Community based participatory approaches to address health disparities in Hawai'i: recent applications in cancer prevention, detection and treatment programs

Assessment of recent trends in the prevalence and incidence of cancer, and its associated risk and protective factors in the State of Hawai'i illustrate that there are definite ethnic, socio-economic, and geographic health disparities. Disparities in access to health care are reflected in decreased and under utilization of all types of preventive cancer screening tests and decreased proportions of people with health insurance coverage. Increases in obesity mirror U.S. national trends and disproportionately affect certain ethnic groups and those with low income. Tobacco use has increased among at-risk populations including: certain ethnic groups, those with low-income and/or low education and those in rural areas. Data that reveal continuing or worsening health disparities imply that either the old methods have not been effective and/or resources are not available or are not being applied to address such disparities. Promising methodologies and programmatic focuses to reduce health disparities are needed as mechanisms for improving the circumstances of at-risk populations. Community based participatory approaches are described here for cancer prevention, detection, and treatment programs that utilize culturally appropriate methods.     

U.S. Department of Energy policies, directives, and guidance for radiological control and release of property

U.S. Department of Energy (U.S. DOE) regulates its operations with a system of rules, directives, and guidance under the Atomic Energy Act. U.S. DOE's policy is to conduct its radiological operations in a manner that ensures the health and safety of its employees, contractors, and the public. U.S. DOE uses an annual dose limit of 100 mrem (1 mSv) with an "as low as reasonably achievable" (ALARA) process to achieve radiological protection. The primary directive for radiation protection of the public and the environment is DOE Order 5400.5. It contains requirements for the protection of the public and the environment from routine operations, including controlling and releasing property. Since the publication of Order 5400.5 in 1990, U.S. DOE has issued guidance for meeting requirements under it; Guide G 441.1-xx consolidates this guidance. DOE applies a dose constraint of 25 mrem y (0.25 mSy y(-1)), plus ALARA, for the release of real property, and 1 mrem y(-1), plus ALARA, for release of personal property. Models and guidance to develop the needed documentation for release of property are easily available and user-friendly. While achieving protection of human health and the environment, U.S. DOE's dose-based release process has resulted in significant cost savings. U.S. DOE has recently adopted a management systems approach for general environmental and public protection programs. The integration of the radiation protection program into this new approach is a high priority.     

Past, present and future of Aedes albopictus in the United States

Aedes albopictus was first detected in Houston, Texas, in 1985. Since then it has spread to 17 states and 122 counties. This exotic species from Asia appears to have arrived in the U.S. in imported used tire casings. Public health concerns have been raised regarding the potential of this species to serve as a vector of arboviruses indigenous to the U.S., such as La Crosse encephalitis, and also for imported dengue. The Division of Vector-Borne Viral Diseases, Centers for Disease Control, has actively pursued a program to determine the distribution of Ae. albopictus in the U.S., monitor the spread of the species and implement procedures that would eliminate the risk of further importation of exotic mosquitoes in used tire casings. The latter goal was achieved in large measure in 1988 with a 98% reduction in imported used tires containing water. The ultimate consequences of establishment of Ae. albopictus in the U.S. is unknown; however, because of its biologic characteristics and broad viral susceptibility, it seems likely that this species will eventually become involved as an arbovirus vector in the U.S.     

Practices,beliefs and knowledge of international and U.S. students regarding food supplements and health foods

Behavioral and cognitive parameters associated with food supplement and health food use were surveyed among a convenience sample of 142 international and 100 U.S. students.

Among the international students, 140 used at least one product in the home country and 135 reported doing so in the university community. Ninety‐seven U.S. students used at least one supplement or health food in the university community. U.S. students used a significantly greater number of products (p < 0.001).

The products used by the greatest number of international students overseas and in the university community and by the greatest number of U.S. respondents were vitamin C, calcium, and yogurt.

Reasons for food supplement use reflected beliefs by both groups that these products prevented or cured specific medical conditions. Health foods in contrast were popular primarily for their taste and culinary attributes.

