Implementing a Routine, Voluntary HIV Testing Program in a Massachusetts County Prison

Although U.S. prison inmates have higher rates of HIV infection than the general population, most inmates are not routinely tested for HIV infection at prison entry. The study objective was to implement a routine, voluntary HIV testing program in a Massachusetts county prison. During admission, inmates were given group HIV pre-test counseling and were subsequently offered private HIV testing. This intervention was compared to a control period during which HIV testing was provided only upon inmate or physician request. Between November 2004 and April 2005, 1,004 inmates met inclusion criteria and were offered routine, voluntary HIV testing. Of these, 734 (73.1%) accepted, 2 (0.3%) were HIV-infected, and 457 (45.5%) had been tested for HIV in the previous year. The testing rate of 73.1% was significantly increased from the rate of 18.0% (318 of 1,723) during the control period (p<0.001). Among the inmates tested for HIV in the prior year, 78.2% had received their last HIV test in the prison setting. Careful attention should be paid to prevent redundancy of testing efforts in the prison population. Implementing a routine HIV testing program among prison inmates greatly increased testing rates compared to on-request testing. Liddicoat is with the Department of Medicine, Greater Los Angeles Veterans Administration, Mail 111G, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA; Zheng, Freedberg, and Walensky are with the Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Freedberg and Walensky are with the Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Zheng, Freedberg, and Walensky are with the Partners AIDS Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Internicola and Golan are with the Suffolk County House of Corrections, Boston, MA, USA; Golan is with the Department of Infectious Disease, Tufts University Medical School, Boston, MA, USA; Rubinstein is with the HIV/AIDS Bureau, Massachusetts Department of Public Health, Boston, MA, USA; Werner and Kazianis are with the Massachusetts State Laboratory Institute, Boston, MA, USA.     

Health Maintenance Organizations: Are they for the inner cities?

Health Maintenance Organizations present some major limitations as a means to address the health care needs in our nation's inner cities. The HMO as it has been affected by HMO legislation is discussed and an identification made of those areas that may adversely affect the delivery of health services to inner-city residents where costs may be greatest for those who can least afford it.Dr. Roman is Director of Ambulatory Care, in the Department of Medicine at Boston City Hospital and the Department of Medicine at Boston University School of Medicine, 818 Harrison Avenue, Boston, Massachusetts 02118.     

Definition of terms and concepts applicable to clinical preventive medicine

This article defines the terms and concepts applied to the teaching of clinical preventive medicine by the Curriculum Development Project—a joint venture of the Center for Educational Development in Health (CEDH) at Boston University and the Association of Teachers of Preventive Medicine Foundation (ATPMF).Dr. Stokes is Professor of Medicine (Section of Preventive Medicine and Epidemiology), Boston University, Boston, MA 02118; Dr. Noren is Director (Administrative Medicine), University of Wisconsin, Madison, WI 53706; and Dr. Shindell is Professor and Chairman (Department of Preventive Medicine), Medical College of Wisconsin, Milwaukee, WI 53233.Supported in part by grants from the National Fund for Medical Education and the Kellogg Foundation.     

