yearly in each grade level. In addition, youth, especially boys, need to be encouraged to spend less time in front of the TV and computer and more time engaging in physical activity. Such efforts in primary prevention would help to address the increasing number of youth who are becoming overweight and obese and who may experience health and social disparities as a result.

End-Stage Renal Disease Due to Diabetes Among Southwestern American Indians, 19902001

Authors: N.R. Burrows; A.S. Narva; L.S. Geiss; M.M. Engelgau; K.J. Acton

Objective:
To assess trends in the incidence of diabetes-related end-stage renal disease (ESRD-DM) among southwestern American Indians (SWAIs).

Setting: 

Method or Intervention:
Using the U.S. Renal Data System between 1990 and 2001, we obtained the total number of new cases of treated ESRD in which diabetes was the primary cause of renal failure. The incidence of ESRD-DM was calculated using census population figures and estimates of the SWAI population with diabetes, and was age-adjusted to the 2000 U.S. population.

Result or Outcome:
Between 1990 and 2001, the annual number of new cases beginning treatment for ESRD-DM increased from 125 to 336. Within the total SWAI population, the incidence of ESRD-DM increased 96% (from 2.8 to 5.5/10,000), and the age-adjusted incidence increased 72% (5.0 to 8.6/10,000). A much lower increase (25%) in the age-adjusted incidence in the SWAI population with diabetes (from 44.8 to 56.2/10,000) suggests that the increase in ESRD-DM incidence in the total population was mostly due to the growing prevalence of diabetes. Since 1996, however, the rate of increase in both the number of new ESRD-DM cases and in incidence in the total population has slowed, and in the population with diabetes, the age-adjusted ESRD-DM incidence has decreased by 26%.

Conclusion or Significance:
The increasing incidence of ESRD-DM in the SWAI population parallels the growing prevalence of diabetes. Since 1996, however, and consistent with national trends, ESRD-DM incidence decreased in the SWAI population with diabetes, which may reflect the recent reduction in risk factors and improvements in diabetes care practices in Indian communities.

Etiology of Chronic Liver Disease Among American IndiansPhoenix, Arizona

Authors: S. Bialek; T. Vogt; J. Redd; A. Lynch; C. Wilson; B. Bell

Objective:
Mortality from chronic liver disease (CLD) is four times higher among American Indians (AIs) than among the overall U.S. population. Our objective is to describe the prevalence of CLD and its etiologies among a sample of Southwestern AIs.

Setting: 
Phoenix Indian Medical Center (PIMC), Phoenix, Arizona.

Method or Intervention:
We reviewed electronic medical records from PIMC to identify AI adults (>18 years old) with CLD who visited PIMC during October 2000September 2002 (the study period). CLD was defined as an International Classification of Diseases 9 (ICD9) code consistent with CLD or abnormal liver tests of at least 6 months duration. Data on demographics, laboratory test results, and diagnoses based on ICD9 codes were abstracted from patients electronic medical records for the period October 1997September 2002. Patients were assigned a CLD etiology using laboratory test results and ICD9 codes. Patients could be assigned multiple etiologies.

Result or Outcome:
Of the 31,839 AI patients who visited PIMC during the study period, 1,573 (4.9%) met the criteria for CLD, of whom 804 (51.1%) were male. A CLD-related ICD9 code was present in 592 (37.6%) patient records, abnormal liver tests of at least 6 months duration but no CLD-related ICD9 code in 383 (24.4%), and both criteria in 598 (38.0%). Overall, 757 (48.1%) had alcohol-related liver disease, 342 (21.7%) had chronic hepatitis C, 191 (12.1%) had nonalcoholic fatty liver disease (NAFLD), 9 (0.6%) had chronic hepatitis B, and 416 (26.5%) had no identified etiology, 186 (44.7%) of whom had not been tested for hepatitis C. Of the 757 patients with alcohol-related liver disease, 534 (70.5%) had been tested for hepatitis C, of whom 172 (32.2%) were positive. The majority of patients with chronic hepatitis C or alcohol-related liver disease were male (55.0% and 62.0% respectively), while more of the patients with NAFLD or no etiology were female (71.2% and 61.8% respectively). A total of 268 (17.0%) patients had at least one ICD9 code consistent with cirrhosis. Eleven (0.7%) had hepatocellular carcinoma. A total of 59 (3.8%) patients with CLD died during October 2000December 2003.

Conclusion or Significance:
Alcohol-related liver disease is the most commonly recognized CLD etiology among AIs in the population studied, but almost a quarter of patients do not have an identified etiology and many have not been tested for hepatitis C virus infection. Prospective population-based studies are needed to better quantify the burden of CLD and its various etiologies among AIs.

Getting the Most Out of Vital Statistics Data: Diabetes-Related Heart Disease Mortality in New Mexico

Authors: H. Krapfl; D. Gohdes; J. Croft 

Objective:
To illustrate how multiple-cause mortality data can enhance interpretation of heart disease (HD) mortality among racial/ethnic groups.

Setting: 
HD deaths for the state of New Mexico from 1999 to 2001.

Method or Intervention:
Multiple-cause mortality files for 19992001 were obtained from the National Center for Health Statistics at the Centers for Disease Control and Prevention. Deaths from HD for New Mexico residents were identified by the International Classification of Diseases, Tenth Revision (ICD-10) codes I00-I09, I11, I13, and I20-I51. Premature heart disease (PHD) was defined as any underlying HD death occurring in persons aged <65 years. Diabetes-related HD was classified as any death where the underlying cause of death was HD and diabetes (ICD-10 codes E10-E14) was reported as any of up to 20 contributing causes of death. Residents were grouped into four racial/ethnic categories: non-Hispanic white, Hispanic of any race, non-Hispanic American Indian, and other. All death rates for HD were calculated with bridged-race population estimates and age-adjusted to the 2000 U.S. Standard Population.

Result or Outcome:
From 1999 to 2001, 24% of all deaths in New Mexico reported HD as the leading cause of death. Of these, 16.6% occurred in persons aged <65 years of age and were therefore classified as premature. The proportion of PHD deaths was substantially higher in the American Indian (29.2%) and Hispanic (20.8%) populations than in whites (13.7%). Diabetes contributed to almost 18% of PHD deaths in American Indians and Hispanics and to 10% of PHD deaths among whites.

Conclusion or Significance:
Multiple-cause mortality data indicate that the contribution of diabetes to PHD is disparate among racial/ethnic groups in New Mexico. These results support continued analysis of these data in a consistent manner and further underscore the growing threat of diabetes to communities in the United States. Much of the progress in decreasing cardiovascular disease in the United States may be lost as increasing diabetes and obesity lead to PHD death in many populations.

Health Services Utilization Among Medicare + Choice Enrollees with Chronic Health Conditions

Author: J.W. Moser

Objective:
To evaluate the effects of having a specific chronic health condition (heart disease, cancer, stroke, chronic obstructive pulmonary disease [COPD], and diabetes) on eight measures of health care utilization among Medicare + Choice health plan enrollees.

Setting: 
The Consumer Assessment of Health Plans Study (CAHPS) surveys from 1997 through 1999 were used as the data sources for this study. Questions contained within these surveys related to the health conditions experienced by enrollees as well as the services they used.

Method or Intervention:
Probit Regression analysis was performed on the CAHPS study data to determine the effect of the presence or absence of a chronic health condition on the rate of health care utilization among Medicare + Choice beneficiaries. Eight measures of health care utilization (doctors office visits, specialists visits, inpatient hospitalizations, emergency room visits, use of prescription medications, use of medical equipment, use of special therapy, and home health care) were used in the analysis of patients with and without chronic medical conditions. Confounding variables that might impact health use (age, educational attainment, gender, health status, race, tax status of the Medicare + Choice organization, and geographic region) were accounted for in the analysis. We assessed both the magnitude of the effects of having a chronic health condition vs. not having a chronic health condition and the overall rank of having a chronic health condition in comparison with other predictive variables of health care utilization.

Result or Outcome:
Study findings indicate that for all five conditions, Medicare beneficiaries with a chronic health condition were more likely to utilize the eight measures of health care services than beneficiaries without a chronic condition. Beneficiaries with a chronic health condition were generally much more likely to be an inpatient at a hospital, visit their doctor, or see a specialist than were beneficiaries without that same health condition. Few differences were observed between persons with and without a chronic health condition in terms of use of special therapy and home health care. Comparision of chronic health conditions with other predictor variables of health utilization, stroke (6), COPD (5), and heart disease (5) were the chronic health condition variables that ranked most often within the top 5 of all 24 predictor variables for the eight indices of health care utilization.

Conclusion or Significance:
Medicare beneficiaries with chronic health conditions were more likely to use nearly all health services than were beneficiaries without chronic health conditions.

Impact of Baby Boomers on Hospitalizations for Coronary Heart Disease and Stroke in the United States

Authors: H.D. Shoob; J.B. Croft

Objective:
Baby boomers, a generation of 80 million persons born in 19461964, comprise one-third of the U.S. population. There is no information on the current impact of the baby boomer population on coronary heart disease and stroke in the United States. This study compares hospitalizations in 2000 for coronary heart disease and stroke in older baby boomers, aged 4554 years (the 19461955 birth cohort), with those of the 19361945 birth cohort in 1990 and the 19261935 birth cohort in 1980.

Setting: 
Hospital.

Method or Intervention:
The annual National Hospital Discharge Survey collects data on discharges from samples of nonfederal short-stay U.S. hospitals. Coronary heart disease (CHD) included all first-listed hospital diagnoses with ICD9-CM codes 410414, 4292, and stroke included codes 430434 or 436438. Estimates of hospitalizations were compared between persons aged 4554 years in 2000, 1990, and 1980. Age-specific prevalences (per 100,000 U.S. civilian population) of hospitalizations were calculated from weighted estimates that accounted for the complex sampling design.

Result or Outcome:
Among all U.S. hospitalizations for CHD, 15.2% of 2,173,364 in 2000, 14.7% of 1964,279 in 1990, and 15.4% of 1,902,172 in 1980 were observed among adults in the 45- to 54-year-old age group. The age-specific prevalence of CHD hospitalizations for adults aged 4554 years was higher in men (1900.6 vs.1690.4 vs. 1251.7) in than women (726.2 vs. 628.5 vs. 536.1) in 1980, 1990, and 2000, respectively. Among all U.S. hospitalizations for stroke, 8.5% of 757,221 in 2000, 6.5% of 647,183 in 1990, and 6.0% of 603,230 were observed among adults in the 45- to 54-year-old age group. The number of stroke hospitalizations in this age group was higher in 2000 than in 1990 or 1980 (64,256 vs 41,937 or 37,420, respectively) as was the prevalence (172.9 vs 166.4 and 164.8 per 100,000, respectively). The age-specific prevalence of stroke hospitalizations for adults aged 4554 years was higher among men (209.6 vs. 198.0 vs. 178.3) than women (122.9 vs. 136.2 vs. 167.7) in 1980, 1990, and 2000, respectively.