International and U.S. students gave high accuracy ratings to academic/medical/scientific sources of nutrition information and low ratings to television and radio commercials, newspaper and magazine advertisements, friends and parents.

The mean score for the international students on the nutrition knowledge test was 17.6 points, that for the U.S. students was 30.9 points.

Low mean scores, together with widespread use of nutritional supplements and a strong belief in unsubstantiated health claims made on behalf of these products suggest that the students surveyed in this study take nutritional supplements without being able to justify their use. Both groups would benefit from accurate nutrition information regarding these products.     

Public health approaches to tobacco use prevention and cessation in the U.S.

Tobacco has a long history of use in the U.S., and its serious health effects have been well-documented during the past half century, U.S. efforts to control tobacco use and tobacco-related morbidity and mortality have been reasonably successful over the past 25 years, during which time there has been a 34 percent reduction in adult smoking. Nevertheless, tobacco use remains a significant public health problem in the U.S., with more than 430,000 tobacco-related deaths per year and over one-fourth of the population continuing to smoke. Many organizations are involved in tobacco use control activities, the most broadly focused of which is the National Cancer Institute (NCI). As an example of the type of program needed to address the problem of tobacco use on a national scale, the NCI's public health research plan and activities are described and its emphasis on a data-based decision matrix in its approach to tobacco and cancer control research and applications of research is discussed. Finally, future approaches to tobacco use control in the U.S. are suggested.     

Medicine and management: a combined educational program

Rapidly evolving characteristics of our health care system are creating new and expanding opportunities for physician managers. Formal graduate degree training in management has become desirable to prepare the physician for these new professional responsibilities. The Schools of Medicine and Management at Northwestern University instituted a formal combined degree program eight years ago. Directed by a physician holding faculty appointments in both schools, the program offers an integrated five year curriculum. During the past eight years, 16 students have matriculated in the program without attrition. Eleven students have completed both degrees on schedule. The results of a comprehensive telephone survey of all U.S. and Canadian medical schools concerning dual degree programs are presented. The advantages and disadvantages of pursuing management training at various stages of a physician's career are discussed.     

In-country and community-based postgraduate family practice training for Micronesian physicians--the Palau AHEC: a collaborative effort

The U.S. Institute of Medicine in its 1998 review of the health care systems among the U.S.-Associated Pacific Islands (USAPI) identified promotion of primary health care (PHC) and training of the regional health workforce including postgraduate training for physicians as priorities. With the support of the health leadership of the USAPI and the Republic of Palau, the John A. Burns School of Medicine (JABSOM) of the University of Hawaii captured U.S. federal Area Health Education Center (AHEC) funds to implement a postgraduate program to train Family Practitioners - physician specialists in primary care for the region. The Palau AHEC has evolved into ajoint activity of JABSOM, the University of Auckland Faculty of Medicine and Health Sciences (UAFMHS), the School of Public Health & Primary Care--Fiji School of Medicine, and Palau Community College to provide Diploma-level training in Family Practice and Community Health for Micronesian physicians.     

NEED AND METHOD OF COORDINATING FEDERAL,STATE AND LOCAL HEALTH AGENCIES IN PROMOTING INDUSTRIAL HYGIENE

This author says that what the country needs is not extension of Federal authority so much as health education of the people to support what exists. The U. S. P. H. S. has already all the power that may constitutionally be given to a Federal health agency. It has a distinct industrial health program, and all it needs is good financial support.     

NEED AND METHOD OF CO?RDINATING FEDERAL,STATE AND LOCAL HEALTH AGENCIES IN PROMOTING INDUSTRIAL HYGIENE

This author says that what the country needs is not extension of Federal authority so much as health education of the people to support what exists. The U. S. P. H. S. has already all the power that may constitutionally be given to a Federal health agency. It has a distinct industrial health program, and all it needs is good financial support.     