Toward understanding elders' health service utilization

Providing appropriate health services to the elderly is emerging as one of the major challenges of this decade. Using the theoretical framework developed by Andersen and Aday, this study attempts to improve our understanding of those factors which inhibit or facilitate elders' use of health services. The data come from a 1974 statewide random probability sample of 1,625 noninstitutionalized elders 65 years of age or older living in Massachusetts. Regression analysis is used to study the effects of predisposing, enabling, and need characteristics on the use of five health services: hospitals, physicians, dentists, home care, and ambulatory care. The model explains from 5% to 27% of the variance in health service utilization. Need characteristics, in general, account for most of the explained variance.Drs. Branch and Jette and Ms. Polansky are with the Department of Social Medicine and Health Policy, Division on Aging, Harvard Medical School, 643 Huntington Avenue, Boston, Massachusetts 02115; Dr. Jette is also with the Massachusetts General Hospital's Institute of Health Professions; Dr. Evashwick and Ms. Rowe are with the Department of Health Services and Long Term Care Gerontology Center, School of Public Health and Community Medicine, University of Washington; and Dr. Diehr is with the Department of Biostatistics, School of Public Health and Community Medicine, University of Washington. Work for this project was supported in part by a grant from the Massachusetts Department of Public Health while the first author was with the Center for Survey Research, a facility of the University of Massachusetts and the Joint Center for Urban Studies of M.I.T. and Harvard University; in part by Grant 90-A-1350/2 from the Administration on Aging of H.E.W. to the Harvard School of Public Health; and in part by Grant 90-AT-2159 from the Administration on Aging of H.E.W. to the Harvard Medical School.     

Sun Protection Policies and Practices at Child Care Centers in Massachusetts

We assessed the relationship between sun protection policies and practices at child care centers in Massachusetts. We hypothesized that centers with sun protection policies were more likely to have regular sun protection practices in place compared to centers without these policies. We conducted a telephone survey with directors or assistant directors at 327 child care centers during the summer of 2002. The main outcome measure was sun protection practices, which included time spent outside during mid-day and the use of sunscreen, hats, and protective clothing by the majority of children assessed over the last 5 program days. The 36-item survey also inquired about the center’s sun protection policy and included demographic questions. Most centers (73%) reported having a written sun protection policy. Sun protection policies were positively associated with reported sunscreen (χ²=14.63, p = 0.0001) and hat use (χ²=30.98, p < 0.0001) and inversely associated with time outside (χ²=10.76, p = 0.001). Seventy-seven percent of centers followed recommended sunscreen practices. However, centers were far less likely to have recommended hat use (36%) and protective clothing (1.5%) practices. A formal sun protection policy may be an effective way to increase sun protection practices in the child care setting. Further research should assess this relationship in other states. Improving and expanding existing state regulations may be a reasonable strategy to increase sun protection at child care centers. Stacey A. Kenfield is a doctoral candidate in the Epidemiology Department, Harvard School of Public Health, Boston, MA; Alan C. Geller is Research Associate Professor in the Department of Dermatology at the Boston University School of Medicine, Boston, MA; Elizabeth M. Richter is Cancer Prevention and Control Director, Bureau of Family and Community Health, Massachusetts Department of Public Health, Boston, MA; Steve Shuman is Health Specialist for ACF Region 1 Head Start Quality Initiative, Boston, MA; David O’Riordan is Assistant Professor at the Cancer Research Center of Hawaii, University of Hawaii, Honolulu, HI; Howard K. Koh is Harvey V. Fineberg Professor of the Practice of Public Health, Division of Public Health Practice, Harvard School of Public Health, Boston, MA; Graham A. Colditz is Professor of Medicine at Harvard Medical School, Boston, MA.     

Determinants of dropout rate among hypertensive patients in an urban clinic

Noncompliance with follow-up is a serious problem in the management of hypertension. A retrospective cohort study examined dropout rates and their determinants among 249 randomly selected outpatients with essential hypertension from the medical clinic of an urban teaching hospital. Data were abstracted from hospital records and a subset of dropouts was interviewed. A lifetable analysis revealed that patients who were initiating therapy or who had been under therapy for less than six months had a 50% chance of remaining in care two years later, while 70% of patients who had been under therapy for more than six months at entry were still in care after this period. Patients who were less severely ill by several indicators were the most likely to drop out. It is hypothesized that the low perceived severity of illness, coupled with the costs and inconvenience of care and the lack of physician enthusiasm for the treatment of mild hypertension leads to noncompliance with follow-up.Dr. Gillum is with the Laboratory of Physiological Hygiene and the Department of Medicine, Schools of Public Health and Medicine, University of Minnesota, Minneapolis, Minnesota. Dr. Neutra is with the Division of Epidemiology of the School of Public Health, University of California at Los Angeles. Dr. Stason is with the Center for the Analysis of Health Practices at the Harvard School of Public Health, Boston, Massachusetts. Dr. Solomon is with the Department of Medicine at Peter Bent Brigham Hospital, Boston, Massachusetts. Reprint requests should be addressed to Dr. Gillum, Laboratory of Physiological Hygiene, University of Minnesota, Stadium Gate 27, 611 Beacon St. SE, Minneapolis, Minnesota 55455.     