Conclusion or Significance:
Baby boomers made a greater impact on the coronary heart disease and stroke patient populations in 2000 than 45- to 54-year-olds in 1990 and 1980. Because the first wave will attain age 65 in 2011, aging of this large cohort is a public health issuethe value of prevention of risk factors is critical. Health systems must also enhance efforts for the early detection and treatment of hypertension, hyperlipidemia, obesity, and diabetes in this age cohort in order to prevent the future health care needs, resources, and costs that would be associated with health care and stroke disability.

Improving Surveys Assessing Physical Activity in Rural Populations: Reliability of Environmental and Behavioral Factors

Authors: M. Elliott; S. Lovegreen; D. Haire-Joshu; J. McGill; R. Brownson

Objective:
Detail the test-retest reliability of assessment of physical activity in a rural population.

Setting: 
Twelve rural communities in southeastern Missouri, Tennessee, and Arkansas.

Method or Intervention:
A stratified systematic sample of respondents to a random-digitdialed survey (n = 358) was contacted for a re-interview. The median period between initial interview and re-interview was 16 days. Physical activity levels and environmental factors related to physical activity were assessed. Intra-class correlation coefficients and Kappa statistics were grouped into poor (0-.39), moderate (.40-.59), and substantial reliability (.60-1). Associations between dichotomous measures of discordance and environmental and sociodemographic measures were studied using logistic regression.

Result or Outcome:
Reliability of measures of moderate and vigorous physical activity was moderate. Measures of walking behavior showed poor to moderate reliability. Assessments of number of and distance to facilities for physical activity had moderate to substantial reliability. Measures of community aesthetics and environment as related to physical activity were moderately reliable, and measures of safety for physical activity had moderate to substantial reliability. Measures of the advice regarding weight control and physical activity had substantial agreement, although measures recording whether a physician helped to develop and follow-up on an exercise plan had poor to moderate reliability. Discordance in the measurement of moderate, vigorous, and walking physical activity was not explained by income, time between interviews, marital status, gender, age, education, barriers, or health status. Discordance in each measure was positively related to meeting exercise recommendations for that measure. Those who reported that they met the recommended level of physical activity on the first survey were more likely to be discordant in their responses on the second survey. Additionally, discordance in the measurement of vigorous activity was positively related to often walking to places near ones home and negatively related to being advised by a physician to reduce ones weight after controlling for meeting the recommendation. Similarly, discordance in reporting walking behavior was positively associated with feeling safe from crime. The reliability of evaluations of the community environment for physical activity was related to income; lower income groups showed less reliable measures.

Conclusion or Significance:
Reliability of measurement of physical activity is lower in groups that claim to be physically active. Sociodemographic factors do not explain discordance in the measurement of physical activity; however, income does relate to discordance in the measurement of some environmental correlates of physical activity.

Indicators for Chronic Disease Surveillance at the Local Level: Assessing Geographic and Racial Disparities

Authors: K. Mertz; K.E. Powell; M. Wu; C. McNamara

Objective:
To assess the burden of chronic disease by geographic area and race in Georgia using newly developed standard chronic disease indicators (CDIs).

Setting: 
CDIs were developed to allow public health officials to uniformly define, collect, and report chronic disease data. The indicators, designed for state-level surveillance, may be useful at the local level, given that state chronic disease programs allocate resources to local health departments and monitor effects of local prevention programs.

Method or Intervention:
We calculated values for a subset of CDIs available for Georgias 19 Public Health Districts, including cardiovascular morbidity (hospitalization rates for acute myocardial infarction [MI] and stroke), cancer incidence (lung, female breast, prostate, and colorectal), rates of deaths with chronic obstructive pulmonary disease (COPD) and diabetes, and prevalence of smoking and obesity. Hospitalization rates (years 20002001), cancer incidence (19992000), and death rates (20002001) were age-adjusted to 2000 standard population and expressed per 100,000 population. Behavioral Risk Factor Surveillance System data (20002002) described risk factors for persons >18 years.

Result or Outcome:
For some indicators, rates were approximately twice as high in some districts as in others. For example, acute MI hospitalization rates ranged from 175 to 333, prostate cancer incidence from 98 to 192, and COPD death rates from 57 to 106. For other indicators, there was less variation: lung cancer incidence ranged from 64 to 86, colorectal cancer from 42 to 62, breast cancer from 96 to 140, and stroke hospitalization rates from 302 to 438. For some indicators, blacks had higher rates than whites in all or most districts; stroke hospitalization rates, prostate cancer incidence, colorectal cancer incidence, and diabetes death rates were higher for blacks in 19, 18, 13, and 19 districts, respectively, and obesity prevalence was significantly higher for blacks in 5 districts. For other conditions, in most districts whites had higher rates; lung cancer incidence and COPD mortality were higher for whites in 13 and 19 districts, respectively, and smoking was significantly higher in 7 districts.

Conclusion or Significance:
Morbidity, mortality, and prevalence of risk factors for chronic diseases varied among districts. In most districts, smoking and related diseases (lung cancer, COPD) were higher among whites, whereas obesity, diabetes mortality, stroke hospitalizations, and colorectal and prostate cancer were more common in blacks. Resources to combat smoking, obesity, and other contributors to chronic disease should be targeted to those districts and races at greatest risk.

Innovative Approaches to Steps Program Evaluation and Surveillance in Four Counties in New York State

Authors: T. A. Melnik; A.E. Ronsani; C.A. Jaconski; E.L. Berberian

Objective:
To convey New York States experience with the development of an innovative approach to Steps to a HealthierUS program evaluation and surveillance to bridge information needs at the local, state, and national level.

Setting: 
The Steps Program is designed to impact multiple outcomes in the community through improved nutrition and physical activity and reduced tobacco use to prevent and control obesity, asthma, and diabetes. Interventions are being implemented among diverse population groups in four counties in New York State selected, in part, because of the disparity of health outcomes in their community. The State Department of Health is responsible for providing technical assistance to support Steps Program evaluation and surveillance at the local, state, and national level.

Method or Intervention:
A logic model approach was used to describe the Steps Program intervention and to conceptualize the evaluation and surveillance plan. Methods to provide information demonstrating the impact of Steps on program inputs, activities, outputs, and short-, intermediate- and long-term behavioral and health outcomes were devised and implemented.

Result or Outcome:
Evaluation plans, and goals and objectives were developed for each of the four Steps communities. Process measures to capture inputs, activities, and outputs were defined with respect to stated objectives and health disparities in each county. Innovations include the development of a Web-based program monitoring system for monthly collection and reporting of process and qualitative information for evaluation. In addition, an ongoing stand-alone, Steps-specific Behavioral Risk Factor Surveillance System sampling 1,500 adults annually in each county was implemented in Year 1 to monitor behavioral and health outcomes, and to provide information related to exposure and awareness of the Steps interventions. Comparable county-specific Youth Risk Factor Surveillance is being planned in partnership with the State Education Department for implementation in Year 2 for a target sample of 1,500 youths annually in each county. Surveillance information is being used to better understand sociodemographic, geographic, and health risk disparities regarding program exposure, interventions, and health outcomes in each of the four communities.

Conclusion or Significance:
Innovations based on a logic model approach are being employed to design and implement Web-based systems and local-level surveillance for Steps Program evaluation in four communities in New York State.

Innovative Uses of Geographic Information Systems Technology to Reveal Health Disparity Burdens in Disadvantaged Communities

Authors: C.M. Croner; T. Lenahan; M.J. Sailing

Objective:
To demonstrate the use of Geographic Information Systems (GIS) as an integral tool in the surveillance and visualization of health inequalities in disadvantaged communitiestargeting especially local public health decisionmakers and stakeholdersfor cost-effective intervention investment.

Setting: 
Eight-county area of northeast Ohio, focusing on Cuyahoga county and the City of Cleveland (Statistical Planning Areas made up of whole or partial contiguous census tracts).

Method or Intervention:
We apply the use of GIS to examine and visualize spatial-temporal characteristics of community health and well-being in Cleveland's African American community. We incorporate into maps community measures of public health outcomes with associative predisposing and census-derived area-based socioeconomic measures.

Result or Outcome:
We are able to show important measureable differences between the nation, the state of Ohio, the northeast region of Ohio, Cuyahoga county, the city of Cleveland and Cleveland African American neighborhoods for key indicators of public health. Clevelands African American neighborhoods are in stress, bearing an inordinate public health burden in terms of infant mortality, environmental lead exposures, inadequate prenatal care, low-weight births, preterm births, teen births, and access to care, among other problems.

Conclusion or Significance:
Use of standardized health and other socioeconomic measurements with census geography, in a GIS, provides for uniform and evidenced-based public health assessment of geographic need in disadvantaged minority communities.

Making the Grade on Womens Health: A National and State-by-State Report Card

Author: M. Berlin 

Objective:
To provide a state-by-state and national overview of womens health status using consistent, reliable data, and to highlight key policies to improve womens health.

Setting: 
USA: 50 states and the District of Columbia

Method or Intervention:
To evaluate the state of womens overall health, the Report Card uses health status indicators and policy indicators. Health status indicators reflect conditions with a significant impact on quality of life and well-being, affect large numbers of women generally or disproportionately affect a specific population or age group, are amenable to prevention or improvement, and are measurable through consistent, reliable data. The 27 indicators fall within 4 categories: womens access to health care services, preventive health care activities, key womens health conditions, and whether women live in healthy communities. The states and the nation received grades for each status indicator, indicating whether the benchmark was met (Satisfactory) or not (Satisfactory Minus, Unsatisfactory, or Fail, based on scores distance from the benchmark). In this 2004 Report Card, grades take into account that states and the nation have several years to achieve those benchmarks based upon Healthy People 2010. To evaluate the performance of state and federal governments in promoting womens health, the Report Card provides 67 policy indicators based on state statutes, regulations, and policies and programs addressing problems identified by health status indicators.