U.S. medical students' attitudes about patients' access to care

OBJECTIVE: Accessing adequate medical services remains a major struggle for many Americans, but U.S. medical students' beliefs regarding access to care have not been thoroughly examined. METHODS: All medical students in the Class of 2003 at 16 U.S. schools were eligible to complete three questionnaires during their medical training: during freshman orientation, orientation to wards, and their senior year (n=2316, response rate=80.3%). Students responded to three questions about health care provision. RESULTS: Overall, 35% of students strongly agreed that "physicians have a responsibility to take care of patients regardless of their ability to pay;" only 5% disagreed. Only 8% disagreed that "access to basic health care is a fundamental human right." We found the same significant associations with opinions on access as we did with "responsibility to treat," although the associations tended to be stronger for access. Only 10% of students agreed that "Managed care, as it is now delivered, is a good way to deliver health care to the U.S. population." CONCLUSION: Most U.S. medical students support universal access to medical care, though variations in this support, its decline with additional years of medical education, and concerns about managed care are noteworthy, and have policy implications for America's health and health care workforce.     

Cancer registry policies in the United States and geographic information systems applications in comprehensive cancer control

OBJECTIVES: Through a long history of cancer policies, public health has a foundation for cancer research and data to use in applying technological advancements for U.S. cancer control efforts. Geographic information systems (GIS) are one technology enabling the visualization of cancer risk patterns associated with incidence, mortality, and accessibility to care. METHODS: U.S. Comprehensive Cancer Control (CCC) program directors were interviewed from 49 of 50 states to assess use and function of GIS tools for mapping data related to cancer control policies and practices. Interviews were coded to obtain frequencies of response associated with content domains mapped using GIS tools and the perceived relative advantages. RESULTS: Significant relationships were found between the mapping of behavioral risk factors, health care services, transportation access, and policy advantages identified by program managers. The mapping of cancer incidence, mortality, and staging, transportation access, and multiple layers of content were found to have significant associations with perceived research advantages. CONCLUSIONS: U.S. CCC program managers recognize several important advantages relating to health policy and research for use of GIS tools in cancer control efforts. The application of GIS in U.S. cancer control efforts is employed unevenly, suggesting the need for innovative policies to support accessibility.     

Sociocultural and community factors influencing the use of Native Hawaiian healers and healing practices among adolescents in Hawai'i

Recently, there has been much emphasis placed on both alternative approaches to health care and the provision of culturally competent care. Despite these trends, few studies have examined the use of alternative therapies on the part of adolescents. Even fewer studies have been done focusing on traditional Hawaiian approaches to health care. This is essential, especially in Hawai'i, where Hawaiians have not attained health parity with other majority ethnic populations, despite significant efforts and funding to achieve this end. This study examines the sociocultural and community factors influencing the use of traditional Native Hawaiian healers and healing practices by adolescents in Hawai'i. The Hawaiian High Schools Health Survey was administered at five high schools on three islands in Hawai'i during the 1993-1994 school year. The sample included 1,321 high school students who preferred either an allopathic or alternative practitioner. Ethnicity, gender, community access, healer preference, health status, level of education, and health insurance status were used to predict healer use and participation in healing practices. Community access and healer preference predicted both healer use and participation in native healing practices. Mental health predicted healer use (i.e., seeing a Native Hawaiian healer in the past six months), but did not predict taking part in native healing practices, such as ho'oponopono and lomilomi. Hawaiian ethnicity, female gender, and a measure of health insurance predicted participation in native healing practices, but not healer use. These results suggest that native healing practices and traditional healers are being used in Native Hawaiian communities and this is perhaps not due to a lack of health insurance. Given the general separation between Western and Native Hawaiian health services, traditional healing practices should be made available in Native Hawaiian communities to see whether a collaboration between Western practitioners and traditional healers can have a greater positive impact on the health of Native Hawaiians, particularly for adolescents.     

Income inequality, social cohesion, and class relations: a critique of Wilkinson's neo-Durkheimian research program.