Efficacy of the emergency unit's filter function in patients with psychiatric symptoms

The fundamental functions of the recently established emergency units/departments include the initial assessment, triage, commencement of treatment and referral for admission to the hospital. Aim: The aim of the study was to analyze psychiatric cases assessed at the department of emergency with particular reference to misdiagnoses and the reasons why emergency physicians failed to reach correct diagnoses. Method: This is a chart review of patients with psychiatric diagnoses evaluated at the Department of Emergency, Mohács City Hospital during 2006. These patients were followed through the electronic database of the hospital and their socio-demographic and clinical characteristics were analyzed. Results: Of the 596 patients who were considered primarily psychiatric cases during 2006, 289 (49%) were admitted to the psychiatric ward, 182 (30%) were referred to outpatient treatment, and 125 (21%) were misdiagnosed and proved to be non-psychiatric emergencies and eventually ended up in other wards (75 patients in internal medicine, 20 in neurology, 12 in intensive care, and 18 in other units). Conclusion: Overall, the diagnostic and triage functions of the department of emergency were satisfactory in psychiatric cases. Medical emergencies that were frequently mistaken for psychiatric cases (e.g. atypical pneumonia, sensory aphasia) deserve particular attention. The authors emphasize the importance of the close collaboration of different medical areas involved in emergency assessment and treatment.     

Medical care for vacationers

Medical services provided to vacationers and employees in Yellowstone National Park were reviewed for the years 1975 through 1977. Both ambulatory and inpatient data were obtained, including diagnoses, place of residence, medications prescribed, and methods of payment. The types of problems and modes of treatment did not differ from typical primary care practices. Health maintenance was the most common reason for outpatient visits. The distribution of diagnoses among park visitors and employees was the same within age categories, although the employees' rate of utilization was nearly twice that of the visitors. Distance from home was directly related to the frequency with which visitors used clinic services.Drs. Woolley, Wright, and Patrick and Mrs. Ford are with the Department of Family and Community Medicine, University of Utah College of Medicine, Salt Lake City, Utah, and Dr. Kronhaus is with Health Systems Research Institute, 715 East 3900 South, Salt Lake City, Utah. Work for this study was supported by Department of Health, Education and Welfare Contract No. 298-76-R-0006, Evaluation of the Utilization Effectiveness of Rural Health Programs. Reprints may be obtained from Dr. Ross Woolley, Department of Family and Community Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132.     

Seasonal variation in weight-for-age in a pediatric emergency room.

OBJECTIVE. The authors assess seasonal variations in the prevalence of low weight-for-age among young children visiting the pediatric emergency room of a city hospital. METHODS. We analyzed data on 11,118 children ages 6 to 24 months who visited the Boston City Hospital Pediatric Emergency Department between July 1989 and June 1992. Medical diagnoses were documented on a randomly selected subsample of 1,569 children. In addition, a questionnaire about food insecurity was administered to a convenience subsample of 269 families with children under 3 years of age. RESULTS. The percentage of children visiting the emergency room with weight-for-age below the fifth percentile was significantly higher for the three months following the coldest months than for the remaining months of the year, controlling for year of measurement. In the subsample, gastrointestinal illness was correlated with both season of measurement and weight-for-age, but the seasonal effect remained for the entire sample after controlling for dehydration. The questionnaire data suggested a relationship between economic stress and food insecurity that might help explain the seasonal effect. Families who were without heat or who were threatened with utility turnoff in the previous winter were twice as likely as other families to report that their children were hungry or at risk for hunger. CONCLUSIONS. Winter and early spring constituted periods of increased nutritional risk in the in this sample of predominantly low-income children, probably because of the increased caloric associated with cold stress and infections. Further research is needed to assess whether decreased caloric availability due to high heating costs, a "heat or eat" effect, also contributes to this phenomenon.     