Result or Outcome:
The nation met only two indicators (mammograms in women aged >40 years, and annual dental visits) and received an overall grade of unsatisfactory. All states and the District of Columbia met one benchmark (annual dental visits) and missed eight (including proportion of women with health insurance, rates of high blood pressure and diabetes, infant mortality, poverty, and wage gap). Twenty-five states improved at least five policies, and the majority of states weakened one to three policies. The policy most consistently improved was preventing tobacco sales to minors. Only one policy goal, Medicaid coverage for breast and cervical cancer treatment, was met by all the states.

Conclusion or Significance:
For most health status indicators, the nation and the states fall short of meeting national goals. Despite interest in health disparities, key differences (including race/ethnicity and age) persist. A number of state governments improved policies in key areas to meet womens health needs, but many states have fallen behind. The 2004 Report Card findings identify pressing issues that must be tackled by policy makers, public health administrators, and care providers. To improve and maintain the health of U.S. women, these issues must be addressed swiftly and accurately.

Measuring Population Health Disparities: The Wisconsin County Health Rankings

Author: A. Kempf 

Objective:
Rank the population health of counties in Wisconsin to promote use of local population health information, identify disparities between counties, encourage population health improvement, and broaden the understanding of the determinants of health.

Setting: 
The Wisconsin Public Health and Health Policy Institute, with assistance from state government, community, and university groups, annually compiles county data and produces the Wisconsin County Health Rankings.

Method or Intervention:
This project is modeled after the United Health Foundations annual State Health Rankings and is based on a model of population health in which a variety of determinants impact health outcomes. Mortality years of potential life lost (YPLL) and self-reported health status are used to develop a summary measure of county health outcomes. A summary measure of health determinants is developed using 18 measures in four (weighted) categories: health care (10%), health behaviors (40%), socioeconomic factors (40%), and physical environment (10%). Data sources include the Centers for Disease Control and Prevention (CDC), the U.S. Census, state vital statistics, and the Wisconsin Department of Health and Family Services. A draft report was developed and shared with local public health officials in late 2003. The report was revised on the basis of feedback, and the Wisconsin County Health Rankings 2003 was released to the public in January 2004. A survey assessing the usefulness of the rankings was sent to all county health officers following its release.

Result or Outcome:
Significant disparities exist in the health outcomes and determinants of Wisconsin counties. Overall, the summary determinant and summary outcome ranks were well correlated (r = 0.75). Compared with the healthiest counties (e.g., Ozaukee), the least healthy counties (e.g., Menominee) showed greater improvement in health over time. Of the county health officers participating in the survey of the rankings (N = 68, 94% response rate), 82% reported that the rankings were useful to their work, and 69% planned to use the rankings in their community. Suggestions received through this survey and other more informal feedback will be incorporated into the 2004 rankings, such as the expansion and improvement of the environmental health components and the inclusion of additional local survey data.

Conclusion or Significance:
The Wisconsin County Health Rankings provides a valuable vehicle for the delivery and discussion of county-level health information and for engaging stakeholders in the discussion of approaches to reduce these observed disparities. This report will continue to be produced annually with special attention given to improving the population health measures and its use in community health improvement efforts.

Neighborhood Disparities in Hospitalizations for Lower Extremity Amputations with DiabetesNew York City, 2003

Authors: A.S. Morarka; D.K. Berger; T.D. Matte

Objective:
To assess neighborhood disparities in hospitalizations due to nontraumatic lower extremity amputations (LEA) with diabetes and examine how much of the disparities are attributable to differences in diabetes prevalence.

Setting: 
New York City.

Method or Intervention:
Hospitalizations to persons aged 18 years and older with a principal procedure code for LEA (ICD-9-CM codes of 84.10-84.19) with diabetes (ICD-9-CM code 250.XX) as the principal, secondary, or tertiary diagnosis were identified from 2003 Statewide Planning and Research Cooperative System (SPARCS) data. Residential zip codes were used to assign hospitalizations to one of New York Citys 42 United Hospital Fund (UHF) Neighborhoods; neighborhood population estimates were based on the 2000 census. The 2003 New York City Community Health Survey (CHS), based on the Behavioral Risk Factor Surveillance System (BRFSS) and designed to provide neighborhood-level estimates, was used to estimate the number of adults with diabetes by age in each UHF neighborhood. UHF neighborhood income categories were defined based on the population of persons living in households with income less than twice the federal poverty level: low (45%90%), middle (30%44%), high (<30%). Age-adjusted hospitalization rates per 1,000 persons and 95% confidence limits were estimated for each neighborhood income group using census population-based denominators. The ratios of age-adjusted hospitalization rates for low- and middle-income neighborhoods relative to high-income neighborhoods were estimated and compared using denominators from census population estimates and from CHS estimates of the number of adults with diabetes.

Result or Outcome:
The age-adjusted LEA hospitalization rates in low-, middle-, and high-income neighborhoods were 0.46 (95% confidence interval [CI] 0.42-0.49), 0.30 (95% CI 0.28-0.33), and 0.18 (95% CI 0.16-0.20), respectively; the hospitalization rate ratios for low- and middle- versus high-income neighborhoods were 2.6 and 1.7, respectively. Using the estimated numbers of adults with diabetes as denominators, the disparities in LEA hospitalization rates were substantially, but not completely, reduced to 1.5 and 1.3 for low- and middle-income relative to high-income neighborhoods.

Conclusion or Significance:
There are large neighborhood disparities in rates of LEA with diabetes in New York City. The higher prevalence of diabetes in low-income neighborhoods accounts for a substantial proportion, but not all of the disparity. These data suggest that improving care of diabetes can only partly address LEA disparities; efforts to reduce disparities in diabetes risk factors and diabetes prevalence are also required. Neighborhood-level estimates of chronic disease prevalence are helpful in understanding disparities in adverse outcomes and in developing intervention strategies.

Physicians and Hispanic Patients Perceptions of Differential Treatment in an Arkansas Specialized Health Care Facility

Authors: W. Gonzalez-Espada; P.A. Vargas

Objective:
To study possible cultural and language barriers between physicians and Hispanic patients that might affect the quality of the health care encounter.

Setting: 
Arkansas Childrens Hospital, General Pediatric Clinic.

Method or Intervention:
Seventeen physicians practicing at the general pediatrics clinic (GPC) of Arkansas Childrens Hospital (ACH), and thirteen Hispanic parents agreed to participate in the study. Participants were informed of their rights using a standard oral consent statement. No personal information was collected, and their voices were electronically disguised. The researchers used a semi-structured interview format to gather information from the participants. Physicians questions dealt mostly with their experiences interacting with people from a different ethnic group in the community and in the hospital setting; their multicultural experiences; communication issues during the health care encounter; their knowledge about concepts such as race, ethnicity, discrimination, and prejudice, and whether they had witnessed any behavior that they considered biased or discriminatory toward Hispanic patients. Specifically for parents, questions probed communication issues during the health care encounter, the use of interpreters, and whether they have experienced or witnessed behaviors that could be considered discriminatory. The interviews lasted between 10 and 30 minutes, and were recorded to accurately gather the participants experiences. Data were transcribed and analyzed using qualitative techniques (contrast-comparative method) as suggested by Merriam (2001) and Rubin and Rubin (1995).

Result or Outcome:
Two physicians mentioned hearing negative remarks from medical staff regarding serving Hispanic families. However, this doesn't seem to be prevalent or to have an effect on the families experience. All the parents evaluated the health encounter with ACH physicians in positive terms and reported that they had never experienced discrimination. At the same time, some parents reported health care encounters to be more businesslike than they are used to, and expressed not being comfortable seeing a different physician with each visit to the GPC clinic. In addition, both parents and physicians expressed frustration when trying to accurately communicate during a health encounter, even when an interpreter was present.

Conclusion or Significance:
This study found no evidence that patients perceived discrimination at Arkansas Childrens Hospital but identified some cultural and language barriers that can potentially affect the quality of the health care provided.

Predictors of Body Mass Index and Its Effect on Colorectal Cancer Incidence, Prevalence, and Mortality

Authors: K. Cullinen; M. Caldwell; K. Melanson; K. Cady-Webster

Objective:
The purpose of this study is to evaluate 1) the behavioral, socioeconomic, demographic, and geographic predictors of obesity and 2) the type and strength of relationships between socioeconomic status and obesity, socioeconomic status and colorectal cancer, and obesity and colorectal cancer.

Setting: 

Method or Intervention:
Data from the National Cancer Institutes Surveillance, Epidemiology, and End Results Program and the U.S. Centers for Disease Prevention and Controls National Program of Cancer Registries and Behavioral Risk Factor Surveillance System will be used to analyze data from the U.S. and Rhode Island populations on socioeconomic status (e.g., income and education); health behaviors (e.g., fruit and vegetable consumption and physical activity); and colorectal cancer incidence, prevalence, and mortality Two levels of quantitative data analysis will be conducted: 1) Using SUDAAN statistical software, multiyear (even years from 1990 through 2002) logistic regression analyses of Rhode Island Behavioral Risk Factor Surveillance data will be run utilizing behavioral, socioeconomic, demographic, and geographic variables, and obesity as measured by body mass index. 2) With Structural Equation Modeling using 5 sets of 5-year moving averages (19901994, 19921996, 19982002) from U.S. and Rhode Island databases, a hypothesis that obesity plays a mediational role in the effect of the independent latent variable, socioeconomic status, on the dependent latent variable, colorectal cancer, will be tested. Analyses will be stratified by age, gender, and race/ethnicity. This will provide a full latent variable model on a national level, as well as evaluate any direct effects of socioeconomic status on colorectal cancer, and obesity as a potential mediator of colorectal cancer. Using SUDAAN statistical software, multiple regression analyses will be performed as follow-up tests.

Result or Outcome:
Nationally, colorectal cancer is the fourth most commonly diagnosed cancer and the second leading cause of cancer death. Although numerous epidemiologic and laboratory studies have linked diets low in fruits and vegetables and decreased physical activity, established risk factors for overweight and obesity, with increased cancer risk, the body of research on overweight, obesity, and colorectal cancer in racial/ethnic minority populations and high-risk individuals remains inadequate.

Conclusion or Significance:
Findings from this data evaluation on all states will identify populations, nationally and in Rhode Island, at highest risk for colorectal cancer and provide valuable information for the development of strategic plans and targeted intervention programs to inform the public, the health community, and state and national policy makers about effective colorectal cancer prevention strategies and needed resources.

Prevalence and Impact of Arthritis Among Utahs Hispanic/Latinos Compared with  Utahs Non-Hispanic/Latino Whites

Authors: R.D. Tanner; R.C. Bullough; M.D. Fredrichs; L. Larsen

Objective:
To assess the prevalence and impact of arthritis in Utahs Hispanic/Latino adults compared withUtahs non-Hispanic/Latino white adults.