Wilkinson's "income inequality and social cohesion" model has emerged as a leading research program in social epidemiology. Public health scholars and activists working toward the elimination of social inequalities in health can find several appealing features in Wilkinson's research. In particular, it provides a sociological alternative to former models that emphasize poverty, health behaviors, or the cultural aspects of social relations as determinants of population health. Wilkinson's model calls for social explanations, avoids the subjectivist legacy of U.S. functionalist sociology that is evident in "status" approaches to understanding social inequalities in health, and calls for broad policies of income redistribution. Nevertheless, Wilkinson's research program has characteristics that limit its explanatory power and its ability to inform social policies directed toward reducing social inequalities in health. The model ignores class relations, an approach that might help explain how income inequalities are generated and account for both relative and absolute deprivation. Furthermore, Wilkinson's model implies that social cohesion rather than political change is the major determinant of population health. Historical evidence suggests that class formation could determine both reductions in social inequalities and increases in social cohesion. Drawing on recent examples, the authors argue that an emphasis on social cohesion can be used to render communities responsible for their mortality and morbidity rates: a community-level version of "blaming the victim." Such use of social cohesion is related to current policy initiatives in the United States and Britain under the New Democrat and New Labor governments.     

CHWs get credit: a 10-year history of the first college-credit certificate for community health workers in the United States

Community health workers have become increasingly important in the U.S. health care system, playing a significant role in basic health promotion and care coordination; however, their status and visibility have not kept pace with their wider use. A major impediment has been the absence of systematic preparation-the field needs standardized education in programs that emphasize the actual skills and knowledge used by community health workers, programs that attract and retain nontraditional students from underserved communities and that foster professional advancement. This article chronicles the 10-year history of the first college credit-bearing community health worker certificate program in the country to address this need. Systematic research resulted in a program centered on the core competencies universally practiced by community health workers regardless of their topical focus. The certificate program combines performance-based methods with popular education into an innovative pedagogical approach that teaches skills, while solidifying, contextualizing, and enhancing crucial experiential knowledge. Program outcomes validate the approach.     

Health care administration in the United States and Canada: micromanagement, macro costs.

A decade ago, U.S. health administration costs greatly exceeded Canada's. Have the computerization of billing and the adoption of a more business-like approach to care cut administrative costs? For the United States and Canada, the authors calculated the 1999 administrative costs of health insurers, employers' health benefit programs, hospitals, practitioners' offices, nursing homes, and home care agencies; they analyzed published data, surveys of physicians, employment data, and detailed cost reports filed by hospitals, nursing homes, and home care agencies; they used census surveys to explore time trends in administrative employment in health care settings. Health administration costs totaled at least dollar 294.3 billion, dollar 1,059 per capita, in the United States vs. dollar 9.4 billion, dollar 307 per capita, in Canada. After exclusions, health administration accounted for 31.0 percent of U.S. health expenditures vs. 16.7 percent of Canadian. Canada's national health insurance program had an overhead of 1.3 percent, but overhead among Canada's private insurers was higher than in the U.S.: 13.2 vs. 11.7 percent. Providers' administrative costs were far lower in Canada. Between 1969 and 1999 administrative workers' share of the U.S. health labor force grew from 18.2 to 27.3 percent; in Canada it grew from 16.0 percent in 1971 to 19.1 percent in 1996. Reducing U.S. administrative costs to Canadian levels would save at least dollar 209 billion annually, enough to fund universal coverage.     

Contacting passengers after exposure to measles on an international flight: Implications for responding to new disease threats and bioterrorism

On May 21, 2000, a passenger with measles traveled from Japan to Hawai'i on a seven-hour flight. When the flight landed, the U.S. Public Health Service (USPHS) Quarantine Station in Honolulu alerted passengers that a suspected case of measles had been identified, but they were not detained. The next day, to offer appropriate post-exposure prophylaxis, the Hawai'i Department of Health (HDOH) attempted to contact all passengers from the flight using information from the airline, U.S. Customs declaration forms, and tour agencies. Of 335 total passengers, 270 (81%) were successfully reached and provided complete information. The mean time from exposure to contact for all respondents was 61 hours (95% confidence interval 57, 66). A total of 202 (75%) of the responding passengers were contacted within 72 hours after exposure, the time period during which administration of measles vaccine would have provided protection for susceptible individuals. The time-to-contact was significantly longer for passengers who did not stay in hotels than for hotel guests. Customs forms proved to be of limited utility in contacting international travelers. This experience highlights the need for more complete and timely methods of contacting passengers potentially exposed to infectious agents aboard flights.     