Emergency room management of patients with sore throats in a teaching hospital: Influence of non-physician factors

The care of 169 patients with sore throats was evaluated retrospectively to determine if the quality of medical care received in a teaching hospital's emergency room is associated with the degree of control managing physicians have over the medical care process. Diagnostic evaluation (temperature, throat and cervical node examination, and throat culture) was controlled by physicians and was judged adequate in 78% to 98% of the patients. Therapy, defined as appropriate antibiotics prescribed only for patients with positive throat cultures for group A beta-hemolytic streptococcus, was dependent on hospital support services, and the patients, as well, and was judged adequate for 62% of the patients; however, in only one of the 67 patients treated with antibiotics was the culture result known before treatment. The bacteriology laboratory processed the cultures slowly; no administrative mechanism existed to follow up patients. Thus, when medical care involved factors outside physicians' direct control, lower quality care was given.From the Department of Medical Care and Hospitals, the Johns Hopkins University School of Hygiene and Public Health and the Department of Medicine, Baltimore City Hospitals. Address reprint requests to Dr. Fletcher, Department of Medicine, McGill University Clinic, Royal Victoria Hospital, Montreal, Quebec, H3A 1A1, Canada. This work was supported in part by grants from the Carnegie Corporation, the Commonwealth Fund of New York City, and the Robert Wood Johnson Foundation, and by grants 5 H01 HS 00110 and 5 T01 HS 00012 from the National Center for Health Services Research and Development and 5 D04 AH 00076 from the National Institutes of Health, Department of Health, Education and Welfare. Dr. Fletcher was a Carnegie Commonwealth Clinical Scholar.     

Participatory action research in youth programming: A theory in use

Participatory Action Research (PAR) is a kind of research that involves participants in the research process and produces knowledge that is useful to service providers, program participants, and other professionals. This article describes an example of PAR conducted by a youth-adult team to evaluate a youth conference based on the philosophy of “youth empowerment.” How participants were included in shaping the research and how researchers collaborated with participants and staff of the program are examined, as well as the specific ways in which the evaluation produced knowledge that was used in the program. This research was made possible by the Massachusetts Department of Public Health and Prevention Support Services of the Medical Foundation, Boston.     

Risk of Mortality during Four Years after Substance Detoxification in Urban Adults

The objective of this analysis was to assess the mortality rate and risk factors in adults, with substance dependence, who are not receiving primary medical care (PC). Date and cause of death were identified using the National Death Index data and death certificates for 470 adults without PC over a period of almost 4 years after detailed clinical assessment after detoxification. Factors associated with risk of mortality were determined using stepwise Cox proportional hazards models. Subjects were 76% male, 47% homeless, and 47% with chronic medical illness; 40% reported alcohol, 27% heroin, and 33% cocaine as substance of choice. Median age was 35. During a period of up to 4 years, 27 (6%) subjects died. Median age at death was 39. Causes included: poisoning by any substance (40.9% of deaths), trauma (13%), cardiovascular disease (13.6%), and exposure to cold (9.1%). The age adjusted mortality rate was 4.4 times that of the general population in the same city. Among these individuals without PC in a detoxification unit, risk factors associated with death were the following: drug of choice [heroin: hazard ratio (HR) 6.9 (95% confidence interval (CI) 1.6–31.1]; alcohol: HR 3.7 (95% CI 0.79–16.9) compared to cocaine); past suicide attempt (HR 2.1, 95% CI 0.96–4.5); persistent homelessness (HR 2.4, 95% CI 1.1–5.3); and history of any chronic medical illness (HR 2.1, 95% CI 0.93–4.7). Receipt of primary care was not significantly associated with death (HR 0.85, 95% CI 0.34–2.1). Risk of mortality is high in patients with addictions and risk factors identifiable when these patients seek help from the health care system (i.e., for detoxification) may help identify those at highest risk for whom interventions could be targeted. Saitz, Cheng, Richardson, and Samet are with the Clinical Addiction Research and Education Unit, Department of Medicine, Boston Medical Center, Boston, MA, USA; Saitz, Gaeta, Cheng, Richardson, and Samet are with the Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA; Saitz and Richardson are with the Youth Alcohol Prevention Center, Boston University School of Public Health, Boston, MA, USA; Gaeta is with the Boston Health Care for the Homeless Program, Boston, MA, USA; Cheng is with the Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA; Larson is with the New England Research Institutes, Watertown, MA, USA; Samet is with the Department of Social & Behavioral Sciences, Boston University School of Public Health, Boston, MA, USA.     