Setting: 
The Hispanic/Latino population in Utah increased 138% from 1990 to 2000 and grew more than twice as fast as the Hispanic/Latino population nationwide. In 2000, there were 201,559 Hispanic/Latino residents in Utah, representing 9.0% of Utahs population. Little is known about the prevalence or impact of arthritis and potential arthritis-related disparities in these Utah residents.

Method or Intervention:
Data describing the Utah Hispanic/Latino population were gathered using the 2001 Utah Hispanic Health Survey and data describing the non-Hispanic/Latino white population were gathered using the 2001 Behavioral Risk Factor Surveillance System (BRFSS) Survey. The questions and methods used in the two surveys were identical. A total of 939 Hispanic/Latino adults completed the Utah Hispanic Health Survey, and 3,445 non-Hispanic/Latino whites completed the BRFSS Survey. Persons with arthritis were defined as those answering yes to the question Have you ever been told by a doctor that you have arthritis? Data were age-adjusted and standardized to the 2000 U.S. population.

Result or Outcome:
A total of 16.8% of Hispanic/Latinos reported diagnosed arthritis compared with 21.7% of non-Hispanic/Latino whites. In both groups, being female and older were primary risk factors for arthritis and those with arthritis had increased odds of hypertension and diabetes. Hispanic/Latinos with arthritis were substantially more likely to report fair or poor health (45.7%) and to be more physically inactive (41.1%) than non-Hispanic/Latino whites with arthritis (23.4% and 23.3%, respectively). Also, 54.2% of Hispanic Latinos with arthritis reported pain limited their activities for 1530 days each month, compared with 21.3% of non-Hispanic/Latino whites with arthritis.

Conclusion or Significance:
It appears that although Hispanic/Latinos do not have increased prevalence of arthritis compared with non-Hispanic/Latino whites, they may suffer more disabling consequences. This is reflected in the fact that Hispanic/Latinos with arthritis were more likely to report fair or poor health and activity limitation due to pain than were non-Hispanic/Latino whites. Additional work is needed to further assess and describe factors contributing to the observed disparities and to implement efforts to reduce these disparities.

Profile of Health Disparities in Diabetes Among the Hispanic/Latino Population in Colorado

Authors: W.C. Muhr; D.R. Greer

Objective:
This study examines health disparities for diabetes prevalence, mortality, hospitalizations, and complications among the Hispanic/Latino population in Colorado and provides recommendations to reduce these disparities.

Setting: 
Even though advances in both medical technology and public health practice have improved the prevention, diagnosis, and treatment of diabetes, epidemiological evidence reveals that not all ethnic groups in Colorado are benefiting equally from these successes. Although Colorado as a whole is a healthy state, Hispanics, who represent more than 15% of the population, are disproportionately impacted by diabetes.

Method or Intervention:
The following data sources were used to analyze diabetes prevalence, mortality, hospitalizations, and complications among the Hispanic/Latino population in Colorado: 2000-2003 Behavioral Risk Factor Surveillance System (BRFSS), 1999-2003 Colorado Vital Statistics Death Files, 2000-2003 Colorado Hospital Discharge Data, and 2003 End-Stage Renal Disease (ESRD) Network.

Result or Outcome:
More than 8% of Hispanic adults reported having been diagnosed with diabetes, significantly higher than the rate for white/non-Hispanic adults (4.4%). Hispanic adults with diabetes were less likely to follow diabetes standards of care, including receiving a hemoglobin A1c checkup, dilated eye exam, diabetes education class, flu shot, and pneumonia vaccination. Diabetes age-adjusted mortality rates for Hispanic males (35 per 100,000) and Hispanic females (33.8 per 100,000) were significantly higher than the rates for white/non-Hispanic males and females (18.5 and 13.9 per 100,000, respectively). According to 2000-2003 hospital discharge data, about 14% of diabetes-related hospitalizations are attributed to Hispanics. The average cost per discharge for Hispanic Coloradans ($19,357) was lower than that for white Coloradans ($20,991); however, Hispanic Coloradans were hospitalized at a younger age (60.4 years) than whites (65.1 years). In 2003, of 1,629 ESRD patients in Colorado, 34% (533) were Hispanic.

Conclusion or Significance:
The following areas are recommended to reduce disparities in diabetes in the Hispanic population: 1) investigate primary social causes of disparities in the Hispanic population and take a comprehensive, systemic approach to address disparities; 2) convene diverse and nontraditional diabetes partners to address the elimination of disparities; and 3) collaborate with Hispanic communities to support leadership development by offering opportunities and compensation for participation.

Putting the Pieces Together: Lifestyle Physical Activity Among Hispanics Using Multiple Surveillance Systems

Authors: S.A. Ham; M.M. Yore; J. Kruger; G.W. Heath; R. Moeti

Objective:
To describe lifestyle physical activity (occupation, transportation, household, leisure-time) in the Hispanic and Latino population using surveillance statistics. Lifestyle physical activity has been shown to reduce chronic disease risk.

Setting: 
Hispanic adult population aged 18+ surveyed by three national surveillance systems.

Method or Intervention:
The 2003 Behavioral Risk Factor Surveillance System (BRFSS), 2001 National Household Transportation Survey (NHTS), and 1999-2000 National Health and Nutrition Examination Survey (NHANES) were analyzed to determine patterns of physical activity among the Hispanic and Latino population. Each national survey asked respondents to self-report their ethnicity. BRFSS asked a general question about Hispanic ethnicity and inquired about occupational activities (n = 15,157). NHTS surveyed Hispanic households (n = 3,708) including those with immigrants from the Caribbean Islands and Central and South America using a 24-hour travel diary. NHANES sampled Mexican-Americans and inquired about household and leisure-time activities (n = 1,554).

Result or Outcome:
Hispanic and Latino adults participated in a wide range of physical activities among the four domains, with differences between men and women. According to the BRFSS, 9% of Hispanic and Latino adults had occupations characterized by engaging in mostly physically demanding work, and 19% had jobs that were mostly walking. From the NHTS, among adults living in Hispanic and Latino households, the prevalence of walking for transportation for greater than 10 minutes was higher in men (12.7%) than in women (10.0%). The prevalence of walking for transportation greater than 10 minutes decreased with time living in the U.S. for those born in Central America and the Caribbean Islands, but increased for those born in South America. According to NHANES, among Mexican-Americans, 46% of women and 51% of men reported doing moderate-intensity house or yard work in the past 30 days. More women (34%) than men (31%) engaged in greater than 10 minutes of moderate-intensity leisure-time sports and recreation in the last 30 days. Vigorous leisure-time activities (greater than 10 minutes in the last 30 days) were more prevalent in men (33%) than in women (24%). The most common leisure-time activities in Mexican-Americans were walking (14.9%), dancing (8.2%), and running (6.5%).

Conclusion or Significance:
Physical activity recommendations encourage accumulation throughout the day of activity in bouts greater than 10 minutes from occupation-related, transport-related, household-related, and leisure-time activity domains. Use of multiple surveillance systems provides information about multiple domains of lifestyle physical activity.

Race, Ethnicity, and Linguistic Isolation as Determinants of Participation in Public Health Surveillance Surveys

Authors: M. Link; A. Mokdad; H. Stackhouse

Objective:
To plan, implement, and evaluate programs designed to eliminate health disparities among racial and ethnic minority populations, public health officials, and researchers require valid and reliable public health surveillance data. Monitoring chronic disease and behavioral risk factors among such populations has, however, proven challenging. This research is designed to assess the degree to which there are disparities among minority populations in participation levels in public health surveillance efforts and to test alternative methods for reducing these disparities.

Setting: 
Monthly public health surveillance of the noninstitutionalized adult public in the 50 states and the District of Columbia conducted in 2003.

Method or Intervention:
The Behavioral Risk Factor Surveillance System (BRFSS) is a random-digit-dialed telephone survey of the noninstutionalized adult population (18 years and older) in the United States. County-level data from the 2003 BRFSS and 2000 U.S. Census are modeled using logistic regression to examine the effects of race, ethnicity, and linguistic isolation on six measures of survey participation (i.e., resolution, screening, cooperation, refusal, refusal conversion, and response rates).

Result or Outcome:
The study finds that even after adjusting for other factors such as socioeconomic conditions, average commute time, use of call screening technology, and level of data collection effort (other factors thought to be related to survey response), areas with higher percentages of African Americans, Hispanics, and those who do not speak English (particularly those speaking only Asian or Indo-European languages) were significantly less likely to participate in the public health surveillance. In response to this finding, the BRFSS is investigating two alternatives for reaching these underrepresented groups: 1) use of alternative survey modes, in particular providing translated hard-copy versions of the BRFSS by mail, and 2) use of specialized language line translation services to offer real-time translation of the BRFSS into languages beyond English and Spanish.

Conclusion or Significance:
The collection of valid and reliable data for public health surveillance in the United States is becoming challenging. Current methods increasingly underrepresent racial, ethnic, and linguistically isolated groups. As a result, the health problems and needs of these groups may be significantly underreported. The development of successful public health interventions and programs capable of reducing health disparities requires that monitoring systems be developed that are capable of tracking the public health of all groups.

Racial and Ethnic Differences in the Prevalence and Impact of Doctor-diagnosed ArthritisUnited States, 2002

Authors: J. Bolen; J. Sniezek; K. Theis; J.M. Hootman; C.G. Helmick; G. Langmaid

Objective:
To describe the prevalence and impact of arthritis among three racial and ethnic groups in the United States. Possible reasons for disparities are discussed and interventions described.

Setting: 
Sample of U.S. population.

Method or Intervention:
The 2002 NHIS sample adult core questionnaire was administered by personal interview to a nationally representative sample (n = 31,044) of the U.S. civilian, noninstitutionalized population aged >18 years; the overall survey response rate was 74.3%. Respondents were asked about health conditions, including doctor-diagnosed arthritis, arthritis-attributable activity limitations, arthritis-related pain, health behaviors, and access to and utilization of health care. Non-Hispanic blacks and Hispanics were oversampled to provide large enough sample sizes for analysis.

Result or Outcome:
About 42.7 million adults (20.8%) in the U.S. have doctor-diagnosed arthritis, with more than one-third reporting arthritis-attributable activity limitations and nearly one-third of those of working age (18-64) reporting arthritis-attributable work limitations. Compared with white non-Hispanics, black non-Hispanics had a similar prevalence of doctor-diagnosed arthritis but much higher proportions with activity limitation, work limitation, and severe pain. Hispanics had a lower prevalence of arthritis but a much higher proportion with work limitation and severe pain.