The pillars of health management education: lessons from the CEE experience.

AUPHA faculty members have had the opportunity to provide health care executive training and to work in partnership with academic institutions in Central and Eastern Europe and in the New Independent States of the former Soviet Union. This article presents some observations on health management education that demonstrate the similarity in issues faced by programs in the U.S. and in CEE. The health management educational partnership program was designed to provide technical assistance to emerging health management programs in the CEE. The partnership program has been mutually beneficial for several reasons. The role of physicians in leadership and the management educational needs that result provide one example of an issue that health management educational programs must address. The emergence of the roles of other health professions and growing contribution that they will make has its parallel in the American ascendance of the role of interdisciplinary team in clinical decision making. The partnership and executive training experiences have caused U.S. partners to focus consciously on pedagogical methods. The nature of the issues faced by emerging CEE health management programs suggests that mutual support among programs in the region after the partnership program is necessary in order to provide a forum for debate. The focus of the debate should continue to be on the role of management in health reform, content of curriculum, research focus and pedagogical methods appropriate for health care management undergraduate and graduate programs. The result will be a strengthening of the health management academic discipline in the region. The future of the AUPHA should predicated on the same principles, the roots from which it has grown.     

Perceived Health Needs of Secondary School Students in Uyo, Akwa Ibom State, Nigeria

ABSTRACT: Nigeria generally has overlooked the health needs of its adolescents. To determine student perceptions of their health-related needs, some 600 students in Uyo, the capital of Akwa Ibom State, were surveyed, and they identified several concerns. Their responses provided the basis to offer five recommendations for action: improve the quality of school health service facilities and personnel available in the secondary schools; implement a comprehensive national program of drug education and control; provide a healthful school environment; assess the quality and quantity of food provided to students, especially in boarding schools; and implement a comprehensive school health education program in Nigerian schools.     

A foreign medical school transfer program: student performance and career choices.

U.S. medical students who have been unable to gain acceptance into medical schools have long sought alternative pathways into American medical practice. The Medical College of Georgia (MCG) has had a transfer program since 1977 to facilitate entry of Georgia Transfer students into the third-year clinical rotations. After completing a remedial program of three to five months, transfer students have entered the third year and performed similarly to regular MCG students. Evaluation of 31 students who have graduated and for whom data are available shows no significant difference in performance when compared to other MCG students in terms of clinical grade point averages and NBME Part 2 scores. These students were also similar to their MCG peers in the number entering residencies within the state.     

Why some countries have national health insurance, others have national health services, and the U.S. has neither

This article presents a discussion of why some capitalist developed countries have national health insurance schemes, others have national health services, and the U.S. has neither. The first section provides a critical analysis of some of the major answers given to these questions by authors belonging to the schools of thought defined as 'public choice', 'power group pluralism' and 'post-industrial convergence'. The second section puts forward an alternative explanation rooted in an historical analysis of the correlation of class forces in each country. The different forms of funding and organization of health services, structured according to the corporate model or to the liberal-welfare market capitalism model, have appeared historically in societies with different correlations of class forces. In all these societies the major social force behind the establishment of a national health program has been the labor movement (and its political instruments--the socialist parties) in its pursuit of the welfare state. In the final section the developments in the health sector after World War II are explained. It is postulated that the growth of public expenditures in the health sector and the growth of universalism and coverage of health benefits that have occurred during this period are related to the strength of the labor movement in these countries.