Guidelines for managing life-threatening food allergies in Massachusetts schools

During the past decade, prevalence of food allergies among children increased. Caring for children with life-threatening food allergies has become a major challenge for school personnel. Prior to 2002, Massachusetts did not provide clear guidelines to assist schools in providing a safe environment for these children and preparing for an emergency response to unintended allergic reactions. In 2001, the Asthma and Allergy Foundation of America/New England Chapter, Massachusetts Department of Education, Massachusetts Department of Public Health, Massachusetts School Nurse Organization, parents, and other professional organizations forged a successful collaboration to develop guidelines for managing life- threatening food allergies in schools. The guidelines assist schools by providing information on food allergies and anaphylaxis, emphasizing the need for team planning and development of an individualized health care plan, giving guidance on strategies to prevent accidental exposure to specific allergens in school settings, and offering information on emergency responses should unintended exposures occur. The collaborative process for developing the guidelines, which continued during the distribution and implementation phases, set a tone for successful multidisciplinary teamwork in local schools.     

Use of passive surveillance data to study temporal and spatial variation in the incidence of giardiasis and cryptosporidiosis

OBJECTIVE: The goal of this study was to evaluate temporal and spatial variations in the reporting of cases of giardiasis and cryptosporidiosis to a passive surveillance system, and to assess the relationship of those variations to source of drinking water, adjusting for socioeconomic variables. METHODS: The authors analyzed temporal and spatial patterns for 4,058 cases of giardiasis and 230 cases of cryptosporidiosis reported to the Massachusetts Department of Public Health for 1993-1996. They linked each reported case to a database containing information on source of residential water supply and socioeconomic characteristics and evaluated the association between these factors and reporting rates using regression techniques. RESULTS: Reports of giardiasis and cryptosporidiosis were highest for the mixed unfiltered drinking water supply category. Reports of giardiasis were associated with income levels. Increases in reporting for both giardiasis and cryptosporidiosis were seen in summer to early fall. During a suspected outbreak of cryptosporidiosis n the city of Worcester in 1995, a significant increase in reported cases was also observed in the Boston metropolitan area. Following the suspected outbreak, weekly giardiasis rates increased slightly in Worcester and the Boston metropolitan area, while reporting of cryptosporidiosis increased dramatically. CONCLUSIONS: Consistently collected passive surveillance data have the potential to provide valuable information on the temporal variation of disease incidence as well as geographic factors. However, passive surveillance data, particularly in the initial period of surveillance, may be highly sensitive to patterns of diagnosis and reporting and should be interpreted with caution.     

Petition drive

Nearly 800 physicians and nurses petitioned the governor of Massachusetts to declare a public health emergency and expand needle-exchange programs in the state. Currently, needle-exchange programs are operated in only four communities: Boston, Cambridge, Provincetown, and Northampton. Injection drug use is the highest mode of transmission among Massachusetts residents who develop AIDS, and 70 percent of female AIDS cases are linked to dirty needles. Governor Paul Cellucci told the Boston Globe that he doesn't think a public health emergency is necessary.     