Conclusion or Significance:
Possible reasons for racial and ethnic disparities in the prevalence and impact of arthritis are lack of health care access and/or utilization leading to delays in seeking medical attention for joint problems; the presence of co-morbid conditions such as obesity, diabetes, heart disease, and cancer; and employment in jobs that are physically demanding. Due to sociocultural differences, it is also possible that racial and ethnic minority groups who do receive appropriate medical treatment for joint problems respond differentially to standard medical interventions. Programs to increase physical activity, decrease body weight, and teach people with arthritis to manage their disease can reduce the disabling effects of arthritis. The racial and ethnic differences in arthritis-attributable activity limitations, work limitations, and severe pain suggests that arthritis interventions may need to target minority populations in different ways. Their availability and accessibility for black and Hispanic populations with arthritis is crucial because the population of people with arthritis is expected to increase dramatically over the next 25 years as the population ages, and limitations due to arthritis are likely to increase dramatically as well. Without widespread implementation of effective interventions blacks and Hispanics will suffer disproportionately from arthritis-related limitations.

Socioeconomic Disparities in Smoking and Recent Cessation in Maine: Individual and Town Level Predictors

Authors: N. Sonnenfeld; D. Maines; S.V. Subramanian

Objective:
To prevent tobacco use, Maine and other states have implemented comprehensive programs that include local community mobilization components. However, state health departments rarely have sufficient data to provide community-specific statistics. In this paper, we illustrate that consideration of area level characteristics can enhance our understanding of socioeconomic disparities in smoking and smoking cessation in Maine.

Setting: 
Individual level data were obtained from the telephone-based Maine Adult Tobacco Use Survey from 4,713 white residents of 432 Maine towns in 1999 and 2000. Models of recent quitting included 1,006 current smokers and former smokers who reported quitting in the last year. Town demographic data were obtained from the year 2000 U.S. Census.

Method or Intervention:
Marginal and mixed regression methods were employed. Marginal results are presented.

Result or Outcome:
At the individual and household levels, educational attainment and living with a smoker were among the variables most strongly associated with increased odds of smoking and decreased odds of quitting. After adjusting for educational attainment, household income was not associated with recent quitting. At the town level, disparities were greater for recent quitting than for current smoking. Compared to towns with 90% or more high school graduates, residents in towns with less than 80% high school graduates and towns with 80-89% high school graduates had fewer recent quitters (odds ratio [OR] 0.35 [95 % confidence interval {CI} 0.19, 0.67] and 0.58 [95% CI 0.32, 1.06]) after adjusting for age, age at initiation, gender, education, marital and employment statuses, and living with a smoker. Towns with 90% or more high school graduates also had fewer smokers than those with fewer high school graduates (OR: 1.47 [95% CI 1.16, 1.86]).

Conclusion or Significance:
This analysis has several implications for programs aimed at reducing health disparities associated with smoking. First, the definition of socioeconomic disparity matters. We often discuss health disparities in relation to income, but at least for recent quitting, disparities related more strongly to education. Barriers associated with educational disadvantage might include limited literacy and lower perceived ability to quit. Second, households matter. Living with a smoker was a strong predictor of smoking behavior. Smoking cessation programs must target households, not individuals. Finally, the broader community matters. Even without data for individual towns, it is possible to identify characteristics of towns that matter. In this case, town educational attainment is associated with individual smoking behaviors, after controlling for individual characteristics. Interventions must address smoking-related disparities at multiple levels including the individual, household, and community.

State Cancer Profiles: A Data Portal for Comprehensive Cancer Control Planning

Authors: T.L. Fairley; C. Friedman; P.A. Wingo

Objective:
Describe how the State Cancer Profiles (SCPs), which were developed by the National Cancer Institute (NCI) and the Centers for Disease Control and Prevention (CDC) to provide a standardized system to characterize cancer burden, can be used for comprehensive cancer control planning for disparate populations.

Setting: 
The SCPs (http://statecancerprofiles.cancer.gov) are an interactive Web site which provides dynamic views of cancer statistics and is the most comprehensive site for such information. The SCPs highlight cancer incidence, mortality, and risk factor data collected from public health surveillance systems such as NCIs Surveillance, Epidemiology, and End Results program, CDCs National Program of Cancer Registries-Cancer Surveillance System, the National Vital Statistics System, and the Behavioral Risk Factor Surveillance System (BRFSS).

Method or Intervention:
Application of the SCPs for comprehensive cancer control planning and to identify special populations who may be disproportionately affected by cancer.

Result or Outcome:
The SCPs include data for 21 cancer sites, eight of which have evidence-based control interventions shown to prevent or reduce the burden of cancer. Cancer incidence and mortality statistics include counts, rates, and trends by sex, age, and race/ethnicity. Prevalence of risk factors, screening, Healthy People 2010 objectives, and demographics are also available.

Conclusion or Significance:
The State Cancer Profiles allow users to quickly explore potential disparities at the national, state, and county levels and provide visual support for determining where and how to focus cancer control efforts. Future plans for the Web site include an expansion of the current race/ethnicity data, socioeconomic status indicators, and other measures of disparity.

STEPS to a HealthierUS Landscape of Surveillance and Evaluation Data Resources

Authors: S.G. Russell; G. MacDonald; D. Garcia

Objective:
To share the collection of national, state, and local surveys and tools, including methodology, protocols, measures and indicators, and surveillance and evaluation data, which may be useful for states and communities conducting surveillance or evaluation activities related to reducing the prevalence and impact of common chronic health conditions: diabetes, asthma, and obesity.

Setting: 
All funded communities of the STEPS to a HealthierUS program and available to the public health community at large.

Method or Intervention:
The surveillance and evaluation data resources were researched, reviewed, prioritized, and organized into four tables: 1) Multiple Preventable Diseases and Risk Factors, which crosscut a variety of STEPS-related conditions, risk factors, or health care issues; 2) Categorical Health Conditions and Risk Factors, which address a specific health condition  asthma, diabetes, or obesity  or related risk factors (nutrition, including eating behaviors and diet, physical inactivity, or tobacco use); 3) Health Systems and Clinical Settings, which focus on health care access and utilization, and quality of health care; and 4) Health Disparities, which address racial/ethnic populations who are affected with a disproportionate prevalence of asthma, diabetes, and obesity and/or related risk factors.

Result or Outcome:
The landscape provides a unifying framework of more than 100 sources of data and tools to assist chronic disease programs that are conducting surveillance or evaluation. The landscape: provides key information on each resource to help state and community programs identify available, timely, and cost-effective tools and data that are relevant to planning, monitoring and evaluation; prioritizes the list of resources to assist the funded states and communities in expediting the process of evaluation data collection, analysis, and reporting; and identifies surveillance data sources that are also used to assess the STEPS-related Healthy People 2010 objectives.

Conclusion or Significance:
Although the scope of the resources is based primarily on federal government sources, in some cases non-governmental sources are included because of their unique focus on a target population, a categorical health condition or related risk factor, system or setting, data collection or analysis method, or a combination of one or more.

Strategies for Surveillance of Autoimmune and Neurological Diseases

Authors: D. Williamson; L. Wagner; J. Shire

Objective:
To discuss the methods and findings of a multiple sclerosis (MS) prevalence study, to evaluate the efficiency of the methods used, and to provide recommendations for future surveillance strategies of autoimmune and neurological diseases.

Setting: 
It is unknown how many people have MS, but an estimated 250,000 to 400,000 people in the United States are affected with this disease. MS primarily affects women, people in the 30 to 60 year-old age group, and Caucasians. Approximately twice as many women are affected by MS than men. Unfortunately, basic epidemiologic data, such as accurate estimates of the incidence and prevalence of this disease, are not available. To address this deficiency, the Agency for Toxic Substances and Disease Registry (ATSDR) awarded funding to three health departments to develop methodologies for determining the prevalence of MS in selected geographic areas within their states. The three geographic areas included in this study were: 1) Lorain County, Ohio; 2) the cities of Sugar Creek and Independence, Missouri; and 3) 19 counties surrounding Lubbock, Texas.

Method or Intervention:
The primary data source for case ascertainment was medical records from neurologists practicing in the study areas. Additional data sources included general practitioners, MS patient advocacy groups, vital statistics data, hospital discharge data, and nursing homes. Records were considered for inclusion in the case count if patients had an office visit between January 1, 1998, and December 31, 2000. Abstracted records of all potential cases were evaluated by a reviewing neurologist according to the Poser criteria of 1983.

Result or Outcome:
Of the 863 abstracted records, 744 were classified by the reviewing neurologist as Definite or Probable MS. The majority of MS cases were identified through neurologists offices. MS prevalence was lowest in Texas (43 per 100,000) and increased as latitude increased (Missouri: 88 per 100,000 and Ohio: 159 per 100,000). MS prevalence among women ranged from 2.6 to 4.1 times higher than the prevalence among men in the three study areas. Prevalence was higher in non-Hispanic whites and individuals 50 to 59 years old.

Conclusion or Significance:
This study demonstrates that the distribution of MS varies considerably with respect to geography, sex, and race/ethnicity. Since the review of medical records provided sufficient data to verify MS diagnosis, we propose that future surveillance activities of MS and other autoimmune and neurological diseases be based on ICD-9 codes as indicated on the medical record.

Success Stories! California and New York Reduce Smoking and Health Disparities

Authors: B. Leistikow; A. Tsodikov

Objective:
United Kingdom officials report that smoking is the leading cause of health inequities. So we assessed associations between U.S. health inequities and both: 1) smoke exposure and 2) state smoking reductions.

Setting: 
The entire United States, California, New York, and the U.S. less Calif. and N.Y. (US-CANY).

Method or Intervention:
A natural quasi-experiment with disparate state and gender-ethnic group cumulative tobacco smoke exposures (smoke loads) and comprehensive versus cigarette tax tobacco control changes. Specifically, lung cancer rates are a smoke load biomarker, integrating in-utero, early initiation, and acute and cumulative dose effects of smoking. So we assessed correlations between lung cancer and all-cause 1999 age-adjusted death rates across the U.S.s eight major gender-ethnicity groups. California and New York each virtually halved their per capita tobacco sales since 1988. So we contrasted Calif. and N.Y. health inequities trends versus the remaining 48 states trends. We assessed gaps each year from 1979-2001 between: a) Calif. or N.Y. versus remaining U.S. death rates and b) White versus African American death rates.