An interpretation of implicit judgments in chart review

The effects of methods that are commonly employed to summarize implicit judgments about quality-of-care assessments, based on medical records, are examined. A sample of 250 medical records, from three outpatient clinics in a municipal hospital, was studied. Two, or three, reviewers judged the quality of both the process of care and the outcome of care, as reflected in each medical record; the reviewers were medical school faculty members. Thirty-seven combinations of the data were used to summarize the judgments made on each medical record. These combinations resulted in significant differences in interpretation within each clinic, but there were only insignificant differences in interpretation across the three clinics. Hence, the use of a single method to summarize data may distort the conclusions. These results demonstrate that data often should be summarized by several methods and that measures of association should be used to supplement tests of significance so as to develop a comprehensive understanding of a set of data.Dr. Horn is Assistant Professor, Department of Health Care Organization, School of Hygiene and Public Health, The Johns Hopkins University, 615 North Wolfe Street, Baltimore, Maryland 21205. Dr. Pozen is presently Assistant Professor, Department of Medicine, Boston University School of Medicine at Boston City Hospital, Thorndike Memorial Laboratories. This study was begun while he was at the Department of Medicine at Baltimore City Hospitals and the Department of Health Care Organization at The Johns Hopkins University. This work was supported by DHEW grant 5-R01-HS-01590 from the National Center for Health Services Research and Development.     

The effect of coordinated,multidisciplinary ambulatory care on service use,charges, quality of care and patient satisfaction in the elderly

This study evaluated a multidisciplinary care center, the Pike Market Clinic (PMC), whose physicians provide and coordinate inpatient and outpatient care for downtown low-income elderly in Seattle. We interviewed users of PMC and their near-neighbors with a 206 item questionnaire to compare their medical and social service use, quality of care, and satisfaction. We then estimated mean annual charges/person for inpatient, outpatient and emergency room services in the two groups. Demographic and health status characteristics were similar in the two groups. PMC patients made significantly more annual visits than neighbors to their primary physicians. Visits to non-primary physicians occurred at the same rate in both groups, but PMC patients were referred more often by their primary physicians. Both emergency room and inpatient use were higher in the neighbor group. Social services were used at the same rate by PMC patients and neighbors. Various indices suggested that quality of care and satisfaction were comparable or superior among PMC patients. Using utilization data, we estimated that neighbors generated charges over $1000/person/year greater than PMC patients. Coordination by PMC providers rather than the availability of multidisciplinary services may be largely responsible for utilization differences between PMC patients and their neighbors.Laura-Mae Baldwin is Assistant Professor of Family Medicine at the University of Washington, Seattle, Washington. Thomas S. Inui is Professor and Chair of Ambulatory Care and Prevention at Harvard Medical School, Boston, Massachusetts. Sally Stenkamp is in practice at Kaiser Permanente in Riverside, California.This research was conducted while the first author was a Robert Wood Johnson Clinical Scholar at the University of Washington. The opinions and conclusions in the text are those of the author and do not necessarily represent the views of The Robert Wood Johnson Foundation. The authors would like to thank Marilyn Bergner, PhD for her review of this work, Betsy Lieberman for her administrative support at the Pike Market Clinic, Beth Lindeman, MD for her assistance in interviewing and the many elderly who opened their homes to the interviewers.     