Result or Outcome:
1) Lung cancer and all-cause death rates are highly correlated (R-squared>0.8, P<.05) across gender-ethnicity groups, with both rates rising in sync across groups from lowest (Asian and Hispanic women) to highest (African American men). 

2) From 1988-2001, African American lung and all-sites cancer and all-cause death rates fell disproportionately in Calif. and N.Y. to levels: a) more than 8% and 17%, respectively, below the remaining U.S.; and b) in N.Y. to rates now U.S./Calif.-N.Y. non-Hispanic white death rates.

Conclusion or Significance:
Smoking may cause, and reducing smoking may reduce, much of U.S. health disparities.

Temporal Changes in the Geographic Disparity of Heart Disease Mortality

Authors: M. Casper; I. Williams; K. Greenlund; K. Moore; E. Tassone

Objective:
To document the temporal changes in geographic disparities of heart disease at the county level from 1962 through 2002.

Setting: 
All counties within the United States

Method or Intervention:
For the years 1962 through 2002, annual county-level data regarding the number of heart disease deaths listed as the underlying cause of death according to the following ICD codes (ICD-7 400-402, 410-443; ICD-8 390-398, 402, 404, 410-429; ICD-9 390-398, 402, 404-429; and ICD-10 I00-I09, I11, I13, I20-I51) were obtained from the National Center of Health Statistics. County-level data on population size were obtained from the Bureau of the Census. County-level age-adjusted (using the 2000 U.S. standard population) and spatially smoothed heart disease death rates were calculated for ages 35 and older. Spatial smoothing was performed by calculating a spatial moving average. Maps of the age-adjusted and spatially smoothed heart disease death rates were mapped in five-year increments using ArcView.

Result or Outcome:
The maps show dramatic changes in the pattern of geographic disparities in heart disease death rates from 1962 through 2002. Whereas during the early 1960s the majority of counties in the highest quintile of mortality were located in the northeast region of the United States, by the late 1990s and early 21st century, the majority of counties in the highest quintile were located in the Mississippi Delta Region and Appalachia. The substantial declines in heart disease death rates that occurred during this time period are reflected in the persistent downward shifts in the range of heart disease death rates across the counties during this time period.

Conclusion or Significance:
These maps provide viewers with important information regarding the dramatic changes that have occurred in the geographic disparities of heart disease mortality over a relatively short time period. These maps provide critical insights into understanding the determinants of geographic disparities in heart disease mortality and highlight the important role that the quality of the social environment  where people work, live and play  can have on the burden of heart disease in a community.

The Incidence of End-Stage Renal Disease, Georgia, 1999-2002

Authors: K. Abe; K. Mertz; K. Powell; M. Wu; P. Cho

Objective:
We sought to assess racial disparities in the burden of end-stage renal disease (ESRD) and its contributing causes in Georgia.

Setting: 
In the United States, approximately 80,000 people per year are diagnosed with ESRD, a condition requiring dialysis or kidney transplant to sustain life. The primary causes of ESRD are diabetes and hypertension for the majority of patients.

Method or Intervention:
ESRD Network 6 is part of the United States Renal Data System (USRDS), a nationwide 18-network ESRD surveillance system that collects information on newly diagnosed and chronic ESRD patients. We used data from ESRD Network 6 to calculate age-adjusted ESRD incidence rates in Georgia and to describe the demographic characteristics of newly diagnosed patients from 1999 through 2002. We also used data from the Behavioral Risk Factor Surveillance System (BRFSS) to compare the prevalence of diabetes (2002) and hypertension (2001) among blacks and whites >18 years old in Georgia.

Result or Outcome:
Each year more than 3,000 persons in Georgia are diagnosed with ESRD. From 1999 through 2002, the age-adjusted incidence rate for ESRD was higher in Georgia (42 per 100,000) than in the nation (33 per 100,000). Of the newly diagnosed ESRD patients in Georgia, 57% were less than 65 years of age and 50% were female. Diabetes was the primary cause of 40% of ESRD cases, and hypertension was the primary cause of 30% of ESRD cases. Although adult blacks were 1.3 times more likely than whites to have diabetes and 1.2 times more likely than whites to have hypertension, blacks were four times more likely than whites to develop ESRD.

Conclusion or Significance:
ESRD is a major public health burden, especially among blacks. Although a higher percentage of blacks than whites suffer from diabetes and hypertension, the racial disparity in the prevalence of ESRD is much greater. The incidence of ESRD might be reduced by: 1) educating patients with diabetes and hypertension of the importance of diligent self-management and timely medical care, and 2) encouraging physicians to monitor the renal function of their patients with diabetes and hypertension.

The Status of the States: Benchmark Scoring for the State Physical Activity Program

Author: T.M. Vehige

Objective:
Assess health education competencies across the 50 states as they relate to physical activity disparities in order to focus technical assistance (TA) efforts of CDCs Physical Activity and Health Branch (PAHB).

Setting: 
n/a

Method or Intervention:
Five benchmarks were created: 1) use of public health data and scientific information for strategic planning; 2) diverse partnerships; 3) use of evidence-based strategies; 4) evidence of sound planning and evaluation; and 5) sustainability. Each state was scored on a 5-point scale using a variety of existing data sources. The top two scores were combined to create a high category and the bottom two scores = low. Chi-square analyses were performed to compare the proportion of high scores across funding (yes/no), FTE (>1 vs. <1), and coalition (yes/no).

Result or Outcome:
High scores for benchmarks 1 through 5 were 54%, 48%, 34%, 40%, and 40%. Low scores were 20%, 20%, 38%, 40%, and 44%. States with obesity or STEPS funding scored higher on benchmarks than states without funding (P< 0.05). States with 1 FTE scored higher on benchmark 1 (P< 0.05) and slightly higher on benchmarks 2 through 5 (ns). States with coalitions scored higher on benchmarks 1, 3, and 4 (P< 0.05).

Conclusion or Significance:
Scores indicate that approximately one in five states could improve in the use of evidence-based strategies and practicing sound planning and evaluation approaches. Furthermore, there appears to be limited sustainability in many states for physical activity programming. PAHB uses these benchmarks to guide their technical assistance to ensure states are addressing disparities.

Tracking Health-Related Quality of Life (HRQOL) to Identify Health Disparities and Guide Health Policy

Authors: D.G. Moriarty; M.M. Zack; R. Kobau; H.S. Zahran

Objective:
To provide information about public domain HRQOL data, Internet resources, and methods that can be used to identify health disparities, guide health policy, and track results.

Setting: 
HRQOL data collected in 50 states and the District of Columbia during 1993-2001 in the Behavioral Risk Factor Surveillance System (BRFSS) and during 2001-2002 in the National Health and Nutrition Examination Survey (NHANES).

Method or Intervention:
The CDC HRQOL-4  a standard core set of Healthy Days measures  has been asked of all participants aged 18 years and older in the BRFSS and of all examinees aged 12 years and older in the NHANES. Data have been analyzed to identify U.S. health trends and disparities by race/ethnicity, socioeconomic status, geography, and other demographic factors. The CDC HRQOL-4 questions assess self-rated health and the self-reported number of days in the previous 30 days when physical health was not good, mental health was not good, and activities were limited due to poor health. Estimates of overall unhealthy days (defined as days in the previous 30 days when a respondents physical or mental health was not good) and frequent mental distress (defined as 14 or more reported mentally unhealthy days during the previous 30 days) were also computed to provide a summary measure of population health and an indicator of population mental health. Additional information, prevalence data, links, and references are on the CDC HRQOL Web site at http://www.cdc.gov/hrqol.

Result or Outcome:
The mean recent unhealthy days for U.S. adults rose from 5.2 days per month in 1993 to 6.0 days in 2001 in the BRFSS. During 1993-2001, HRQOL worsened in most demographic groups  especially adults aged 45-54 years, high school graduates without further education, and those with annual household incomes less that $50,000. In 18 states, unhealthy days increased; only North Dakota reported a decrease. American Indians and Alaska Natives consistently reported the worst HRQOL of all race/ethnic groups during this period  including 14.4% who reported frequent mental distress (FMD)  in contrast to Asian/Pacific Islanders who consistently reported the best HRQOL  including only 6.2% who reported FMD. Adult participants in the 2001-2002 NHANES reported similar HRQOL levels and racial/ethnic and socioeconomic disparities in HRQOL.

Conclusion or Significance:
Population HRQOL tracking can be used to identify and prioritize population health needs and disparities and have the potential to track improvements over time.

Trends in Mortality and Hospitalizations for Valvular Heart Disease in the United States, 1980-2000

Authors: H.D. Shoob; C. Ayala; A. Hyduk; J.B. Croft; G.A. Mensah; Z. Zheng

Objective:
Valvular heart disease (VHD) is the underlying cause for 20,000 deaths annually and a contributing factor for more than 42,000 deaths from heart failure, stroke, and sudden death each year in the U.S. This study provides a national perspective on the impact of VHD, which includes disorders of the mitral, atrial, and tricuspid valves.

Setting: 
National Vital Statistics Data and Hospital Discharge Data.

Method or Intervention:
Death certificate data from the National Vital Statistics System and information on discharges from the National Hospital Discharge Survey from 1980-2000 were used to obtain age-adjusted and age-specific estimates of VHD as any contributing cause of death or hospitalization. VHD was defined by ICD-9 codes 424.0, 424.1, 424.2, 424.3, or 424.9 during 1980-1998 and ICD-10 codes I34-I38 during 1999-2000.

Result or Outcome:
Death rates (per 100,000) with VHD as any contributory cause increased from 9.1 in 1980 to 15.5 in 2000, were higher for men than women, higher for whites than blacks, and increased with age. Almost 90% of all deaths with reported VHD occurred among adults aged >65 years; 57% were among women. The number and age-adjusted prevalence (per 100,000) of hospitalizations with VHD as any listed diagnosis increased from 307,862 (152.9) in 1980 to 906,822 (330.9) in 2000. Almost 30% of hospital diagnoses for VHD occurred among persons aged <45 years; 61% were among women.

Conclusion or Significance:
Mortality from VHD increased over the last two decades. Women and older adults represent the majority of decedents and hospital patients with VHD. Public health initiatives should support public and professional education efforts to increase awareness that early detection is vital for prompt, effective treatment.

Trying to Quit: Low-Income Smokers Access to Cessation Care in a Managed Care Environment

Authors: M. Fleming-Moran; K. Li; J. Gibson; M. Garland

Objective:
To determine the proportion of current smokers in a primary care provider (PCP), managed care, safety net insurance program having access to at least one cessation advisement visit in the previous year. Does the length of enrollment in the program (<1, 1, 2+ years) increase a smokers chance of getting cessation advice?

Setting: 
Federally funded primary care clinics are coordinated by a state universitys medical school in a Midwestern urban setting. The client population is predominantly minority, Medicaid/Medicare, and/or working poor. Advantage-program clients (study population) meet 200% or less of federal poverty guidelines, but are not Medicaid-eligible.

Method or Intervention:
Telephone CATI-structured surveys were administered in English or Spanish to 731 Advantage enrollees, representing 317 new clients (<1 year), 281 one-year clients, and 133 third-year enrollees. Descriptive analyses of the 295 current smokers (Behavioral Risk Factor Surveillance System definition) by gender, ethnicity, age, education, knowing their PCP, and other characteristics, and receiving smoking cessation advice in the past year (n = 186), used Chi-square analyses. Predisposing (gender, age, ethnicity), enabling (education, know PCP), health need (coronary heart disease [CHD] risk scale), and time in Advantage enrollment were tested in a logistic regression model, using a forward selection process.

Result or Outcome:
Advantage smokers who are female (72%), white (70.4%), over 65 (85.0%), who know their PCP (68.5%), and have at least one other CHD risk factor (obesity, hypertension, high cholesterol) (89.3%) are more likely to have at least one cessation visit than male (49%), minority (54.5%), younger smokers who do not know their PCP (51.0%), or have no other CHD risk factors (46.2%). Time in the Advantage program is also associated with getting 1+ cessation visits (>1 year: 71.2%; <1 year: 53.1%). Each additional CHD risk factor beyond smoking doubles the likelihood of cessation advice (O.R. 2.02 [Confidence interval {CI} 1.5-2.8]); female gender (1.95 [1.1-3.3]) and age over 65 (1.5 [1.09-2.12]) increased likelihood; minority status reduced chances of advisement (0.41 [.24-70]). Time in the Advantage program did not enter the model.

Conclusion or Significance:
Low-income populations have greater prevalence of smokers. Safety net programs increase access to and continuity of primary care. While the Advantage program successfully routes high-risk smokers to cessation care, more than 45% of smokers reported no provider advice to reduce their (and others) exposure. Use of administrative data and provider prompts to target younger smokers, working-age men, and minorities would reduce costs associated with adverse CHD, respiratory, and reproductive outcomes in these client populations.

Using Cancer Registry Data to Describe Possible Disparities in Patterns of Care for Three Cancers

Authors: L.G. Alley; J. Wike; S. Stewart; C. Friedman

Objective:
The Institute of Medicine (IOM) recommends that information from existing data systems be used to assess the quality of cancer care and quality of data collected in the United States and to evaluate variations in adherence to established standards of care. In response, CDC conducted a three-year study to assess the quality of data collected by population-based, central cancer registries and to determine the extent to which patients are receiving appropriate stage-specific treatments.

Setting: 
Eight population-based cancer registries funded by CDCs National Program of Cancer Registries (NPCR), a program that covers 96% of the U.S population.

Method or Intervention:
Study cases were derived from random samples of patients, diagnosed with localized breast and prostate cancers and stage III colon cancer, receiving cancer care within the geographic areas covered by the participating registries between 1996 and 1998. Data sets containing information on a subset of study variables collected in the original, routine registry operations for identified study cases were also submitted to CDC. To assess the patterns of care received by study cases, detailed clinical data on treatment and patient, facility, and tumor characteristics were re-abstracted from hospital and non-hospital medical records by trained study staff at each study site. Study variables such as age, race/ethnicity, socioeconomic status, and health insurance are being examined relative to whether and the extent to which they may contribute to disparities in patterns of care received. The completeness and validity of routinely collected registry data also are being assessed by comparing a subset of the re-abstracted data with the same variables contained in the original registry record for each study case.

Result or Outcome:
Two preliminary datasets were submitted to CDC at pre-determined designated points in the project. Extensive work has been done to standardize the data format and content of these preliminary datasets in preparation for the final consolidated data submission in December 2004. Appropriate aggregated results will be presented at the March 2005 conference.

Conclusion or Significance:
Results from this study will add significantly to understanding the extent to which appropriate stage-specific treatments for the three cancers are being used and will help identify groups of patients (e.g., by age, racial/ethnic groups) who are receiving less than adequate care.

Using the Perinatal Periods of Risk (PPOR) Approach for Reducing Health Disparities in Feto-Infant Mortality 

Authors: J. Skala; A. Johnson

Objective:
To use the Perinatal Periods of Risk (PPOR) approach to identify risk factors which reduce racial and ethnic disparities in feto-infant mortality.

Setting: 
Since 1997, CityMatCH has worked with the CDC, March of Dimes and, community partners to define, test, and disseminate the PPOR approach in U.S. urban communities to improve womens and infants health. CityMatCH utilized its Practice Collaborative (PC) model with 12 member cities to address racial and ethnic disparities in feto-infant mortality. The PPOR approach divides or maps fetal-infant mortality by birthweight and age of death into four strategic prevention areas: maternal health/prematurity, maternal care, newborn care, and infant health. The division of feto-infant mortality enables communities to identify, further investigate, and develop strategies with the greatest opportunities for local impact.

Method or Intervention:
From 2000 to 2002, the PPOR approach was used in the PC to build community and analytic readiness, to map and further investigate city-specific feto-infant mortality, and to translate findings into targeted community-driven actions to address racial and ethnic health disparities. The PC provided selected community action teams with strategic leadership, scientific support, effective cross-communication, structured peer exchange, continuous assessment, and promotion of data-driven policy and program decisions to address health disparities.

Result or Outcome:
All PPOR-PC cities found the widest gaps and greatest excess of feto-infant deaths in the Maternal Health/Prematurity (VLBW 24 weeks) Period of Risk cell. The overall excess (compared to the rates of a national reference group) ranged from 3.9 to 14.9. VLBW deaths alone contributed from 22.9% to 73.7% of the overall excess of mortality. According the national 1998-2000 PPOR analysis, investigating feto-infant deaths to women 20 + age and 13+ years of education, the rate for black non-Hispanic women (6.4) is almost triple for the rate for white non-Hispanic women (2.2) in the maternal health/prematurity cell. In fact, the maternal health/prematurity rate for black non-Hispanic women (6.4) was more than the overall feto-infant mortality rate for white non-Hispanic women (5.8). As a result, many of the PC cities focused on preconception health for African American women. Interventions primarily focused on factors associated with diabetes and pregnancy-related hypertension.

Conclusion or Significance:
All participating cities report that PPOR is an effective approach for addressing health disparities with targeted prevention strategies. The PC has been instrumental in developing cities capacity to conduct PPOR analysis in the context of community change to reduce factors that lead to health disparities in maternal and child health.

Utilizing Multiple Data Sources to Understand Disparities and Focus Asthma Interventions in Minneapolis/St. Paul

Author: J. Heins

Objective:
To share the experience of a community-based project in utilizing multiple data sources in focusing interventions and suggest strategies for adopting this methodology in other settings.

Setting: 
The American Lung Association of Minnesota, in collaboration with the Healthy Learners Board, received a seven-year, up to $6 million Controlling Asthma in American Cities Project (CAACP) grant from the CDC to develop and implement a five-year strategic plan to improve childhood asthma in Minneapolis and St. Paul.

Method or Intervention:
To monitor the impact of this projects efforts, four outcome measures were identified, including hospitalizations, emergency department visits, symptom-free days, and absenteeism of students with asthma. Through the monitoring of these outcome measures, the CAACP is not only able to track its impact, but also better understand community disparities and focus interventions more effectively for individuals and communities. Presenters will discuss the data collection methods for the four outcome measures, how the measures together provide a clearer picture of children with uncontrolled asthma in Minneapolis and St. Paul, and how the data has been used to guide the projects strategic planning.

Result or Outcome:
Specifically, presenters will discuss: 1) Advantages and limitations of hospitalization and emergency department visit data. 2) Methods and findings from a symptom-free day survey, printed in English, Spanish, Hmong, and Somali, which was sent to the parents of students known to have asthma in kindergarten to 8th grade in both Minneapolis and St. Paul Public Schools. The survey measured the frequency of childrens daytime and nighttime asthma symptoms, inhaler use, and functional limitations. A 50% return rate was achieved. Presenters will discuss methods to identify and reach parents of children with asthma, follow-up methods, and incentives. Information about geographic location (ZIP code), demographics, race/ethnicity, and socioeconomic status will be shared. An itemized budget for this survey will also be shared. 3) Absenteeism data for children with asthma compared with the districts general student body from two large urban school districts will be presented along with the methods for obtaining absenteeism data. 4) How these multiple data sources have been utilized in strategic planning. The CAACP used these four outcome measures to tailor their strategic plan and focus their resources for childcare provider in-service trainings, school asthma classes, group asthma education for families, and environmental assessments and modifications.

Conclusion or Significance:
Utilization of multiple data sources has been an effective planning tool for intervention to most appropriately focused resources within a diverse community.

Weight Loss Surgery in the United States, 1995-2002

Authors: C. Mehrotra; M. Serdula; T.Naimi; L. Kettle-Khan; D. William

Objective:
To assess trends in weight loss surgery (WLS) and associated charges in the U.S. and to assess characteristics of WLS recipients.

Setting: 
In the U.S., the increase in morbid obesity has created tremendous demand for weight reduction interventions. Few population-based studies have assessed trends in WLS procedures and their associated charges, nor have they examined the characteristics of those undergoing WLS procedures.

Method or Intervention:
We analyzed data from the National Inpatient Sample  the largest all-payer hospital inpatient care database in the U.S.  from 1995-2002 and collected information from 1,000 hospitals from 35 states in 2002.

Result or Outcome:
Between 1995 and 2002, the number of WLS procedures increased from 7,592 to 69,113 (rate ratio 8.4, P<0.001). The highest rate of WLS was among 40- to 49-year-olds (52.4 per 100000), but the largest increase was observed among those in the 50 to 59 years of age group (rate ratio 11.1, P <0.001). Women accounted for most procedures (85%) throughout the study period. Inflation-adjusted total charges for WLS increased from $198 million to $1,973 million (an increase of 895%), and the inflation-adjusted average charge per procedure increased by 32%, despite the fact that average length of stay declined significantly. 