Treatment Outcomes for Substance Abuse among Adolescents with Learning Disorders

This paper assesses whether chemically dependent adolescents with comorbid learning disorders (LDs) derived less effective treatment results when compared to chemically dependent adolescents without LD and examines the moderating effects of prior treatments, treatment length, and treatment completion. Two hundred one adolescents were recruited between 1992 and 1993 from Massachusetts residential treatment centers and subsequently followed up 6 months after enrollment. Compared to chemically dependent teenagers without LD, those with LD were twice as likely to re-use substances at least once by follow-up. LD teenagers were more likely to attend Alcoholics/Narcotics Anonymous if they had prior admissions to treatment programs and longer treatment length. LD teenagers who completed treatment also experienced a greater decrease in current depression compared to LD teenagers not completing the treatment. This study is the first to consider outcomes of substance abuse treatment for adolescents with LD and contributes to the growing literature on comorbidity and substance abuse treatment.Stephen L. Buka, ScD, is an associate professor in the Department of Society, Human Development and Health and the Department of Epidemiology, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115, USA. Phone: +1-617-4323870. Fax: +1-617-4323755. E-mail: sbuka@hsph.harvard.edu.Garrett M. Fitzmaurice, ScD, is an associate professor in the Department of Biostatistics and Division of General Medicine, Brigham and Women’s Hospital, 1620 Tremont St., Boston, MA 02120, USA. Phone: +1-617-5257508. Fax: +1-617-4325619. E-mail: fitzmaur@hsph.harvard.edu.Marie C. McCormick, MD, ScD, is a professor in the Department of Society, Human Development and Health, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115, USA. Phone: +1-617-4323759. Fax: +1-617-4323755. E-mail: mmccormi@hsph.harvard.edu     

Obstacles to and future goals of ten comprehensive community health promotion projects

Over 100 project staff, community coalition members, and other representatives from 10 comprehensive community health promotion projects in the western United States were surveyed two years into a three year funding cycle about: (1) the problems or obstacles they judged as preventing successful completion of their current goals and objectives, and (2) future goals and objectives they envisioned for their projects. The key issues confronting respondents were diverse, although issues around the process of implementing community health promotion programs were cited more frequently than issues related to the content of health promotion. When respondents were asked to prioritize Future Goals in the second survey, consensus across communities was obtained despite broad differences in the type of community surveyed and the health problem targeted. This study identifies the common organizational and community development problems faced by newly emerging community health promotion programs and has implications for other communities involved in designing, implementing, and evaluating community-wide health promotion programs.Drs. Altman (Associate Director), Howard-Pitney (Evaluation Director), Rogers (Director) and Mr. Endres (Community Organizer) are with the Health Promotion Resource Center, Stanford Center for Research in Disease Prevention, Stanford University School of Medicine. At the time this paper was written, Ms. Linzer was a graduate student at the Harvard School of Public Health, Boston, Massachusetts. Kate Lorig, Dr.P.H., is Senior Research Scientist in the Department of Immunology and Rheumatology at the Stanford University School of Medicine.This research was partially supported by grants from the Henry J. Kaiser Family Foundation, Menlo Park, California and the Pew Memorial Trust, Philadelphia, Pennsylvania.     

When bullets don't kill.

The Massachusetts Department of Public Health has created the first statewide surveillance system in the nation that tracks both fatal and nonfatal weapon injuries. The authors summarize findings for 1994 and discuss their public health implication. Suicides were the leading cause of firearm fatality, while self-inflicted injuries accounted for only 3% of nonfatal firearm injuries. Risk of violence-related injuries varied dramatically across the state. In Boston, one in 38 black male teenagers ages 15 to 19 was shot or stabbed in 1994, in contrast to one in 56,000 for white females of any age living in suburban communities. In Boston, non-Hispanic black male teenagers were at 41 times higher risk than white male teenagers for gun injuries. Shooting homicides increased sixfold during the late 1980s among black Boston males, while homicides by other means remained stable. In other Massachusetts cities, injury rates were higher among 20 to 24-year-olds than among teenagers, and, in some areas, incidence rates were as high or higher among Hispanic males than among non-Hispanic black males. Between 1985 and 1994, the proportion of firearm injuries caused by semiautomatic pistols increased from 23% to 52%, according to police ballistics data.