Conclusion or Significance:
WLS surgeries increased dramatically from 1995 to 2002, and WLS has increased most among older adults and men. However, charges for these procedures have increased at an even faster pace, even after adjusting for inflation. Given the importance of obesity, and given the cost and potential complications associated with WLS, prospective studies about the long-term efficacy and cost effectiveness of WLS are urgently needed.

Policy and Legal

Diabetes Awareness, Training, and Action Program: North Carolinas Response to the Care of School Children with Diabetes Law

Author: P. Hudson Collins

Objective:
To convey information, materials, and strategies used in implementing the statewide Diabetes Awareness, Training, and Action (DATA) Program in North Carolina.

Setting: 
All 2,300 public schools in N.C. where a child with diabetes is enrolled.

Method or Intervention:
The N.C. Department of Public Instruction, the N.C. Department of Health and Human Services, N.C. Diabetes Advisory Council, American Diabetes Association, Wake Forest Baptist University Medical Center, Wake Area Health Education Centers, Blue Cross Blue Shield of N.C. Foundation, N.C. Healthy Schools, and the Cancer Control Branch all collaborated to respond to SB 911, The Care of School Children with Diabetes. This included forming a state-level task force to respond to the law; developing and producing training materials; designing and implementing six regional trainings across the state using a train-the-trainer model; seeking private funding for the project; developing the care plans and all reporting forms; creating parent awareness; and providing evaluation reports to various state agencies. The law requires all school children who have diabetes to have an Individual Diabetes Care Plan in place, upon parental request. In addition, it requires schools where children with diabetes are enrolled to provide general training for all faculty and support staff, and two volunteer emergency care providers for students with diabetes.

Result or Outcome:
All students with diabetes have a plan of care in place, which is determined by the primary care provider, school, and parent. Emergencies due to diabetes have decreased and general awareness and acceptance of procedures related to diabetes control are better understood, accepted, and monitored in the school setting.

Conclusion or Significance:
An Individual Health Care Plan should be in place for children with any type of health care need. While diabetes was the test case in this situation, children with all chronic conditions should have access to care plans to avoid the need for a state law that relates to just one chronic condition.

Educating California School Board Members: Aligning Policies for Student Health and Achievement

Authors: P. Agron; V. Berends

Objective:
To share the development, implementation, and outcomes of a three-year intervention aimed to educate California school board members about the important role school nutrition policies can play to increase the health and academic achievement of students.

Setting: 
California Project LEAN (CPL), the California School Boards Association (CSBA), the University of South Florida, the California Parent Teachers Association, and 10 regional collaboratives worked together to educate school board members across California. Special outreach efforts were directed toward school districts serving low-income children.

Method or Intervention:
The purpose of this project was to evaluate the effectiveness of a statewide communication campaign to increase school district nutrition policies. Formative research was conducted to understand the factors that influence policy decision-making for California school board members and included a literature review, a media analysis, key informant interviews, and a statewide survey of California school board members and superintendents. The formative research served as the foundation for the development of a social marketing plan and the intervention strategies. Research indicated that CSBA was highly respected by its membership; therefore, the following activities were implemented jointly by CSBA and CPL: 1) the development of a Healthy Food Policy Resource Guide, 2) advertisements and articles published in CSBA communications, 3) trainings of more than 300 school board members across the state, and
4) local mobilization led by CPL regional coordinators.

The evaluation of this three-year project consisted of surveys of school board members that received the guide and attended a training; key informant interviews; and a post-survey of school board members and superintendents.

Result or Outcome:
Evaluation findings suggest that the guide was useful to school board members and that members who attended trainings planned to raise the issue of nutrition policy for discussion at a school board meeting. A number of California districts have established policies that support healthy eating. Post-surveys and post-interviews are currently being analyzed, and final data will be available by January 1, 2005. The impact of this project continues to be realized as more school districts request assistance to mobilize to offer healthier foods for their students.

Conclusion or Significance:
The nation is experiencing an unparalleled obesity epidemic. Many of the foods children eat at school are high in fat, sugar, and calories. These practices can contribute to inadequate diets and the acquisition of poor dietary habits. Developing targeted campaigns with respected education partners can provide local policy makers with resources to help them establish policies to support healthy eating.

Legal Barriers in the Care of People with Substance Use Disorders

Author: E.M. Edwards

Objective:
To convey the impact of legal barriers on access to substance abuse treatment and recovery from addiction.

Setting: 
A national policy panel of physicians, lawyers, and others  chaired by Kurt Schmoke, former mayor of Baltimore and current dean of Howard University School of Law  reached unanimous consensus on two principles and 10 recommendations to end legal and social discrimination against people with substance use disorders.

Method or Intervention:
The panel received public input through hearings and written testimony and developed a 30-page report, which will be distributed at the conference.

Result or Outcome:
People seeking treatment or recovery from alcohol or other drug disease should not be subject to legally imposed bans or barriers based solely on their addiction.

Conclusion or Significance:
Legal barriers exacerbate health disparities by denying people with addictions health care, food, education, and shelter solely because of their health problems. Fewer people reach recovery, and other social problems that also impact health, such as homelessness and crime, continue.

Minorities as Research Subjects: Rights and Responsibilities

Author: J.R. Leonard

Objective:
To convey rights and responsibilities of research subjects based upon federal regulations and to describe CDC requirements for inclusion of women and racial and ethnic minorities in research.

Setting: 
Research involving human subjects is required to better understand, control, and reduce health disparities. Thousands of biomedical and public health research studies are conducted annually. While minorities are disproportionately represented by poor health, they are usually only a small percentage of participants or subjects in this research. The Tuskegee study of untreated syphilis in the Negro male also known as The Tuskegee Syphilis Study is but one example of why minorities may not participate in biomedical and public health research. It is important that minorities not be excluded from research from which they may benefit or which is designed to improve general health. It is equally important that minorities be aware of their rights and responsibilities to assure their protection as research participants.

Method or Intervention:
Health care professionals conducting U.S. Department of Health and Human Services-sponsored research involving human subjects must maintain compliance with the federal regulations, 45 CFR 46, Protection of Human Subjects.

Result or Outcome:
This poster provides a discussion of the 45 CFR 46 definition of research and human subjects, a general description of federal regulations on the protection of human subjects, the roles and responsibilities of research investigators and research participants, and an overview of the Institutional Review Board (IRB). Additionally, the CDC policy, Inclusion of Women and Racial and Ethnic Minorities in Research, is discussed.

Conclusion or Significance:
Increased participation of minorities as research subjects may lead to a better understanding of health disparities and more effective interventions designed to reduce health disparities.

Overcoming Barriers in Access to Specialized Health Care Services

Author: D. Doran

Objective:
Identify factors limiting access to specialized services and develop strategies to overcome these barriers, focusing on barriers that are amenable to resolution through health care policy, regulation, or statute, and on innovative strategies that could be implemented within the resource constraints of our health care system.

Setting: 
Interdisciplinary statewide initiative.

Method or Intervention:
A Quality Initiatives Workgroup (QIW) of the New York State Public Health Council (PHC) was convened to look specifically at issues and potential resolutions associated with disparities in access to specialty care for New York residents. Members of the PHC and experts from pertinent fields comprise the work group. In addition to gathering input from QIW panel members on clinical, analytical, and financial issues, the group set out to gather information through roundtable discussions with a broad range of experts (including regulators, insurers, providers, researchers, patient advocates, medical educators, and professional societies), literature reviews, and responses from a survey aimed at gaining a broad perspective on barriers and potential solutions to accessing specialty care.

Result or Outcome:
The QIWs review of expert testimony, questionnaire responses, and pertinent research conclude that disparities in access to care exist and that these disparities have a significant and costly impact on the overall health of New York residents. Factors associated with barriers to appropriate health care fall into the following categories: Health care delivery issues (including provider awareness and implementation; patient-provider communications; and system navigation issues); availability of services; insurance coverage; and applied research and quality initiatives. Specific issues, goals, and recommended actions are identified in each of these areas. Sufficient evidence is available to support implementation of well-planned strategies aimed at reducing existing inequities. In evaluating strategies for overcoming barriers, the QIW recommends an initial focus on seven clinical areas: heart disease, stroke, cancer, major orthopedic conditions, diabetes, end-stage renal disease, and HIV/AIDS. These diseases impact a substantial portion of the population and have relatively mature and accepted clinical treatment protocols (thus making them amenable to monitoring), and inequities to care have been identified in the literature for them.

Conclusion or Significance:
Recommended actions  some of which are being implemented  will be discussed. These recommendations will provide a stimulus, foundation, and preliminary framework for appropriate groups to build upon, offer guidance for evaluating the provision of specialized services, identify challenges that cut across the health care sector, and provide a road map for remediation. This is a call to action!

The USDA Fresh Fruit and Vegetable Snack Program: Effective Policies Promoting Exciting Environments in Schools

Authors: T. Fox; D. Beth; L. Enote

Objective:
To raise awareness about the exciting USDA Fresh Fruit and Vegetable Program and motivate participatns to take action, influence policy, and promote healthier school environments, while impacting childrens health.

Setting: 
The free fruit and vegetable snack program is operating in eight states and three tribal organizations (approximately 220 schools and more than 120,000 students). One state and one tribal nations experiences will be highlighted.

Method or Intervention:
Federal legislation in 2002 and 2004 provided funding to states to implement policies and interventions to provide free fruits and vegetables to school children. One of the largest public health initiatives to increase fruits and vegetable consumption among school children (regardless of economic status), the fruit and vegetable program has been implemented and evaluated formally and informally. Results from an evaluation done in the original four states proved the program a huge success, leading to its expansion as part of the Child Nutrition Reauthorization Act of June 2004. Collaboration and partnering among a variety of organizations and individuals, including public health and school nutrition professionals, fruit and vegetable industry representatives and organizations, policy makers, students, and school officials, helped drive this policy change and turn this exciting pilot into a permanent, funded program.

Result or Outcome:
The USDA evaluation conducted on the first four states and a tribal organization found that when 64,000 school students had access to free fruits and vegetables throughout the school day, amazing things started to happen. Students: Ate more fruits and vegetables; ate less high calorie, high fat vending choices; ate more healthy meals as part of the school lunch program; had better attention spans; felt better; and had fewer discipline problems. The program transformed schools into models of healthy behavior, improved learning environments, and promoted health equality by serving snacks, free of change, to all school children.

Conclusion or Significance:
This session will highlight the exciting fruit and vegetable program and discuss ways to expand it, through policy initiatives, to additional states, schools, and tribal nations. Participants will learn how to impact policy and advocate for change to promote this successful program.

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